Steven Pinsky

Thyroid cancer occurring as a late consequence of head and neck irradiation. Evaluation of 1056 patients

From January 1 to September 30, 1974, we examined 1056 of 5266 subjects (20.1%) who had received therapeutic irradiation primarily for infections and inflammatory disease of the upper respiratory tract at our institution during the 1940s and 1950s. The tonsillar and nasopharyngeal region was the treatment site in 85% of those examined. Palpable nodular thyroid disease was found in 16.5%, and nonpalpable lesions were detected by 99m Tc pertechnetate thyroid imaging in an additional 10.7%, for a prevalence of nodular disease of 27.2%. Operation on 71% with nodular disease revealed thyroid cancer in 33% (60 of 182). Preliminary analysis for potential risk factors suggests a correlation between radiation exposure and the presence of thyroid nodules (P less than 0.001). These findings indicate that nodular thyroid disease, both benign and malignant, continues as a major health problem for at least 35 years in exposed subjects.

Radiation-induced tumors of the head and neck following childhood irradiation. Prospective studies

Nodules were found in 1108 subjects who received childhood radiation for benign conditions of the cervical area at our institution. This is 37.5% of 2958 subjects, out of a total of 5379, for whom there is follow-up information. Of the 848 subjects who have had thyroidectomies, 297 (35.0%) had thyroid cancer. In addition to thyroid tumors, salivary, neural, and probably parathyroid tumors also occurred as a late consequence of childhood radiation. Prospective studies of the subjects indicate that thyroid nodules are continuing to occur at a constant rate. The measurement of serum thyroglobulin is helpful in identifying individuals for whom the risk of developing a nodule is increased. Follow-up of patients with nonsurgically-treated nodules indicates that some of their nodules are progressive. At the present time there is no indication that radiation-induced cancers behave differently than ones in other settings. However, some of their characteristics, especially their multicentricity and occurrence in younger individuals, indicate that continued follow-up is necessary. On the basis of the data generated by the follow-up program at our institution and programs elsewhere, recommendations for screening, treatment, and follow-up are made. The recommendations stress the importance of estimating risk based on radiation dose, previous tumors, and serum thyroglobulin, in arriving at clinical decisions for these subjects.

Plasma Thyroglobulin in Detecting Thyroid Carcinoma after Childhood Head and Neck Irradiation

The level of thyroglobulin in plasma was measured in 904 subjects with a history of head and neck irradiation during childhood to evaluate its potential value in screening for and differentiating thyroid neoplasms. Mean plasma thyroglobulin level was significantly elevated in subjects with nodular thyroid disease versus those without evidence of nodules (49.8 versus 27.0 ng/ml). However, the overlap with normal subjects does not allow thyroglobulin assays to serve as the only screening procedure. The mean levels in subjects with benign and malignant thyroid nodules were indistinguishable (48.8 versus 53.9 ng/ml). Thirteen percent of otherwise normal-appearing subjects had elevated values that may represent clinically inapparent thyroid disease. It is concluded that in screening large numbers of persons at risk for thyroid neoplasia, thyroglobulin assays are useful in combination with other modes of evaluation. The assay is without value in distinguishing benign from malignant disease.

The Use of 67Ga Scanning in the Staging of Hodgkin's Disease1

Gallium-67 whole body scanning has been used to determine the extent of Hodgkins disease in 20 patients. Disease sites have been confirmed by pathological examination of tissue obtained at laparotomy or local excision biopsy, as well as chest radiographs and physical examination of superficial lymph node groups. Of 29 disease sites, 23 (79%) were correctly identified by 67Ga scanning. Six areas were thought to be involved by disease on the basis of the scan but were found to be uninvolved at surgery. Gallium-67 scanning is recommended as a useful supplement in the staging of Hodgkins disease.

The use of 67 Ga scanning in the staging of Hodgkin's disease.

Gallium-67 whole body scanning has been used to determine the extent of Hodgkins disease in 20 patients. Disease sites have been confirmed by pathological examination of tissue obtained at laparotomy or local excision biopsy, as well as chest radiographs and physical examination of superficial lymph node groups. Of 29 disease sites, 23 (79%) were correctly identified by 67Ga scanning. Six areas were thought to be involved by disease on the basis of the scan but were found to be uninvolved at surgery. Gallium-67 scanning is recommended as a useful supplement in the staging of Hodgkins disease.

The Sensitivity and Specificity of 99mTc-Sulfur Colloid Liver Imaging in Diffuse Hepatocellular Disease

The sensitivity and specificity of 99mTc-sulfur colloid liver-spleen imaging in diffuse hepatocellular disease and the significance of image patterns found in these diseases are presented. By visually quantifying the image alterations found in biopsy-proven cases of diffuse hepatocellular disease and analyzing the correlation between the histological diagnosis and the quantified image alteration (individually and by groups), the 99mTc-sulfur colloid liver-spleen image was found to be highly sensitive (83%). Relative discriminatory values were derived for each image finding and a specific image pattern was found in cirrhosis.

99mTc-Pertechnetate Thyroid Scintigraphy in Patients Predisposed to Thyroid Neoplasms by Prior Radiotherapy to the Head and Neck

Histories, physical examinations and 99mTc-pertechnetate imaging were used to evaluate 1,452 persons who had had x-ray therapy to the neck region for benign conditions 18 to 35 years previously. Thyroid abnormalities were found in 301 patients (21%) and thyroid malignancy was found in 29% of 193 patients with abnormal studies who were explored surgically. Thyroid imaging detected 96% of these abnormalities, 40% of which would not have been unequivocally established by physical examination alone. Nuclear imaging could not distinguish benign from malignant lesions.

Continuing Occurrence of Thyroid Nodules After Head and Neck Irradiation: Relation to Plasma Thyroglobulin Concentration

We re-examined 158 subjects from a group of 226 previously normal persons who had received head and neck irradiation, 113 with elevated plasma thyroglobulin levels at their first visit and 113 with normal levels. Twenty-four subjects had thyroid scintigrams that had changed in the follow-up interval of 24 to 60 (mean = 45.3) months. Twelve subjects subsequently had thyroidectomy, and five malignancies were found. In the other 12 the changes tended to be more subtle, but in nine they very likely represented thyroid nodules. We conclude that the prevalence of radiation-induced nodules is not decreasing. More changes (17 of 24) occurred in subjects who initially had elevated plasma thyroglobulin levels (p less than 0.05). However, the difference was not significant when the analysis was limited to the almost certain development of a nodule. Longer follow-up will be needed to ascertain whether a high thyroglobulin level predicts a greater risk of developing thyroid nodules.

Scintigraphic Thyroid Abnormalities after Radiation: A Controlled Study with 99mTc Pertechnetate Scanning

We did 99mTc-pertechnetate thyroid scintigraphy on 99 subjects with no history of therapeutic irradiation to the head or neck. They were compared with 198 irradiated patients selected from a group of over 1700 who were evaluated because of radiation treatment for benign head and neck conditions during childhood. The two groups were similar with respect to age and sex distribution. There were significantly more abnormal scintigrams in the irradiated group (55 of 198 patients versus one of 99 controls). Even after patients and controls with palpable nodules were excluded from the analysis there were still more abnormal scintigrams in the irradiated group (16 of 150 irradiated versus one of 97 control subjects). We conclude that thyroid nodules, including the smaller, nonpalpable nodules discovered by scintigraphy, are related to previous radiation therapy. For persons at substantial risk, such as those who received high-dose treatment (greater than 700 R) during childhood, the data support the use of screening scintigraphy, even with normal findings on palpation.

Sequential scintigraphic staging of small cell carcinoma

Thirty patients with small cell carcinoma (SCC) of the lung were sequentially staged following a history and physical exam with liver, brain, bone, and gallium‐67 citrate scans. Scintigraphic evaluation disclosed 7 of 30 patients (23%) with advanced disease, stage IIIMI. When Gallium‐67 scans were used as the sole criteria for staging, they proved to be accurate and identified six of the seven patients with occult metastatic disease. Gallium‐67 scans proved to be accurate in detecting thoracic and extrathoracic metastases in the 30 patients with SCC, especially within the liver and lymph node‐bearing area. The diagnostic accuracy of gallium‐67 fell in regions such as bone or brain. Despite the limitations of gallium‐67 scanning, the authors conclude that these scans are useful in staging patients with SCC and should be the initial scans used in staging such patients.