2022 Vol. 46, No. 7
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2022, 46(7): 389-391.
doi: 10.3760/cma.j.cn121381-202206015-00196
Abstract:
Differentiated thyroid cancer (DTC) patients always holds a good prognosis under standard surgery, selective 131I therapy and TSH suppression therapy. The goals of 131I therapy are characterized as remnant ablation, adjuvant treatment, and treatment of known disease, which are supposed to refine initial staging, facilitate follow-up, decrease recurrence, and improve disease-specific survival. However, there are still many issues to be clarified in clinical practice. For example, in the assessment of postoperative disease status before 131I therapy, it is difficult to estimate subclinical lesions, and there is no Tg threshold to guide 131I therapy, which makes the decision of adjuvant treatment even harder. In the follow-up, there is no uniform response criterion for 131I therapy in structural disease, the presence of TgAb will interfere with the judgement of disease status; 131I cumulative dose-related complications also need to be monitored and managed. This issue contains several articles related to the 131I treatment of DTC patients, discusses the difficulties in current 131I treatment and the explorations of Chinese scholars in several aspects.
Differentiated thyroid cancer (DTC) patients always holds a good prognosis under standard surgery, selective 131I therapy and TSH suppression therapy. The goals of 131I therapy are characterized as remnant ablation, adjuvant treatment, and treatment of known disease, which are supposed to refine initial staging, facilitate follow-up, decrease recurrence, and improve disease-specific survival. However, there are still many issues to be clarified in clinical practice. For example, in the assessment of postoperative disease status before 131I therapy, it is difficult to estimate subclinical lesions, and there is no Tg threshold to guide 131I therapy, which makes the decision of adjuvant treatment even harder. In the follow-up, there is no uniform response criterion for 131I therapy in structural disease, the presence of TgAb will interfere with the judgement of disease status; 131I cumulative dose-related complications also need to be monitored and managed. This issue contains several articles related to the 131I treatment of DTC patients, discusses the difficulties in current 131I treatment and the explorations of Chinese scholars in several aspects.
2022, 46(7): 392-396.
doi: 10.3760/cma.j.cn121381-202203005-00195
Abstract:
Objective To analyze the affecting factors of the successful rate of first 131I ablation after operation in patients with differentiated thyroid carcinoma (DTC). Methods Clinical data of 159 DTC patients (51 males and 108 females with an age range of 24–78 (46.5±11.9) years) with total thyroidectomy or subtotal thyroidectomy and who received the first 131I ablation in the Fourth Hospital of Hebei Medical University from April 2013 to March 2022 were retrospectively analyzed. The patients were divided into 3 groups according to the doses (2.96 GBq, 3.70 GBq and 5.55–7.40 GBq) of the first 131I treatment. The criteria for successful remnant ablation was as follows: diagnostic whole body scan showing that the thyroid bed had no radioactivity concentration at (4±1) months after 131I ablation. The effects of gender, age, surgical methods, pre-therapeutic thyroid-stimulating hormone (TSH) and thyroglobulin (Tg) levels, the time between operation and 131I ablation, and 131I dosages on efficacy of thyroid remnant ablation were analyzed. χ2 test was used to analyze the counting data. Results Among the 159 DTC patients, the successful rate of thyroid ablation was 70.4% (112/159). The successful rates of thyroid ablation in three treatment groups were 58.3%(21/36) (2.96 GBq group), 69.2%(63/91)(3.70 GBq group), and 87.5%(28/32)(5.55–7.40 GBq group) and the difference was statistically significant (χ2=7.071, P<0.05). The successful thyroid ablation rates in patients with total thyroidectomy were higher than those in patients with subtotal thyroidectomy and the difference was statistically significant (74.2%(95/128) vs. 54.8%(17/31), χ2=4.502, P<0.05). The successful thyroid ablation rate in pre-therapeutic TSH≥30 mU/L patients were higher than those in TSH<30 mU/L patients and the difference was statistically significant (73.9% (99/134) vs. 52.0%(13/25), χ2=4.844, P<0.05). The successful thyroid ablation rates in groups of gender, age, Tg level, and the time between operation and 131I ablation had no significant difference (χ2=0.311–3.073, all P>0.05). Conclusion The 131I dosages, surgical methods, and pre-therapeutic TSH levels are the affecting factors of the success rates of thyroid ablation in DTC patients with total thyroidectomy or subtotal thyroidectomy.
2022, 46(7): 397-404.
doi: 10.3760/cma.j.cn121381-202203002-00199
Abstract:
Objective To investigate the efficacy response and influencing factors of higher dose 131I in patients with metastasis-free intermediate-to-high risk differentiated thyroid cancer (DTC). Methods The clinical date of 378 patients with intermediate-to-high risk DTC who attended in the First Hospital of Shanxi Medical University from January 2018 to December 2020 were retrospectively analyzed. The patients included 103 male and 275 female with a median age of 45(13–85) years. All patients were given the first 131I remnant ablation and/or adjuvant therapy at a dose range of 3.70–5.55 GBq. Postoperative residual thyroid 99TcmO4− image was performed before 131I treatment, and 131I post-treatment whole body scan (Rx-WBS) was performed 2–7 days after treatment. All patients were followed up at least 6 months with a median follow-up time of 16.3 months. The efficacy response evaluation system was evaluated according to the 2015 American Thyroid Association assessment system, and its influencing factors were analyzed. Spearman rank correlation analysis was used to evaluate the correlation between 99TcmO4− image target/non-target (T/NT) ratio and Rx-WBS score.The Mann-Whitney U test, χ2 test or Fisher's exact probability method was utilized to analyze whether the difference between the excellent response (ER) and non-excellent response (nER) groups was statistically significant for all observed indicators. Binary multivariate Logistic regression was used to analyze the independent influencing factors of prognostic ER, receiver operator characteristic (ROC) curves were utilized to obtain optimal diagnostic thresholds. Results Stistically significant differences were observed in maximum tumor diameter, postoperative stimulated thyroglobulin (psTg) level, N stage, and interval time between the two groups of ER and nER (Z=−7.127, −2.702, Fisher's exact probability method, χ2=6.783; all P<0.05). The differences were statistically insignificant for age, sex, capsule involvement, tumor multifocality, T-staging, risk of recurrence stratification, first dose of 131I treatment, thyroid-stimulating hormone (TSH) level, urinary iodine level, 99TcmO4− image T/NT values, and Rx-WBS score (Z=−1.505 to −0.664, χ2=0.064–5.501, Fisher's exact probability method; all P>0.05). Spearman rank correlation analysis showed a moderate correlation between 99TcmO4− image T/NT values and Rx-WBS imaging scores (r=0.530, P<0.001). A multivariate Logistic regression analysis showed that psTg level was the independent risk factor of ER. The ROC curve analysis showed that the optimal cut-off value of ER was 5.90 ng/ml, the sensitivity was 83.76%, and the specificity was 59.81%. Conclusions Patients with intermediate-to-high risk DTC treated with higher dose of 131I had the same good ER proportion regardless of the amount of residual thyroid indicated by thyroid 99TcmO4− imaging. Patients receiving 131I treatment within 2 months after surgery may obtain better ER proportion. Meanwhile, psTg was an independent risk factor for predicting ER proportion in patients with metastasis-free intermediate-to-high risk DTC.
2022, 46(7): 405-411.
doi: 10.3760/cma.j.cn121381-202203031-00204
Abstract:
Objective To investigate the therapeutic efficacy and influencing factors of postoperative 131I treatment for pulmonary metastatic differentiated thyroid cancer (DTC). Methods The clinical data of 108 patients with pulmonary metastatic DTC who were admitted to the Affiliated Hospital of Qingdao University from January 1993 to March 2021 were retrospectively analyzed. There were 42 males and 66 females, with a median age of 54.3(17–77) years old and a median follow-up of 4.19(1.13–23.45) years. Before and after 131I treatment, serum thyroid-stimulating hormone (TSH), thyroglobulin (Tg), and thyroglobulin antibody (TgAb) levels were detected; moreover, chest CT, 131I whole-body scan, neck ultrasound, and other imaging examinations were performed to evaluate the progression of lung metastases. The efficacy of 131I treatment was evaluated following the Response Evaluation Criteria for Solid Tumors (RECIST) 1.1 and the change in serum stimulated thyroglobulin (sTg) level before 131I treatment. On the basis of the efficacy of 131I treatment, the patients were divided into the disease control group and disease progression group. The ratio of sTg level to TSH level before the second 131I treatment compared with the first 131I treatment was calculated (△sTg/TSH). Chi-square test and Kruskal-Wallis rank sum test were used for univariate analysis of the clinical pathological characteristics of the two groups. Logistic regression was used for multivariate analysis of the indicators with statistically significant differences in the above univariate analysis. The predictive value of △sTg/TSH for disease progression was evaluated by receiver operating characteristic (ROC) curve and the optimal cut-off value. Results Among 108 patients, 86 patients (79.6%) were in the disease control group after surgery and 131I therapy. A total of 22 patients (20.4%) were in the disease progression group. The results of univariate analysis showed significant differences between the two groups in age, pathological type, long diameter of the primary DTC lesion, serum sTg level before the first 131I treatment, △sTg/TSH, long diameter of lung metastases, iodine uptake of lung metastases, and diagnosis time (H=−3.194, χ2=19.142, H=−2.888, −2.499, −4.140, χ2=15.380, 4.069, 10.362; all P<0.05). Multivariate logistic regression analysis showed significant differences in the pathological type, △sTg/TSH, and long diameter of lung metastases between the two groups (B=3.059, 0.048, 4.140; OR=21.314, 1.050, 62.798; 95%CI: 1.112–408.369, 1.009–1.092, 1.528–2 581.064; all P<0.05). The optimal cut-off value of △sTg/TSH for predicting disease progression was −0.785%, and the area under the curve of the ROC was 0.809(95%CI: 0.701–0.917, P<0.001). Conclusion Pathological type, △sTg/TSH, and long diameter of lung metastases are independent risk factors affecting the efficacy of postoperative 131I treatment and predicting the progression of pulmonary metastatic DTC.
2022, 46(7): 412-418.
doi: 10.3760/cma.j.cn121381-202203030-00197
Abstract:
Objective To explore the relationship between the disappearance time of thyroglobulin antibody (TgAb) and clinical outcomes in TgAb-positive (≥40 IU/ml) differentiated thyroid cancer (DTC) patients before 131I therapy and analyze the influencing factors. Methods A total of 126 TgAb-positive DTC patients who underwent total thyroidectomy and 131I therapy in the Affiliated Hospital of Qingdao University from January 2014 to January 2019 were retrospectively analyzed. The patients included 15 males and 111 females, aged 11−74(42.1±11.5) years old. The patients were divided into the excellent and non-excellent response group according to the clinical outcomes at the last follow-up. The chi-square, independent-samples t, and Mann-Whitney U tests were used to analyze the age, the gender, the maximum diameter of the primary tumor, whether the tumor was multifocal, whether the tumor is combined with Hashimoto's thyroiditis, the preoperative thyroid peroxidase antibody (TPOAb) level, the TgAb level (preoperative and before the first 131I therapy), the TgAb declined rate at 1/6/12 months after the first 131I therapy, the disappearance time of TgAb, the total 131I dosage, the tumor stage, the lymph node stage, the lymph node metastasis rate, and the recurrence risk stratification before the first 131I therapy. The differences between the two groups were further analyzed by Logistic regression analysis. The receiver operating characteristic (ROC) curve was used to determine the cut-off value for judging clinical outcomes. Results A total of 109 patients formed the excellent response group, and 17 patients formed the non-excellent response group. In the univariate analysis, the TgAb declined rate at 12 months after the first 131I therapy (89.84% (82.81%, 94.70%) vs. 83.01% (74.99%, 91.08%), Z=−2.168, P=0.030), the disappearance time of TgAb ((25.06±17.96) months vs. (45.41±22.11) months, t=−4.206, P<0.001), and the total 131I dosage (3 700(3 700, 3 700) MBq vs. 5 550(3 700, 10 545) MBq, Z=−4.388, P<0.001) showed statistically significant differences. The Logistic regression analysis showed that the disappearance time of TgAb (OR=1.036, P=0.034) and the total 131I dosage (OR=1.033, P=0.001) were the independent risk factors for predicting the clinical outcomes. ROC curve analysis showed that when the cut-off value of the disappearance time of TgAb was 31.5 months (area under the curve=0.766, 95%CI: 0.650−0.881, P<0.001), the sensitivity and specificity of predicting clinical outcomes were the highest, 78.00% and 70.60%, respectively. Conclusions For TgAb-positive DTC patients before 131I therapy, the disappearance time of TgAb and the total 131I dosage were the independent risk factors of the clinical outcomes. The patients were likely to obtain excellent response with the disappearance time of TgAb within 31.5 months after the first 131I therapy, and the total dosage of 131I required by the patients in the excellent response group was much lower than that required by the patients in the non-excellent response group.
2022, 46(7): 419-424.
doi: 10.3760/cma.j.cn121381-202102025-00136
Abstract:
The impairment of salivary gland function is a common adverse reaction in radiotherapy and chemotherapy of head and neck tumors, which has a serious impact on the quality of life and treatment effect of patients. The incidence of salivary gland dysfunction increases with the increase of the incidence of head and neck diseases. Clear prevention and treatment methods are urgently needed. At present, a large number of domestic and foreign studies have revealed the possible mechanism of the impaired salivary gland function caused by radiation therapy and provided some prevention and treatment measures for clinical reference. This review focuses on the mechanism, symptoms, diagnosis and prevention of salivary gland dysfunction caused by 131I therapy.
The impairment of salivary gland function is a common adverse reaction in radiotherapy and chemotherapy of head and neck tumors, which has a serious impact on the quality of life and treatment effect of patients. The incidence of salivary gland dysfunction increases with the increase of the incidence of head and neck diseases. Clear prevention and treatment methods are urgently needed. At present, a large number of domestic and foreign studies have revealed the possible mechanism of the impaired salivary gland function caused by radiation therapy and provided some prevention and treatment measures for clinical reference. This review focuses on the mechanism, symptoms, diagnosis and prevention of salivary gland dysfunction caused by 131I therapy.
2022, 46(7): 425-429.
doi: 10.3760/cma.j.cn121381-202111007-00198
Abstract:
131I therapy for differentiated thyroid cancer (DTC) is a mature technology with remarkable effects. As one of the main methods of postoperative comprehensive treatment for patients with DTC, it has been widely used in clinical. But the resulting manifestations of salivary gland radiation injury (dry mouth, parotid gland swelling pain, and taste alteration, etc.) have a certain impact on DTC patients' survival quality. In recent years, various salivary gland radiation injury protective agents have emerged, but their exact efficacy is limited and the treatment plan has not been standardized and unified. The author reviews the research progress on radiation injury of salivary gland and its prevention and treatments in DTC patients treated with 131I after operation.
131I therapy for differentiated thyroid cancer (DTC) is a mature technology with remarkable effects. As one of the main methods of postoperative comprehensive treatment for patients with DTC, it has been widely used in clinical. But the resulting manifestations of salivary gland radiation injury (dry mouth, parotid gland swelling pain, and taste alteration, etc.) have a certain impact on DTC patients' survival quality. In recent years, various salivary gland radiation injury protective agents have emerged, but their exact efficacy is limited and the treatment plan has not been standardized and unified. The author reviews the research progress on radiation injury of salivary gland and its prevention and treatments in DTC patients treated with 131I after operation.
2022, 46(7): 430-440.
doi: 10.3760/cma.j.cn121381-202203015-00206
Abstract:
Objective To evaluate the predictive value of 18F-FDG PET/CT derived multivariate radiomic model in human epidermal growth factor 2 (HER-2) status for primary breast cancer (BC). Methods A total of 273 BC patients aged 26−78(51.8±10.8) years with complete clinical data and imaging data who underwent 18F-FDG PET/CT imaging before any treatment from January 1, 2010, to December 31, 2019, were included in the retrospective study. According to HER-2 status in primary BC lesion, the BC patients were classified into HER-2 positive group and HER-2 negative group. The differences in clinical characteristics and PET/CT metabolic parameters between the two groups were compared. For radiomic analysis, a multivariate radiomic model based on PET/CT was established after lesion segmentation and radiomic feature extraction. Furthermore, all the candidates were randomly divided into the training set and testing set at a ratio of 7∶3. Receiver operator characteristic curve analysis was used to determine the predictive power of PET metabolic parameters and develop a radiomic model in HER-2 status. Furthermore, the average performance of the radiomic model in the prediction of HER-2 status was determined after tenfold cross-validation. The Wilcoxon rank sum test was performed to compare the differences in PET metabolic parameters between the two groups. Chi-square test was used for qualitative data, whereas two independent sample t test was used for quantitative data with normal distribution. Mann-Whitney U rank sum test was employed for quantitative data that did not obey normal distribution. Results A total of 106 patients were classified in HER-2 positive group, and 167 patients were in the negative group. The proportion of patients with axillary lymph node metastasis in the HER-2 negative group was higher than that in the HER-2 positive group (85.03%(80/106) vs. 75.47%(142/167)), and the difference was statistically significant (χ2=3.900, P<0.05). By contrast, no significant difference was found in age, pathological type, and tumor stage between the two groups (t=−0.028, χ2=5.429, 1.891; all P>0.05). For the five PET metabolic parameters between the two groups, namely, maximum standard uptake value, mean standard uptake value, peak of standard uptake value, metabolic tumor volume, and total lesion glycolysis, no statistically significant difference was found in the study (Z=−1.583 to −0.064, all P>0.05). In the training set, the area under the curve (AUC), accuracy, sensitivity, and specificity of the radiomic model were 0.913(95%CI: 0.871–0.954), 0.882(95%CI: 0.832–0.922), 0.849(95%CI: 0.759–0.910), and 0.910(95%CI: 0.841–0.952), respectively. In the testing set, the AUC, accuracy, sensitivity, and specificity of the radiomic model were 0.820(95%CI: 0.723–0.918), 0.830(95%CI: 0.738–0.900), 0.875(95%CI: 0.701–0.959), and 0.807(95%CI: 0.683–0.892), respectively. After tenfold cross-validation, the average AUC, accuracy, sensitivity, and specificity of the imaging omics model were 0.818, 0.847, 0.908, and 0.764, respectively. Conclusions The established multivariate radiomic model based on 18F-FDG PET/CT images outperformed the traditional PET metabolic parameters in the prediction of HER-2 status for primary BC. This model can contribute to the clinical screening of a potential sensitive population for trastuzumab monoclonal antibody treatment and finally improve the prognosis for BC.
2022, 46(7): 441-447.
doi: 10.3760/cma.j.cn121381-202110003-00202
Abstract:
Objective To compare the differences in acute hematological adverse reactions induced by craniospinal irradiation (CSI) with intensity-modulated radiotherapy (IMRT) and conventional radiotherapy (CRT). Methods The clinical data and hematological data of 48 patients with central nervous system malignant tumors who underwent CSI treatment at the 900th Hospital of Joint Logistics Support Force of PLA from January 2008 to May 2021 were analyzed retrospectively. The patients included 32 males and 16 females, aged 3–56(14.7±5.6) years old. On the basis of the radiotherapy technique used, the patients were divided into the CSI-IMRT group (16 cases) and CSI-CRT group (32 cases). Acute hematological adverse reactions during radiotherapy were compared between the two groups according to the Common Terminology Criteria for Adverse Events version 4.0. The independent sample t test was used to compare the measurement data, and the χ2 test was used to compare the count data. Results No significant difference was found between the CSI-IMRT group and the CSI-CRT group in terms of gender, histopathological type, tumor location, spinal cord invaded, surgery, and the Eastern Cooperative Oncology Group score (χ2=0.511–5.730, all P>0.05). No significant difference in the onset time of myelosuppression (5–26(10.8±6.8) days vs. 5–29(10.3±6.2) days) and the time of most severe myelosuppression (9–34(20.1±6.0) days vs. 7–36(16.0±8.0) days) between the CSI-IMRT group and CSI-CRT group (t=0.221, −1.653; both P>0.05). No significant difference in the incidence of decreased white blood cell (WBC) and platelet counts and hemoglobin content between the CSI-IMRT group and CSI-CRT group (87.5%(14/16) vs. 78.1%(25/32), 56.2%(9/16) vs. 31.2% (10/32), 56.2%(9/16) vs. 53.1%(17/32); χ2= 0.615, 2.788, 0.042; all P>0.05). No significant difference was observed in the incidence of decreased WBC and platelet counts and decreased hemoglobin content (severe myelosuppression) in grades Ⅲ–Ⅳ (25.0% (4/16) vs. 21.9% (7/32), 12.5% (2/16) vs. 3.1% (1/32), 6.2% (1/16) vs. 9.4% (3/32); χ2= 0.059, 1.600, 0.136; all P>0.05]. Conclusions No significant difference in the incidence of myelosuppression and severe myelosuppression (grade Ⅲ or above) induced by CSI-IMRT and CSI-CRT. CSI-IMRT has dosimetric advantages and is worthy of further clinical application.
2022, 46(7): 448-454.
doi: 10.3760/cma.j.cn121381-202109017-00200
Abstract:
Objective To analyze the results of occupational health examinations of benzene and X-ray combination workers in Suzhou Industrial Park in 2016 and provide theoretical basis for occupational protection. Methods A total of 219 workers who underwent occupational health examinations at the Suzhou Industrial Park Centers for Disease Control and Prevention in 2016 were selected and retrospectively analyzed. Workers included 64 benzene workers, 52 X-ray workers, 50 benzene and X-ray combination workers, and 53 people without history of exposure to occupational disease hazard factors (control group). The basic information of inspected personnel was collected through questionnaires. Benzene concentrations in the workplace were detected by solvent desorption-gas chromatography, and the X-ray ambient dose equivalent rate around the workplace and the individual effective dose of the inspected personnel were determined to judge whether occupational disease hazard factors exceeded the exposure limit. Occupational health examinations, including internal medicine examinations, blood routine examinations, thyroid function examinations, lymphocyte chromosomal micronucleus rate determination and lens opacity were carried out. The occupational health examination results of different working groups were compared. The measurement data were compared between two groups by independent-samples t test and least significant difference t test, and the comparison between multiple groups was by one-way analysis of variance and Kruskal-Wallis H test. Pearson χ2 test or Fisher's exact probability method was used in the comparison of enumeration data between groups. Results The ages of workers in the X-ray and benzene and X-ray combination groups were significantly higher than those of workers in the control group [(29.8±4.4) years old vs. (27.8±4.5) years old, (30.3±3.6) years old vs. (27.8±4.5) years old; t=−2.015, −2.546; both P<0.05). The per capita annual effective dose of workers and the ambient dose equivalent rate of the workplace in the X-ray and benzene and X-ray combination groups, and the time weighted average concentrations of benzene of workers in the benzene and benzene and X-ray combination groups were all lower than the prescribed limits. The red blood cell (RBC) count and hemoglobin level of the benzene group; the hemoglobin level and lymphocyte count of the X-ray group; and the hemoglobin level, white blood cell count, lymphocyte count and platelet count of the benzene and X-ray combination group were significantly lower than those of the control group (t=−0.747 to 62.388, all P<0.05). The RBC and lymphocyte counts of the benzene and X-ray combination group were significantly higher and significantly lower, respectively, than those of the benzene group (t=−38.298, 0.230; both P<0.01). Compared with the control group, the X-ray and the benzene and X-raycombination groups had significantly lower serum free triiodothyronine (FT3) level and significantly higher serum free thyroxine level (t=−42.441 to −18.997, all P<0.05). The serum FT3 level of the benzene and X-ray combination group was significantly higher than that of the X-ray group (t=−23.662, P<0.01). There was no significant difference in the chromosomal micronucleus rate of peripheral blood lymphocytes between the control group, X-ray group and benzene and X-ray combination group (H=1.268, P>0.05). The incidence of lens opacity in the X-ray group was significantly higher than that in the control group (χ2=7.644, P<0.01). Conclusions Benzene and X-rayhave a certain degree of influence on blood routine indices, thyroid function indices, lymphocyte chromosomal micronucleus rate and lens opacity of workers and may show a certain combined effect. The radiation protection and health monitoring of benzene and X-ray combination workers should be strengthened.
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