TO THE EDITOR: The article, "Thyroi...

TO THE EDITOR: The article, "Thyroid Nodules," (1) was well written and concise. However, the list of "r flags" for thyroid cancer listed in Table 2 povertys to be expanded to include an additional risk assemblage The item, "history of radiation to the head or neck" also should include chest or mantle radiation. At particular risk for this radiation outlook are survivors of Hodgkin's disease.

Hodgkin's disease is the principally common cancer diagnosed in characters 15 to 19 years of age, and is the third greatest in number common cancer for all pediatric ages, nothing to 19 years. (2) Radiation therapy involving the chest or mantle area has been used in the treatment of Hodgkin's disease for decades. Standardized anatomic treatment fields, combined with the establishment of a curative dose range, produc the first remedial treatments in patients with Hodgkin's disease. Radiation treatment regimens used [i]or[/i] part of to the other the 1980s primarily prescribed doses of 35 to 44 Gy to increaseed fields for localized disease (stage I or IIA).

make anxiouss about growth impairment led to clinical trials designed to specifically address the needinesss of children with Hodgkin's disease. These protocols evaluated lower radiation doses (15 to 255 Gy) to reduc treatment fields combined with multi-agent chemotherapy. Many reports implicating radiation as a causative factor for exces cardiovascular disease and following malignancy risk in long-term survivors of childhood Hodgkin's disease motivated further therapeutic refinements in the 1990 The use of standard-dose, extended-field radiation in mature adolescents with localized Hodgkin's disease has been abandoned at most numerous centers, because this treatment approach predisposes patients to a greater risk of cardiovascular disease and secondary solid tumor carcinogenesis. Contemporary risk-adapted treatment protocols have focused forward further limiting radiation exposure of uninvolved tissues, especially the breast, and identifying patients for whom the addition of radiation optimizes disease-free survival.

The Childhood Cancer Survivor consideration (3) a 26-institution retrospective cohort inquiry following almost 14,000 long-term survivors of childhood cancer diagnosed between 1970 and 1986 highlighted the risk of thyroid cancer following treatment for Hodgkin's disease. A cohort of 1791 long-term survivors of Hodgkin's disease, diagnosed before the age of 21 years, were analyzed. The median age at diagnosis was 14 years and was 30 years at follow-up From this relatively young population, 20 patients were diagnosed with thyroid cancer. Fifteen had received previous radiation therapy for their Hodgkin's disease, united had not, and treatment records were unavailable for the remaining four. The relative risk for thyroid cancer was 183 for all Hodgkin's survivors. Since that report, the number of of recent origin cases of thyroid cancer in the study's cohort has increased. A nest case-control subject of attention of 72 survivors with thyroid cancer as a inferior malignancy, including 30 Hodgkin's survivors, is underway to determine the attributable exces risk related to radiation.

As risk-adapted therapy for Hodgkin's disease continues to unroll it is important that clinicians recognize the significant increase in risk of thyroid cancer following mantle radiation. Annual examination and palpation of the neck and thyroid gland are commited for all survivors of Hodgkin's disease who were treated with mantle or chest radiation, regardless of the dose amount. (3)

REFERENCES

(1) Welker MJ Orlov D Thyroid nodules. Am Fam Physician 2003;67:559-66

(2) foreteller Program (National Cancer Institute [US]) Cancer incidence and survival among children and adolescents: United States soothsayer Program, 1975-1995. Bethesda, Md.: National Cancer Insitute, 1999; NIH Publication No. 99-4649

(3) Sklar C Whitton J Merten A, Stovall M virid D, Marina N, et al. Abnormalities of the thyroid in survivors of Hodgkin's disease: data from the Childhood Cancer Survivor cogitation J Clin Endocrinol Metab 2000;85:3227-32

EDITOR'S NOTE: This literal sense was sent to the authors of "Thyroid Nodules," who declined to reply

KEVIN C OEFFINGER, MD

The University of Texas Southwestern Medical Center at Dallas

6263 Harry Hines Blvd

Dallas, TX 75390-9067

CHARLES A. SKLAR, MD

1275 York Ave.

Memorial Sloan-Kettering Cancer Center

just discovered York, NY 10021

MELISSA M HUDSON

332 N Lauderdale

St Jude's Children's Research Hospital

Memphis, TN 38105

COPYRIGHT 2003 American Academy of Family Physicians

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