Levothyroxine in Women with Thyroid Peroxidase Antibodies before Conception (2019)

Type of publication:
Journal article

Author(s):
Dhillon-Smith, Rima K; Middleton, Lee J; Sunner, Kirandeep K; Cheed, Versha; Baker, Krys; Farrell-Carver, Samantha; Bender-Atik, Ruth; Agrawal, Rina; Bhatia, Kalsang; Edi-Osagie, Edmond; Ghobara, Tarek; Gupta, Pratima; Jurkovic, Davor; Khalaf, Yacoub; MacLean, Marjory; McCabe, Christopher; Mulbagal, Khashia; Nunes, Natalie; Overton, Caroline; Quenby, Siobhan; Rai, Raj; Raine-Fenning, Nick; Robinson, Lynne; Ross, Jackie; *Sizer, Andrew; Small, Rachel; Tan, Alex; *Underwood, Martyn; Kilby, Mark D; Boelaert, Kristien; Daniels, Jane; Thangaratinam, Shakila; Chan, Shiao Y; Coomarasamy, Arri

Citation:
The New England Journal of Medicine 2019; 380:1316-1325

Abstract:
BACKGROUND Thyroid peroxidase antibodies are associated with an increased risk of miscarriage and preterm birth, even when thyroid function is normal. Small trials indicate that the use of levothyroxine could reduce the incidence of such adverse outcomes.METHODS We conducted a double-blind, placebo-controlled trial to investigate whether levothyroxine treatment would increase live-birth rates among euthyroid women who had thyroid peroxidase antibodies and a history of miscarriage or infertility. A total of 19,585 women from 49 hospitals in the United Kingdom underwent testing for thyroid peroxidase antibodies and thyroid function. We randomly assigned 952 women to receive either 50 μg once daily of levothyroxine (476 women) or placebo (476 women) before conception through the end of pregnancy. The primary outcome was live birth after at least 34 weeks of gestation.RESULTS The follow-up rate for the primary outcome was 98.7% (940 of 952 women). A total of 266 of 470 women in the levothyroxine group (56.6%) and 274 of 470 women in the placebo group (58.3%) became pregnant. The live-birth rate was 37.4% (176 of 470 women) in the levothyroxine group and 37.9% (178 of 470 women) in the placebo group (relative risk, 0.97; 95% confidence interval [CI], 0.83 to 1.14, P = 0.74; absolute difference, -0.4 percentage points; 95% CI, -6.6 to 5.8). There were no significant between group differences in other pregnancy outcomes, including pregnancy loss or preterm birth, or in neonatal outcomes. Serious adverse events occurred in 5.9% of women in the levothyroxine group and 3.8% in the placebo group (P = 0.14).CONCLUSIONS The use of levothyroxine in euthyroid women with thyroid peroxidase antibodies did not result in a higher rate of live births than placebo. (Funded by the United Kingdom National Institute for Health Research; TABLET Current Controlled Trials number, ISRCTN15948785.).

Thyroid tolerance in adjuvant supraclavicular fossa nodalradiotherapy in breast cancer (2016)

Type of publication:
Conference abstract

Author(s):
*Pettit L., *Welsh A., *Khanduri S.

Citation:
Radiotherapy and Oncology, April 2016, vol./is. 119/(S558)

Abstract:
Purpose or Objective: Hypothyroidism is the most commonly reported long-term toxicity following radiotherapy to structures near to the thyroid gland. Emami suggested the thyroid gland tolerance as 45Gy (TD 5/5) although a much wider range of 10-80 Gy has been reported in the literature. When irradiating the supraclavicular fossa (SCF) in adjuvant radiotherapy for breast cancer, it is inevitable that the thyroid gland will receive a high dose of radiation due to its proximity to the target volume. Recently there has been a move to CT based delineation of the CTV and organs at risk (OAR) in patients requiring nodal radiotherapy for breast cancer compared with the previous bony land mark/field based techniques. Dose received by the thyroid gland and subsequent late toxicity has not yet been well studied in breast cancer. Material and Methods: Patients undergoing external beam radiotherapy to the breast or chest wall plus SCF between 01/04/15-01/10/15 were identified. Radiotherapy planning contrast enhanced CT scans were taken. External beam radiotherapy was planned with tangents using a field in field approach with a matched direct anterior field. A low weighted posterior field was added if deemed appropriate for adequate dose coverage. Angle corrections were used as appropriate. A dose of 40.05 Gy in 15 fractions prescribed at depth was employed. CTV’s were contoured in accordance with the RTOG contouring atlas. The thyroid gland was prospectively delineated and D5% was recorded. Results: Seventeen patients undergoing adjuvant SCF radiotherapy were identified. T stage was as follows: T1:2 patients, T2:9 patients, T3:4 patients, T4a:1 patient,T4d:1 patient. N stage; N1:1 patient, N2:14 patients, N3:2 patients. Fourteen were hormone receptor positive, 3 hormone negative. Twelve were HER2 negative, 5 HER2 positive. Mean D5% thyroid was 37.9Gy (range 7-42.7 Gy). Excluding one patient with a previous hemi-thyroidectomy, the mean D5% thyroid was 39.8 Gy (range 16-42.7 Gy). An abnormality requiring referral to a surgeon for was discovered in one patient. Conclusion: Our departmental tolerance for the thyroid gland was set as 40Gy (for 2.67Gy per fraction). It is hard to achieve this without compromise of the CTV. The effect modern chemotherapy/targeted agents may have on this prior to receiving radiotherapy is inknown. Baseline TSH recording is desirable. Long-term follow up to detect clinical or biochemical thyroid dysfunction is needed to inform practice but would present challenges with capacity in busy oncology departments.

Link to more details or full-text: https://user-swndwmf.cld.bz/ESTRO-35/ESTRO-35-Abstract-book3/585

Incidence of malignancy in solitary thyroid nodules (2015)

Type of publication:
Journal article

Author(s):
Keh, S M, *El-Shunnar, S K, Palmer, T, *Ahsan, S F

Citation:
Journal of Laryngology and Otology, Jul 2015, vol. 129, no. 7, p. 677-681

Abstract:
This study aimed to investigate the prevalence and clinical significance of solitary thyroid nodules in patients who underwent thyroid surgery. A retrospective review was performed of the case notes of all adult patients who underwent thyroid surgery from January 2003 to December 2009. All patients with solitary thyroid nodules identified by ultrasonography were included. In total, 225 patients underwent thyroid surgery. The prevalence of solitary thyroid nodules was 27.1 per cent (61 out of 225 patients). Seventy-two per cent of patients were women and the mean age at presentation was 52 ± 16 years. In all, 75.4 per cent of solitary nodules had neoplastic pathology and the malignancy rate was 34.4 per cent. The sensitivity and specificity of fine needle aspiration cytology for neoplasm detection were 73.9 per cent and 80.0 per cent, respectively. There was no association between the various ultrasonography parameters and malignancy risk (p > 0.05). Solitary thyroid nodules should be investigated thoroughly with a high index of suspicion because there is a high probability (34.0 per cent) of malignancy.