Association of thyroid carcinoma with malignant lymphoma.

Radiation-associated thyroid carcinoma is of clinical importance in modern radiation therapy of both Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL), because anatomically the thyroid is often in the radiation field. We have reviewed the records of HD and NHL patients seen at Roswell Park Memorial Institute (RPMI) between 1910 and 1960 to determine associated occurrence of thyroid cancer. Radiation therapy was the major therapeutic modality with the occasional use of single agent chemotherapy with nitrogen mustard, triethylene melamine (TEM), chlorambucil and prednisone. There were 519 patients with HD and 863 with NHL. The thyroid glands of 439 (84%) HD and 544 (63%) NHL patients were included in the field of radiation. The mean age of patients with HD was 39 yr while for those with NHL, it was 53 yr. The mean survival in HD was 4.2 yr and in NHL 3.8 yr. There were three cases of thyroid cancer among the HD patients occurring 31, 44 and 48 yr, respectively, after radiation therapy. When compared with the number of thyroid cancers expected to develop, the incidence was significantly greater (p less than 0.005). In contrast, three NHL patients were found to have thyroid cancer at the time of surgery or postmortem examination. This number is again greater than expected in such a population (p less than 0.005); however, in only two cases could the cancer be considered as a sequela to NHL treatment. In all three cases the cancer turned out to be subclinical thyroid carcinoma, incidentally found at surgery or autopsy. One of the patients is still alive without evidence of either disease. The reason for this difference between patients with HD and NHL treated with a similar principle is unclear. Some of the factors contributing to this difference may include: the younger age of HD patients at diagnosis; the longer survival of patients with HD as compared with those with NHL; differences in the sites of radiation and type of treatment given; and possible differences in immunological status between the two groups.

Suppressive therapy for postirradiation thyroid nodules.

From the thyroid screening program at the Roswell Park Memorial Institute in Buffalo, New York, 85 patients with thyroid nodules who had received previous irradiation to the head and neck were identified. The diagnosis was confirmed microscopically by needle aspiration cytology and the patients were treated with thyroid replacement therapy. In 24 patients, the nodules disappeared completely; a partial response (more than 50% reduction in size) was seen in 26; 11 patients were improved (20% to 50% reduction in size); 14 had stable disease (less than 20% reduction in nodule size) and in 10 the condition progressed (an increase of more than 20% in nodule size). Six of 21 patients who underwent operation had well differentiated tumours. The number of cases of Hashimoto's thyroiditis (14) was high. Suppressive therapy will separate those patients whose nodules will disappear completely and who will thus be spared operation. Continued follow-up of such patients is essential. All other patients should be offered operation since thyroid nodules are malignant in 30% of cases.

Radiation-associated thyroid carcinoma.

Since February, 1977, 735 patients having a history of receiving radiation therapy for benign conditions of the head and neck areas during infancy and childhood were examined in a thyroid screening program, and 159 patients were found to have palpable thyroid nodules. These patients had thyroid function tests and indirect laryngoscopy and were followed closely on suppression therapy consisting of either Cytomel or thyroid extract. Thyroidectomy was advised in those in whom the nodules persisted or increased in size. This study documents the incidence of carcinoma and other benign pathological changes and postoperative complications in this group of patients. So far, 49 patients had either a lobectomy with isthmusectomy or a total thyroidectomy. Eleven patients were found to have carcinoma (six had papillary, four had mixed papillary and follicular, and one had follicular carcinoma). Three patients had a therapeutic modified neck dissection following the documentation of microscopic involvement of paratracheal lymph nodes. A high incidence of chronic nonspecific thyroiditis, postradiation fibrosis, and follicular adenomas were also found in these patients. Three patients had temporary hypocalcemia (two weeks) and none had wound infection, hematoma, or postoperative nerve palsy. Of patients who had surgical resection, 22.4% showed thyroid carcinoma.

Hypercalcemia complicating childhood malignancies: a report of seven cases with some pathophysiological considerations.

A group of seven children with different malignant processes presenting with hypercalcemia was studied. Bone destruction, diffuse metabolic abnormalities, abnormal acid-base homeostasis and recurrent hypercalcemia characterized these patients. A different mechanism leading to the production of hypercalcemia and/or bone destruction by cancer cells is considered. The results of this report suggest that parathyroid hormone production (P.T.H.) by the parathyroid glands is normal and that ectopic secretion of PTH or PTH-like material is negligible in these cases.

cis-Dichlorodiammineplatinum(II) and DTIC in malignant melanoma.

Twenty-nine patients with advanced malignant melanoma were randomized to receive DTIC at a dose of 200 mg/m2 iv on Days 1-5 and cis-dichlorodiammine-platinum(II) at a dose of 40 mg/m2 iv on Days 1 and 4, repeated every 4 weeks (group A), or the same drugs plus procarbazine at a dose of 75 mg/m2 orally daily on Days 1-8 and vincristine at a dose of 1.4 mg/m2 iv on Day 1 (group B). These drugs were generally well-tolerated, but five of 16 patients in group A and six of 13 patients in group B required dose modification for either hematologic or renal toxicity. There were six objective responses among 16 patients in group A including one complete regression, while there were two objective responses among 13 patients in group B.

Anaplastic carcinoma of the thyroid following external irradiation.

Two patients with anaplastic carcinoma of the thyroid following irradiation for Hodgkin's disease are presented, and the previously reported cases briefly reviewed. The risk of late development of thyroid carcinoma is life-long and high-dose irradiation in patients with prolonged life expectancy may result in anaplastic carcinoma as well as less malignant histological forms.

Spinal cord involvement in chronic lymphocytic leukemia.

A patient with typical chronic lymphocytic leukemia (CLL) who developed central nervous system involvement is presented. The CLL was of B-cell origin and the neurological involvement consisted of perivascular infiltration in the spinal cord.

Anaplastic cardcinoma of the thyroid in a population irradiated for Hodgkin Disease, 1910--1960.

Post-irradiation carcinoma of the thyroid is usually histologically well-differentiated. In general, those subjects who developed carcinoma had been exposed to low-to-moderate doses of irradiation for benign conditions. We reviewed the charts of 520 patients with Hodgkin's disease seen at Roswell Park Memorial Institute, and found 2 cases of anaplastic carcinoma amongst other thyroidal abnormalities. The existing reports of post-irradiation carcinoma are reviewed and suggestions are made for the management of heavily irradiated, potentially cured patients with Hodgkin's disease.

The coagulopathy associated with aortic aneurysms.

The authors in this article record their experience with eight-four patients with abdominal aortic aneurysms. Twenty-seven patients (32%) presented with ruptured aneurysms with an overall mortality of 56%. Of the unruptured aneurysms, 67% were operable with a mortality of 5.3%. The highest mortality amongst the patients with ruptured aneurysms was in the group who was shocked. In the group with ruptured aneurysms, of those in whom platelet counts were performed, 50% were abnormally low, and 56% had evidence of abnormal coagulation. Seventy per cent of those with coagulation abnormalities died. In the unruptured group 28.2% had thrombocytopenia but no other abnormalities of coagulation. All patients undergoint aneurysm resection should have a platelet count and a full clotting screen. Therapy should be directed to normalization of the coagulation system.

Disseminated tuberculosis, bone marrow necrosis and lymphoma: a case report.

Tuberculosis often complicates lymphoma, and bone marrow necrosis has been described in disseminated tuberculosis. However, the association of lymphoma, disseminated tuberculosis and bone marrow necrosis is rare. We report a patient with this triple association. After a 3-week influenza-like illness the patient was admitted to hospital semicomatose with pancytopenia and hyponatraemia. During routine examination a bone marrow trephine biopsy revealed diffuse lymphomatous infiltration with scattered necrotic foci. On Ziehl-Neelsen staining these foci exhibited numerous acid-fast bacilli. The patient subsequently died and at autopsy was found to have widely disseminated non-reactive tuberculosis.