Background: Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer. Methods: The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Gr...

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2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer.

Background: Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the publication of the American Thyroid Association's guidelines for the management of these disorders was published in 2006, a large amount of new information has become available, prompting a revision of the guidelines. Methods: Relevant articles through December 2008 were reviewed by the task force and categorized by topic and level of evidence according to a modified schema used by the United States Preventative Services Task Force. Results: The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to optimal surgical management, radioiodine remnant ablation, a...

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Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer

NOTE The report of the Committee without its annexes appears as Official Records of the General Assembly, Sixty-third Session, Supplement No. 46. The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning the legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries. The country names used in this document are, in most cases, those that were in use at the time the data were collected or the text prepared. In other cases, however, the names have been updated, where this was possible and appropriate, to reflect political changes. Scientific Annexes Annex A. Medical radiation exposures Annex B. Exposures of the public and workers from various sources of radiation INTROdUCTION 1. In the course of the research and development for and the application of atomic energy and nuclear technologies, a number of radiation accidents have occurred. Some of these accidents have resulted in significant health effects and occasionally in fatal outcomes. The application of technologies that make use of radiation is increasingly widespread around the world. Millions of people have occupations related to the use of radiation, and hundreds of millions of individuals benefit from these uses. Facilities using intense radiation sources for energy production and for purposes such as radiotherapy, sterilization of products, preservation of foodstuffs and gamma radiography require special care in the design and operation of equipment to avoid radiation injury to workers or to the public. Experience has shown that such technology is generally used safely, but on occasion controls have been circumvented and serious radiation accidents have ensued. 2. Reviews of radiation exposures from accidents have been presented in previous UNSCEAR reports. The last report containing an exclusive chapter on exposures from accidents was the UNSCEAR 1993 Report [U6]. 3. This annex is aimed at providing a sound basis for conclusions regarding the number of significant radiation accidents that have occurred, the corresponding levels of radiation exposures and numbers of deaths and injuries, and the general trends for various practices. Its conclusions are to be seen in the context of the Committee's overall evaluations of the levels and effects of exposure to ionizing radiation. 4. The Committee's evaluations of public, occupational and medical diagnostic exposures are mostly concerned with chronic exposures of …

sources and effects of ionizing radiation

Hematopoietic stem-cell transplantation, which is used to treat both malignant and nonmalignant conditions, was first conceived more than 50 years ago, but problems associated with transplanting a nonsolid organ and modulating the immune response had to be solved before the procedure could be used clinically. This review summarizes background information about hematopoietic stem-cell transplantation and discusses the current role of the procedure.

https://www.nejm.org/doi/pdf/10.1056/NEJMra052638

Hematopoietic Stem-Cell Transplantation

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Management guidelines for patients with thyroid nodules and differentiated thyroid cancer.

Background The late effects of bone marrow transplantation, including cancer, need to be determined in a large population at risk. Methods We studied 19,229 patients who received allogeneic transplants (97.2 percent) or syngeneic transplants (2.8 percent) between 1964 and 1992 at 235 centers to evaluate the risk of the development of a new solid cancer. Risk factors relating to the patient, the transplant, and the course after transplantation were evaluated. Results The transplant recipients were at significantly higher risk of new solid cancers than the general population (observed cases, 80; ratio of observed to expected cases, 2.7; P<0.001). The risk was 8.3 times as high as expected among those who survived 10 or more years after transplantation. The cumulative incidence rate was 2.2 percent (95 percent confidence interval, 1.5 to 3.0 percent) at 10 years and 6.7 percent (95 percent confidence interval, 3.7 to 9.6 percent) at 15 years. The risk was significantly elevated (P<0.05) for malignant melanom...

https://www.nejm.org/doi/pdf/10.1056/NEJM199703273361301

Solid Cancers after Bone Marrow Transplantation

Risk of lymphoproliferative disorders after bone marrow transplantation: a multi-institutional study.

Since the early 1980s, adjuvant tamoxifen therapy has been commonly used in the treatment of early stage breast cancer to improve survival and to reduce the incidence of contralateral breast cancer among postmenopausal women (1). However, the estrogenic effect of tamoxifen on the uterus (2) has been reported to increase the risk of uterine corpus cancer by twofold to threefold (3-6). Recently, an elevated risk of gastrointestinal cancer, particularly colorectal and stomach cancers, was associated with tamoxifen therapy in clinical trials (7). Because late effects of tamoxifen could adversely affect the risk-benefit ratio in ongoing chemoprevention trials, we evaluated the risk of second cancers among 87 323 women with breast cancer reported to the Surveillance, Epidemiology, and End Results (SEER) Program (8). To select women who were most likely to have received tamoxifen, we included patients with breast cancer who were 50 years of age or older, who were diagnosed with early stage disease (i.e., localized or regional) from 1980 through 1992, and who survived at least 2 months (n = 101 930). Since many women given chemotherapy also received steroids, which are classified as hormones in SEER, we excluded those individuals from the analysis (n = 14 607). Of the remaining 87 323 women, 14 358 were known to have received hormones for their first course of therapy (designated as the tamoxifen group, since approximately 90%-95% of these patients received tamoxifen [Hankey B, Harlan L: personal communication]), whereas 72 965 women were not known to have received hormones (the no/unknown tamoxifen group). Observed-toexpected ratios (O/E) of second cancers were calculated using standard methods (9,10). Patients with breast cancer initially treated with tamoxifen developed second cancers at a rate slightly higher than that expected in the general population (O/E =1.12; 95% confidence interval [CI] = 1.03-1.21) and identical to that experienced by patients with no/unknown tamoxifen therapy (O/E = 1.12; 95% CI = 1.09-1.15) (Table 1). Significant excesses of uterine corpus cancer were seen in both treatment groups, with higher risks following tamoxifen therapy (O/E = 2.03; 95% CI = 1.592.55 versus O/E = 1.23; 95% CI = 1.111.36). We observed little difference in the severity of grade or stage of uterine corpus cancer on the basis of initial therapy (Table 1), in contrast with a previous report suggesting a tendency toward higher grade lesions following tamoxifen treatment (11). Of the 73 women who developed uterine corpus cancer after tamoxifen therapy, six died of this cancer. The actuarial risk of uterine corpus cancer among postmenopausal women after adjuvant tamoxifen therapy was 1.8% at 10 years, compared with 0.9% expected in the general population. Cancers of the colon and rectum were not in excess following tamoxifen therapy (O/E = 1.04; 95% CI = 0.831.30 and O/E = 1.02; 95% CI = 0.661.49, respectively), and stomach cancer was not significantly increased (O/E = 1.23; 95% CI = 0.69-2.03), in contrast svith the findings of a recent report (7). Tamoxifen therapy appeared to decrease the risk of contralateral breast cancer (O/E= 1.12; 95% CI = 0.96-1.30 versus O/E = 1.62; 95% CI = 1.55-1.69), and a more detailed report of this result is planned. Women in the no/unknown tamoxifen group had a statistically significant lower risk of leukemia and of cancers of the liver, lung, and brain (Table 1). To sharpen the treatment comparisons, we evaluated a subgroup of women for whom adjuvant tamoxifen was infrequently used, so that misclassification of therapy would be small. Among 17 952 patients with localized breast cancer initially treated between 1980 and 1984, the risk of uterine corpus cancer was nearly identical to that experienced in the general population (O = 121 and O/E = 0.99; 95% CI = 0.82-1.19). This finding suggests that at least part of the excess risk observed in the no/unknown tamoxifen group is related to tamoxifen therapy not reported to the SEER Program. Among tamoxifen-treated patients, the risk of all second cancers, excluding contralateral breast cancer, was significantly increased among survivors of 5 or more years (O/E = 1.32; 95% CI = 1.02-1.68), whereas no excess cancer risk was found for the no/unknown tamoxifen group in this follow-up interval (O/E = 0.96; 95% CI = 0.90-1.02) (Table 2). A notable increase in uterine corpus cancer (O/E = 3.59; 95% CI = 1.96-6.02) and a nonsignificant excess of stomach cancer (four cases; O/E = 2.61; 95% CI = 0.70-6.69) were observed 5 years or more after breast cancer diagnosis among women who received tamoxifen therapy. Although the number of patients with breast cancer evaluated in this study is large, few tamoxifen-treated patients have been followed for more than 10 years, limiting our ability to evaluate long-term survivors. Other limitations include a lack of detailed information on initial and subsequent therapy and an absence of data on other factors affecting second cancer risk, such as menopausal estrogen use and hysterectomy. Our results support the link between tamoxifen therapy and subsequent de-

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Donna A. Shriner

Papers

Solid Cancers after Bone Marrow Transplantation

Risk of lymphoproliferative disorders after bone marrow transplantation: a multi-institutional study.

Second Cancers After Adjuvant Tamoxifen Therapy for Breast Cancer