Internal Medicine Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.
National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.
Oncology. 2023;101(6):362-368. doi: 10.1159/000530463. Epub 2023 May 9.
Therapy-related leukemia is a term that describes the occurrence of leukemia following exposure to hematotoxins and radiation to emphasize the difference from leukemia that arises de novo. Many agents and host factors contribute to this entity of leukemias. Therapy-related acute myeloid leukemia has an extensive literature review in contrast to therapy-related chronic myeloid leukemia (t-CML). Radioactive iodine (RAI), an established agent in the management of differentiated thyroid carcinomas, has raised concern due to its possible carcinogenic effects.
In this article, we reviewed all the reports from the 1960s to date related to t-CML following RAI on Google Scholar and PubMed. We have identified 14 reports and found that most reports were for men under the age of 60 years with primary papillary thyroid carcinoma and mixed follicular-papillary thyroid carcinoma who developed t-CML mainly between 4 and 7 years after exposure to varying doses of I131. However, the mean dose was 287.78 millicuries (mCi). It was reported that a statistically significant increase in leukemia following RAI therapy (relative risk of 2.5 for I131 vs. no I131). Also, there was a linear relationship between the cumulative dose of I131 and the risk of leukemia. Doses higher than 100 mCi were associated with a greater risk of developing secondary leukemia, and most of the leukemias developed within the initial 10 years of exposure. The precise mechanism through which RAI provokes leukemia is largely unclear. A few mechanisms have been proposed.
Although the risk for t-CML appears to be low based on current reports and does not represent a contraindication to RAI therapy, it should not be disregarded. We suggest including it in the risk-benefit discussion before initiating this therapy. Long-term follow-up for patients is advisable for those who received doses over 100 mCi with a complete blood count, possibly yearly, for the first 10 years. The new onset of significant leukocytosis post RAI exposure should raise the suspicion for t-CML. Further studies are needed to establish or refute a causal relationship.
治疗相关性白血病是一个术语，用于描述在接触血液毒素和辐射后发生的白血病，强调与新发性白血病的区别。许多因素和宿主因素促成了这种白血病。与治疗相关性慢性髓细胞白血病（t-CML）相比，治疗相关性急性髓细胞白血病有广泛的文献综述。放射性碘（RAI）是治疗分化型甲状腺癌的一种已确立的药物，由于其可能的致癌作用而引起关注。
在本文中，我们在 Google Scholar 和 PubMed 上检索了自 20 世纪 60 年代以来与 RAI 后 t-CML 相关的所有报告。我们共确定了 14 份报告，发现大多数报告为年龄在 60 岁以下的男性，患有原发性乳头状甲状腺癌和混合滤泡-乳头状甲状腺癌，主要在接触不同剂量的 I131 后 4 至 7 年发展为 t-CML。然而，平均剂量为 287.78 毫居里（mCi）。据报道，RAI 治疗后白血病的发生率显著增加（I131 相对于无 I131 的相对风险为 2.5）。此外，I131 的累积剂量与白血病的风险之间存在线性关系。剂量高于 100 mCi 与继发性白血病的发生风险增加相关，大多数白血病发生在接触后的最初 10 年内。RAI 引发白血病的确切机制尚不清楚。提出了几种机制。
尽管根据目前的报告，t-CML 的风险似乎较低，并且不代表 RAI 治疗的禁忌症，但不应忽视。我们建议在开始这种治疗之前，将其纳入风险效益讨论中。对于接受剂量超过 100 mCi 的患者，建议进行长期随访，包括全血细胞计数，在前 10 年中可能每年进行一次。RAI 接触后新发显著白细胞增多症应怀疑为 t-CML。需要进一步的研究来确定或反驳因果关系。
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