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THYROID CANCER AND THERAPY WITH 131I
373 defects and congenital talipes; 1 had an of the pelvis and penis; the and malformation ::;;phaloce1e :htrJ had a reduction defect of one lower leg only. There was z nothing characteristic in the type of limb defects differenting these boys from the other malformed children. 3 of the : children of the mothers treated for threatened abortion were crk. The child of the control mother who had a history of hor-
: had
severe arm
mone exposure was a
boy.
This study is too small to be conclusive but the figures point ir, the same direction as those of Janerich et al.5 Further studies are urgently needed, the suspicion that hormonal pregnancy tests can be teratogenic makes it prudent to discontinue :he use of these tests. This decision has been made by the medial authorities in Sweden. BO HELLSTRÖM Departments of Pediatrics and Clinical Genetics, JAN LINDSTEN Karolinska Hospital, 104 01 Stockholm, Sweden
KJELL NILSSON
SIR Most reports on the possible association between the
contraceptives by the mother and congenital abnormalities in the baby’-3 refer to the use of the oral contraceptives after conception. In a small personal series of congenital abnormalities the severity of abnormalities in the babies was the same whether the mothers had taken the pill after conception or had become pregnant immediately after ceasing the
use of oral
pilh During the period of 17 months between April, 1974, and September, 1975, twelve patients with gross congenital abnormalities which could be regarded as defects of embryogenesis under my care. The mothers of six of the infants had either never taken oral contraceptives or had not taken any for at least 9 months before conception. All these infants had œsophageal atresia with tracheo-resophageal fistula (T.O.F.) and the only one who had another abnormality was an infant who developed hydrocephalus which was controlled by shunting. Three of the remaining mothers had been on the pill and had planned a pregnancy, becoming pregnant in the month after ceasing the pill. The resulting three babies had: (1) T.O.F. and tetralogy of Fallot; (2) Down syndrome of the usual trisomy 21 type and anorectal atresia; and (3) cloacal exstrophy. Two of the remaining 3 mothers had never planned the pregnancy and became pregnant whilst still taking the pill. The final mother had some guilt feeling whilst taking the pill and admitted to taking it irregularly and it was obvious that she had taken it after conception. The abnormalities of these 3 babies were as follows: (1) T.O.F. and anorectal atresia; (2) combined tracheal and oesophageal tube; and (3) multiple abcame
normalities including anorectal agenesis, absent right kidney and dysplastic left kidney, absent gallbladder, hemivertebrae, and atrial and septal defects. No firm conclusion can be drawn from this small series. However, while care must be taken not to engender anxiety in pregnant women who have been exposed to the pill, especially since the large prospective French survey showed no increase n congenital malformations in women taking sex hormones durmg their pregnancy,4 it would seem prudent to suggest that tomen should stop taking the pill 2 or 3 months before a further planned pregnancy. Children’s Medical Research Foundation,
THYROID CANCER AND THERAPY WITH 131I
SIR,-In your editorial on irradiation O the thyroid gland’ you cite MacDougall’s review2 of 15 cases of thyroid cancer after 131 therapy. A critical reappraisal of this review reveals that: in 2 of the 15 cases external radiotherapy has been applied also; 2 cases are reported twice; in 1 case no histological confirmation was available; and in 1 case there was an interval of 3 months between administration of 1311 and the discovery of the tumour, suggesting the presence of the tumour at the time of therapy. There remain 10 cases of thyroid carcinoma developing after treatment with radioactive iodine. One more case was lately reported.3 Assuming the incidence of thyroid cancer 0-5-4-0/person/year4 and the number of patients treated for hyperthyroidism with radioactive iodine 200 000-400 000, a yearly incidence in this population of 1-16 cases of thyroid carcinoma can be expected. In this context a report’ of 21 714 adults treated with 1311 is relevant. During an observation period of 3-19 years (mean 8 years) no increase in thyroid-cancer incidence was found. The role of therapy with 131I in inducing thyroid cancer in man is difficult to exclude, but from the figures available a positive relationship cannot yet be established. Central Isotope Laboratory, State University Hospital,
Groningen, D. A. PIERS
Netherlands
ULTRASOUND MONITORING OF FETAL MOVEMENTS
SIR,—Professor Kubli and his colleagues (July 10, p. 91) unfortunately seem to misinterpret the purpose of our paper.6 We were not claiming that we were the first group to observe fetal movements using ultrasound and nor were we claiming that we are the only group working on the monitoring of fetal movements using ultrasound. We are aware that centres in several countries are studying this topic but their small number leads us to suggest that this particular area of research with its important implications is still neglected. We apologise for not mentioning the studies of Professor Kubli, for we certainly appreciate their significance. Our statement, therefore, that "monitoring of fetal movements as an indicator of normal and abnormal fetal development appears to have been neglected" does not require correction. We do feel that the results of other workers to date, excellent as they are in many respects, have shown only limited dimensions of fetal movements and have not as yet answered the questions we posed. As Professor Kubli and his colleagues state, a large and particularly complex problem is that of quantification, and it reeds to be approached from many angles. With regard to the monitoring of fetal movements in utero, we feel that only the first few sentences have indeed been written in what is, effectively, a blank book. Department of Obstetrics and Gynæcology, University Hospital of
J. HIGGINBOTTOM
South Manchester
Department of Anatomy, University of Manchester Department of Radiology, University Hospital of South Manchester
K. M. BAGNALL P. F. HARRIS
J. H. SLATER G. A. PORTER
Royal Alexandra Hospital for Children,
Camperdown, Sydney, New South Wales 2050, Australia
1 David, T. J., O’Callagham, S. E. Lancet, 1974, i, 1236. 2 Janerich, D. T., Piper, J. M., Glebatis, D. M. New Engl. J.
IAN S. REID
Med. 1974,
291,
697.
3 Janerich,D T. Lancet, 1975, i, 682. N, Goujard, J., Huel, G., Rumeau-Rouquette, C. Revue Méd. fr.
4 Spira,
1972, 41, 2683.
1. Lancet, 1976, i, 1278. 2. MacDougall, I. R. J. Am. med. Ass. 1974, 227, 438. 3. Wiener, J. D., Thijs, L. G., Meijer, S. Acta med. scand. 1975, 198, 329. 4. Doll, R., Paine, P., Waterhouse, J. Cancer Incidence in Five Continents. U.I.C.C., Berlin, 1966. 5. Dobyns, B. M., Shelline, G. E., Workman, J. B., Tompkins, E. A., McConahey, W. M., Becker, D. V. J. clin. Endocr. Metab. 1974, 38, 976. K. M., Harris, P. F., Slater, J. H., Porter, G. A. 6. Higginbottom, J.,
Bagnall,
Lancet, 1976, i, 719.
: had
severe arm
mone exposure was a
boy.
This study is too small to be conclusive but the figures point ir, the same direction as those of Janerich et al.5 Further studies are urgently needed, the suspicion that hormonal pregnancy tests can be teratogenic makes it prudent to discontinue :he use of these tests. This decision has been made by the medial authorities in Sweden. BO HELLSTRÖM Departments of Pediatrics and Clinical Genetics, JAN LINDSTEN Karolinska Hospital, 104 01 Stockholm, Sweden
KJELL NILSSON
SIR Most reports on the possible association between the
contraceptives by the mother and congenital abnormalities in the baby’-3 refer to the use of the oral contraceptives after conception. In a small personal series of congenital abnormalities the severity of abnormalities in the babies was the same whether the mothers had taken the pill after conception or had become pregnant immediately after ceasing the
use of oral
pilh During the period of 17 months between April, 1974, and September, 1975, twelve patients with gross congenital abnormalities which could be regarded as defects of embryogenesis under my care. The mothers of six of the infants had either never taken oral contraceptives or had not taken any for at least 9 months before conception. All these infants had œsophageal atresia with tracheo-resophageal fistula (T.O.F.) and the only one who had another abnormality was an infant who developed hydrocephalus which was controlled by shunting. Three of the remaining mothers had been on the pill and had planned a pregnancy, becoming pregnant in the month after ceasing the pill. The resulting three babies had: (1) T.O.F. and tetralogy of Fallot; (2) Down syndrome of the usual trisomy 21 type and anorectal atresia; and (3) cloacal exstrophy. Two of the remaining 3 mothers had never planned the pregnancy and became pregnant whilst still taking the pill. The final mother had some guilt feeling whilst taking the pill and admitted to taking it irregularly and it was obvious that she had taken it after conception. The abnormalities of these 3 babies were as follows: (1) T.O.F. and anorectal atresia; (2) combined tracheal and oesophageal tube; and (3) multiple abcame
normalities including anorectal agenesis, absent right kidney and dysplastic left kidney, absent gallbladder, hemivertebrae, and atrial and septal defects. No firm conclusion can be drawn from this small series. However, while care must be taken not to engender anxiety in pregnant women who have been exposed to the pill, especially since the large prospective French survey showed no increase n congenital malformations in women taking sex hormones durmg their pregnancy,4 it would seem prudent to suggest that tomen should stop taking the pill 2 or 3 months before a further planned pregnancy. Children’s Medical Research Foundation,
THYROID CANCER AND THERAPY WITH 131I
SIR,-In your editorial on irradiation O the thyroid gland’ you cite MacDougall’s review2 of 15 cases of thyroid cancer after 131 therapy. A critical reappraisal of this review reveals that: in 2 of the 15 cases external radiotherapy has been applied also; 2 cases are reported twice; in 1 case no histological confirmation was available; and in 1 case there was an interval of 3 months between administration of 1311 and the discovery of the tumour, suggesting the presence of the tumour at the time of therapy. There remain 10 cases of thyroid carcinoma developing after treatment with radioactive iodine. One more case was lately reported.3 Assuming the incidence of thyroid cancer 0-5-4-0/person/year4 and the number of patients treated for hyperthyroidism with radioactive iodine 200 000-400 000, a yearly incidence in this population of 1-16 cases of thyroid carcinoma can be expected. In this context a report’ of 21 714 adults treated with 1311 is relevant. During an observation period of 3-19 years (mean 8 years) no increase in thyroid-cancer incidence was found. The role of therapy with 131I in inducing thyroid cancer in man is difficult to exclude, but from the figures available a positive relationship cannot yet be established. Central Isotope Laboratory, State University Hospital,
Groningen, D. A. PIERS
Netherlands
ULTRASOUND MONITORING OF FETAL MOVEMENTS
SIR,—Professor Kubli and his colleagues (July 10, p. 91) unfortunately seem to misinterpret the purpose of our paper.6 We were not claiming that we were the first group to observe fetal movements using ultrasound and nor were we claiming that we are the only group working on the monitoring of fetal movements using ultrasound. We are aware that centres in several countries are studying this topic but their small number leads us to suggest that this particular area of research with its important implications is still neglected. We apologise for not mentioning the studies of Professor Kubli, for we certainly appreciate their significance. Our statement, therefore, that "monitoring of fetal movements as an indicator of normal and abnormal fetal development appears to have been neglected" does not require correction. We do feel that the results of other workers to date, excellent as they are in many respects, have shown only limited dimensions of fetal movements and have not as yet answered the questions we posed. As Professor Kubli and his colleagues state, a large and particularly complex problem is that of quantification, and it reeds to be approached from many angles. With regard to the monitoring of fetal movements in utero, we feel that only the first few sentences have indeed been written in what is, effectively, a blank book. Department of Obstetrics and Gynæcology, University Hospital of
J. HIGGINBOTTOM
South Manchester
Department of Anatomy, University of Manchester Department of Radiology, University Hospital of South Manchester
K. M. BAGNALL P. F. HARRIS
J. H. SLATER G. A. PORTER
Royal Alexandra Hospital for Children,
Camperdown, Sydney, New South Wales 2050, Australia
1 David, T. J., O’Callagham, S. E. Lancet, 1974, i, 1236. 2 Janerich, D. T., Piper, J. M., Glebatis, D. M. New Engl. J.
IAN S. REID
Med. 1974,
291,
697.
3 Janerich,D T. Lancet, 1975, i, 682. N, Goujard, J., Huel, G., Rumeau-Rouquette, C. Revue Méd. fr.
4 Spira,
1972, 41, 2683.
1. Lancet, 1976, i, 1278. 2. MacDougall, I. R. J. Am. med. Ass. 1974, 227, 438. 3. Wiener, J. D., Thijs, L. G., Meijer, S. Acta med. scand. 1975, 198, 329. 4. Doll, R., Paine, P., Waterhouse, J. Cancer Incidence in Five Continents. U.I.C.C., Berlin, 1966. 5. Dobyns, B. M., Shelline, G. E., Workman, J. B., Tompkins, E. A., McConahey, W. M., Becker, D. V. J. clin. Endocr. Metab. 1974, 38, 976. K. M., Harris, P. F., Slater, J. H., Porter, G. A. 6. Higginbottom, J.,
Bagnall,
Lancet, 1976, i, 719.