ORIGINAL ARTICLE

Thiamazole Pretreatment Lowers the 131I Activity

Needed to Cure Hyperthyroidism in Patients With
Nodular Goiter

Aglaia Kyrilli, Bich-Ngoc-Thanh Tang, Valérie Huyge, Didier Blocklet,

Serge Goldman, Bernard Corvilain, and Rodrigo Moreno-Reyes
Division of Endocrinology (A.K., B.C.), Department of Nuclear Medicine (D.B., S.G., R.M.-R.), Erasme
Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium; Department of Nuclear Medicine (B.-N.-
T.T.), Clinique St Joseph, 6700 Arlon, Belgium; and Department of Nuclear Medicine (V.H.), Clinique
Sainte Anne St Rémi, 1070 Brussels, Belgium

Context: Relatively low radioiodine uptake (RAIU) represents a common obstacle for radioiodine
(131I) therapy in patients with multinodular goiter complicated by hyperthyroidism.
131
Objective: To evaluate whether thiamazole (MTZ) pretreatment can increase I therapeutic
efficacy.

Design and Setting: Twenty-two patients with multinodular goiter, subclinical hyperthyroidism,
and RAIU ⬍ 50% were randomized to receive either a low-iodine diet (LID; n ⫽ 10) or MTZ 30 mg/d
(n ⫽ 12) for 42 days. Thyroid function and 24-hour RAIU were measured before and after treatment.
Thyroid volume was evaluated by either magnetic resonance imaging or single photon emission
computed tomography.

Results: Mean 24-hour RAIU increased significantly from 32 ⫾ 10% to 63 ⫾ 18% in the MTZ group
(P ⬍ .001). Consequently, there was a 31% decrease in the calculated median therapeutic 131I
activity after MTZ (P ⬍ .05). No significant changes in 24-hour RAIU were observed after diet. In the
MTZ group, median serum TSH levels increased significantly by 9% and mean serum free T4 and free
T3 concentrations decreased by 22% and 15%, respectively, whereas no changes in thyroid function
were observed in the LID group. Thyroid volume did not significantly change in either of the two
groups. At 12 months after radioiodine treatment, median serum TSH was within the normal range
in both groups.

Conclusions: MTZ treatment before 131I therapy resulted in an average 2-fold increase in thyroid
RAIU and enhanced the efficiency of radioiodine therapy assessed at 12 months. MTZ pretreatment
is therefore a safe, easily accessible alternative to recombinant human TSH stimulation and a more
effective option than LID. (J Clin Endocrinol Metab 100: 2261–2267, 2015)

ultinodular goiter (MNG) is an important public grees of thyroid autonomy is a frequent complication of
M health problem, and its prevalence depends mainly
on the population’s iodine status ranging from 1% in the
MNG. It is estimated that approximately 22% of patients
with long-standing MNG will develop subclinical or overt
iodine-sufficient population of the Framingham study to hyperthyroidism (2, 4). Because international guidelines
15% in Danish populations with mild iodine deficiency do not recommend one particular therapeutic option for
similar to Belgium (1–3). The development of variable de- autonomous MNG, the treatment choice is guided by the

ISSN Print 0021-972X ISSN Online 1945-7197 Abbreviations: CT, computed tomography; CV, coefficient of variation; FT3, free T3; FT4,
Printed in USA free T4; LID, low-iodine diet; MNG, multinodular goiter; MRI, magnetic resonance imaging;
Copyright © 2015 by the Endocrine Society MTZ, thiamazole; RAIU, radioiodine uptake; rhTSH, recombinant human TSH; ROI, region
Received January 6, 2015. Accepted April 6, 2015. of interest; SPECT, single-photon emission CT; Tg-Ab, antithyroglobulin antibodies; TPO-
First Published Online April 13, 2015 Ab, thyroid antiperoxidase antibodies; UIC, urinary iodine concentration; WBC, white
blood cell.

doi: 10.1210/jc.2015-1026 J Clin Endocrinol Metab, June 2015, 100(6):2261–2267 press.endocrine.org/journal/jcem 2261

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2262 Kyrilli et al Thiamazole and Radioiodine Therapy Efficacy
clinical presentation, patients’ preferences, and local med-
ical practices (5, 6). Surgery is certainly the treatment of
choice for patients with MNG carrying a risk of malig-
nancy and for those with compressive symptoms (6). Ra-
dioiodine therapy (131I) has been increasingly used to treat
autonomous MNG in view of its safety, low cost, and the
possibility of administration on an outpatient basis. An
average reduction in goiter volume of 40% has been re-
ported 1 year after treatment, and this reduction may
reach 50 – 60% after 3–5 years with considerable individ-
ual variations (4). Radioiodine therapy increases the risk
of hypothyroidism that occurs in 22–58% of cases 5– 8
years after therapy (4). The frequent finding of relatively
low radioiodine uptake (RAIU) in MNG can compromise
the efficacy of 131I therapy, and very high activities of 131I
may be required in these circumstances. To address this
problem, recombinant human TSH (rhTSH) has been used
successfully to increase RAIU in MNG (7–12). However,
the use of rhTSH in this indication is not formally recom-
mended (5). In addition, its high cost constitutes a major
limitation for its use in many countries.
The aim of this study was to determine whether pre-
treatment with thiamazole (MTZ) could increase the ef-
fects of 131I by enhancing 24-hour RAIU and thereby de-
creasing the 131I activity needed to treat patients with
subclinical hyperthyroidism and MNG.
Subjects and Methods
Study population and design
This is a single-center, prospective, randomized case-control
trial involving a total of 22 patients referred for 131I therapy for
autonomous MNG at the Nuclear Medicine Department of Uni-
versité Libre de Bruxelles (ULB) Erasme Hospital in Brussels,
Belgium. Inclusion criteria were the presence of subclinical hy-
perthyroidism (serum TSH ⬍ 0.4 mU/L, and normal level of
thyroid hormones) and RAIU at 24 hours ⬍ 50%. Graves’s dis-
ease was ruled out on the basis of clinical presentation and thy-
roid scintigraphy. Thyroid stimulating Ig and TSH-binding in-
hibitor Ig were not measured. Malignancy was ruled out by fine-
needle aspiration biopsy in suspected nodules. Exclusion criteria
included prior thyroid surgery, use of thiamazole (synonym of
methimazole) within the 6 months preceding their enrollment,
and prior radioiodine treatment. Patients with solitary autono-
mous nodules were also excluded. Autonomous nodules were
scintigraphically defined by the presence of an area of increased
radionuclide intake in comparison with remaining extranodular
parenchyma as previously described (7)
Baseline serum TSH, free T4 (FT4), free T3 (FT3), thyroid
antibodies, and a urinary iodine concentration in spot samples
were determined. Initial evaluation also included a thyroid scin-
tigraphy, estimation of thyroid volume, and RAIU measurement
at 24 hours. Patients were randomized into two groups to receive
either MTZ 30 mg/d or a low-iodine diet (LID) for 42 days.
Randomization was done according to a computer-generated
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J Clin Endocrinol Metab, June 2015, 100(6):2261–2267
model with a block size of two. In one patient recruited in the
MTZ group, MTZ was discontinued because he developed ur-
ticaria and raised liver transaminases. This patient was not in-
cluded in the study and did not participate at any evaluation.
Food sources rich in iodine in Belgium are few. Patients received
written instructions to avoid iodized salt, any iodine-containing
vitamins or medication, fish, shellfish, and other seafood, and
dairy products. During the second visit, 42 days after baseline, a
re-evaluation of thyroid function tests, scintigraphy, thyroid vol-
ume, thyroid RAIU, and urinary iodine determination was per-
formed to exclude subsequent iodine contamination. MTZ was
stopped 3 days before the second RAIU measurement. Radioio-
dine therapeutic activity was calculated based on the second
RAIU, and 131I was administered within 2 days on an outpatient
basis in accordance with the Belgian radioprotection rules. Se-
rum TSH and FT4 were measured 12 months after treatment to
evaluate 131I efficacy in all 10 patients in the LID group and in
10 of 12 patients in the MTZ group. In the MTZ group, one
patient was lost during follow-up, and the other patient received
levothyroxine 2 months after administration of 131I. The ethics
committee of ULB Erasme Hospital approved the study protocol,
and all patients provided informed consent.
Thyroid function
Serum TSH was measured by immunochemiluminometric as-
say (Roche). The assay coefficient of variation (CV) of TSH was
2.4% at a mean of 0.09 mU/L. Serum FT4, FT3, thyroid anti-
peroxidase antibodies (TPO-Ab), and antithyroglobulin anti-
bodies (Tg-Ab) were measured by electrochemiluminescence
competition assay (Module E; Roche). The CV of FT4 was 3.6%
at a mean of 1 ng/dL, and the CV of FT3 was 3.5% at a mean of
3 pg/mL.
The CV of TPO-Ab was 4.3% at a mean of 100 U/mL, and the
CV of Tg-Ab was 6.3% at a mean of 50 U/mL. Urinary iodine
concentrations (UICs) were measured by spectrophotometric de-
tection based on the Sandell-Kolthoff reaction. The CV of UIC
was 4.9% at a mean of 53 ␮g/L.
Scintigraphy
Scintigraphy was performed 20 minutes after iv injection of
222 MBq of 99mTc- pertechnetate using a ␥-camera Sopha Med-
ical DSX (SMV International) equipped with a pinhole collima-
tor with 205-mm height, 295-mm diameter, and a 5-mm
aperture.
Estimation of thyroid volume
Thyroid volume was evaluated with either magnetic reso-
nance imaging (MRI) or single-photon emission computed to-
mography (SPECT)-computed tomography (CT) to adapt ad-
ministered 131I activities to thyroid size. All patients had thyroid
volume measured with the same method at the two study points.
The first 11 patients had an MRI, using a 1.5-T whole body
magnetic resonance imager (Gyroscan ACS-Power Trak 6000;
Philips), with a maximum gradient strength of ⫾20 mT/m. In the
subsequent 11 patients, thyroid volume was estimated by
SPECT-CT on a Phillips Brightview camera equipped with a
low-energy parallel-hole high resolution collimator. A low-dose
flat panel CT acquisition (120 kV, 30 mA, 30 cm FOV) was first
obtained, followed by a SPECT of 64 steps in a 256 ⫻ 256 matrix
(energy window, 140 keV ⫾ 20%). CT data were reconstructed
using the filtered back projection method. SPECT acquisition
doi: 10.1210/jc.2015-1026 press.endocrine.org/journal/jcem 2263

was reconstructed iteratively using the Astonish method group and 66.5 ⫾ 14 years in the MTZ group (non sig-
(Philips), with three iterations and eight subsets. Fused CT and nificant). Similarly, the female:male ratio did not vary sig-
SPECT reconstructed data were displayed with the Fusion
nificantly between the two groups: 8:2 in the LID group
Viewer software (Phillips), and three-dimensional regions of in-
terest (ROIs) were placed on the SPECT volume to delineate the and 10:2 in the MTZ group, respectively. All patients were
functional volume of the gland. Because SPECT and CT are TPO-Ab and Tg-Ab negative. Baseline thyroid function
coregistered, the three-dimensional ROIs were automatically and volume and their evolution after 42 days of LID or
displayed on the CT, allowing measurement of ROI volume in MTZ treatment are shown in Table 1. Only three patients
milliliters.
had a thyroid volume above 100 mL: 120, 134, and 206
131 mL, respectively. None of the patients spontaneously com-
RAIU and calculated I activity
plained of local compressive symptoms before treatment
The thyroid RAIU was determined at 24 hours after the oral
administration of 10 ␮Ci (0.37 MBq) of sodium 131I. The 131I or during the follow-up.
activity needed for the treatment was calculated according to the As expected, serum TSH increased significantly (P ⬍
following formula: .001), although within the normal range in the MTZ
R activity ␮Ci ⫻ thyroid size (gr) group. Serum FT4 levels decreased by 22% (P ⬍ .05) and
␮Ci activity ⫽ serum FT3 by 15% (P ⬍ .05) in the MTZ group. In three
24 h uptake (%)
of 12 patients in the MTZ group, FT4 fell below normal
R activity (required activity) varied between 90 and 200 ␮Ci/g levels without any symptom of hypothyroidism. No mod-
according to thyroid size to compensate for the relatively high
radio resistance of large glands (8). ifications of thyroid function were found in the LID group.
Thyroid volume did not vary after 42 days of LID or MTZ
Statistical analysis treatment. Median UIC was low and was similar in both
Statistical analysis was performed with the help of GraphPad groups at baseline and 42 days after LID or MTZ treat-
Prism, version 5.04 (GraphPad Software Inc). Normally distrib- ment. In the LID group, but not in the MTZ group, median
uted data were expressed as the mean ⫾ SD; non-normally dis- UIC was significantly lower at 42 days compared to base-
tributed data (TSH, thyroid volume, and calculated 131I activity)
line median.
were expressed as the median (Interquartile range: 25–75 per-
centile). Depending on the normality of the variable studied, In the MTZ group, the increase in RAIU was associated
parametric or nonparametric tests were used. The t test and with a more homogenous distribution of 99mTc-pertech-
Mann-Whitney test were used to evaluate the differences at base- netate after treatment, as illustrated in Figure 1.
line between the two groups. Paired t test and the Wilcoxon A 2-fold increase in mean 24-hour RAIU from 32 ⫾
matched-pairs signed rank test were used to evaluate within- 10% at baseline to 63 ⫾ 18% was observed after 42 days
group changes before and after treatment. The level of statistical
significance was chosen as P ⬍ .05.
of MTZ treatment (Figure 2) (P ⬍ .001). No increase in
24-hour RAIU was observed in the LID group: mean RAIU
of 37 ⫾ 7% at baseline and 39 ⫾ 10% after 42 weeks of
Results LID.
The MTZ-enhanced RAIU led to a 31% decrease in the
All patients were treated with radioiodine at the end of the required median 131I activity needed to treat the patients,
42-day protocol. The 12-month follow-up was completed from 16.0 mCi (Interquartile range: 12.3–34.5) at baseline
by all patients in the LID group and by 10 of 12 patients to 11.0 mCi (Interquartile range: 8.3–14.0) after treat-
in the MTZ group. Mean age was 70.7 ⫾ 7 years in the LID ment (P ⬍ .001) (Figure 2). The maximal activity autho-

Table 1. Thyroid Function and Thyroid Volume Before and After 42 Days of LID and MTZ Treatment
Baseline After Treatment

LID MTZ LID MTZ

TSH, mU/L 0.09 (0.04 – 0.17) [10] 0.13 (0.04 – 0.30) [12] 0.09 (0.04 – 0.20) [10] 1.55 (0.78 –1.85) [12]a,b
FT4, ng/dL 1.27 ⫾ 0.20 [10] 1.25 ⫾ 0.20 [12] 1.25 ⫾ 0.16 [10] 0.98 ⫾ 0.33 [12]a,b
FT3, pg/mL 3.60 ⫾ 0.5 [10] 3.30 ⫾ 0 .6 [12] 3.40 ⫾ 0.7 [10] 2.80 ⫾ 0.4 [12]a,b
Volume, mL
MRI 87 (45.7–184.5) [4] 55 (29 – 63) [7] 74 (46 –180) [4] 58 (30 – 63) [7]
SPECT-CT 39 (31–56) [6] 44 (31.5– 61) [5] 42 (35.5– 61.3) [6] 50 (42.5– 60.0) [5]
UIC, ␮g/L 110 (70 –116) [9] 64 (47–129) [12] 68 (34 –147) [10]a 40 (20 –56) [11]
Data are expressed as median (25th-75th percentiles) [number of cases] or median ⫾ SEM [number of cases].
a
Different from baseline, P ⬍ .05,
b
Different from LID group after treatment, P ⬍ .05.

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2264 Kyrilli et al Thiamazole and Radioiodine Therapy Efficacy J Clin Endocrinol Metab, June 2015, 100(6):2261–2267

ALARA (as low as reasonably

achievable) principle, aiming to re-
duce the unnecessary exposure of pa-
tients, health personnel, and the gen-
eral public to ionizing radiation.
Concerning the patients, it is note-
worthy that this reduction lowers the
extra thyroidal tissue radiation
burden.
Whether it is beneficial to treat
subclinical hyperthyroidism has
long been a controversial issue. Evi-
Figure 1. Typical aspect of 99mTc-pertechnetate thyroid scintigraphy before (left) and after
(right) 42 days of MTZ treatment.
dence for increased risk of atrial fi-
brillation, increased cardiovascular
and overall mortality, fracture risk,
rized by Belgian law for an outpatient administration is 15 and diminished quality of life associated with subclinical
mCi. After MTZ-induced RAIU enhancement, a greater hyperthyroidism in a variety of studies has prompted con-
proportion of patients who initially exceeded the legal sensus groups to consider treatment as a reasonable option
threshold could receive the outpatient calculated 131I ac- for patients over 60 years old and/or with evidence of heart
tivity in the MTZ group as compared to the LID group: disease and/or bone loss (9, 10). Treatment options in-
seven of 12 (58.3%) in the MTZ group vs two of 10 clude thionamides and radioiodine—the latter being pre-
(20.0%) in the LID group (P ⬍ .05). The patients whose ferred especially in the presence of toxic or autonomous
calculated activity exceeded the legal threshold at the end MGN or solitary nodules. Surgery is a valid option in
of the study received the maximal authorized activity of 15 young patients or in cases of suspicious nodules (9).
mCi: one of 12 (8.3%) in the MTZ group (instead of a Two previous nonrandomized studies evaluated MTZ
calculated 131I activity of 32 mCi) vs six of 10 (60.0%) in as an adjuvant treatment for 131I therapy of MNG (11,
the LID group (instead of calculated 131I activities of 18, 12). In the first study, the authors treated nine patients
18, 106, 45, 16, and 35 mCi).
with different doses of MTZ to obtain a serum TSH ⬎ 6
The evolution of serum TSH 12 months after 131I ad-
mU/L and then administered a fixed activity of 1110 MBq
ministration in the two groups is shown in Figure 3. Ra-
(30 mCi) (11). The duration of therapy was considerably
dioiodine treatment cured hyperthyroidism in all patients
longer (2.8 mo), and RAIU significantly increased from
in both groups despite the fact that patients in the MTZ
21.3 ⫾ 8.1% to 78.3 ⫾ 15.3%. Hypothyroidism ensued
group received a lower 131I activity. Moreover, in the
after radioiodine therapy in five of nine patients. In the sec-
MTZ group, three of 10 patients (30%) developed hypo-
ond study, 10 –15 mg/d of MTZ were administered to in-
thyroidism after 131I therapy, but none in the LID group.
crease RAIU above 50%, and a fixed 1110 MBq 131I activity
Median TSH at 12 months after 131I was significantly
was administered. The average duration was 3 months, and
higher in the MTZ group compared to the LID group, 2.55
all five patients developed hypothyroidism (12).
mU/L (1.65–5.38) vs 1.21 mU/L (1.0 –1.78), respectively
Our results confirm that MTZ induces a significant
(P ⬍ .05).
RAIU enhancement within a considerably shorter period
of time (42 d vs 3 mo). The strength of our study lies in its
randomized design. Furthermore, by using a calculated
Discussion
instead of a fixed therapeutic 131I activity, the extra thy-
To our knowledge, this is the first randomized clinical trial roidal tissue radiation was probably lowered without
131
designed to evaluate the effect of MTZ pretreatment on compromising the therapeutic efficacy of I. Because the
131
radioiodine therapy in patients with subclinical hyperthy- I calculated activity was not given to 60% of patients in
roidism and MNG. Our results clearly demonstrate that the LID group, the interpretation of differences of thyroid
the use of MTZ before 131I therapy induced an average function at 12 months between MTZ and LID groups is
2-fold increase in 24-hour RAIU and a significant reduc- difficult. The design of the study does not permit compar-
tion of the 131I activity needed to cure subclinical hyper- ison of the efficacy of both treatments. However, the sig-
thyroidism in patients with MNG, without compromising nificantly higher TSH at 12 months in the MTZ group
therapeutic efficacy as shown by 12-month TSH values. suggests that lowering 131I activities in patients treated
This reduction in administered 131I activity follows the with MTZ did not affect the efficacy of radioiodine ther-

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doi: 10.1210/jc.2015-1026 press.endocrine.org/journal/jcem 2265

serum TSH, which is known to stimulate the expression of

the Na/I symporter, responsible for the uptake of iodine.
It is well known that minor side effects of MTZ include
rash, urticaria, pruritus, and gastrointestinal intolerance
(13). One of our patients could not be included in the study
because he developed urticaria and pruritus with in-
creased serum liver transaminase levels. Withdrawal of
MTZ rapidly restored hepatic function tests to normal
levels. Major side effects comprise rare cases of agranu-
locytosis (0.2– 0.5%) and hepatotoxicity, for which inci-
dence is not clearly known (0.1– 0.2%) (13, 14). We
checked baseline white blood cell (WBC) count and liver
function tests for all our patients, but we did not routinely
monitor their hepatic function tests or WBC count during
the 6 weeks of therapy. Risk of MTZ-induced agranulo-
cytosis is known to be dose dependent (8.6-fold increase
with doses ⬎ 40 mg/d) and age related (6-fold increase in
patients ⬎ 40 y old), and WBC count fails to predict its
onset (14). Although others have reported that WBC
count may help predict granulocytopenia (15), routine
blood counts are not recommended by current guidelines
including those of the American Thyroid Association (5).
rhTSH has recently been used in clinical trials to optimize
radioiodine treatment of MNG. Thyroid stimulation by
rhTSH can result in an approximately 2- to 4-fold increase
in RAIU and in a 35–56% gain in goiter volume reduction
(16 –30). Mean RAIU obtained after rhTSH stimulation
Figure 2. A, Change in mean RAIU after 42 days of LID or MTZ.
**, P ⬍ .001. Error bars represent SEM. B, Calculated median 131I
displays interindividual variations. It is dose dependent
activity after 42 days of LID or MTZ. *, P ⬍ .05; **, P ⬍ .001. Error and inversely correlated with baseline RAIU (22, 23, 25–
bars represent interquartile range of median. 28). The dose of rhTSH used varied from 0.01 to 0.9 mg
given at different time intervals from 24 to 72 hours before
radioiodine therapy, although 24 hours was found to be
apy. In addition, our results indicated that prior MTZ
the optimal time point for the greatest increase of RAIU.
washout of 3 days did not interfere with radioiodine out-
In most studies, rhTSH-stimulated RAIU reaches an ab-
come. The increase in RAIU can be explained by two dif-
ferent mechanisms. First, by inhibiting thyroid peroxi- solute value of 60 – 65%, which is similar to our findings.
dase, MTZ blocks iodine organification and depletes the In contrast with the supranormal acute TSH peaks in-
intrathyroid iodine pool. Second, the inhibition of thyroid duced by rhTSH, MTZ-induced stimulation of thyroid
hormone synthesis by MTZ induces a slight increase in uptake is a slow process that leads to a progressive nor-
malization of TSH levels.
Nieuwlaat et al (31) have shown that rhTSH induces
significant changes in the regional distribution of radio-
iodine in nodular goiters. Recombinant TSH stimulates
radioiodine uptake in relatively “cold” areas more than in
relatively “hot” areas, as depicted on scintigraphy, result-
ing in a more homogenous radioiodine distribution. In our
study, we observed the same effect with MTZ, although
TSH was only moderately enhanced after treatment. After
MTZ treatment, previously “resting” tissues surrounding
hyperfunctioning areas were reactivated. The conse-
Figure 3. TSH serum levels (mU/L) before and after 12 months of 131I quence of the homogenization of radioiodine uptake is
treatment in the LID and MTZ groups. Data are available for all patients
in the LID group and for 10 of 12 patients in the MTZ group. *, P ⬍ that besides hyperfunctioning nodules, perinodular thy-
.05. roid tissue is also irradiated, explaining the greater fre-

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2266 Kyrilli et al Thiamazole and Radioiodine Therapy Efficacy J Clin Endocrinol Metab, June 2015, 100(6):2261–2267

quency of hypothyroidism and goiter volume reduction easily accessible alternative to rhTSH stimulation and a
compare to the administration of 131I alone. A significant more effective option than a LID.
increase in permanent hypothyroidism after rhTSH-stim-
ulated 131I treatment (52% 5 y after rhTSH compared to
16% after 131I alone) has been reported (21, 28). We sim- Acknowledgments
ilarly found a greater proportion (30%) of patients devel-
We thank all caring physicians that have addressed their patients
oping hypothyroidism 12 months after MTZ-enhanced
131 for our study protocol, as well as the secretary, nurses, and staff
I therapy, suggesting that there may be a possibility for
of the Endocrinology and Nuclear Medicine Department for
further lowering of the administered 131I therapeutic ac-
their precious collaboration throughout our study. We thank
tivity for those patients without indication for thyroid vol- Global Science Editing, UK, for English language revisions.
ume reduction.
Another relevant issue is that rhTSH can induce a tran- Address all correspondence and requests for reprints to:
sient thyroid swelling and cervical pain within the first Rodrigo Moreno-Reyes, MD, PhD, Department of Nuclear Med-
week of treatment. This effect seems to be dose dependent icine, Erasme Hospital, Université Libre de Bruxelles, Route de Len-
nik 808, 1070 Brussels, Belgium. E-mail: rmorenor@ulb.ac.be.
and is mostly reported in trials using 0.3– 0.9 mg of rhTSH Disclosure Summary: The authors have nothing to disclose.
(23, 24). On the contrary, in our patients MTZ treatment
did not affect thyroid volume, and this is obviously a po-
tential advantage for patients with large goiter volumes. References
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