Thyroid Scanning with Technetium 99m Pertechnetate'

WYLIE J. DODDS, M.D., and MALCOLM R. POWELL, M.D.

TECHNETIUM 99m pertechnetate SETTING OF BACKGROUND SUPPRESSION

(99IDTc04 -) is a useful radioactive label

for thyroid scanning. It is of particular
merit when emphasis is placed upon a low
dose of thyroid radiation, optimal resolu-
tion, and scanning of thyroid glands in
th ~:;~::~·,eo
Background SK
count rote
eo 00 "80
5K 5K SK

which function is decreased or partly 50% 70%

blocked. K=1000
Counts/min
Harper et at. (4) reported the first
Fig. 1. A. Normal ratio of thyroid to background
pertechnetate scan of the thyroid in 1964, count in a euthyroid patient. A setting of background
and the next year the same group published suppression of 10 to 20 per cent is sufficient.
a paper on pertechnetate thyroid scans in a to Band C. Examples of diminished ratios of thyroid
background count resulting from thyroid suppression
series of 86 patients (1). Recently, Quinn or hypofunction. Higher settings of background sup-
pression of 50 or 70 per cent are necessary for a satis-
and Brand (6) reported on 767 patients in factory scan.
whom pertechnetate scans were obtained of D. Pertechnetate is not concentrated by the thy-
roid gland, and no scan is obtainable.
the thyroid gland, incidental to brain scans.
Certain aspects of this method of thyroid The pulse-height analyzer was set for a
labeling deserve further elucidation and are 126-to-154-keV window, the time constant
described in the present report. at 0.02 second, and scanning speed at 30
or 44 em per minute. A 127 -hole, fine-
MATERIAL AND METHOD focus collimator was employed. The cor-
During a six-month period, the thyroid rect setting of background suppression,
glands of 41 selected patients were scanned which is of critical importance to the suc-
with pertechnetate. All patients with cess of this method, is discussed later.
hypothyroidism or iatrogenically sup- The suppression levels were set at 10 to
pressed thyroid function who had insuffi- 70 per cent, allowing only a minimal
cient uptake for 1311 thyroid scanning were imaging of nontarget areas.
included in the series. Pertechnetate scans 1311 thyroid scans are generally per-

were done in euthyroid patients for three formed after twenty-four hours. By that
reasons: (a) The dosimetry in children is time most of the labeled iodide in the
favorable. (b) The high count rates and thyroid gland has been organified, as
ease of collimation allow better evaluation thyroid hormone and serum levels of iodide
of small thyroid nodules. (c) In patients are negligible. In contrast, scanning of
not able to return the following day for a the thyroid gland with pertechneta.te is
twenty-four-hour, 13ll thyroid scan, scan- performed about one hour after its intra-
ning is possible within an hour after ad- venous administration, when relatively
ministration of the label. high nontarget count rates are always
99IDTc04 - was administered intrave- present. Selection of background suppres-
nously in doses of 1 to 5 mCi. The usual sion depends on the ratio of count rates
dose in adults was 2 mCi and in children over the gland to nontarget rates adjacent
1 mCi. After a period of thirty to sixty to it. Figure 1 illustrates some typical ex-
minutes, both dot and photoscans were ob- amples of target and nontarget count ratios
tained with a 3-inch rectilinear scanner." found during programming of a pertech-
1 From the Department of Radiology and the Nuclear Medicine Section, University of California School of Med-
icine, San Francisco, Calif. Accepted for publication in Apri11968.
Partially supported by USPHS Grant GM 1272.
2 Nuclear Chicago "Pho-Dot" Scanner.
RADIOLOGY 91: 27-31, July 1968. (V.a.B.)
27
28 WYLIE J. DODDS AND MALCOLM R. POWELL July 1968

Fig. 2. Pertechnetate scan of a normal thyroid gland shows normal size and homogeneous labeling.
Fig. 3. Despite an uptake of radioactive iodine of 6 per cent at twenty-four hours, a pertechnetate scan of the
thyroid gland of this 25-year-old hypothyroid woman was excellent.

netate thyroid scan. The background TABLE I lists the results of evaluation of
suppression in each instance was set ap- scan quality in these 3 groups according to
propriately. In practice, the background whether the scan was entirely satisfactory
suppression is set just high enough to or poor for clinical diagnosis and whether
eliminate most of the nontarget counting visualization occurred. Scans of the 12
from the scan. A faint register of non- patients who were clinically euthyroid were
target count rate is permitted, however, to all of excellent quality (Fig. 2).
show that the apparent size of the thyroid The diagnosis of hypothyroidism was
gland in the scan is not misleadingly small established in 14 patients after clinical and
from too high a setting of background sup- laboratory evaluations and after deter-
pression. Usually a background suppres- mination that the uptake of radioiodide
sion setting of 10 to 20 per cent is ample for was decreased. Pertechnetate thyroid
euthyroid subjects, whereas patients with scans were of good diagnostic quality in
hypothyroidism or suppressed thyroid func- 9 of these (Fig. 3) and of limited diagnostic
tion may require suppression settings of 50 quality in 3; in only 2 was the thyroid
per cent or more. gland not visualized.
Uptake of radioiodide was suppressed
RESULTS
below 12 per cent at twenty-four hours or
Results of the pertechnetate thyroid 8 per cent at five hours in 15 patients who
scanning are considered in 3 groups of pa- had received exogenous medication capa-
tients: those who are euthyroid, those ble of inducing this degree of suppression.
who are hypothyroid, and those with The medications had been given for various
thyroid suppression by exogenous agents. reasons, including Graves's disease, sup-
pression of thyroid nodules, and weight
TABLE I: QUALITY OF PERTECHNETATE 99m reduction. Thyroid active substances
THYROID SCANS were being taken by 12 patients. The
No. No doses were as high as 7 grains of Proloid
of Good Poor Visual- daily but more often consisted of desic-
Patients ization
cated thyroid, 3 grains a day, or its equiva-
Euthyroid 12 12
Hypothyroid 14 9 3 2 lent. A few patients were receiving iodides
Thyroid suppression 15 9 5 1 and one was taking 800 mg of propyl-
TOTAL 41 30 8 3
thiouracil daily, together with Lugol's
Vol. 91 THYROID SCANNING WITH TECHNETIUM 99m PERTECHNETATE 29

Fig. 4. Examples of exogenous thyroid suppression. A. A scan of good quality demonstrates some irregu-
larity of labeling but no discrete "cold" nodule in a 41-year-old woman who was taking 3 grains of desiccated thy-
roid daily. The horizontal white stripe is an artefact of scanning.
B. Scan obtained on a 49-year-old woman receiving thyroid medication, propylthiouracil, and Lugol's solution.
The labeling is irregular.

solution and triiodothyronine. Sufficient

trap function remained in many of these
suppressed thyroid glands for satisfactory
visualization by pertechnetate scanning,
and in only one patient was visualization
completely absent. Figure 4 shows some
typical results in this group. Scans of ex-
cellent diagnostic quality were obtained in
several instances in which successful scan-
ning with conventional doses of 1311 would
have been most difficult.

DISCUSSION
Imaging of the thyroid gland by the
pertechnetate method depends upon thy-
roidal maintenance of a concentration
gradient between plasma levels of per-
technetate and intrathyroidallevels. This
concentrating mechanism is referred to as
the thyroid "trap." The thyroid "trap"
depends upon thyroid-stimulating hor-
mone (TSH) and the functional integrity of
the thyroid gland in response to this stimu-
lation. The normal thyroid acinar cell
responds to TSH by increasing its capacity
to trap monovalent anions, such as iodide
and pertechnetate. Function of the thy-
Fig. 4. C. In the scan of this 45-year-old woman
taking Lugol's solution, 10 drops t.i.d., the thyroid is
sufficiently labeled for imaging. The submaxillary
glands are visualized in the upper neck because in this
patient target count rate was low and the scan was
programmed with high sensitivity.
roid "trap" does not necessarily correspond
to the clinical state of a patient. For ex-
ample, in some patients with hypothy-
roidism resulting from hereditary enzyme
abnormalities, a normal or even an ex-
30 WYLIE J.
Fig. 5. A. A "cold" nodule is seen at the right lower pole of the thyroid gland in this 18-year-old girl.
B. The labeling in the scan of an enlarged gland in this 30-year-old man is somewhat irregular, and the left lobe
contains a "cold" nodule.
panded thyroid "trap" may exist. An-
other example is a patient with Graves's
disease who is receiving antithyroid drugs.
Such a patient is often clinically euthyroid,
and the protein-bound iodine is normal at a
time when the thyroid "trap" is consider-
ably expanded. It is emphasized that the
thyroid "trap" may be expanded in vol-
ume and that the plasma-to-thyroid gradi-
ent may be increased for these monovalent
anions.
In many instances when useful thyroid
scans with conventional scanning doses of
131 1 are unachievable, thyroid scans ob-
tained with pertechnetate are entirely
satisfactory or even of excellent quality.
This success is attained because pertechne-
tate may be given in millicurie doses and
does not irradiate the thyroid gland unduly.
The conventional scanning dose of 50 ,uCi of
13lJ delivers about one thousand times more
radiation to the gland than does a I-mCi
dose of pertechnetate (8). Scans of similar
quality are obtainable with large doses of
131
1 but are prohibited because of the exces-
sive radiation to the thyroid.
Various mechanisms may suppress the
thyroid gland. Exogenous thyroid hor-
mone depresses TSH levels, to which the
thyroid gland responds by decreasing both
the volume and the gradient of the thyroid
DODDS AND MALCOLM R. POWELL July 1968
"trap." Enough trapping function re-
mains in most suppressed thyroid glands,
however, to permit adequate pertechnetate
to label the trap sufficiently for visualiza-
tion by scanning. Exogenous iodine de-
presses the thyroid "trap" transiently and
enlarges the iodide pool. Again, because
pertechnetate can be administered in milli-
curie doses, scanning of the thyroid gland is
usually possible, even after recent doses of
iodinated radiographic contrast agents and
other iodides. Finally, antithyroid drugs
block the function of the thyroid gland
beyond its "trap." The resultant decrease
in circulating thyroid hormone causes an
increase in TSH secretion, which enlarges
the thyroid and the "trap." Therefore,
labeling of the "trap" in these glands is
easily accomplished. 13lJ scans, however,
would be unsuccessful because of the small
amount of organification of iodide and the
low target count rates available with con-
ventional doses of 131!.
Careful attention to programming of the
rectilinear scan is important in obtaining
optimal pertechnetate thyroid scans. Pre-
cise background suppression at a level
where nonthyroidal background will just be
visible in the scan is essential for satisfac-
tory scans when low target-to-nontarget
counting ratios are present. Despite the
Vol. 91 THYROID SCANNING WITH TECHNETIUM
low counting ratios, the large number of
counts available above background provide
excellent scanning statistics.
Maximal thyroid-to-plasma pertechne-
tate ratios have been noted in human sub-
jects within thirty to sixty minutes after
intravenous injection (5). Several pre-
liminary experiments on dogs (3) showed
maximal thyroid-to-background ratios
three to four hours after intravenous
injection of the isotope, but because of the
short half-life of technetium, the total
available count rate had fallen so far by
that time that earlier visualization by this
method would have been more efficient.
The suppressed thyroid gland has been
stressed in this discussion of the pertechne-
tate scan since it is in this gland that the
technic must be precise in order to obtain a
good scan. The technic also has decided
advantages in instances other than those of
diminished function or suppression of the
thyroid gland. Since the dose of radiation
to the thyroid gland is low with pertechne-
tate scanning, this isotope is preferred in
children (2). Thyroid neoplasms have
been reported in children treated with
13II (7). The 99lliTc04- gamma radiation
energy of 140 keY allows finer collimation
which, with the higher available count
rates, affords better resolution and count-
ing statistics of defects of thyroid labeling
(Fig. 5). This resolution may be critical in
evaluation of small "cold" nodules. The
other major advantage of the technic is
that it facilitates the visualization study
soon after injection of the labeled material.
Thus, the waiting period varying from a
minimum of several hours to the usual
twenty-four hours, as is necessary for the
131l scanning technic, is avoided.
99m PERTECHNETATE 31
SUMMARY
Radioisotope scanning of the thyroid
gland by means of labeling with technetium
ggm pertechnetate and the scanning tech-
nic for visualization of a suppressed gland
are described in detaiL Thyroid scanning
with pertechnetate offers several advan-
tages: (a) The radiation to the thyroid
gland compared to that from conventional
13II scanning doses is greatly decreased.
(b) The scan may be performed almost im-
mediately after injection of the label, and
radiation energy is collimated easily. (c)
Higher count rates are available than with
13II scanning technics, resulting in im-
proved resolution of small defects and
visualization of suppressed glands.
Department of Radiology
University of California
San Francisco Medical Center
San Francisco, Calif. 94122
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2. DODDS, W. J., AND POWELL, M. R.: Lingual
Thyroid Scanned with Technetium 99m Pertechnetate:
Report of Two Cases. Am. J. Roentgenol. 100: 786-
791, August 1967.
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