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Thyroid imaging
function studies
Radioiodine therapy


Thyroid imaging and function
studies

Evaluation for clinical palpable


nodules
Thyroid scintigraphy and radiotracer
uptake studies
U.S. and F.N.A
Laboratory data
Thyroid scintigraphy

Determining the functional status of


the thyroid nodules.
Detection of the extra-thyroid
metastasis form thyroid carcinoma.
The thyroid tissue origins from
mediastinal masses.
Correcting the physical finding with
abnormalities in the image.
Radiopharmaceuticals

Iodine-131
Iodine-123
Technetium-99m
Radiopharmaceuticals

Iodine Pertechnetate
a precursor of ion (TcO4-)
thyroid hormone .
concentration
concentration
(100:1 than plasma)
Organification.
Bound to
thyroglobulin.
Physics and dosimetry
iodine-131
Iodine-131

not good choice for routine thyroid


scintigraphy
The presence of beta particle
emissions
The relative high energy of the
principal gamma ray emissions for
gamma camera.
The long half-life
Physics and dosimetry
iodine-123
Iodine-123

Better for thyroid image


Electron capture
Gamma energy is ideally suited for
gamma camera(159 keV)
Half-life is suitable (13.2hr)
Iodine-123

Disadvantage
Prepared from I-124 and I-125
Higher radiation precursors
Short half-life
Commercial limited
Higher cost
Physics and dosimetry
Technetium-99m
Technetium-99m

Better for thyroid scintigraphy


Reliably available from molybdenum-
99 /Tc99m generator system
Ideal half-life (6hr)
Suitable energy (only gamma ray
140KeV)
Pharmacokinetics
radioiodine
GI absorbs ion by Oral administration
Into circulation
Rapid uptake and Organification of iodine
Detectable within minutes.
Reached the follicular lumen within 20-
30 minutes
Normal range for uptake is 10%-30% of
the administered dose at 24 hr
Pharmacokinetics
radioiodine
I-123 I-131
Detection after Detection after 1
several hours day delay
delay
Pharmacokinetics
Technetium-99m
Iv administration
Rapid uptake by thyroid but not
organification
Optimal uptake for imaging is 20-30
min with the 0.5-3.75% of the
reagent
Technetium-99m &
radioiodine

Concordant localization and identical


scintigraphy
Dis-concordant in a small percentage
of thyroid nodules for the loss of the
organification
Precautions

Breast feeding
Pregnancy
Interference of stable iodine
contained in foods and medications
Breast feeding
I-123
Resumed after several days if the amount
used if no more than 30 uCi used
Usual imaging dosage is 100-400 uCi
I-131
Should be terminated for several weeks
Tc99m pertechnetate
Resumed in 24 hr
radioiodine
precaution for pregnancy
Radioiodine can cross placenta
Fetal thyroid can concentrate iodine
after 10th -12th gestation weeks.
Resulting in hypothyroidism and
cretinism.
Interference for radioiodine
uptake
Several non-iodine drug can affect
that.
1 mg of stable iodine can cause
significant reduction of the 24 hr
radioiodine uptake
10 mg can effectively block the
gland, with 98% reduction uptake.
Normal thyroid scintigraphy

In the euthyroid adult the thyroid


gland weights 15-20 g.
Butterfly shape with lateral lobe
extending along each side of the
thyroid cartilage of the larynx
The lateral lobes are connected by an
isthmus that crosses the trachea
anteriorly below the level of the cricoid
cartilage.
The right lobe is often larger than the
left.
The lateral lobes typically measure 4-5
cm from superior to inferior poles and
1.5-2 cm wide.
The pyramidal lobe is a paramedian
structure that arises from the isthmus,
either to the right or left lobe of the
middle, and represents functioning
thyroid tissue in the thyroglossal duct
tract.
Normal thyroid scintigraphy

Homogeneous
Uniform distribution
Variation
Middle or medial of the lateral lobes
owing to the thickness
Activity of the Isthmus varies greatly
among patients, with little or no activity
and prominent activity
TC-99m pertechnetate

Thyroid tissue
Salivary gland
Esophagus activity seen to the left of
middle and can confirm by having
patient swallow, hollowed by a
repeat image.
Clinical applications
indication for thyroid scintigraphy
Further evaluation of findings on physical
examination
Detection of metastases with thyroid carcinoma
Follow-up of radioiodine therapy for differentiated
thyroid cancer
Determination of functional status of thyroid
nodules
Differential diagnosis of mediastinal masses
Detection of extra thyroidal tissue (lingual thyroid)
Screening after dead and neck irradiation.
Clinical applications
Goiter
Refers to an enlargement of the thyroid gland
Endemic goiters
Iodine deficiency-induced hyperplasia
Colloid nodular goiters
Nontoxic goiters
Graves disease
Toxic goiter
Thyroid carcinoma
Other neoplasm-lymphoma
Active phase of thyroiditis
Scintigraphy of Goiter
multinodular colloid goiters
Inhomogeneous uptake of tracer
Cold areas of various sites
Carcinoma changes rate is low (1-
5%)
Highly suspicion: out of proportion in
size to other cold areas or enlarging
suddenly.
Scintigraphy of Goiter
Graves disease
Uniform with intensely increased
uptake
The pyramidal lobe is frequently seen
Not generally considered an
indication for obtaining a thyroid
scinitigram (?)
Clinical applications
thyroid nodules
Extremely common
The incidence increases with age
More common in women
Likehood of malignancy:
Multiple nodule (multiple nodular
goiters, less than 5%)
Solitary cold nodule (5-40%)
Scintigraphy for thyroid
nodules
Cold nodules-nonfunctioning
The majority of the thyroid nodules
As small as 3 cm can be detected by pinhole collimator
Hot nodules-functioning
Function equal to the surrounding normal thyroid
Indeterminate
Need to close to correct between physical examination and
scintigraphy findings.
Oblique view with a pinhole collimator
The management is the same as the cold nodules.
Cold nodules

Risk factors of malignancy


prior history of radiation to the head
and neck or mediastinum
>1000-1500 rads
Solitary cold nodules in young female
Multiple nodular goiters in elderly
Hot nodules

Hyper functioning
Autonomous
Out of negative feedback control
Hot nodules

Autonomous nodules
Thyroid gland produces much hormone
Greater than 3-4 cm
suppress pituitary TSH
Extra-nodular thyroid tissue is not visualable
Small nodules
Extra-nodular thyroid tissue is visualable
Spontaneous involution
Cystic degeneration
Hot nodules

Hot nodules with hyperthyroidism


Large(3-4 cm), multiple nodules
Autonomous hot nodule with
Thyrotoxicosis
Plummers disease
Discordant nodules

Possibility of discordant between


radioiodine and Tc-99m
pertechnetate
Radioiodine-cold
Tc-99m pertechnetate-hot
2-3 % in Tc-99m pertechnetate hot
nodules
Substernal thyroid

D.D mediastinal masses


Goitrous enlargement with
downward extension
Abnormal migration during develop
Substernal thyroid

I-131 is better than Tc99m


Delayed performed (48-72 hr)
Function and tracer uptake in sternal
thyroid is poor
Blood clearance of the background
activity
Cervical thyroid should also be noted
Clinical applications
other ectopic thyroid tissue
The thyroglossal duct runs from the
foramen cecum at the base of the tongue
to the thyroid
Lingual thyroid complete failure to migrate
Absence of tracer uptake in the expected
cervical area
Thyroid tissue may be found along the tract
of the thyroglossal duct.
Clinical applications
thyroiditis
Acute thyroiditis
Suppurative bacterial infection
Focal abscess
subacute thyroiditis
Granulomatous thyroiditis
De Quervains disease
Non-suppurative
Etiology unproved-virus infection (URI, neck tenderness)
Initial phase would be a Thyrotoxicosis
Chronic thyroiditis
Hashimotos thyroiditis
Lymphocytic infiltration
More common in women with goiter or hypothyroidism
Rarely with hyperthyroidism-hashitoxicosis
Scintigraphy for acute &
subacute thyroiditis
Acute thyroiditis
Cold nodule for the focal abscess
Subacute thyroiditis
Decrease or absent uptake of
radioiodine in the affected part of the
gland
Gallium-67 imaging :inflammatory
process
Scintigraphy for chronic
thyroiditis
Highly variable and depend on the
stage in the natural history
Normal in the early stage
Later, diffuse enlargement
Eventually, hypothyroidism,
inhomogeneous with hot and cold
areas
Clinical applications
thyroid cancer metastasis
Follicular carcinoma
Mixed papillary-follicular carcinoma
Papillary carcinoma
Medullary carcinoma
Ana plastic carcinoma
Thyroid cancer metastasis

The most common sites of


metastasis are locally in the lymph
nodes of the neck, lung ,and bone.

nodal activity is focal ,intense,


starburst pattern on parallel-hole
collimators
Thyroid cancer metastasis

Imaging is performed 48-72 hr after


radioiodine administration.

More lesion are demonstrated in this


time than at 24 hr.
I-131 follow-up imaging

The preparations and dosage are


controversial.
Thyroid hormone replacement is withdraw for
4-6 weeks to stimulate TSH secretion.

Use bovine TSH before imaging.


Not satisfactory for increasing I-131 uptake
allergy
Scanning dosages for follow-up
imaging
Controversial
More metastasis deposits are seen with
higher doses
5-10 mCi of I-131 for detecting metastasis
As little as 5 mCi with less satisfactory
uptake of sequent therapeutic dose
Diagnostic dose should be limited 1-2 mCi
Tumor imaging

Thalium-201 chloride
Tc-99m sestamibi
For location metastasis in patients
with increased thyroglobulin and
negative radioiodine whole body
scintigraphy
Iodine -131 MIBG for Medullary
carcinoma
meta-iodo-benzyl-guanidine
Neurosecretory storage vesicles of
chromaffin cells
Sensitivity is low (30%)
Soft tissue metastasis is more
visualized than bone metastasis.
Medullary carcinoma of
thyroid
Indium -111 somatostatin receptor
scintigraphy for Medullary carcinoma
Iodine -131 MIBG
FDG-PET
Thyroid function studies

Thyroid percent uptake


Suppression test
Stimulation test
Per chlorate discharge test
Thyroid percent uptake

The earliest applications radiotracer


in medicine.
The degree of radioiodine uptake
parallels the functional activities of
the thyroid hormone produced
Normal uptake range 10-30%
Sensitivity and specific test of serum
T3 T4
Thyroid percent uptake

DD hyperthyroidism
Increase uptake
Graves disease
Plummers disease
Decrease uptake
Subacute thyroiditis
Thyrotoxicosis factitia
Suppression test

Not used in current routine practice.


Autonomous functioning glands
TSH level is a sensitivity test now
Suppression test

Receiving 25 mg T3 qid for 8 day


24hr uptake is repeated beginning at
7th day.
It is fall in the percentage of uptake
to less 50% of the baseline and less
the 10% overall.
Stimulation test

Infrequent use now.


D.D primary and secondary
(pituitary) hypothyroidism
Primary-failure to response to
exogenous TSH
Secondary-increasing radioactivity after
TSH administration
Stimulation test

Receiving 10 units of TSH iv


The radiotracer repeats beginning
the next day.
Primary-no response
Secondary-radiotracer doubling
Per chlorate discharge test

to detect defects in
Intra-thyroidal iodide
organification
Per chlorate discharge test

Dissociation of the trapping and


organification function
Congenital enzyme deficiency
associated with deafness (Pendred's
syndrome),
Some chronic thyroiditis
During the treatment of PTU
Per chlorate discharge test

I is "trapped" by the thyroid gland


through an energy-requiring active
transport mechanism
Once in the gland, it is rapidly bound
to thyroglobulin
Per chlorate discharge test

thiocyanate
inhibit active (SCN-)
iodide perchlorate
transport (ClO4-)
cause the release of
the intrathyroidal
iodide not bound to
thyroid protein
Per chlorate discharge test

administration of radioiodine orally


counts are obtained at frequent
intervals (every 10 or 15 minutes).
Two hours later, 1g of KClO4 orally
repeated epithyroid counts continue
to be obtained for an additional 2
hours
In normal individuals

little loss of the thyroidal


radioactivity accumulated prior to
induction of the "trapping" block
radioiodine accumulation in the
thyroid gland ceases after the
administration of the iodide transport
inhibitor
Per chlorate discharge test

Less than 10% discharge of


radioiodine:
Normal
Hyperthyroidism on inadequate
antithyroid drug therapy
Greater than 10% washout:
Organification defect
Radioiodine treatment

Hyperthyroidism
Thyroid cancer
Hyperthyroidism
indications for iodine-131
therapy
Graves disease (diffuse toxic goiter)
Plummers disease (toxic nodular
goiter)
Functioning thyroid cancer
(metastasis)
Hyperthyroidism
Contraindication for iodine-131
Thyrotoxicosis factitia
therapy
Subacute thyroiditis
Silent thyroiditis (atypical ,subacute, lymphocytic,
transient, postpartum)
Struma ovarii
Thyroid hormone resistance
Secondary hyperthyroidism
Thyrotoxicosis associated with Hashimotos disease
(hashitoxicosis)
Jod-Basedow phenomenon (iodine-induced
hyperthyroidism)
Radioiodine treatment

Goal
Euthyroid in a reasonable length of time
with a single radioiodine dose
Gravesdiseas-80-120 uCi/g
Standard dose:5-10mCi
Higher for Graves opthalmopathy
More than 90% patients are cured with a
single dose
Hypothyroidism-hormone replacement
Radioiodine treatment

Plummers disease
Hyperthyroidism caused by toxic
nodules
More radio-resistant
Inhomogenity, rapidly radioiodine
turnover ,low retain dose
Increase dose to 15-29 mCi
Radioiodine treatment

Metastases from differentiated


thyroid cancer
Controversial with small , early stage
lesions
Residual, recurrence differentiated
thyroid cancer - improved survival
rate with I-131
Radioiodine treatment

Metastasis more common at neck,


lung and bone
Bone metastasis is more difficult
eradicated than lung metastasis
Initial dose 150-200mCi
Repeated doses up to 1Ci
Radioiodine treatment

Follow-up imaging is performed


yearly until the metastatic lesions
are elimination
Serum thyroglobulin tumor marker
If the level is increase in a post-op
patient. it may be a recurrence
Then performed imaging to localize the
lesion
Radioiodine treatment

Not statistically significances of


leading the secondary cancer by
radioiodine Tx
Not reduce fertility
Congenital defects are not increased
in the child of treated patients
attention

Thanks for your


attention