Radiology
NUCLEAR MEDICINE 12. Hal Anger (1920 2005)
Radiation is all around us.
Everything in nature, every creature and every material
contains, and always has contained, radioactive substances. You are
radioactive yourself, and so is your dog, your car, your coffee, and your
mother-in-law.
Ionizing Radiation
- Radiation of sufficient energy to disrupt DNA strands
- Radiation given to patients is as low as possible
- Photons (x-rays, gamma rays)
- Particles (alpha, beta, neutrons)
NUCLEAR MEDICINE
-Branch or specialty of medicine and medical imaging that uses the
nuclear properties of matter in diagnosis and therapy
-Makes use of radionuclides and relies on the process of
radioactive decay in the diagnosis and treatment of disease
-In diagnosis, a small amount of a radioactive substance is
administered to the patient and the radiation emitted is measured
-It documents o r g a n s t r u c t u r e a n d function
-Identifies ab n o rm al iti es early i n t h e c o u r s e o f a disease, long
before some medical problems are apparent with other diagnostic tests
o Radiology: Radiation comes from the MACHINE
Nuclear Medicine: Radiation from the PATIENT
HISTORY
-Nuclear medicine as it is known today evolved from a series of
discoveries and landmark events
-The exact beginning of nuclear medicine cannot be pinpointed to
a specific time and place
-Probably, the most notable of these discoveries was that of the x-ray
in 1895, and also of artificial radioactivity in 1934
1. Henri Becquerel (1852-1908)
o French physicist discovered radioactivity in 1896
2. Wilhelm Roentgen (1845-1923)
o German physicist who discovered x-rays in 1895
3. Pierre Curie (1859-1906)
o French physicist who, along with his wife, isolated Polonium
and Radium in 1898
4. Marie Sklodowska Curie (1867-1934)
o Winner of 2 Nobel Prizes for her achievements in physics
and chemistry
5. Irene Joliot-Curie (1897-1956)
o French scientist and Nobel Laureate
6. Jean Frederic Joliot-Curie (1900-1958)
o French physicist and Nobel Laureate
7. Georg Von Hevesey (1859-1906)
-Hungarian-Danish chemist who won the 1943 Nobel Prize in
chemistry for developing radioactive isotopes as laboratory tracers
When he was still a student, he noticed that he had frequent bouts of
indigestion, which he thought was due to leftover food which their
landlady serves. He added to the leftover food some radiotracer. Usually
the landlady would be serving them meatloaf on Sundays. When the
landlady served the food the following Sunday, he tried to detect if there
was any radioactivity present in the food. That was when he found out
that the landlady was actually recycling the food.
8. Ernest O. Lawrence (1901-1958)
-American physicist who won the 1939 Nobel Prize in Physics for the
invention of the cyclotron
The cyclotron is the machine usually being used for the production of
different radioisotopes.
9. Glenn T. Seaborg (1912-1999) and John J. Livingood
-Using a n a d v a n c e d c y c l o t r o n , a l o n g w i t h F r e d
i n t ro d u c e d
Fairbrother, they 1st Iron-59 in 1937
10. Emilio Segre (1905-1989)
-Italian physicist working with Seaborg, they discovered
Technetium-99m (more common radioisotope being used now) in
1938
11. Marshall Brucer (1913-1994)
-A Father of Nuclear Medicine and 1st president of the society of
nuclear medicine
Page 1 of 8
-Revolutionized the field of nuclear medicine with his development of
the gamma camera in 1958 This is now known as the Anger
camera, the machine that we use to take images of patients in
nuclear medicine.
-In 1946, a patient was treated with radioactive iodine (Iodine-131 / I-
131). The treatment caused the cancer to virtually disappear. Some
people consider this event to be the true beginning of nuclear
medicine. However, widespread use of radiopharmaceuticals did not
begin until the early 1950s.
-1st application of therapeutic nuclear medicine.
-This patient came to the hospital and presented symptoms of
hyperthyroidism. He was previously operated on the thyroid 7 years
prior because of thyroid cancer. So they were wondering why would a
patient present with hyperthyroidism when he no longer has a thyroid
gland? They found out that he has a tumor-like growth in his skull, his
pelvis, lungs, and ribs. They took a biopsy, and it consisted of thyroid
tissue. He was given a dose of radioactive Iodine with the hope that it
will take up Iodine and be irradiated. After 2 months, he was treated. It
was the first application of radioactive Iodine in the treatment of
patients with thyroid cancer.
13. David KUHL (1962)
-Introduced emission reconstruction tomography. This method later
became known as SPECT and PET. It was extended to transmission x-
ray scanning, known as CT.
-In the 1970s, most internal organs had been visualized with the use of
nuclear medicine. This included liver and spleen scanning, brain tumor
localization, and gastrointestinal tract studies.
-During the 1980s, radiopharmaceuticals were used in critical diagnoses
such as heart diseases. This decade saw the development of highly
sophisticated nuclear medicine cameras and computers.
Philippine Setting
-Philippines embarked on the beneficial application of nuclear science
and technology with the establishment of the 1st radioisotope
laboratory at the Philippine General Hospital in 1956 by DR.
PAULO CAMPOS along with Visitacion Manipol
- 1958: Creation of the Philippine Atomic Energy
Commission now known as the Philippine Nuclear Research
Institute
- 1965: The 1st gamma camera was installed at John F. Cotton
Hospital.
- 1976: Planar myocardial perfusion scans using Thallium-201 were
performed at the Philippine Heart Center
- 1986: 1st SPECT camera installed at Makati Medical Center
- 2000: PET scan installed at St. Lukes Medical Center
NUCLEAR MEDICINE
-In diagnosis, a small amount of a radioactive substance is
administered to the patient and the radiation emitted is measured
-It documents organ structure and function (in contrast to diagnostic
radiology, UTZ, CT, and MRI which are largely based on anatomy)
-Identifies abnormalities early in the course of a disease, long
before some medical problems are apparent with other diagnostic tests
-The majority of these diagnostic tests involve the formation
of an image using a GAMMA CAMERA. Imaging may also be
referred to as radionuclide imaging or nuclear scintigraphy.
-Images can be superimposed on images from CT or MRI to
highlight which part of the body the
radiopharmaceutical is concentrated in. This practice is often
referred to as image fusion or co-registration.
RADIOIMMUNOASSAY
-Amount o f radiation from a nuclear medicine procedure is
comparable to (usually smaller than) that received during a diagnostic
x-ray
-Natural radioactive decay for elimination from patient
-In therapy, radionuclides are administered to treat disease or provide
palliative pain relief
-Other diagnostic tests are probes to acquire measurements from parts
of the body, or counters for the measurement of samples taken from
the patient (thyroid uptake)
 Radiology
DESIRABLE CHARACTERISTICS OF RADIONUCLIDES FOR emitted by the patient would then be passing through the collimator ->
IMAGING Only those that has perpendicular read to the collimator would reach the
- Minimum particulate emission sodium iodide crystals -> covert photons into light energy -> light
- Primary photon between 50-500 keV energy goes to photomultiplier tube and converted to current ->
Tc-99m = 140 keV These pulses go through the multichannel analyzer -> Convert electric
Technetium is the most suitable radioisotope that we use in nuclear energy into pixels, processed to an image
imaging -Constant bombardment of radiation coming from the patient
- Physical half-life greater than the time required to prepare material cumulatively will collect and from pixels and can form the image of the
for injection organ you are trying to image.
- Effective half-life longer than imaging time -It takes time when you take and image, depending on the organ.
- Suitable chemical form and activity Kidneys: 6-30 min
- Low toxicity
Whats the difference between a radionuclide from the SCOPE OF NUCLEAR MEDICINE
radiopharmaceutical? 1. Diagnostic
Radiopharmaceutical: Radioisotope or radionuclide coupled to a -In-vivo procedures
pharmaceutical component. -Imaging (scanning)
The pharmaceutical component gives the specificity for the radionuclide -Non-imaging (uptake studies)
to be taken up by the organ that you want to visualize. -In-vitro procedures
-Radioimmunoassay (RIA)
RADIOPHARMACEUTICAL -Immunoradiometric assays (IRMA)
1. Free of any toxicity or secondary effects
2. Should not dissociate in-vitro or in-vivo 2. Therapeutic
3. Should be readily available or easily compounded -Benign diseases (e.g. hyperthyroidism, hemophilic/arthritic
4. Should have reasonable cost joints)
-Malignant diseases (e.g. thyroid cancer, liver cancer, lymphoma)
Radiopharmaceutical Half-life -Palliation (e.g. metastatic bone pains)
Tc-99m 6 hrs.
CLINICAL APPLICATIONS
I-123 13.2 hrs. Endocrinology
Xenon-133 (Xe-133) 5.2 days -Hormonal assays
-Uptake measurements
Gallium-67 (Ga-67) 78.3 hrs. -Organ imaging
Indium-111 (In-111) 2.8 days
Oncology
Thallium-201 (Tl-201) 73.1 hrs. -Bone scan
-Scintimammography
Fluorine-18 (F-18) 110 mins. - Whole body iodine scan
Ga-68 68 mins. - Bone marrow scintigraphy
-Lymphoscintigraphy
Carbon-11 (C-11) 20 mins.
Nitrogen-13 (N-13) 10 mins. Cardiology
Oxygen-15 (O-15) 2 mins. -Myocardial perfusion imaging
-Radionuclide ventriculography
Rubidium-82 (Rb-82) 1.3 mins.
Nephrology / urology
Gastroenterology / hepatobiliary
Neurology
Pulmonary
Ophthalmology
Infectious disease

THYROID SCINTIGRAPHY
Evaluation of morphology and function of the thyroid gland
Isotopes Used:
1. Tc-99m pertechnate: trapped by thyroid gland
2. I-131: trapped and organified

INDICATIONS
UNSEALED RADIONUCLIDES USED FOR THERAPY: 1. Relate structure to function
- Phosphorus-32 (P-32), Yttrium-90 (Y-90) Nodular or diffuse enlargement
- I-131, I-131 MIBG, I-131 lipiodol 2. Determine function of a palpable nodule
- Strontium-89 (Sr-89), Samarium-153 (Sm-153), Hot or cold nodule
Rhenium-186 (Re-186) Post-therapy evaluation for toxic adenoma
3. Locate ectopic thyroid tissue
BASIC COMPONENTS OF A GAMMA CAMERA Lingual thyroid
Collimator 4. Evaluation of the neck or substernal mass
Scintillation crystal Thyroglossal duct cyst
Photomultiplier tubes 5. Assist in evaluation of hyperthyroidism
Preamplifiers
Pulse height analyzer NORMAL THYROID SCAN
Digital correction circuitry -Uniformly distributed tracer
Control console -No labeling defects seen
Picture archiving system -Inject Technetium, wait for 15 minutes, and position the patient in the
How are images formed in nuclear medicine imaging? camera. We try to see whether the thyroid takes up radioisotope
Introduce radioisotope IV, orally -> Position the patient in gamma uniformly.
camera (gamma camera head is composed of the collimator, sodium -A normal thyroid gland would have a uniform distribution of the
iodide crystals, and the photomultiplier tubes) -> Radioisotope being radiotracer throughout the thyroid gland.

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-What if we dont see a thyroid glands if you do a thyroid scan? DDx:
Post-thyroidectomy
HYPOFUNCTIONING NODULE
Case:
36 years old female presenting with an anterior neck mass
Solid mass on PE, moves when swallowing
Doctor requested for a thyroid scan, and you see an area of decreased
uptake.
Possible differentials for a hypofunctioning nodule: Malignancy when it
replaces normal thyroid tissue, Cyst, Colloid or Adenoma, Hematoma,
Fibrosis.
Other images for hypo functioning nodule:
It could almost fill up the entire lobe of the thyroid gland. It could be
very large, and of different sizes.
It could also be
multinodulor. Several nodules replacing the thyroid tissue.
TOXIC ADENOMA
30 year old male with s/s of hyperthyroidism
PE shows palpable mass on right side of neck
-Scan shows solitary hot nodule with non- visualization of the rest of
the gland
-Probably, patient had a left lobectomy. Theres compensation of the
remnant thyroid tissue -> Symptoms of hyperthyroidism to compensate
for the loss of the contralateral lobe
-What if patient did not have surgery? Toxic Adenoma. Right lobe is
hyperactive, and depresses the activity of the contralateral lobe. Thats
why you cant visualize the left lobe.
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Radiology
-This is what you call the hot nodule. Cold nodule: hypo functioning
nodules. Hot nodule: area of increased uptake compared to the rest of
the thyroid gland. There is increased uptake of the radiotracer in that
palpable nodule. Usually these patients would be presenting with
symptoms of hyperthyroidism.
LINGUAL THYROID
-8 year old male with a mass in the root of the tongue
-Scan shows a midline functioning thyroid tissue in the base of the
tongue
-Usually seen in pediatric patients. When they stick out their tongue,
you will see a mass at the base.
You wouldnt see any uptake in the anterior neck, because this lingual
thyroid would be the only functioning thyroid tissue. Theres a failure of
development of the thyroid gland. Usually it starts from the tongue, goes
down, descends and is situated in the anterior neck during the
embryological stage. In this patient, theres failure of descent.
Should you operate on this patient? Better not, because its the only
functioning thyroid tissue that the patient has. If you take it out, the
patient becomes hypothyroid. Unless if there are obstructive symptoms
already, operate on the patient and give synthetic thyroid hormone.
These patients usually present as hypothyroid. This lingual thyroid cant
produce enough hormone for the body.
EVALUATION POST-THYROIDECTOMY
-Identifies any remnant or residual thyroid in a post-thyroidectomy
patient

I-131 WHOLE BODY SCINTIGRAPHY
-Post-surgical or post therapy procedure in the evaluation of
patients with well differentiated thyroid carcinoma.
-Evaluate for functioning thyroid residual/remnant in the neck
-Detection of thyroid cancer metastases.
-Detection of thyroid cancer recurrence.
-Applicable only in well differentiated thyroid
carcinomas such as papillary and follicular including Hurthle cell
CA.
THERAPEUTIC NUCLEAR MEDICINE
THYROID
Benign I-131 therapy for patients with Graves disease and Toxic
adenoma
Malignant Treat patients with well differentiated thyroid
carcinoma
-I-131 therapy for ablation of post-surgical residual thyroid tissue in the
neck and eradication of functioning local and distant thyroid metastasis.
PROPERTY: Make use of beta energy emitted by the radioisotopes. I-
131 also has gamma ray used for imaging at 354-360 units
RADIOIODINE IN THERAPY
BENIGN THYROID CONDITIONS
-Employed in thyroid therapy for hyperthyroidism
-I-131 is a beta-emitting radionuclide
-Physical half-life of 8.1 days
-A principal gamma ray of 364 keV
-A principal betaparticle with a maximum energy of 0.61 MeV
-Average energy of 0.192 MeV
-Mean range of tissue of 0.4 mm. Max range in tissue =2.4 mm
INDICATED FOR:
-For hyperthyroidism (Graves disease, toxic nodular goiter), recurrent
disease, and those contraindicated to anti-Thyroid Drugs (such as
Methimazole, PTU) and Surgery.
NOT INDICATED FOR
-Severe Acute Thyroiditis
-Silent painless thyroiditis
-Post-partum thyroiditis
-Thyrotoxicosis factitia
-Hyperthyroxinemia
How will you treat patients with hyperthyroidism?
-Initially: Anti-thyroid medications-Propylthiouracil (PTU), Methimazole
Allergic reaction to anti-thyroid medications: Sore throat, Fever, WBC
count goes down (Leukopenia), etc * Discontinue anti-thyroid
medications *
Alternative treatment: Surgery (with a lot of complication), Radioactive
Iodine Therapy (lesser side effects)
GOALS OF THERAPY
The goal is for our patient to be EUTHYROID after undergoing active
Iodine therapy. But some patients may become hypothyroid when all
thyroid tissues get ablated after the active iodine therapy.
HYPERTHYROIDISM
-To achieve a non-hyperthyroid status
-Euthyroid state or
-Iatrogenic hypothyroidism (that is completely compensated to the
euthyroid state).
-Oral Levothyroxine.
LARGE NON-TOXIC NODULAR GOITER
-Reduction of thyroid volume to relieve symptoms caused by
compression of the goiter on the structures in the neck.
PATIENT PREPARATION
1. For a sufficient time before therapy, Patients must discontinue use
of iodine-containing medications and preparation that could
potentially affect the ability of thyroid tissue to accumulate iodide.
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Radiology
2. Pre-treatment of selected patients with ATDs to deplete thyroid
hormone stores.
3. Physician must explain the procedure, treatment, complication
and side effects, therapeutic alternatives and expected
outcome to the patient. Radiation exposure. The patient usually
needs to follow radiation precautions after receiving therapy.
4. Consent is obtained prior to therapy
5. DYSGEUSIA (altered or distorted sense of taste) are very
uncommon side effects. Candies or sour foods induce salivation.
6. Small (1-5%) chance of mildly painful radiation thyroiditis after
treatment. Swelling when iodine concentrates in the thyroid glands
after the procedure.
7. The form should also explain likelihood of eventual
hypothyroidism.
8. OPHTHALMOPATHY may worsen or develop after therapy for
Graves disease especially in smokers. Steroids minimize
Ophthalmopathy.
9. Patients with severe hyperthyroidism may occasionally
experience an exacerbation of symptoms within the 1st 2 weeks
after I-131 therapy. Some experience exacerbation of palpitations,
easy fatigability and tremors after therapy.
10. There is no evidence of an increased risk of thyroid carcinoma
or malignancy, an increased risk of infertility or an increased
incidence of birth defect caused by I-131. It is important that
patients follow precautions for radioactive iodine therapy.
11. There exists a small risk of pre-existing or coexisting thyroid cancer
in patients with toxic nodular goiter and Graves disease
12. A final item to consider including on the informed consent form is
that most experts recommend waiting 6-12 months after I-131
therapy before trying to conceive.
13. I-131 therapy is always contraindicated in pregnant women.
Thorough hx for pregnancy! Ask for the LMP
FACTORS AFFECTING I-131 EFFECTIVENESS
Dose itself
Uptake into the organ
Over-all gland size
Transit through the thyroid
Status of iodine sufficiency (or deficiency)
Radiation sensitivity
DOSE CALCULATION
Fixed dose vs calculated dose vs empirical dose.
5 mCi- not so enlarged thyroid
10 mCi- intermediate size thyroid
15 mCi large thyroid
30 mCi- toxic adenoma
-Request for a thyroid uptake and scan to ascertain how large the thyroid
gland is. Compute it with the aim of delivering around 100-160 uCi/gm
-High dose- risk for development of hypothyroidism.
5000-15,000 rads or 50-150 Gray
There is no difference between fixed and calculated dose.
-Goal: Euthyroid state (very hard to give the exact amount to achieve
this) or Hypothyroid state (Indications: Patients allergic to Anti-thyroid
medications or hyperthyroid for a very long time)
UPTAKE INTO THE ORGAN
-Hyperthyroid uptake ranges from 30-90%.
-Distribution: homogenous vs. in homogenous
-24 hr- RAIU and scan as appropriate indicators
TRACER UPTAKE vs THERAPY UPTAKE
-Difference is usually <15%
-Therapy uptake decreased by iodine contaminants (food and drugs)
GLAND SIZE (or weight) DETERMINATION
-Easy
-Difficult (experience provides good estimation)
THYROID IMAGING (scan and Ultrasound)
-Helpful for diffuse enlargement or nodule formation (higher doses for
toxic nodular goiter)
 Radiology
-Prior use of anti-thyroid medications (PTU but not Methimazole) IDEAL TREATMENT
confers radio-resistance For well differentiated thyroid carcinoma (papillary and follicular thyroid
-Treatment failure vs use higher I131 dose. cancers)
1. Near total thyroidectomy / Total thyroidectomy
TREATMENT GOALS -Most ideal treatment because you want to take out all thyroid tissues
Effect on Thyroidal Physical Configuration and lymph nodes.
-Decrease in global size (for diffuse enlargement) -Should be done over subtotal thyroidectomy
-Decrease in nodule number and dimensions (for nodular -Prevent recurrence of the carcinoma
enlargement) 2. Followed by Radioactive iodine ablation
3. Lifetime thyroid hormone suppression
Effects on thyroidal function
-Desired: Euthyroid state WHY TOTAL THYROIDECTOMY OR NEAR TOTAL?
-Inevitable: Hypothyroidism a. Incidence of multi-centricity in both lobes
-Unintended: Persistent Hyperthyroidism (Very low dose. May need PRO: To retain some thyroid tissue for thyroid function
another dose of radioactive iodine therapy) CON: Thyroid cancer may be multi-centric, not just in one lobe. It would
-Unfortunate: Thyroid storm (Lack of preparation. Very high levels of be easier to administer exogenous thyroid hormones
thyroid hormones during therapy)
b. Issue of dedifferentiation of well differentiated thyroid carcinoma
IMPLICATION to anaplastic type if you dont take out the rest of the thyroid gland
-The patient should be in a euthyroid state with anti-thyroid medications
before starting iodine therapy to prevent thyroid storm. TREATMENT DEPENDENT ON THE FOLLOWING: (Skipped)
-After computing the dose, give iodine in the form of capsule or solution Risk factors involved:
<15mCi- No need for admission Age: appears to be the most important prognostic factor, prognosis
>15mCi- For hospital admission-For isolation to prevent for DTC is better for patients younger than 40 years of age
exposing other people to unnecessary radiation Metastases: Poor prognosis
Extent of tumor invasion in the surrounding capsule or blood vessels
RAI-131 TREATMENT OUTCOMES Size: greater than 4 cm (poor prognosis)
Clinical Thyroidal Outcome-Hypothyroidism
Other risk factors
Clinical Non-Thyroidal Outcomes -Invasiveness: capsular or extra-thyroidal, tall variant variety of papillary,
Risk for carcinogenesis: very little intense immunostaining for vascular endothelial factor (VEF)
Other effects: hardly, if at all -Incomplete resection and tumor size
Safety & Efficiency -Increased serum thyroglobulin levels
-Expression of the tumor suppressor gene p53
THYROID CANCER: I131
Well differentiated thyroid carcinoma, we do radioactive iodine Staging (American Joint Committee on Thyroid cancer)
therapy as an adjunct to thyroid surgery. (Skipped)
TNM Classification
ROLE OF I-131 IN THYROID CANCER: -Most popular prognostic scoring system
1. Adjunct to thyroid surgery: for ablation of thyroid remnants -Tumor is divided into solitary or multifocal
2. As definitive treatment of metastatic disease: for ablation of -Based mainly on the extent of tumor and age
metastatic deposits -Regional lymph Nodes
3. To decrease risks of recurrences -Cervical and upper mediastinal lymph nodes - N
4. To facilitate long-term surveillance (Imaging techniques and -Metastasis-None or distant M
Tumor marker monitoring)
TNM Definitions:
PREVALENCE Philippines o T0: No evidence of tumor
o T1: Tumor 1cm or less limited to the thyroid
18th Most frequent cancer in males
o T2: More than 1 cm 4cm
4th among females
o T3: Over 4 cm
7th combined o T4: Tumor of any size
TYPES:
Lymph nodes (N)
a. Papillary: 70-80% o NX: lymph node cannot be assessed
b. Follicular: 10-15% o N0: none
c. Mixed o N1: regional lymph node mets
d. Medullary: 5-10% o N1a: mets ipsilaterally
e. Anaplastic: 1-2% o N1b: bilaterally, midline, or contralateral cervical or
mediastinal lymph nodes
Well-differentiated thyroid carcinomas (Only sensitive to I-131)
Papillary Distant metastasis
Follicular o MX: mets cannot be assessed
Mixed o M0: none
o M1: distant mets
PAPILLARY THYROID CANCER
-Most common, most curable PAPILLARY AND FOLLICULAR CANCER
-Often localized in the neck (50%) but may involve commonly the lymph
nodes Under 45 years old
-Occasionally spread via the lymphatics o Stage I: any T, any N, M0
o Stage II: any T: any N, M1
FOLLICULAR THYROID CANCER
-Less frequent, involving the older age group 45 years and older
-Curable but spreads thru the hematogenous route hence it o Stage I: T1, N0, M0
metastasizes to the lungs, bones, and elsewhere. o Stage II: T2, N0, M0 / T3, N0, M0
-But they still respond to radioactive therapy o Stage III: T4, N0, M0 / any T1, N1, M0

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 Radiology
o Stage IV: any T, any N, M1 3. Patient operated on however no thyroid hormones or
-More than 45 years of age you already have stage 3 and 4 radioactive iodine therapy

THERAPEUTIC OPTIONS (skipped)
-Standard
-Depending on clinical evaluation and risk factors
-Surgery may range from lobectomy-Lower incidence of complications
but 5-10% will have a recurrence
Total or near total thyroidectomy (TT/ NTT)-Advocated due to high
incidence of multicentric involvement of both lobes and dedifferentiation
of cell types, after which, ablate the thyroid remnants
**This shows that patients who had surgery + radioactive iodine
therapy + levothyroxine suppression had decreased death rate and
lower recurrence rates.
CANCER DEATH RATES AFTER THYROID REMNANT
ABLATION (skipped)

WHY STILL ABLATE REMNANTS?

How to determine if there is residual thyroid tissue left?
o Thyroid scan
o Ultrasound
o PET CT
o I-131 scan
-Studies (Beierwaltes, Mazzaferri) have shown that a post-operative
course of therapeutic (ablative) doses of I-131 results in a
decreased recurrence rate of papillary and follicular CA of the thyroid
-Another surgery is difficult in the recurrence of the thyroid cancer and
may lead to complications such as hypoparathyroidism

WHY STILL ABLATE WITH I-131?

-It is simple, safe and effective in patients with aggressive thyroid
cancer and many centres use it routinely for well-differentiated thyroid
cancers.
PROGNOSIS
-It is generally excellent for papillary and follicular thyroid CA for
adults under age 45 years. Follicular CA have a cancer mortality rate
that is 3.4 times higher than papillary CA.
-Patients with primary tumors over 1 cm and undergo subtotal
thyroidectomy or lobectomy have a 2.2-fold increase over those who had
TT or NTT
-Increase oral fluid intake and take frequent baths to excrete the
radiotracer from the body
-Hurthle cell carcinoma: variant of follicular CA
-More aggressive; Higher risk of recurrence
-Decrease recurrence with radioactive iodine therapy
-Patients who have not received RAI have mortality rates that are
increased two- fold by ten years and three-fold by 25 years over
those who have received ablation
-Risk of recurrence is two-fold higher in men than in women
-1.7-fold higher in multifocal than in unifocal tumors
-From the studies of Loh, KC, and Hay, ID show the advantage of doing
the radioactive iodine theraphy vs surgery and giving exogenous
hormone.
The death rate of patients who had remnant ablation with I-131 is almost
zero, as compared to those with thyroid suppression only.
So near total/total thyroidectomy, then radioactive iodine therapy. After
radioactive iodine therapy, give them thyroid hormone suppression
with levothyroxine
Give suppressive doses of levothyroxine, not just replacement doses.
We want the TSH levels to be suppressed to decrease the rate of
recurrence.
INDICATIONS WITH REGARDS TO THE AJCC STAGING
Stage I & II: Lobectomy/NTT/TT
-I-131 may be an option especially for micro carcinomas (less than 10
mm) but most studies advocate this as results have shown a decreased
recurrence rate but is not considered routine
-Thyroid hormone suppression
Kaplan Meier analysis of intrathyroidal cancer with respect to the
use of I-131
o Survival was almost the same for the first 8-10 years.
o After 10 years, survival is better with those treated with I-131

Micropapillary CA
-<1 cm
-Treatment: lobectomy or near total thyroidectomy
-But some develop metastasis years after being diagnosed

TOTAL RECURRENCE RATE VS DIFFERENT MODALITIES

OF TREATMENT (Skipped)

Stage III
-Total thyroidectomy plus removal of involved lymph nodes or other
extrathyroidal sites
-I-131 ablation IF the tumor demonstrates uptake of this isotope
-Thyroid hormone suppression

Stage IV
-The most common sites of metastases are the LYMPH NODES,
Graph for comparison of 3 patients who had undergone surgery: LUNGS, AND BONES. Treatment of lymph nodes is often curative but
1. Patient after undergoing thyroidectomy received radioactive for distant metastases, especially skeletal, may produce significant
iodine therapy palliation.
2. Patient who been operated on was given levothyroxine; and -TT

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 Radiology
-I-131 I-131 TREATMENT AND FOLLOW-UP
-External beam radiation if I-131 uptake is minimal
-Thyroid hormone suppression
-Stage IV well differentiated thyroid carcinoma = metastasis
-Radioactive iodine therapy may not be enough
-Subject patients to external beam radiation therapy especially if there
are lesions in the bone.

Post 3 days prior to 6 months post

thyroidectomy therapy therapy

-This patient has papillary thyroid carcinoma and had a scan prior to
radioactive iodine therapy showing lesions in the lungs, skull,
physiologic uptake in the intestines and the urinary bladder. The patient
received a dose of 150 mCi. More lesions may appear on post therapy
whole body scan after therapy.
-We usually evaluate patients 6 months after treatment with another
whole body scan to check.
-If still with metastatic lesions and thyroglobulin levels are still elevated
after 6 months, repeat radioactive therapy

SPECT-CT

STANDARD THERAPY: EMPIRICAL DOSE (ALARA)

-Neck: 100 mCi, although there is that option of using 50-60 mCi. (50-
100mCi)
-Lymph node or Lung metastasis: 150 mCi
-Skeletal metastasis: 200-250 mCi
-Can give repeated radioactive iodine therapy to patients as long as the
remnants or the metastatic lesions still concentrate the iodine with a limit
up to 1,000 mCi. More than that, patients can develop secondary
cancers. Post thyroidectomy to check whether there are remnants or
-As long as cumulative doses does not exceed 1,000 mCi due to metastatic lesions
danger of leukemias and hematopoietic problems -December 2005 -Post-I-131 scan after receiving 150 mCi
-Monitor with CBC regularly -August 2006 post therapy
-Leukemia develop in higher cumulative doses, not on single doses
-Some doctors give as low as 50 mCi. Studies have shown that 50 mCi
is as effective as giving 100 mCi.

EFFICACY OF LOW DOSE VS. HIGH DOSE

(IAEA STUDY DONE LOCALLY E. BARRENECHEA)

Low dose (50-60 mCi)

o Failure in 48.6% and success in 51.4% with a
o p-value of 1.00 which is not significant

High dose
o Failure of 36% and success of 63.4% with a
o p-value of 0.027 which is significant This is a patient with metastatic lesions in the lungs After treatment,
there is clearing of the lesions after radioactive iodine therapy.
Local study (Barrenechea)
o Philippine setting Follow-up whole body scan (WBS) 8 months later showed
o Mostly papillary: 67% clearing of the lung mets
o 44% success using 50 mCi
o 75% success using 100 mCi OTHER DEVELOPMENTS IN THE MANAGEMENT OF TCA
(Skipped)
SUCCESS OF THERAPY -Use of recombinant human TSH-both for diagnosis and treatment
-Absence of radioactivity in the thyroid bed on scintiscan after using 3-5 avoids the discomfort of hypothyroidism, recent studies claim 100%
mCi of I-131 which is usually done 3-6 months after ablation using high successful ablation without sacrificing the quality of life.
dose of radioactive iodine -Use of Omeprazole / antiemetics
-After radioactive iodine therapy, request for a post therapy whole body -Thyroxine as replacement rather than suppressive in selected cases
scan to check where your iodine concentrated. Pre-treatment scanning (levothyroxine)
may result to scanning reaction and patients may not respond well
therapy.

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 Radiology
OTHER OPTIONS -May either make use of Yttrium-90, Rhenium-186, or Erbium-169
-Clinical trials evaluating new approach should also be considered After injection to the joint area, there is pannus or scar formation in the
-Chemotherapy with Bleomycin (Harada) or with Doxorubicin alone or joint area to decrease inflammatory process. Also used in patients with
Doxo with Cisplatin (Shimaoka) and chemotherapy (Gottlieb) have been hemophilic arthrosis.
tried for advanced thyroid CA (usually chemotherapy has no role in the
management of well differentiated thyroid carcinoma.) HEPATOCELLULAR CARCINOMA
-Use of Sorafenib in locally recurrent or metastatic, progressive, -Adjunctive treatment of inoperable hepatocellular CA to see if survival
differentiated DTC that is refractory to radioactive iodine treatment. time can be prolonged as well as reduce incidence of recurrence in
patients after resection of primary tumor
MEDULLARY CANCER -Isotopes used are I-131 lipiodol, Rhenium-188 lipiodol, and Yttrium-
-Total thyroidectomy 90 microspheres (delivered directly to the tumor)
-Radioactive iodine has no place in the treatment
-Palliative chemotherapy may help RADIOIMMUNOTHERAPY
-External radiation: no evidence that it provides any survival advantage
-Type of targeted therapy that delivers radiation directly to the cancer
-The ablation of thyroid remnants or residuals is left upon the discretion
cells.
of the attending physician. The pros and cons should be weighed in
-We couple an antibody which is directed towards an antigen. More
favor of the patients welfare, considering risk factors, and economics.
commonly used is Yttrium. Commonly used in patients diagnosed with
-Most physicians do routine ablation considering it has more beneficial
NHL.
effects than risks.
-ZEVALIN- treatment of NHLCoupled with Yttrium
-Monoclonal antibody directed against CD 20 antigen found in 90% of B
Indications for ABLATIVE TREATMENT WITH I-131 AFTER
cells (target)
SURGERY are:
-Targets CD20 antigen found in the B-cell and the Yttrium-90 would
-Distant metastases
attack the surrounding B-cells with the high energy beta radiation
-Incomplete resection of the tumor
reducing cellular damage almost to the molecular level
-Complete excision of tumor but with high risk of mortality associated
-Relapsed of refractory, low grade or follicular B-cell non-
with the tumor or with high risk of relapse due to age, histology, or extent
Hodgkins lymphoma (NHL)
of the disease
-Previously untreated follicular NHL, who achieve a partial or
-Elevated serum thyroglobulin over 10 ng/ml
complete response to first-line chemotherapy
-Differentiated thyroid cancers, namely papillary, follicular, or mixed are
prevalent in the Philippines mostly among the female population. The
CONCLUSION
old notion that it is an indolent disease is not always true and we should
-Nuclear medicine uses safe, non-invasive tools for assessing
not be too complacent about the disease.
metabolic tissue function.
-Well-differentiated thyroid cancers, namely papillary and follicular, as
-Some procedures allow imaging of entire body in one study.
well as mixed tumors, should be taken care of by the nuclear medicine
-Helpful even in cases of altered anatomy
physician after NTT or Total thyroidectomy.
-Aid in choosing appropriate therapeutic plans
-It requires an ideal follow-up of 10 years.

ANAPLASTIC CA External beam radiation

-Thyroidectomy
-Surgery, tracheostomy if necessary
-Radioactive therapy has no role in Medullary and Anaplastic CA
MALIGNANT BONE PAIN TREATMENT (PALLIATION)
-Therapy for painful osseous metastasis, palliation of pain and not a
cure. (analgesia is no longer sufficient)
-Radionuclides used are Strontium-89, Chloride, Rhenium-186,
hydroxyethylenediphosphate and Samarium-153,
ethylenediaminetetramethylene phosphonic acid. These are bone
seeking radioisotopes. Deposit in areas of increased bone repair and
turnover also seen in metastatic lesions in the bone. Given via IV.
-Do a whole body scan to check for osteoblastic lesions. Effective for
osteoblastic lesions but not for osteolytic conditions.
Alternative: Samarium
-Chemotherapy: 30% partial remission with Doxorubicin
-Radioactive iodine has no place in the treatment
-Combination of chemo and irradiation may prolong survival (Haigh,
2001)
-There is a need to individualize therapy depending on personal
experiences and peculiarity of the disease.
-I-131 is an important element in the triad to ensure success of
treatment of the disease.
-Radioactive iodine certainly decreases incidence of recurrences,
increases longevity, esp. for localized neck lesions and even large
tumors. Cure even to those cases with invasive properties
-It promises a cure even to those cases with invasive properties as
evidently seen in the local experience.
-For distant metastases, it produces palliation, if not a cure, but
repeated dosing may be necessary.

RADIOSYNOVIORTHESIS
-For the efficient local treatment of chronic inflammatory joint disease
-For haemophilic arthropathy

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