Iodine 131 thyroid Therapy. Sara G. Johnson, MBA, CNMT, NCT President SNMMI-TS VA Healthcare System San Diego

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1 Iodine 131 thyroid Therapy Sara G. Johnson, MBA, CNMT, NCT President SNMMI-TS VA Healthcare System San Diego

2 OBJECTIVES Describe the basics of thyroid gland anatomy and physiology Outline the disease process of hyperthyroidism and thyroid cancer Describe the use of Iodine-131 in the treatment of thyroid conditions Dr. Ryan Niederkohr will discuss the 2015 American Thyroid Association Guidelines

3 RADIONUCLIDES IODINE I-131 Physical half-life: 8 days Principle gamma photon: 364 kev Beta particle emission: MeV High radiation absorbed dose (50 rads/50 uci) Therapeutic agent; minimal diagnostic utility

4 Development of Thyroid Gland 7 weeks of gestation thyroid develops Starts at base of tongue Migrates caudally down to neck Week 12 fetal thyroid hormones

5 Lingual Thyroid 1 month old serum labs Reveal hypothyroidism slide courtesy of e.v.belezzuoli, M.D.

6 Development of Thyroid Gland 7 weeks of gestation thyroid develops Starts at base of tongue Migrates caudally down to neck Week 12 fetal thyroid hormones Remnant of midline tissue arising from the isthmus the pyramidal lobe.

7 Pyramidal lobe Normal variant Seen in % of population Thyroglossal duct Yousem, David M. Nerurology imaging1996 Vol 6:2;453

8 Thyroid Anatomy Butterfly shaped organ located in the front of the neck just above the collar bone. Left and right lobes are connected by an isthmus. The normal thyroid gland weighs about 20 grams.

9 Thyroid Anatomy cont. The lobes contain most the functioning thyroid cells Functional units are epithelial cells arranged in follicles Cells trap iodide from blood stream organify and couple to form T3 & T4

10 Thyroid Endocrine Function Synthesis of thyroid hormone Thyroxine (T4) 80% T4 Triodothyronine (T3) 20% T3 T3 posses about 4x the hormone strength of T4

11 Thyroid homone Secretion TRH Hypothalamus TSH Pituitary Thyroid Gland - Thyroid hormones High blood conc. Of hormones inhibit TSH & TRF

12 Factors affecting uptake Size of the body s iodine pool Competitive inhibition counteracts active process of radioiodine accumilation Functional status of the gland Hypo decreased uptake Hyper increased uptake Time post administration

13 FACTORS AFFECTING UPTAKE DECREASED UPTAKE Thyroid Hormones Thyroxine (T4) Triiodothyronine (T3) Excess Iodine (Expanded Iodine Pool) Saturated solution of potassium iodide Some mineral supplements, cough medicines, and vitamin preparations Iodine Food supplements Iodinated drugs (e.g., amiodarone) Iodinated skin ointments Congestive heart failure Renal failure DURATION OF EFFECT 4-6 weeks 2 weeks 2-4 weeks 2-4 weeks Weeks to months 2-4 weeks

14 FACTORS AFFECTING RADIOIODINE UPTAKE DECREASED UPTAKE Radiographic Contrast Media Water-soluble intravascular media Oral cholecystographic agents Fat-soluble media (lymphography) Noniodine-Containing Drugs Adrenocorticotropic hormone, adrenal steroids Monovalent anions (perchlorate) Penicillin Antithyroid drugs Propylthiouracil (PTU) Methimazole (Tapazole) Bromides DURATION OF EFFECT 2-4 weeks 4 weeks to indefinite Months to years Variable 3-5 days 5-7 days

15 Factors increasing uptake Iodine deficiency Pregnancy Rebound phase after discontnuance of thyroid hormones & antithyroid drugs, recovery from thyroiditis Choriocancinoma (uterine tumor) Hydatid-form mole Renal failure

16 Diseases of the Thyroid Hypothyroidism Hyperthyoidism Thyroid cancer

17 Iodine 131 treatment Hypothyroidism not indicated Hyperthyroidism Graves disease (diffuse toxic goiter) Plummer s disease (toxic nodular goiter)

18 Graves Disease anxiety, Irritability, Fatigue, difficulty sleeping, weight loss, rapid or Irregular heart beat, brittle hair, exophalmus

19 % uptake % uptake = net counts in thyroid X 100 Net counts in phantom Normal 6 hour uptake % = appox 12% Normal 24 hour uptake % = appox. 7 30% Normal varies by institution

20 GRAVES DISEASE Most common etiology of thyrotoxicosis Diffuse/homogeneous uptake on scintigraphy Markedly elevated %RAIU Excellent response to therapy with I-131 slide courtesy of e.v.belezzuoli, M.D

21 MULTINODULAR TOXIC GOITER Symptoms mild compared with Graves Inhomogenous uptake on scintigraphy %RAIU my be normal or low Generally more resistant to RAI therapy Yousem, David M. Nerurology imaging1996 Vol 6:2;453

22 TOXIC ADENOMA Occurs in 5% of patients with solitary palpable nodule Toxic nodule suppresses uptake in extranodular gland %RAIU mildly elevated or normal Suppressed tissue receives minimal I-131 radiation slide courtesy of e.v.belezzuoli, M.D

23 SUBACUTE THYROIDITIS Includes de Quervain s, silent thyroiditis, and post-partum thyroiditis Minimal visualized activity on scan %RAIU markedly depressed RAI therapy not indicated slide courtesy of e.v.belezzuoli, M.D

24 HYPERTHYROIDISM THERAPY OPTIONS Surgery Antithyroid medication

25 ANTITHYROID MEDICATION Propylthiouracil (PTU), methimazole Block organification/synthesis of thyroid hormone Frequent adverse effects (50% of patients) Permanent remission more frequent with younger patients, mild disease, small goiters Used to cool down patient prior -131 to I Tx Biggest drawback once removed return to hyperthyroid state.

26 HYPERTHYROIDISM THERAPY OPTIONS Surgery Antithyroid medication RAI Therapy

27 GRAVES DISEASE I-131 THERAPY DOSING Standard dose (10-15 mci) Arbitrary high dose (20-30 mci) Calculated dose ( uci/g thyroid tissue)

28 Thyroid radioiodine uptake 100 Graves Uptake (%) 50 Normal 0 Graves rapid iodine turnover Time (hours) Adapted from The Requisites, Nuclear Medicine: 3rd edition: 2006 slide courtesy of e.v.belezzuoli, M.D.

29 GRAVES DISEASE I-131 DOSE CALCULATION I-131 dose (uci) = uci/g desired x gland wt (g) %RAIU (24 hr)

30 Graves Disease 45 y/o female Hyperthyroid Large Gland (100 g) RAIU 48%/79% 120uCi/g x 100g = 15.2 mci.79 slide courtesy of e.v.belezzuoli, M.D.

31 Thyroid radioiodine uptake 100 Graves Uptake (%) 50 Normal 0 Graves rapid iodine turnover Time (hours) Adapted from The Requisites, Nuclear Medicine: 3rd edition: 2006 slide courtesy of e.v.belezzuoli, M.D.

32 GRAVES DISEASE RAPID IODINE TURNOVER 55 y.o. female; hyperthyroid, diffuse goiter (60 g) RAIU 50% / 28% 120uCi/g x 60g 0.28 = 25.7 mci slide courtesy of e.v.belezzuoli, M.D

33 Thyroid radioiodine uptake 100 Graves Uptake (%) 50 Normal 0 Graves rapid iodine turnover Time (hours) Adapted from The Requisites, Nuclear Medicine: 3rd edition: 2006 slide courtesy of e.v.belezzuoli, M.D.

34 I-131 HYPERTHYROID TX COMPLICATIONS Exacerbation of hyperthyroid symptoms Hypothyroidism

35 TOXIC NODULAR GOITER I-131 THERAPY DOSING More resistant to RAI therapy Higher/maximal outpatient I-131 doses utilized Usual dose mci I-131 Low risk of hypothyroidism due to extranodular suppressed thyroid tissue slide courtesy of e.v.belezzuoli, M.D

36 slide courtesy of e.v.belezzuoli, M.D. HYPERTHYROIDISM Graves Thyroiditis TMNG Labs TSH, FT4, +TSI TSH, FT4, TSH, FT4, T3 Scan Diffuse homogeneo us activity Minimal visualizd activity Inhomogene ous hot / cold nodules %RAIU / RAI TX Yes No Yes

37 I-131 treatment for Cancer Functioning Thyroid Cancer Papillary (>70%) Follicular (appox 15%) Medullary (appox. 5-8 %) Hurthle Cell (Appox. 3%) Anaplastic (appox. 2%) Non Funcitioning thyroid Cancer Does not trap or organify iodine

38 Thyroid Cancer Cold Nodules % of nodules are Cold on scan. FNA needed to diagnosis

39 I-131 Therapy Patient preparation Stop antithyroid medication for 1 week prior (Hyperthryroid Tx) Stop Thyroid replacement weeks months (Ca Tx except for rtsh) Low iodine diet Pregnancy test as necessary Correlation with lab work Informed Consent

40 I-131 Treatment Post Therapy restrictions Avoid close contact with small Children & Pregnant Women 1 week Avoid close/intimate contact with other adults 3 4 days. Strict personal hygiene for 3-4 days Avoid pregnancy for 6-12 months

41 RAI Therapy Goals for Thyroid Cancer Post surgical ablation of thyroid remnant Disease Surveillance Therapy for recurrent/metastatic disease

42 slide courtesy of e.v.belezzuoli, M.D.

43 slide courtesy of e.v.belezzuoli, M.D.

44 RAI REMNANT ABLATION PROTOCOL Total/near-total thyroidectomy Withdraw thyroid hormone; verify TSH > 30 Low dose (1-3 mci) I-131 for pre-tx scan I-131 whole body scan at hours Admit for High dose - Discharge Pt exposure levels < 7mr/hr mrem exposure to others Whole Body I-131 Scan 7-10 days post Therapy

45 SURVEILLANCE WITHDRAWAL PROTOCOL Withdraw thyroid hormone; verify TSH > 30 Obtain thyroglobulin (Tg) level I-131 scanning dose (5-10 mci) I-131 whole body scan at hours High dose I-131 Tx if scan positive

46 SURVEILLANCE THYROGEN (rtsh) PROTOCOL Thyroid hormone withdrawal not required Day 1: Thyrogen injection #1 Day 2: Thyrogen injection #2 Day 3: Dose I-131 (3-5 mci) TSH blood test Day 5: Whole body I-131 scan Tg blood Test

47

48 SURVEILLANCE I-131 SCAN/Tg DISCORDANCE Tg level relatively low (<10) Repeat I-131 scan/tg level in 6-12 months Tg level high RAI Tx PET scan if post Tx I-131 scan is negative

49 Pet scan for Thyroid Cancer When? Use selectively Thyroglobulin positive, but iodine-negative Negative Pet cancer is slow growing Positive pet aggressive cancer usually stage iv Wan, Q. SNM Meeting Abstract 552. June 2003

50 Conclusion We have over 60 years of experience with Iodine 131. Iodine 131 is an excellent therapy for hyperthyodism. Most Thyroid Cancers respond very favorably to Iodine 131 therapy Dr. Ryan Niederkohr will discuss the 2015 American Thyroid Association Guidelines

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