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Indian Journal of Nuclear Medicine : IJNM : The Official Journal of the Society of Nuclear Medicine, India logoLink to Indian Journal of Nuclear Medicine : IJNM : The Official Journal of the Society of Nuclear Medicine, India
. 2013 Dec;28(Suppl 1):S25–S28.

Thyroidology

PMCID: PMC3868032
Indian J Nucl Med. 2013 Dec;28(Suppl 1):S25–S28.

Thy-01: Comparison of 24 h neck uptake using camera based and standard uptake probe based methods undertaken with 25 uCi of 131I capsule in patients with benign thyroid conditions

Biju K Menon, Ramesh D Rao, Amit Abhyankar, MG Ramakrishna Rajan, Sandip Basu

Radiation Medicine Centre, B.A.R.C, Tata Memorial Centre Annexe, Parel, Mumbai, Maharashtra, India

Objective: To make a quantitative comparison of thyroid uptake values calculated using camera based and thyroid uptake probe based methodologies in patients with benign thyroid disorders (mostly patients of hyperthyroidism) after administration of 25uCi 131I capsule.

Materials and Methods: Patients undergoing 25 uCi 131I thyroid uptake and scan in our centre for various indications were included for the study. These patients mostly belonged to hyperthyroidism group who underwent the procedure before being considered for 131I therapy for thyrotoxicosis. Based upon the patient profile, the patients were categorized into two groups: (a) Patients with hyperthyroidism and (b) Patients with non-thyrotoxic group. 25 uCi capsule was administered and 24 h thyroid uptake by thyroid probe was undertaken by standardized institutional protocol. Uptake was calculated by the equation background subtracted neck counts/background subtracted standard counts. Gamma camera with high energy collimator was used to calculate neck uptake for calculation of uptake by gamma camera based methods. Standard capsule was scanned and counts were calculated by drawing ROI around the capsule image. Similarly neck counts were obtained by drawing ROI around thyroid image. Background subtraction was done by drawing ROI near thyroid image. Data of these two different groups were compared with paired t-test.

Result: A total of 50 patients were included in this study (32 hyperthyroid and 18 non-thyrotoxic). The difference in % uptake observed by these two methods does not vary significantly in both the groups. For group (a) the uptake value varied from 40.13% to 98.6% while for group (b) the uptake value varied from 1.48% to 34.29%. In Group (a) P value from t-test is 0.418 and for group (b) P value is 0.444.

Conclusion: Camera based uptake can be used as an alternative method for thyroid uptake using probe based method, by which this could be useful to centres who do not possess thyroid uptake probe. In a routine setting this could reduce patients inconvenience and save scan time as the quantitative value can be obtained by single neck scan.

Indian J Nucl Med. 2013 Dec;28(Suppl 1):S25–S28.

Thy-02: Comparision of radioactive iodine (I-131), F-18 FDG and 68-Ga DOTATATE PET scans in advanced follicular cell derived thyroid cancers

Pankaj Kumar, Gaurav Malhotra, Ramesh V Asopa

Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Jerbai Wadia Road, Parel, Mumbai, Maharashtra, India

Objectives: Somatostatin receptor expression has not been well studied in non-medullary thyroid cancers. The aim of this study was to prospectively evaluate and compare radioiodine, F-18 FDG and Ga-68 DOTATATE PET scans in advanced differentiated thyroid cancers.

Materials and Methods: Twelve consecutive patients (4 male and 8 female; age range: 44-75 years; median age: 57 years) harboring 68 lesions of advanced differentiated thyroid cancers (6 papillary, 5 follicular and 1 poorly differentiated thyroid cancer) were included in the study. All patients underwent whole body diagnostic scans with I-131, F-18 FDG and Ga-68 DOTATATE PET scans as per the institution protocol. Only patients with at least one radioiodine positive metastatic lesion were included while those with a negative whole body radioiodine scan were excluded from the study. The lesions in all three scans in each patient were tabulated and comparatively analyzed.

Results: 44/68 (64.7 %), 47/68 (69.1 %) and 44/68 (64.7 %) lesions were positive on I-131, F-18 FDG and Ga-68 DOTATATE PET scans respectively. There was a concordance rate of 45.6%, 47.1% and 48.5% between I-131 and F-18 FDG PET scan, I-131 and Ga-68 DOTATATE PET scan and F-18 FDG PET scan and Ga-68 DOTATATE PET scan respectively. Notably, 23.5% lesions on F-18 FDG PET scan and 19.1 % lesions on Ga-68 DOTA PET scan did not show radioiodine uptake when each of these modalities was individually compared with radioiodine (I-131) imaging.

Conclusions: In patient with advanced thyroid cancers, both F-18 FDG PET and Ga-68 DOTA PET imaging should be performed in addition to routine radioiodine scan. Somatostatin receptor expression in substantial number of lesions with advanced thyroid carcinoma probably reflects varying biology of metastases as compared to the primary and makes them amenable to peptide receptor radionuclide therapy.

Indian J Nucl Med. 2013 Dec;28(Suppl 1):S25–S28.

Thy-03: Evaluation of somatostatin receptor targeted imaging in non-131I concentrating metastatic differentiated thyroid carcinoma and determining the feasibility of PRRT with lutetium-177-DOTATATE in scan positive cases

Bhargavi Jois, Ramesh Asopa, MGR Rajan, Sandip Basu

Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Parel, Mumbai, Maharashtra, India

Objectives: To evaluate somatostatin receptor expression in non-131I concentrating metastatic differentiated thyroid carcinoma by 99mTc-HYNIC-TOC/Gallium68-DOTATATE PET-CT scintigraphy and to determine the feasibility of lutetium-177-DOTATATE (therapeutic analogue) therapy in cases with positive cases.

Materials and Methods: Twenty patients diagnosed with DTC with non iodine concentrating metastasis and elevated serum thyroglobulin levels underwent Ga-68 DOTATATE PET-CT/ Tc 99m HYNIC TOC scan for the evaluation of positivity of SSTR. Based on the visual grading, SSTR positive lesions were graded into four categories (Grade I-IV) in comparison with the hepatic uptake on the scan. Patients with Grade III and IV uptake in lesions (equal to or more than hepatic uptake on scan) were scheduled for Lu-177 DOTATATE administration.

Results: Amongst twenty patients studied, thirteen patients (65%) showed SSTR positive lesions expression demonstrating uptake ranging from Grade I-IV and 7 patients (35%) did not demonstrate any tracer uptake. On a lesion specific analysis, out of the total 67 metastatic lesions, 4 lesions (13.8%) demonstrated Grade I tracer uptake, 20 lesions (69%) Grade II (less than liver), 4 lesions (13.8%) Grade III (= liver uptake) and 1 lesion showed Grade IV uptake (more than liver). Interestingly, an elevated serum chromogranin. A level was documented in three of the patients with Grade III and IV tumor uptake. In one patient the diagnosis changed to medullary carcinoma thyroid (MCT) which revealed high calcitonin level and final immunohistochemistry proved this to be MCT. A comparison of Ga-68 DOTATATE PET-CT and Tc-99m HYNIC TOC in four patients who underwent both the scans, demonstrated no significant differences in the tracer concentration in the metastatic lesions in any of the patients. Based upon the criterion of high tracer uptake and the patient consent, finally two out of three patients were treated with lutetium-177 DOTATATE. On follow-up, a significant fall in serum thyroglobulin level was noted in one of the patients and the other patient was lost to follow-up.

Conclusion: Avid expression of the SSTR on Ga-68 DOTATATE PET-CT/ Tc-99m HYNIC TOC scintigraphy in non 131I concentrating metastatic differentiated thyroid cancer is observed in a relatively low fraction of patients that could favor the feasibility of lutetium-177 DOTATATE therapy. Though seen in a small fraction, taking into account that no treatment exists in this group, somatostatin receptor targeted imaging can be an alternative diagnostic modality in the therapeutic decision making with PRRT and monitoring.

Indian J Nucl Med. 2013 Dec;28(Suppl 1):S25–S28.

Thy-04: Examining rhTSH primed 131I therapy protocol in metastatic thyroid carcinoma: Comparison with traditional thyroid hormone withdrawal protocol

Deepa Prajapati, Sushma Kaisar, Kamaldeep, Sushama Awasare, Amit Abhyankar, Ramesh Asopa, MGR Rajan, Sandip Basu

Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Parel, Mumbai, Maharashtra, India

Objectives: (a) Assess the feasibility and efficacy of rhTSH primed 131I therapy protocol in patients of differentiated thyroid carcinoma with distant metastatic disease, (b) perform lesional dosimetry in this group of patients compared to the traditional protocol, (c) to document the practical advantages (patient symptoms, background clearance and hospital stay) of the rhTSH protocol compared to the traditional thyroid hormone withdrawal protocol (d) to document and record any adverse effect of this strategy and (e) to compare the renal functional parameters and the serum TSH values achieved in either of the protocols, in this group of patients.

Materials and Methods: Comparison of lesional dose, hospital stay, renal function tests and symptom profile was undertaken between the traditional thyroid hormone withdrawal protocol and rhTSH based therapy protocol. Dosimetric calculations of metastatic lesions were performed using lesion uptake and survey meter readings for calculation of effective half life. CT (non-contrast) was used for assessment of tumor volume. Quality of life was assessed using the EORTC-QOL forms.

Results: The study included 37 metastatic DTC patients having lung/or skeletal metastases or both. Functional scale and global health status were significantly better in the rhTSH protocol compared to the thyroid hormone withdrawal protocol (P < 0.001). Mean symptom scale was significantly more in the thyroid hormone withdrawal protocol (45.25) compared to the rhTSH protocol (13.59) (P < 0.001). Mean effective half life of 131I in metastatic lesions was less during the rhTSH protocol (29.49 h) compared to the thyroid hormone withdrawal protocol (35.48) but the difference was not statistically significant (P = 0.056). Mean 24 h % uptake of the lesions during the traditional protocol was (4.84%) which was slightly higher than the 24 h % uptake during the rhTSH protocol (3.56%) but the difference was not found to be statistically significant (P = 0.301). Mean tumor dose per mCi was less during the rhTSH protocol (6.04 rad/mCi) than during the thyroid hormone withdrawal (8.68 rad/mCi) and the difference was statistically significant (P = 0.049) though visual analysis of the rhTSH post therapy scans showed avid concentration of 131I in the metastatic sites and revealed more lesions in 30% of the patients compared to the traditional large dose scan and equal number of lesions in 65% of the patients. Renal function was found to be comparable; serum TSH level achieved was significantly higher in rhTSH group.

Conclusion: Overall rhTSH primed 131I therapy protocol was found to be feasible and a good alternative to the thyroid hormone withdrawal protocol though the lesional dosimetry findings need to be further examined in subsequent studies. rhTSH primed pre-treatment scan undertaken at 24 h after diagnostic dose is suboptimal to determine whether a metastatic lesion is concentrating I-131 and post-treatment scan is important for the correct impression.

Indian J Nucl Med. 2013 Dec;28(Suppl 1):S25–S28.

Thy-05: Significance of fludeoxyglucose-positron emission tomography, thyroglobulin suppressibility in patients with elevated thyroglobulin, 131I negative metastatic thyroid carcinoma: Emphasis on group with fludeoxyglucose-positron emission tomography negative disease

Rohit Ranade, Purushottam Kand, Sandip Basu

Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Parel, Mumbai, Maharashtra, India

Aims: To study the prognostic value of FDG PET negativity in thyroid carcinoma patients with suppressible thyroglobulin and negative radioiodine scan.

Material and Methods: Study population – DTC patients for management of metastatic thyroid cancer with elevated Tg on follow-up, negative 131I whole body scan and negative FDG PET scan were included. Patients were subjected to a TSH stimulated assessment by 131-I whole body scan, serum thyroglobulin levels and whole body FDG PET scan for evaluation of metastatic disease burden. Same patient was subjected to a follow-up evaluation of serum Thyroglobulin and whole body FDG PET scan under TSH suppression using thyroxine sodium. Comparison between the findings of FDG-PET in patients demonstrating suppressible thyroglobulin.

Results: 24 patients (14 male and 10 female) were included in the study. All the patients had a negative whole body FDG PET scan but had stimulated Tg which was >5 ng/dl (Range: 5.1->250 ng/ml) indicating the presence of disease. All patients (22 patients) showed variable Tg suppressibility (% Tg suppressibility >90% in 11 patients; % Tg suppressibility 65-90% in 7 patients and % Tg suppressibility <65% in 4 patients); with FDG PET scan being normal in all of these patients both on stimulation or suppression. All the patients were asymptomatic during this period. No definite correlation could be established either with the status of metastasis or the histopathology with the suppressibility of Tg. The average period of patients being asymptomatic in this study was more than 3 years with 9 patients and 10 patients being asymptomatic for 1-3 years duration.

Conclusion: In this study, we observed an entity with “elevated Thyroglobulin but normal FDG-PET” exists as a reality in the practice of DTC. A negative FDG-PET in the setting of raised thyroglobulin level acts as a strong favorable prognostic marker to predict symptom free status in the follow-up period in this group of patients. Suppressibility of Tg (more than 65%) is observed in a significant fraction of these patients, which appears to be independent of the status of metastasis or the histopathology. Whether there exists any relation between the extent of suppressibility and their long-term outcome requires to be examined in future prospective studies.

Indian J Nucl Med. 2013 Dec;28(Suppl 1):S25–S28.

Thy-06: Is single dose of levothyroxine culprit for osteoporosis in hypothyroid patients?

Madhur Kumar Srivastava, Aseem Bhatnagar1

Departments of Nuclear Medicine, JIPMER, Puducherry, 1INMAS, New Delhi, India

Introduction: Levothyroxine is recommended drug for therapy in hypothyroidism and for suppression of the pituitary thyroid axis. It has a better patient compliance due to single daily dosage and physicians can easily titrate the dose by measuring TSH in blood.

Aim: To study the sequential serum levels of FT3, FT4 and TSH in hypothyroid patients after giving therapeutic dose of levothyroxine at different time intervals till 24 h and to evaluate its clinical significance.

Materials and Methods: 20 hypothyroid patients (17 female and 3 male) taking 150-200 μgm/dl were enrolled. Consent of each patient was taken and procedure explained to them. 2 patients had total thyroidectomy and rest had nongoitrous hypothyroidism. After collecting fasting blood samples, they were administered 200 μgm of levothyroxine of same brand. Four blood samples were taken at 1 h, 3 h, 6 h and 24 h after ingestion. All samples were analysed for FreeT3, FreeT4 and TSH using electochemiluminescence technique.

Result: Mean age of patients was 39.6 ± 8.6 years and average weight was 76 ± 16.4 kg. FT4 levels in blood showed 25-40% increase by 1 h postmedication which remained high till 6 h (P < 0.001) and therapeutic range was exceeded in 6/20 (30%) patients. FT3 levels in blood showed 5-20% increase in blood levels at 1 h (P = 0.35) which remained high till 6 h though therapeutic range was not exceeded in any patient. TSH levels in blood decreased by 25-40% at 3 h postmedication (P < 0.001), which remained depressed after 6 h in all 20 patients.

Conclusion: 1. Single therapeutic dose of levothyroxine can transiently increase FT4, FT3 levels in blood and this can be a contributing factor of osteoporosis. 2. Levothyroxine should not be taken on the day of thyroid function testing as TSH result may be falsely interpreted as being below the normal range.

Indian J Nucl Med. 2013 Dec;28(Suppl 1):S25–S28.

Thy-07: Lung and skeletal metastases in patients with differentiated thyroid carcinoma and evaluation of response to radioiodine therapy

Swati Rachh, Rasna Tiwari, Nilam Patel, Rinku Patel

Department of Nuclear Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India

Introduction: The most common site of metastases in differentiated thyroid carcinomas (DTCs) is the lungs followed by bone. In our study, we aimed to determine the ratios of lung and skeletal metastases in patients with DTCs and response to radioiodine therapy.

Materials and Methods: A total 500 patients with DTCs who were admitted in the radioiodine therapy ward were included in the study. High doses of 131I were administered to the patients with lung and bone metastases. Responses to therapy were evaluated with 131I scans and stimulated thyroglobulin levels were examined at least 6 months to 1 year after therapy.

Results: Lung metastases were detected in 46 (9.2%) of 500 patients with DTCs. The primary tumors in these patients were histological classified as papillary 35 (76.1%), follicular 11 (23.9%). 31 (67.4%) patients have documented lung metastasis only, 13 (28.3%) patients had lung and skeletal metastasis and 1 (2.3%) patient had lung, liver and kidney metastasis. 28 out of total 46 patients with complete follow-up data in which we evaluated the response of therapy, complete response to therapy was obtained in 4 (14.3), partial response was obtained in 13 (46.4%) and no response could be obtained in 11 (39.3%). Skeletal metastases were detected in 35 (7.0%) of 500 patients with DTCs. The primary tumors in these patients were histological classified as papillary 13 (37.1%) and follicular 22 (62.9%). 21 patients have documented skeletal metastasis only (58.3%). 16 out of total 35 patients with complete follow-up data in which we evaluated the response of therapy, complete response to therapy was obtained in 3 (18.8%), partial response was obtained in 4 (25%) and no response could be obtained in 10 (62.5%).

Conclusion: Although lung and skeletal metastases from DTCs are rare, those are more common in advanced ages and males. High doses of 131I therapy may be partially beneficial in these patients. Thus repetition of therapy is frequently required. Patients with only lung/skeletal metastasis has good prognosis. Radioiodine avidity (especially with negative radiological findings) and papillary histo pathology has good prognosis.

Indian J Nucl Med. 2013 Dec;28(Suppl 1):S25–S28.

Thy-08: Lingual thyroid: A case report

M Mathur, P Asha

Jawaharlal Nehru Cancer Hospital and Research Centre, Bhopal, Madhya Pradesh, India

A 6-year-old female child was referred for thyroid scintigraphy to evaluate the swelling on the posterior part of tongue. The swelling was clinically visible and palpable, red in colour. The thyroid scan was done with 99m Tco4 and the concentration of radioactivity was seen at the posterior part of the tongue consistent with clinically visible and palpable swelling. No other site of concentration of radioisotope was seen. Hence the diagnosis of the only functional ectopic lingual thyroid was established. Lingual thyroid is a rare congenital anomaly of thyroid gland in which thyroid gland is situated at ectopic location along the course of thyroglossal tract. This is more common in females. Rarely the whole gland is ectopic. Lingual thyroid gland forms a rounded swelling at the back of tongue. It may represent the only thyroid tissue present. It can cause dysphagia, impairment of speech, respiratory obstruction or hemorrhage. Thyroid scan is excellent at not only confirming the diagnosis, but also identifying the presence of any thyroid tissue elsewhere in the neck. Lingual thyroid is best treated by full replacement with thyroxin. Excision or ablation with radioiodine is sometimes necessary.

Indian J Nucl Med. 2013 Dec;28(Suppl 1):S25–S28.

Thy-09: Evaluation of micronuclei frequency in peripheral blood lymphocytes of hyperthyroid patients

Yogita S Raut, Uma S Bhartiya, Purushottam Kand1, Rohini W Hawaldar2, Ramesh V Asopa, Lebana J Joseph, MGR Rajan

Radiation Medicine Centre, Biomedical Group, Bhabha Atomic Research Centre, C/O Tata Memorial Hospital Annexe, 1P.D Hinduja National Hospital Medical and Research Centre, Mahim, 2Tata Memorial Centre, Parel, Mumbai, Maharashtra, India

Objectives: Thyroid hormones are essential for normal development and growth of the body and are involved in regulation of basal metabolic rate (BMR). Alterations in the thyroid hormone levels, particularly excess of the thyroid hormones are known to cause oxidative stress which can exert damaging effect on biomolecules including DNA. The aim of our study was to evaluate the possible cytogenetic damage due to excess of the thyroid hormones on DNA by measuring micronuclei frequency in peripheral blood lymphocytes of patients suffering from hyperthyroidism.

Materials and Methods: The study consisted of 80 patients visiting Radiation Medicine Centre for diagnosis and treatment of various thyroid disorders. Out of which 49 patients were euthyroid and 31 patients were hyperthyroid as indicated by their thyroid hormone levels. Whole blood sample of these patients were processed for micronuclei frequency in peripheral blood lymphocytes by cytokinesis-blocked assay protocol.

Results: Micronuclei frequency demonstrated significant elevation in the hyperthyroid patients in comparison to euthyroid group (20.5 ± 4.3 MN/1000 BN cells vs. 11.9 ± 5.0 MN/1000BN cells, P < 0.001).

Conclusions: This preliminary observation indicates significant increase in DNA damage in hyperthyroid patients. In conclusion, acute T4 overdose should be handled promptly and effectively.

Indian J Nucl Med. 2013 Dec;28(Suppl 1):S25–S28.

Thy-10: Adapting serum TSH IRMA kit for estimating TSH in whole blood - For use in neonatal screening of congenital hypothyroidism

J Kumarasamy, Yogita Raut, MGR Rajan

Immuno Assay Development Programme, RMC, BARC, TMH Annexe, Parel, Mumbai, Maharashtra, India

Introduction: In order to screen neonates for congenital hypothyroidism, collecting large amount of blood (1-2 mL from neonates) is difficult and unnecessary if, TSH can be estimated reliably in small amount (i.e. ≈ 500μL) of whole blood. As whole blood TSH kits are not available we have tested five commercial serum TSH IRMA kits for their suitability to measure TSH in whole blood samples.

Materials and Methods: Serum TSH standards were adjusted to 50% hematocrit by adding equal volume of washed, packed RBCs from normal healthy volunteers. This reconstituted whole blood standards were used to evaluate the performance by analyzing 47 whole blood samples in each of the five kit studied.

Results: It was possible to measure TSH in whole blood in all the kits studied without any RBC interference. Significant correlation was obtained between the serum TSH values and the whole blood TSH values.

IZOTOP hTSH-IRMA Kit y = 1.0823x + 0.2516, r = 0.992, n = 47,

IMMUNOTECH hTSH-IRMA Kit y = 1.0067x + 0.7377, r = 0.982, n = 47,

Coat -A-Count hTSH-IRMA Kit y = 0.9874x + 0.387, r = 0.986 n = 47,

RADIM hTSH-Kit y = 0.9842x + 0.7518, r = 0.991, n = 47.

Conclusions: While this study demonstrates the possibility of measuring TSH in whole blood using the adult samples, the real scenario of using such a methodology in neonates need to be demonstrated using the neonate samples.

Articles from Indian Journal of Nuclear Medicine : IJNM : The Official Journal of the Society of Nuclear Medicine, India are provided here courtesy of Wolters Kluwer -- Medknow Publications

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