RIT in benign thyroid disease

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Radioiodine treatment in benign thyroid diseases

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  • 1. : , , . . . 401 . .

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  • Graves ,
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  • (De Quervain )

6. 7.

  • ( - )
  • -131

8. 9. U.S.

  • To 69% -131 ATD .Graves' .

10. 11. E.U.

  • 84%ATD,
  • 10 %
  • 6 % -131

12. E.U.

  • ATD,
    • 43 %
    • 32 % ATD
    • 25 % -131

13. Saul Hertz 1941 14. 15.

16. ATD &

  • 1-2 , ~ 30%
  • /
  • .
  • ---------------------------------------------------------------------
  • : , , , , ..
  • Cooper, NEJM 05; Nakamura, JCEM 07; Sosa, JCEM 08; Kaguelidou, JCEM 08

17. ATD&

  • A) /
  • B) -131 .
  • --------------------------------------------------------------------
  • ATD 2-5 . I-131
  • McDermott, Am J Med 1983; Sarkar, Semin Nucl Med 2006

18. & (Sherman, Surgery 2006)

  • 78 patients had surgery at age < 18 yr, 1986-2003
  • Complications: Transient hypoparathyroidism (6%) and recurrent laryngeal nerve palsy (1%)
  • Hyperthyroidism cured in 75 patients, reoccurred in 3
  • ------------------------------------------------------------------------------
  • Surgery for Graves uncommon in the United States
  • Complication rates
    • 0-6 22%
    • 7-12 11%
    • 13-17 11%
  • Traditional indications for surgery in Graves: suspicious nodule, failure of PTU in Graves during pregnancy

19. -131 & Rivkees, JCEM 2004 20. -131 & 21. Long-term safety of I-131 treatment in children

  • 36 Follow-up.
  • 116 < 20 , -131.
  • 1990-91: ..,
  • 2001-02: .., .
  • 1 .

R ead , JCEM 2004 22. Swedish and U.S. populations

  • 602 -131 < 20 .
  • 10 Follow-up.
  • 80 Ci/g (88 Gy).
  • 2vs .0,1Ca
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  • Shore RE. Radiat Res1992

23. 24. Today, surgery is rarely performed in the US, but still is in the UK, but it is performed in third-world countries that cannot afford the radioiodine.http://www.tpa-uk.org.uk/surgery_vs_radioiodinetherapy.php 25. Clinical Endocrinology, 2008 698UK -131 hyperthyroid Graves disease, subclinical hyperthyroidism and nontoxic goitre 40 % 21 % 13 % 5 % Nontoxic goitre * 0,4 % 63 % 35 % Subclinical hyperthyroidism 0,4 % 19 % 80 % Graves disease / I-131 ATD 26. 27. 28. Council directive Euratom 97/43

  • ...for all medical exposure of individuals for radiotherapeutic purposes exposures of target volumes should be individually planned.

29. Radioiodine therapy of benign thyroid disorders: what are the effective thyroidal half-life and uptake of 131I?

  • The mean effective half-life of I-131 measured during radioiodine therapy was
    • 5.4 days in Graves' disease,
    • 6.4 days in nontoxic goitre,
    • 6.6 days in toxic goitre, and
    • 5.7 days in toxic uninodular adenoma.
  • The mean maximal uptake of I-131 measured during radioiodine therapy was
    • 64% in Graves' disease,
    • 42% in nontoxic goitre,
    • 38% in toxic goitre, and
    • 31% in toxic uninodular adenoma.

30. -131 .Graves

  • -131

31. 32. -131 .Graves

  • -131, /.
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33.

  • : , . , , , , ..
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  • I-131, . ( ).
  • Auer, Am Heart J 2001; Hak, Annals Int Med 2000; Imaizumi, JCEM 2004;
  • Squizzato, Stroke 2005; Kvetny, Clin Endocrinol 2004; Franklyn, JAMA 2005

-131 .Graves 34. 35. 36. .Graves : &

  • Peters, Euro J Clin Invest 1995
    • 15,000 rads (150 Gy): 67%
    • 25,000 rads (250 Gy): 84%
  • Reinhardt, EJNM 2002
    • 15,000 rads (150 Gy): 27%
    • 30,000 rads (300 Gy): 68%
    • 42 ml goiter: 25,000 rads100%

37. 38. . Graves 13 : I-131? ( 60g, uptake = 60%)

  • 1. 5 mCi (185 MBq)[ ]
  • 2. 10 mCi (370 MBq)[ ]
  • 3. Deliver 50 Ci/g (1.85 MBq/g) = 5 mCi
  • 4. Deliver 150-200 Ci/g (5.5-7.4 MBq) = 15-20 mCi
  • 2010 Annual Meeting, Society of Nuclear Medicine

39. 40. 41. Lithium &-131 42. 43. Graves & I-131

  • 15% .
  • , /, 3, -131.
  • TSHR-A b .
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Tanda, Clin Endocr20 08; Vannuchi, JCEM20 09; Prabhakar, Endocr Rev20 03 ; Acharya ,Clin Endocrinol (Oxf). 2008 44. Graves & I-131 Ponto KA, Thyroid. 2010The tale of radioiodine and Graves' orbitopathy. 45. Graves &

  • Lowery AJ, Surgeon. 2009
  • there is increasing evidence that total thyroidectomy may have a beneficial effect
  • Azzam I, Pediatr Endocrinol Rev. 2010
  • total thyroid ablation that combines surgery with radioactive iodine, is increasingly gaining attention for the treatment of patients with GO, especially those undergoing thyroid surgery, but also for those with severe unresponsive ophthalmopathy. Studies supporting this approach are awaited.

46. Management of Graves: Key Points

  • Iodine-131
  • -increasing preference for near-term hypothyroidism
  • - dose for large goiter, ATD, severe hyperthyroidism
  • - may occasionally worsen eye disease, hyperthyroidism
  • ATD
  • -to control hyperthyroidism before definitive treatment
  • - may use as primary therapy of Graves, with limited success
  • - preferred modality in pregnancy; prevents Graves in fetus
  • Surgery
  • -co-existing suspicious mass, ATD failure in pregnancy
  • 2010 Annual Meeting, Society of Nuclear Medicine

47. 48.

  • /
  • Bauer, Ann Intern Med 01; Cooper, JCEM 07; Kang, Surgery 02

49.

  • -131

/ - - - - - / - uptake 24 hr 50.

  • (Kang, Surgery 2002)
    • . , 2%
    • . . 3%
  • & Graves (Senyurek, Surgery 2008)
    • .. 6% , 12% ,3%Graves

51. -131

  • Huysmans, Annals Intern Med 1994
    • Mean dose of 70 mCi (2590 MBq); range 42-98 mCi
    • 40% in goiter volume, 36%in tracheal lumen
  • Bonnema, JCEM 1999
    • Mean dose 61.6 mCi (2279 MBq); range 27-125 mCi
    • 34% in goiter volume, 18%in tracheal lumen
  • ------------------------------------------------------------------------------------------- ------
  • Limitations: large dose, modest volume reduction; rarely, may develop Graves disease after I-131 (Nygaard, JCEM 97)

52. Toxic Nodular Goiter: Key Points

  • For large MNG, surgery preferable but may not be feasible because of operative risk. High dose I-131 therapy is an alternative
  • Surgery may help discover incidental cancer
  • I-131 therapy of single toxic nodule may not eliminate the neck mass altogether
  • Late hypothyroidism after I-131 therapy not uncommon

53.

  • 39 patients, age 35-75 years, treated with 100 Ci/g
  • Single dose in 30 patients, > 1 dose in others
  • Volumes
          • 54% decrease in nodule volume at 12 mo
          • 18% decrease in non-nodular volume
  • 10% became overtly hypothyroid *