Possibility of limiting the un-justified irradiation in 131I therapy of Graves' disease: A thyroid mass-reduction based method for the optimum activity calculation

ObjectiveIn Graves' disease therapy, the amount of ¹³¹I is usually decided following two different modalities: the administration of a fixed activity or of an activity individually calculated based on a fixed value of target absorbed dose. Although the effectiveness of each of these approaches is good (about 80% of patients cured), the ALARA principle must be applied avoiding the un-justified radioactivity to the patient himself, the people living/working near him and the environment. In this paper a new approach to the ¹³¹I therapy in Graves' disease, based on the optimum value of the final thyroid mass, is presented.Design97 Graves' disease patients (29 males) were randomly assigned into three groups (GR1, GR2, GR3). In two of them (GR1, GR3) the radioiodine administering activity was calculated based on two fixed thyroid absorbed dose values (100 Gy for GR1; 400 Gy for GR3), in GR2 it was calculated based on the desired final optimum thyroid mass value m_f = 0.24 m₀/U₀ResultsThe rate of cured patients are 48% (GR1), 97% (GR2) (z-test, p < 0.001) and 97% (GR3). The average activity administered to GR2 (393 ± 157 MBq) is lower than that administrered to GR3 patients (524 ± 201 MBq) (p = 0.007, two-tails unpaired t-test); the thyroid absorbed dose in GR2 (262 ± 78 Gy) is lower than in GR3 patients (407 ± 23 Gy) (p < 0.001, two-tails unpaired t-test).ConclusionOur results demonstrate that the thyroid-mass based approach optimizes the treatment avoiding an un-justified excess or a not-effective too low activity without time and resources consuming.     

Thyrotropin receptor antibody activities significantly correlate with the outcome of radioiodine (131I) therapy for hyperthyroid Graves' disease.

The outcome of 131I therapy for 109 patients with Graves' disease was analysed according to pretreatment laboratory data including thyrotropin receptor antibody (TRAb) activities. Forty-five percent of patients became euthyroid, and 13% of patients became hypothyroid within one year after 131I therapy. Forty-two percent of patients remained hyperthyroid one year after 131I therapy. Pretreatment values for serum T4, T3, and the estimated weight of the thyroid were significantly higher in the hyperthyroid group. The mean for the TRAb index of the hyperthyroid group was significantly higher than that of the euthyroid group. Life table analysis revealed a significant effect of the TRAb index on the rate of hyperthyroidism after 3 months or later. These results appear to suggest that the TRAb index is one of the factors which influence the outcome of 131I therapy for Graves' disease.     

A new method to evaluate the residual activity in patients undergoing 131I thyroid therapy

The radioiodine administration is a standard therapeutic approach to both benign thyroid diseases, such as hyperthyroidism, and carcinomas. The high administered ¹³¹I activities are of radiation protection concern, due to relevant patient residual contamination. The aim of this work was to develop a new procedure based on external radiometric surveys and on a mathematical model in order to estimate the ¹³¹I activity in patients undergoing hyperthyroidism radioiodine therapy.In the first stage of this study, a suitable detector was chosen and its response vs. activity was characterized. The experimental verification was performed measuring the ambient dose equivalent rate from patients receiving radioiodine administration. The results confirm the reliability of the proposed method, as shown by the slight differences between the administered activities and the ones calculated from external measurements. Furthermore, the same procedure was applied to detect the percentage residual activity in patients at two preset time intervals: 4 hours and 4 days after the radioiodine administration. The obtained results clearly highlight that the method can ensure a level of reliability compatible with the radiation protection purposes.     

Diagnostic scintigraphy and effectiveness of 131I radioiodine therapy in differentiated thyroid carcinoma (DTC)

INTRODUCTION: Since the effect of pre-therapeutic scintigraphy on the outcome of DTC treatment is debated, we evaluated factors affecting the effectiveness of (131)I therapy with respect to the delay between diagnostic scintigraphy and the application of radioiodine. MATERIAL AND METHODS: In the studied group of 60 patients with DTC, mean age 54.6 +/- 13.0 years, four weeks prior to the planned diagnostics, L-thyroxine was withdrawn and the following tests performed: (131)I (4 MBq) uptake above the neck, thyroid volume by USG, TSH and hTg level. Wholebody scintigraphy (37 MBq) was performed. The time between this diagnostic scintigraphy and application of (131)I (3657 MBq) was calculated. Based on whole-body 131I scintigraphy (74 MBq) performed 1 year after radioiodine treatment, the patients were divided into: group I - 42 patients with no tracer accumulation, and group II--18 patients who continued to accumulate (131)I in the neck. RESULTS: The differences between the median values of (131)I uptake and of thyroid volumes, and between the TSH and hTg median values in the two groups of patients were found not to be statistically significant. The average times between diagnostic scintigraphy and (131)I treatment in group I and II (9.4 vs. 8.3 weeks, respectively) were not significantly different either. CONCLUSION: Despite the different effectiveness of supplementary (131)I treatment, patients in group I and group II showed no statistically significant differences in the studied parameters. It appears that the diagnostic (131)I activity of 37 MBq and the time between diagnostic scintigraphy and application of (131)I did not have any effect on the results of the treatment in our group of patients.     

Scintigrams of the thyroid gland; the diagnosis of morphologic abnormalities with I131

Functioning thyroid tissue containing sufficient radioiodine can be visualized by scanning the gland with a directional scintillation counter.(4) This visual representation of the gland is called a "scintigram." Scintigrams have been invaluable in the detection and study of both "toxic" and non-functioning nodules, diffuse enlargement in hyperthyroidism and the subsequent reduction in gland size after treatment, carcinoma, and aberrant thyroid tissue.     

Radioiodine-131 therapy (RIT) in benign thyroid diseases: Personalized prescription based on objectives with optional use of pharmacological modulators

¹³¹I therapy (RIT) in benign thyroid diseases is the oldest and most currently used application of internal radiotherapy. With the new molecular ¹²³I-TS images one may identify 15 presentations that can benefit from RIT. With three groups of activity determination corresponding to a dozen approaching protocols, several judgmental criteria (eu-, hypo-, hyperthyroidism, relapses etc.) and varying timeframes to assess the success, a “best method of activity calculation” makes little sense. Four clinical objectives must be first identified (goal): antitoxic (euthyroidism), ablative (hypothyroidism), reductive (to reduce a targeted volume) and preventive (to prevent progression from compensated to overt hyperthyroidism) ¹³¹I-RIT. A dose response relationship as regards the target volume reduction is firmly established in the short term (1-year) and explains the clinical outcome in Thyroid Functional Autonomy (TFA). In Grave's disease (GD), other factors may interfere that make the long-term function less predictable. Pharmacological modulators of ¹³¹I-RIT such as antithyroid drugs (ATDs) and LT3 must be skillfully handled. ATDs interfere with iodine kinetics, enhance the heterogeneity of the spatial dose deposition and diminish the accuracy of absorbed dose deposition, especially when using poorly controlled dosimetric approaches. Short LT3 administration suppresses TSH that allows direct targeting of the autonomously functioning thyroid tissue. The three main groups and variants of activity calculation are presented in detail. Calculating the activity allows a 50% average reduction in the ¹³¹I administered dose. Medical strategy should favour the informed patient's choice, after excluding the rare medical causes prompting discussion of an ablative approach. In TFA, low occurrence of hypothyroidism is the rule provided the treatment be given with a TSH < 0.1 mU/L, spontaneously or after LT3 suppression (compensated variety). In GD a long-term remission is rare (< 30%) and should be thoroughly discussed since it leads to euthyroidism in approximately 50% after a 12-year follow-up. Depending on the etiology (GD/TFA) and the 4 clinical goals, ¹³¹I RIT planning is presented with optional choice of a patient adapted method of activity calculation and appropriate management of pharmacological modulators.     

Estimation of 131I thyroid doses for the evacuees from Pripjat

  The thyroid doses of 49 360 inhabitants of Pripjat evacuated after the accident at Chernobyl were reconstructed. During their evacuation most of the evacuees passed through highly contaminated territories. The evaluation of a large-scale public survey showed that only about 50% of the evacuees had left the contaminated areas within 5 days and that 30% of them stayed there for more than 30 days. As a first step, the model of dose estimations was improved, and thyroid doses were assessed for the group of evacuees for whom the ¹³¹I activity in the thyroids was measured. The ¹³¹I incorporation during the first 5 days after the accident was described by a single-intake model (inhalation); later incorporations were assumed to be proportional to the radioiodine activity in milk. As a second step, the correlation between the calculated doses and individual parameters (place of residence in Pripjat, intake of stable iodine, and age at the time of the accident) was described by an empirical equation. This equation was applied to all evacuees who completed the questionnaires of the public survey. Previous dose assessments were found to overestimate the thyroid doses especially for the younger evacuees. On the basis of these estimations, collective doses and the resulting radiation risks for thyroid cancer were assessed for different age groups. Received: 28 November 1995 / Accepted in revised form: 6 March 1996     

Graves' disease and atrial fibrillation: the case for even higher doses of therapeutic iodine-131.

Seventy five consecutive patients with Graves'' disease complicated by atrial fibrillation were given a large single therapeutic dose of 600 MBq (16.2 mCi) iodine-131 in an effort to control their hyperthyroidism rapidly and thus restore sinus rhythm. Patients were initially followed up every three months after treatment and then at yearly intervals. The mean period of follow up was 3.1 years. A total of 44 of the patients became hypothyroid and 31 euthyroid, and 33 (75%) and 14 (45%) of these patients, respectively, reverted to sinus rhythm (p less than 0.01). Of the 33 who became hypothyroid and reverted to sinus rhythm, 30 had developed the hypothyroidism within six months after treatment. These results are a strong case for increasing the dose of radioiodine in patients with Graves'' disease complicated by atrial fibrillation in an effort to speed the onset of thyroid failure and thus maximise the rate of reversion to sinus rhythm.