Accuracy considerations when using early (four- or six-hour) radioactive iodine uptake to predict twenty-four-hour values for radioactive iodine dosage in the treatment of Graves' disease

Is There Any Need for Adjusting 131I Activity for the Treatment of High Turnover Graves' Disease Compared to Normal Turnover Patients? Results from a Retrospective Cohort Study Validated by Propensity Score Analysis

Purpose

To compare ¹³¹I-therapy outcomes in high turnover and normal turnover Graves' disease patients and predict optimal first ¹³¹I activity for high turnover patients.

Methods

Retrospective cohort design (1:2) validated by propensity score analysis. Cohort 1, high turnover (2-h RAIU/24-h RAIU ≥ 1), n = 104, and cohort 2, normal turnover (ratio < 1), n = 208, patients were compared for post ¹³¹I outcome. The cure was defined as a combined euthyroid and stable hypothyroid state following ¹³¹I treatment. Logistic regression analysis was used for identifying prognostic factors. The propensity score was applied; 77 matched pairs (1:1 ratio) of high and normal turnover patients were selected as a validation set.

Results

First ¹³¹I cure rates of 28% in high turnover and 66% in normal turnover groups (p = 0.001) were noted. The therapy cycles (median, 2 vs. 1) and cumulative ¹³¹I activity (median, 15 vs. 7 mCi) were required to cure hyperthyroidism in cohort 1 and cohort 2, respectively. Age (> 44 years), higher grade of goitre, and 2-h RAIU (> 37%) were associated with ¹³¹I therapy failure. The high turnover patients needed a factor of 1.5-2 times more ¹³¹I activity to achieve a similar cure rate compared to the normal turnover patients. The first-dose cure rate was 31% vs. 60% by propensity score analysis (n = 154), no way different (28% vs.66%) from the whole group of 312 patients.

Conclusion

High turnover Graves' disease patients, if administered standard ¹³¹I activity, the outcomes shall be poor. To improve the success rate, ¹³¹I activity should be increased by 1.5 to 2 times in the high turnover patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13139-020-00674-3.

The Role of Nuclear Medicine in the Clinical Management of Benign Thyroid Disorders, Part 1: Hyperthyroidism

Benign thyroid disorders, especially hyper- and hypothyroidism, are the most prevalent endocrine disorders. The most common etiologies of hyperthyroidism are autoimmune hyperthyroidism (Graves disease, GD), toxic multinodular goiter (TMNG), and toxic thyroid adenoma (TA). Less common etiologies include destructive thyroiditis (e.g., amiodarone-induced thyroid dysfunction) and factitious hyperthyroidism. GD is caused by autoantibodies against the thyroid-stimulating hormone (TSH) receptor. TMNG and TA are caused by a somatic activating gain-of-function mutation. Typical laboratory findings in patients with hyperthyroidism are low TSH, elevated free-thyroxine and free-triiodothyronine levels, and TSH-receptor autoantibodies in patients with GD. Ultrasound imaging is used to determine the size and vascularity of the thyroid gland and the location, size, number, and characteristics of thyroid nodules. Combined with lab tests, these features constitute the first-line diagnostic approach to distinguishing different forms of hyperthyroidism. Thyroid scintigraphy with either radioiodine or ^99mTc-pertechnetate is useful to characterize different forms of hyperthyroidism and provides information for planning radioiodine therapy. There are specific scintigraphic patterns for GD, TMNG, TA, and destructive thyroiditis. Scintigraphy with ^99mTc-sestamibi allows differentiation of type 1 from type 2 amiodarone-induced hyperthyroidism. The radioiodine uptake test provides information for planning radioiodine therapy of hyperthyroidism. Hyperthyroidism can be treated with oral antithyroid drugs, surgical thyroidectomy, or ¹³¹I-iodide. Radioiodine therapy is generally considered after failure of treatment with antithyroid drugs, or when surgery is contraindicated or refused by the patient. In patients with TA or TMNG, the goal of radioiodine therapy is to achieve euthyroid status. In GD, the goal of radioiodine therapy is to induce hypothyroidism, a status that is readily treatable with oral thyroid hormone replacement therapy. Dosimetric estimates based on the thyroid volume to be treated and on radioiodine uptake should guide selection of the ¹³¹I-activity to be administered. Early side effects of radioiodine therapy (typically mild pain in the thyroid) can be handled by nonsteroidal antiinflammatory drugs. Delayed side effects after radioiodine therapy for hyperthyroidism are hypothyroidism and a minimal risk of radiation-induced malignancies.

Prediction of thyroidal 131I effective half-life in patients with Graves' disease

Purpose

Calculation of effective thyroidal half-life (Teff) of iodine-131(¹³¹I) is cumbersome and tedious. The aim of this study was to investigate factors that could be used to predict Teff and to develop a Teff prediction model in Graves' disease patients.

Methods

A total of 256 patients with GD were involved in this study. We investigated the influences of age, gender, disease duration, thyroid weight, antithyroid drugs, antithyroid drugs discontinuation period (ADP), thyroid function indexes, thyroid autoantibodies, thyroid-stimulating hormone receptor antibody (TRAb) level and radioactive iodine uptake (RAIU) values before ¹³¹I therapy on Teff, applying univariate and multivariate analyses.

Results

Teff correlated negatively with thyroid peroxidase antibody, TRAb and thyroid weight, as well as positively with 24-hour, 48-hour, and 72-hour RAIU. Additionally, a longer ADP (especially≥ 14d) or without antithyroid drugs before ¹³¹I therapy led to a longer Teff. Stepwise multiple linear regression analysis showed that 24-hour and 72-hour RAIU were statistically significant predictors of Teff (P<0.001). The relationship was: predictive Teff=5.277+0.295×72-hour RAIU-0.217×24-hour RAIU (r =0.865, P < 0.001).

Conclusion

The present results indicate that prediction of Teff from 24-hour and 72-hour RAIU is feasible in patients with Graves' disease, with high prediction accuracy.

Analysis of risk factors of rapid thyroidal radioiodine-131 turnover in Graves' disease patients

Rapid iodine-131(¹³¹I) turnover in the thyroid gland is an important feature of Graves’ disease (GD) and also a strong predictor of radioiodine therapy failure. The aim of this study was to explore the predictors of rapid ¹³¹I turnover. The clinical data on 2543 patients were retrospectively reviewed. Patients were divided into 2 groups depending on present or absent with rapid ¹³¹I turnover defined as a 4-hour to 24-hour ¹³¹I uptake ratio of ≥1. Overall, 590 cases (23.2%) had a rapid ¹³¹I turnover. In the univariate analysis, gender, age, FT₃/FT₄ concentration, disease duration, with or without antithyroid drugs (ATD), time of ATD, thyroid weight and thyroid textures displayed significant differences. Cutoff values of age, FT₃ and thyroid weight to predict rapid ¹³¹I turnover were 38 years, 35 pmol/l and 56 g by receiver operating characteristic curves. Binary logistic regression analysis further revealed higher probability of rapid ¹³¹I turnover in patients with thyroid weight ≥56 g (odds ratio [OR]:3.7, 95% confidence interval [CI]: 3.032–4.559), age <38 years (OR:2.3, 95%CI: 1.906–2.856), FT₃ concentration ≥35 pmol/l (OR:7.6, 95%CI: 5.857–8.563) and females (OR:2.2, 95%CI: 1.757–2.791). In conclusion, larger goiters, younger age, higher FT₃ concentration and females are independently associated with rapid ¹³¹I turnover in GD patients.

Calculation of therapeutic activity of radioiodine in Graves' disease by means of Marinelli's formula, using technetium (99mTc) scintigraphy

The therapeutic activity of ¹³¹I administered to patients with Graves' disease can be calculated by means of Marinelli's formula. The thyroidal iodine uptake (¹³¹IU_max) needed for the calculation is usually determined with the use of ¹³¹I. The purpose of the paper was to estimate ¹³¹IU_max on the basis of technetium uptake in the thyroid at 20 min (^99mTcU_20min). Eighty patients suffering from Graves' disease were qualified for radioiodine therapy with measurement of fT₄, fT₃, thyroid-stimulating hormone and its receptor (TRAb). Prior to the treatment, all the patients were euthyroid. ¹³¹IU_max for each patient was determined according to the levels of ¹³¹I after 24 h (¹³¹IU_24h), while effective half-life (T _eff) according to the measurements of ¹³¹IU_24h and ¹³¹I uptake after 48 h (¹³¹IU_48h). Additionally, on the day before measuring ¹³¹IU_24h, ^99mTcU_20min was calculated for each patient. It was demonstrated that there existed a correlation, with statistical significance at p < 0.05, between the following pairs of values: TRAb and ¹³¹IU_24h, TRAb and ^99mTcU_20min, and ^99mTcU_20min and ¹³¹IU_24h. The interdependence between ¹³¹IU_24h and ^99mTcU_20min at the level of significance p < 0.05 is described by the following algorithms: ¹³¹IU_24h = 17.72 × ln (^99mTcU_20min) + 30.485, if TRAb < 10 IU/ml, and ¹³¹IU_24h = 18.03 × ln (^99mTcU_20min) + 38.726, if TRAb > 10 IU/ml. It is possible to predict thyroid iodine uptake ¹³¹IU_24h in Graves' disease on the basis of measuring the uptake of ^99mTcU_20min. This shortens the time necessary for diagnosis and enables the calculation of ¹³¹I activity using Marinelli's formula.

Differentiation between Graves' disease and painless thyroiditis by diffusion-weighted imaging, thyroid iodine uptake, thyroid scintigraphy and serum parameters

The aim of the present study was to assess the apparent diffusion coefficient (ADC) in diffusion-weighted imaging (DWI), thyroid radioactive iodine uptake (RAIU), thyroid scintigraphy and thyrotropin receptor antibody (TRAb) levels in the differential diagnosis between Graves' disease (GD) and painless thyroiditis (PT). A total of 102 patients with GD and 37 patients with PT were enrolled in the study. DWI was obtained with a 3.0-T magnetic resonance scanner, and ADC values were calculated. RAIU and thyroid scintigraphy were performed. Tissue samples were obtained from patients with GD (6 cases) following thyroidectomy, and from patients with PT (2 cases) following biopsy. Receiver operating characteristic (ROC) curves were drawn, optimal cut-off values were selected, and the sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were assessed. It was found that the ADC, TRAb and RAIU were significantly higher in GD than in PT (P<0.05). ROC curves showed areas under the curves for RAIU, ADC and TRAb that were >0.900. RAIU was the reference method. Sensitivity, specificity, accuracy, PPV and NPV were 96.078, 91.892, 95.000, 97.059 and 89.474% for ADC, and 88.235, 75.676, 84.892, 90.909 and 70.000% for TRAb, after the optimal thresholds of 1.837×10^-3 mm²/sec and 1.350 IU/ml were determined respectively. Histopathology showed that tissue cellularity in PT was much higher than in GD due to massive lymphocytic infiltration. The results of the present study indicate that RAIU, ADC and TRAb are of diagnostic value for differentiating between GD and PT. DWI has great potential for thyroid pathophysiological imaging because it reflects differences in tissue cellularity between GD and PT.

Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome

Radioiodine ((131)I) therapy of benign thyroid diseases was introduced 70 yr ago, and the patients treated since then are probably numbered in the millions. Fifty to 90% of hyperthyroid patients are cured within 1 yr after (131)I therapy. With longer follow-up, permanent hypothyroidism seems inevitable in Graves' disease, whereas this risk is much lower when treating toxic nodular goiter. The side effect causing most concern is the potential induction of ophthalmopathy in predisposed individuals. The response to (131)I therapy is to some extent related to the radiation dose. However, calculation of an exact thyroid dose is error-prone due to imprecise measurement of the (131)I biokinetics, and the importance of internal dosimetric factors, such as the thyroid follicle size, is probably underestimated. Besides these obstacles, several potential confounders interfere with the efficacy of (131)I therapy, and they may even interact mutually and counteract each other. Numerous studies have evaluated the effect of (131)I therapy, but results have been conflicting due to differences in design, sample size, patient selection, and dose calculation. It seems clear that no single factor reliably predicts the outcome from (131)I therapy. The individual radiosensitivity, still poorly defined and impossible to quantify, may be a major determinant of the outcome from (131)I therapy. Above all, the impact of (131)I therapy relies on the iodine-concentrating ability of the thyroid gland. The thyroid (131)I uptake (or retention) can be stimulated in several ways, including dietary iodine restriction and use of lithium. In particular, recombinant human thyrotropin has gained interest because this compound significantly amplifies the effect of (131)I therapy in patients with nontoxic nodular goiter.

Prediction of late (24-hour) radioactive iodine uptake using early (3-hour) uptake values in Japanese patients with Graves' disease

Measurement of 24-hour radioactive iodine uptake (RAIU), which is commonly used to calculate the dose of radioiodine (RI) therapy, cannot be accomplished in a single day. The purpose of this study was to predict 24-hour RAIU from 3-hour RAIU in Japanese patients with Graves' disease, and to investigate other factors that could be used to predict 24-hour RAIU. A total of 66 Japanese patients (14 men and 52 women; age, 17-83 years) with Graves' disease who had undergone both 3-hour and 24-hour ¹²³I RAIU measurements between January 2006 and September 2011 were included in this study. Stepwise multiple regression analyses were performed in order to identify factors that could be used to predict 24-hour RAIU. The investigated factors were gender, age, thyroid volume, TSH, free thyroxine (FT4), free triiodothyronine (FT3), serum creatinine, second generation assay TSH receptor antibody (TRAb2), antithyroid drugs discontinuation period (ADP), iodine restriction period and 3-hour RAIU. The ADP was converted to an ordinal scale ADP score (ADPS) for multiple regression analyses. Multiple regression analyses showed that 3-hour RAIU (P < 0.001), FT3 (P < 0.001) and ADPS (P < 0.001) were statistically significant predictive factors of 24-hour RAIU. The relationship between 24-hour RAIU (LU) and 3-hour RAIU (EU), FT3 and ADPS was: LU = 11.5 + 29.1 × log₁₀ EU + 23.0 × log₁₀ FT3 - 2.7 × ADPS (r = 0.82, P < 0.001). The present results indicate that prediction of LU from EU, FT3 and ADPS is feasible in Japanese patients with Graves' disease.

Thyroidal radioactive iodide uptake in the lactating rhesus monkey

Although radioactive iodide uptake (RAIU) is one of the reliable diagnostic methods for thyroid function in adult humans, especially in the diagnosis of thyrotoxicosis, there are limited data for RAIU during pregnancy and lactation in humans and animals. Therefore, we proposed to validate RAIU for the lactating rhesus monkey to further human model studies in thyroid disease. RAIU was performed at 6 and 24 h using 100 µCi of 123I orally in four lactating monkeys. The thyroid and thigh were counted using a scintillation probe and multichannel analyser. A dose/standard ratio of counts/minute was calculated to compensate for background, utilizing differences in the activity between the dose administered and a standard. Thyroidal RAIU varied significantly among monkeys: 6.71 ± 2.40% for the 6 h uptake and 15.44 ± 7.71% for the 24 h uptake. These data showed that the RAIU test may allow a rational clinical approach to thyroid function testing for lactating rhesus monkeys. Additional studies are needed for assessing thyroid function in rhesus monkeys of varying ages and gender with clinical abnormalities.

Tissue-specific dosimetry for radioiodine therapy of the autonomous thyroid nodule

A tissue-specific dosimetric method based on gamma camera acquisitions was developed to determine the 131I activity to administer to patients with autonomous thyroid nodules (ATN) to deliver 200 Gy to the nodule and to evaluate the correspondent dose to extranodular tissue. Twenty patients with ATN were given 111 MBq of 123I i.v. and their neck was imaged 2, 4, 24, 48, and 120 hours after administration to evaluate separate iodine kinetics for nodule and contralateral lobe. The volumes of nodule and lobe were measured on the 4 hour scintigraphic image, after optimization of the method on a thyroid phantom. Three simplified dosimetric methods were then considered and compared to the reference method in terms of 131I activity: (a) three point method, based on 4, 24, and 120 h acquisitions, (b) fixed T1/2 method, that measures only the 24 h uptake and assumes an effective half-life of 5 days for the nodule, (c) fixed activity method, based on the administration of 413 MBq of 131I. The mean 131I activity to administer to the 20 patients was 413 MBq (range 65-1327) and the mean dose to the contralateral lobe was 43 Gy (range 11-121). The percentage differences in 131I activity between the reference method and the simplified methods were in the ranges: (a) -14%, 13%, (b) -42%, 74%, (c) -69%, 533%. The relevant dose to extranodular tissue and the great interpatient variability of the radioiodine activity required to give a predetermined dose to ATN suggest that a tissue specific dosimetric approach based on gamma camera acquisitions is fundamental. A simple method based on only three uptake measurements is a reliable alternative to the five point method when the clinical workload of a Nuclear Medicine department is particularly heavy.