Acute changes in thyroid volume and function following 131I therapy of multinodular goitre

OBJECTIVE Many textbooks claim that radioIodine (¹³¹I) treatment should be given with care to a goitre with substernal extension, for fear of acute swelling of the gland and thus respiratory problems. Since ¹³¹I Is used increasingly in the treatment of non-toxic as well as toxic goitre we have evaluated the acute changes in thyroid volume following ¹³¹I therapy. DESIGN Evaluation of potential acute changes in thyroid volume and function after ¹³¹I treatment in patients with non-toxic goitre treated because of compression symptoms or for cosmetic reasons, as well as In patients with toxic goitre. PATIENTS Out-patients with multinodular goitre, either non-toxic (n= 20) or toxic (n= 10). Excluded were patients with a substernal goitre. MEASUREMENTS Ultrasonically determined thyroid volume and standard thyroid function variables were Investigated before and 2, 7, 14, 21, 28 and 35 days after treatment. RESULTS In non-toxic goitres the thyroid volume did not increase significantly, the maximum increase in the median volume being 4% on day 7. Serum levels of free T3 and free T4 Indices increased by 20% (day 7) and 13% (day 14) (P= 0·002), respectively. Likewise thyroid volume in toxic nodular goitre did not change significantly after ¹³¹I treatment (maximum median increase was 2%). None of the patients presented symptoms of tracheal compression. CONCLUSIONS ¹³¹I treatment of non-toxic as well as toxic multinodular goitre does not seem to increase thyroid volume.     

Thyroid volume and function after 131I treatment of diffuse non-toxic goitre

OBJECTIVE Traditional treatment modalities of diffuse non-toxic goitre are thyroid hormone suppression or surgery. When treating nodular non-toxic goitre with ¹³¹I treatment a reduction in thyroid volume to about 50% has been observed. In the present study we evaluated the effect of ¹³¹I treatment of diffuse non-toxic goitre. DESIGN Retrospective study of patients treated for a diffuse non-toxic goitre and followed by evaluation of thyroid volume measured by ultrasound. PATIENTS Ten selected patients from our out-patient clinic with diffuse non-toxic goitre. MEASUREMENTS Thyroid volume was measured by ultrasound and thyroid function by serum values of T4, T3, T3 uptake ratio, TSH, TSH receptor antibodies and thyroid peroxidase antibodies (anti-TPO). Measurements were performed before and 1, 3, 6 and 12 months (and 18 months (n=7), thyroid volume measured in six patients)) after ¹³¹I treatment. RESULTS Thyroid volume declined in all patients from median 41 (range 27–160) ml to 20 (range 9–108) ml over 1 year, a reduction of 47%. One patient developed transient and one persistent hypothyroidism in the follow-up period. Both had elevated anti-TPO levels before treatment (331 and 9185 U/ml) and demonstrated titre increases of 2.5 and 30 times after 3 and 6 months, respectively. Pretreatment values were reached after 1 year. The other eight patients had normal anti-TPO levels and free T4 and T3 indices did not change during follow-up, whereas serum TSH levels demonstrated upward trends within the normal range (P<0.05). TSH receptor antibodies were normal and remained so in all patients. CONCLUSION S¹³¹I treatment of diffuse non-toxic goitre reduces thyroid volume by approximately 50% within 12–18 months. Hypothyroidism, during a limited follow-up period, developed only in patients with positive anti-TPO levels before treatment.     

Treatment of metastatic carcinoid tumours, phaeochromocytoma, paraganglioma and medullary carcinoma of the thyroid with 131I-meta-iodobenzylguanidine (131I-mIBG)

OBJECTIVE: Meta-iodo-benzyl-guanidine labelled with 131-iodine [(131)I-mIBG] has been used extensively for imaging tumours originating from the neural crest but experience with its therapeutic use is limited, particularly for non-catecholamine secreting tumours. In order to assess the therapeutic response and potential adverse effects of the therapeutic administration of (131)I-mIBG, we have reviewed all patients who had received this form of treatment in our department. DESIGN: Retrospective analysis of the case notes of patients with neuroendocrine tumours who received treatment with (131)I-mIBG and were followed-up according to a defined protocol in a given time frame. PATIENTS: Thirty-seven patients (18 with metastatic carcinoid tumours, 8 metastatic phaeochromocytoma, 7 metastatic paraganglioma and 4 metastatic medullary carcinoma of the thyroid) treated with (131)I-mIBG over a 15-year period were included in this analysis. MEASUREMENTS: The symptomatic, hormonal and tumoural responses before and after (131)I-mIBG therapy over a median follow-up duration of 32 months (range 5-180 months) were recorded. Of the 37 patients (22 males; median age 51 years, range 18-81 years), 15 were treated with (131)I-mIBG alone whereas the other 22 received additional therapy. RESULTS: A total of 116 therapeutic (131)I-mIBG doses were administered [mean cumulative dose 592 mCi (21.9 GBq); range 200-1592 mCi (7.4-58.9 GBq)]. None of the patients showed a complete tumour response. However, 82% of patients treated with (131)I-mIBG alone and 84% who received additional therapy showed stable disease over the period of follow-up. Overall survival during the period of the study was 71%. The overall 5-year survival rate was 85% (95% confidence interval, 72-99%) for all patients and 78% (95% confidence interval, 55-100%) for the carcinoid group alone, according to Kaplan-Meier analysis. Symptomatic control was achieved in all the patients treated with (131)I-mIBG alone, and in 72% of those receiving additional therapy. Hormonal control was noted in 50% and 57% of patients, respectively. (131)I-mIBG therapy was safe and well tolerated. Serious side-effects necessitating the termination of (131)I-mIBG therapy were seen in only 2 of our patients. CONCLUSIONS: (131)I-mIBG therapy produces symptomatic and hormonal improvement and moderate tumour regression/stabilization in patients with metastatic neuroendocrine tumours with minimal adverse effects. It may be a valuable alternative or additional therapeutic option to the currently available conventional treatment modalities.     

Prediction of cure and risk of hypothyroidism in patients receiving 131I for hyperthyroidism

Context There is little consensus regarding the most appropriate dose of radioiodine (¹³¹I) to be administered to patients with hyperthyroidism. Objective To compare the efficacy of fixed dose regimens of ¹³¹I in curing hyperthyroidism and to define simple clinical and biochemical factors that predict outcome in individual patients. Design Consecutive series of hyperthyroid subjects treated with ¹³¹I. Setting Single Secondary/Tertiary Care Hospital Clinic. Participants A total of 1278 patients (1013 females and 262 males, mean age 49·7 years) presenting with hyperthyroidism between 1984 and 2006. Intervention Treatment with ¹³¹I using a fixed dose regimen. Main outcome measures Probability of cure and risk of development of hypothyroidism following a single dose of ¹³¹I. Results Patients given a single dose of ¹³¹I of 600 MBq (n = 485) had a higher cure rate (84·1%) compared with those receiving either 370 MBq (74·9%, P < 0·001) or those given 185 Bq (63%, P < 0·001). An increased incidence of hypothyroidism by 1 year was evident with higher doses (600 MBq: 60·4%; 370 MBq: 49·2%, P = 0·001; 185 Bq: 38·1%, P < 0·001). Binary logistic regression analysis identified a 600 Bq dose of ¹³¹I [adjusted odds ratio, AOR 3·33 (2·28–4·85), P < 0·001], female gender [AOR 1·75 (1·23–2·47), P = 0·002], lower presenting serum free T4 concentration [AOR 1·01 (1·01–1·02), P < 0·001] and absence of a palpable goitre [AOR 3·33 (2·00–5·56), P < 0·001] to be independent predictors of cure. Similarly, a 600 MBq dose [AOR 3·79 (2·66–5·38), P < 0·001], female gender [AOR 1·46 (1·05–2·02), P = 0·02], younger age [AOR 1·03 (1·02–1·04), P < 0·001], absence of a palpable goitre [AOR 3·85 (2·38–5·88), P < 0·001] and presence of ophthalmopathy [AOR 1·57 (1·06–2·31), P = 0·02] were identified as independent factors predicting the probability of development of hypothyroidism at one year. Based on these findings, formulae to indicate probability of cure and risk of hypothyroidism for application to individual patients were derived. Conclusions Simple clinical/biochemical criteria can be used to predict outcome after ¹³¹I treatment. These factors determine that males, those with severe biochemical hyperthyroidism, and those with a palpable goitre require larger doses (600 MBq) in order to achieve cure.     

Chronic radiodermatitis following cardiac catheterisation: a report of two cases and a brief review of the literature

Cardiac angiography produces one of the highest radiation exposures of any commonly used diagnostic x ray procedure. Recently, serious radiation induced skin injuries have been reported after repeated therapeutic interventional procedures using prolonged fluoroscopic imaging. Two male patients, aged 62 and 71 years, in whom chronic radiodermatitis developed one to two years after two consecutive cardiac catheterisation procedures are reported. Both patients had undergone lengthy procedures using prolonged fluoroscopic guidance in a limited number of projections. The resulting skin lesions were preceded, in one case, by an acute erythema and took the form of a delayed pigmented telangiectatic, indurated, or ulcerated plaque in the upper back or below the axilla whose site corresponded to the location of the x ray tube during cardiac catheterisation. Cutaneous side effects of radiation exposure result from direct damage to the irradiated tissue and have known thresholds. The diagnosis of radiation induced skin injury relies essentially on clinical and histopathological findings, location of skin lesions, and careful medical history. Interventional cardiologists should be aware of this complication, because chronic radiodermatitis may result in painful and resistant ulceration and eventually in squamous cell carcinoma.     

Intra-synovial 131I Human Serum Albumin (HSA) in the Investigation of Joint Disease

A procedure of radioisotope scanning using intra-synovial ¹³¹I HSA for the investigation of joint disease has been described. This has been shown to be useful in outlining cystic swellings related to joints. The most important application of the technique is the diagnosis of popliteal or calf cyst rupture which is difficult to distinguish from thrombophlebitis. Conventional radiography using phlebograms or arthro-grams has disadvantages which have not been encountered with this new technique. The radiation dose administered is not considered to be a hazard.     

Adult T-cell leukaemia and lymphoma: report of two cases and a brief review of the literature

Human T-cell lymphotropic virus type 1 (HTLV-1) can cause adult T-cell leukaemia/lymphoma (ATLL). Two patients originating from the Caribbean area with ATLL are described. The first patient developed respiratory insufficiency due to acute T-cell leukaemia. The diagnosis was suspected because of characteristics of abnormal lymphocytes in the blood smear. The second patient had lymphadenopathy and developed severe hypercalcaemia. Both patients were typical cases of ATLL. The pathogenesis, clinical manifestations, pitfalls and treatment of this intriguing disease are discussed.     

Otological manifestations of acute leukaemia: report of two cases and review of literature

Otological manifestations exceptionally reveal acute leukaemia, whereas leukaemic infiltration of any tissue is frequent at postmortem examination. We present two cases of acute myeloblastic leukaemia revealed by a loss of hearing due to a middle‐ear leukaemic infiltration. The characteristics of such a clinical and radiological finding are emphasized. It is suggested that middle and inner ear can be a ‘sanctuary’ localization, which might sometimes require radiation therapy to achieve durable and complete remission.     

Therapy-related acute myeloid leukaemia after successful therapy for acute promyelocytic leukaemia with t(15;17): a report of two cases and a review of the literature

We describe two patients with positive t(15;17) acute promyelocytic leukaemia (APL) that developed into a therapy-related myelodysplasia 2-2.5 years after complete remission (CR) and then evolved into therapy-related acute myeloid leukaemia (t-AML). Both patients received anthracyclines as potential leukaemogenic drugs. In both cases, cytogenetic changes usually occurring after use of alkylating agents were noticed: monosomy 7 associated with monosomy 5 or 5q- chromosome. A review of the literature on t-AML occurring after successful therapy for APL showed only one report similar to these two cases. These observations suggest that anthracyclines can cause t-AML similar to that induced by alkylating agents.     

The role of 123I-diagnostic imaging in the follow-up of patients with differentiated thyroid carcinoma as compared to 131I-scanning: avoidance of negative therapeutic uptake due to stunning

OBJECTIVE: Some patients with relapsed differentiated thyroid cancer may show rising thyroglobulin (Tg) levels despite a lack of 131I uptake on routine whole body imaging. A significant proportion of these patients, after therapy doses of 131I, may demonstrate positive 131I uptake with a subsequent fall in serum Tg, implying a therapeutic effect. Attempts to identify such patients by increasing the dose of the diagnostic 131I tracer may lead to inhibition of subsequent uptake after the therapy dose, an effect referred to as 'stunning' and associated with a reduction in therapeutic effect. 123I is a short half-life gamma-emitter, thought to be unlikely to cause stunning, which may thus be more suitable than 131I for diagnostic imaging of thyroid cancer. DESIGN AND PATIENTS: The efficacy of the 123I radionuclide was determined in a longitudinal study of 12 patients who were selected only because they showed elevated serum Tg and a negative diagnostic 131I whole body study prior to therapy with 131I. RESULTS: There was almost complete concordance in uptake between 123I diagnostic imaging and the final scans carried out after 131I therapy (hereafter known as therapy studies) in 11 out of 12 patients at their first evaluation, in each of four patients receiving 123I at their second evaluation and in a single patient receiving 123I at a third evaluation. One patient had a positive 123I study but a negative 131I therapy study: following therapy Tg declined from 5.5 pg/l to undetectable levels, implying a therapeutic effect, and suggesting that the negative uptake was not the result of stunning. Two negative diagnostic 123I studies were followed by negative therapy studies, and thus there were no false negatives. 123I correctly identified disease in the nine patients with metastases in the lungs, mediastinum and bone at the first evaluation, in all four patients at the second evaluation and in the single patient at the third evaluation. At the end of the study, patients had received up to three 131I therapy doses, Tg had risen in four patients, fallen in eight and become undetectable in one patient. CONCLUSIONS: 123I is highly sensitive in diagnosing local recurrence and metastatic disease, and produces scintigraphic images which concord well with uptake following 131I therapy. It is proposed that 123I imaging, in combination with serum Tg measurements, should replace 131I tracer imaging as an indicator of the potential efficacy of 131I therapy. Stunning, with its detrimental effects on 131I therapy, may thus be avoided. The possibility of false negative images due to the stunning phenomenon must always be borne in mind if there is a discrepancy between positive 131I imaging studies and a surprisingly negative subsequent 131I therapy scan.     

Mucoepidermoid carcinoma of the thyroid: a case report and literature review

The mucoepidermoid carcinoma is a neoplasia that usually occurs at salivary glands, breast, pancreas and gastrointestinal tract. The primary occurrence on thyroid gland is rare and only 33 cases were previously published. Although the majority of cases of mucoepidermoid carcinoma of the thyroid (MECT) show a benign evolution, this paper describes a patient with an aggressive tumor. A literature review over clinical, histopathological, immunohistochemical features and histogenetic origin was discussed.     

Otological manifestations of acute leukaemia: report of two cases and review of literature.

Otological manifestations exceptionally reveal acute leukaemia, whereas leukaemic infiltration of any tissue is frequent at postmortem examination. We present two cases of acute myeloblastic leukaemia revealed by a loss of hearing due to a middle-ear leukaemic infiltration. The characteristics of such a clinical and radiological finding are emphasized. It is suggested that middle and inner ear can be a 'sanctuary' localization, which might sometimes require radiation therapy to achieve durable and complete remission.     

Studies on Circulating Soluble Fibrin: Separation of 125I-Des-AB Fibrin and 131I-Fibrinogen by Gel Filtration

The behaviour of labelled des-AB fibrin in plasma was studied by gel filtration after it had been injected into rabbits. Purified rabbit [125I]des-AB fibrin was prepared by clotting of [125I]fibrinogen by thrombin and solubilizing the formed clot in buffered 3 M urea. Gel filtration of this material on urea-equilibrated columns showed a single peak identical to the elution profile of fibrinogen. This indicated the existence of monomeric des-AB fibrin. When plasma from rabbits injected with monomeric [125I]des-AB fibrin and [131I]fibrinogen was gel-filtered through plasma-equibrated columns, two separate peaks of radioactivities were obtained. The first peak eluted mainly with the void volume and contained [125I]des-AB fibrin whereas the second peak eluting within the fractionation range contained [131I]fibrinogen. Identical elution profiles were obtained in in vitro studies when monomeric [125I]des-AB fibrin was mixed with plasma containing [131I]fibrinogen and gel-filtered through plasma-equilibrated columns. We conclude from these studies that monomeric des-AB fibrin formed high-molecular weight aggregates or changed its conformation posing as a larger molecule than fibrinogen when injected into rabbits. No complex formation between des-AB fibrin and fibrinogen was observed as [131I]fibrinogen was not incorporated into des-AB fibrin aggregates. Thus, soluble des-AB fibrin can circulate in the blood without forming fibrin-fibrinogen complexes.     

The importance of a tumor capsule in columnar cell thyroid carcinoma: a report of two cases and review of the literature.

Two cases of papillary columnar cell thyroid carcinoma are presented. A 49-year-old man presented with lymph node and pulmonary metastases at diagnosis; a 51-year-old woman developed local recurrence and lung and bone metastases 3 years postsurgery. Death occurred after 52 and 57 months, respectively. The first case lacked a tumor capsule, although the second exhibited capsule remains with extensive tumor cell infiltration. A review is made of all similar cases reported to date in the literature, placing emphasis on the epidemiological and prognostic differences observed in terms of circumscribed or noncircumscribed tumor. The presence of a capsule was associated with a higher frequency of female patients and a favorable prognosis. In contrast, tumors profusely infiltrating the thyroid parenchyma or extrathyroid tissues in the absence of a capsule, found in similar proportion of men and women had a fatal prognosis.     

In Vivo Behaviour of Homologous Urea-Soluble 131I-Fibrin and 125I-Fibrinogen in Rabbits: the Effect of Fibrinolysis Inhibition

The in vivo behaviour of urea-soluble fibrin monomer (FM) was compared with that of fibrinogen in rabbits. Purified rabbit 125I-fibrinogen was injected into 36 unanaesthetized rabbits. Three days later the rabbits received either purified rabbit 131I-FM I mg/kg body weight, which corresponds to cI% of the circulating plasma fibrinogen pool 131I-fibrinogen, or buffered urea only. The distribution volume of FM was 43.4 +/- 6.9 ml/kg and of fibrinogen 43.5 +/- 7.7 ml/kg (mean +/- SD). The elimination curve of urea-soluble FM as represented by the clottable 131I-radioactivity. plotted on a semi-logarithmic paper, consisted of an initial steep decay within the first 6 h and a slow flattening of the slope 6 to 24 h after injection of FM. Although a terminal single-exponential slope, as observed in fibrinogen elimination, could not be computed for the 24 h following FM injection the mean half-life time of the last segment of the clottable-radioactivity curve, between 12 h and 24 h, was 12 h. Within 24 h a mean of 83-5% of the injected FM were removed from the circulating blood. The elimination characteristics of fibrinogen were not influenced by the injected FM. Control experiments showed that buffered 3.0 M urea, the solvent of FM, does not influence distribution volume and elimination of 125I-fibrinogen. The distribution of 131I as well as 125I-radioactivities in organs representing FM and fibrinogen respectively did not differ from each other. Elevated levels of 131I-radioactivity, however, were found in the urine after FM injection suggesting an accelerated elimination of FM in comparison to fibrinogen. Fibrinolysis inhibition with high doses of aprotinin did not significantly reduce the urinary excretion of 131I-radioactivity representing breakdown of FM. Furthermore, inhibition of the fibrinolytic system had no influence on the elimination characteristics of either fibrinogen or FM. In order to explain the results obtained in this study the following theory is proposed. Intravenously injected FM forms complexes with fibrinogen and fibrinolytic degradation products. The complexes continuously increase in size until they dissociate into fibrin oligomers and carrier proteins. The oligomers are eliminated whereas the carrier proteins recycle.     

Langerhans cell histiocytosis of the thyroid: a report of two cases and review of the literature.

Langerhans cell histiocytosis (LCH) is a monoclonal disease of histiocytes that can involve many or very few organ systems. It is a relatively benign disorder with a 3% mortality in adults. LCH rarely involves the thyroid gland. We report two cases, both presenting in males with a goiter. Both patients were treated with subtotal thyroidectomy. The first patient also received radiotherapy to his thyroid bed and scalp. We summarize the prior reported cases of LCH involving the thyroid and review the current treatment modalities used for LCH.     

Lingual thyroid carcinoma: a case report and review of the literature.

Ectopic thyroid tissue may reside anywhere along its embryologic path of descent. Most ectopias manifest as simple thyroglossal duct cysts in conjunction with a normally developed thyroid gland in its usual thyroid cervical bed. Lingual thyroid is a rare developmental abnormality characterized by the failure of the thyroid gland, or remnants, to descend from its embryologic site of origin at the foramen cecum to its usual pretracheal position. Carcinoma arising in a lingual thyroid is even more unusual with fewer than 30 cases reported in the literature. We report the second case of lingual papillary thyroid carcinoma and review the clinical features, natural history, diagnosis, and treatment of lingual thyroid carcinoma.