ENDOCRINE SCINTIGRAPHY

1.

THYROID
a) Imaging
i)
I-123:best for imaging thyroid +Nodules
(1) Longer time to the scanner after injection
allows tracer washout and reveal true
identity of nodule
ii) Tc-99m: best for imaging hyperthyroid patients
(1) low target to background ratio - BAD
(2) Quick washout and therefore less time to
find nature of a nodule
(3) if nodule hot with Tc-99 addition I-123 must
be performed to rule out discordant nodules
(a) Discordant nodules: hot with Tc-99 and
cold with I-123 --> potentially
malignant
b) RAIU
i)
indicated for 1) differentiation of Graves disease
(high) 2) assisting in calculation of radio-iodine
dose 3) assessment of suspected toxic
multinodular goiter
ii) Subacute Viral - LOW
c) Congenital
i)
Lingual thyroid - high risk of hypothryoidism
ii) Thyroglossal duct cyst
d) Hypothyoidism
i)
Hashimoto's
(1) autoimmune with increased risk of papillary
thyroid cancer
ii) dietary, and prior hyper T3 post radioactive
iodine treatment
iii) Neonatal - agnesis, Lingual thyroid --> cretanism
e) Hyperthyroidism
i)
Graves: hyperplasia secondary to autoimmune
antibodies
(1) nonpregnant, nonlactation give I-131
ii)
toxic nodule and factitous
f)
Goiter
i)
seen with hypo, hyper and normal thyroid
ii) Multinodular Goiter
(1) adenomatous hyperplasia - see hot nodules
on cold background
iii) Nontoxic goiter
(1) related to iodine deficiency
g) Thyroiditis
i)
rapid gland enlargement +/- nodules
ii) Bacterial: Staph, Strep or Pneumococcus
(1) airway compromise and vascular thrombosis
iii) Subacute viral (low RAIU)
(1) deQuervains/granulomatous
(2) thyroid pain and hyperT3 followed by URI
(3) Acute: uptake low or absent
(4) resolves within few months
iv) Riedel thyroiditis
(1) inflammatory fibrosing process involving
thryoid and the neck
h) Secondary hyperthyroidism
i)
in patients with hydatiform moles or
choriocarcinoma --> HCG is similar to TSH

2.
3.

THYROID NODULES
a) Terms
i)
Hot nodules = hyperfunctioning
(1) usually adenomas and rarely malignant
ii) Cold nodules = hypofunctioning
(1) adenomatous tissue or malignant (10-15%)
iii) Indeterminate nodule (Not WARM!!)
(1) benign or malignant
iv) Discordant nodules: hot with Tc-99 and cold with
I-123 --> potentially malignant

b)

4.

Differential
i)
Follicular Adenoma
(1) Hurthle cell adenoma, colloid adenoma...
ii) Adenomatous Hyperplasia (Colloid Nodules)
(1) 50% of nodules
(2) Cycles of hyperplasia and involution
iii) Thyroid Cysts
(1) Usually cystic degeneration of an
adenomatous nodule or follicular adenoma
(2) 0.5%-3.0% malignant --> FNA
iv) Thyroid Cancer
(1) regression of nodule size after synthroid =
BENIGN
(2) Papillary Carcinoma
(a) Most common - 75%
(b) lymphatic spread then hematogenous
(3) Follicular Carcinoma
(a) 15% of cases
(b) hematogenous spread
(4) Medullary Carcinoma
(a) C-Cells; perifollicular cells --> calcitonin
(b) MEN II
(c) does not concentrate I-131, mets
dectected by T1-201 and Tc-99m
(5) Anaplastic Carcinoma
(a) Lethal - 5yr is 4%
(6) Staging
(a) After treatment patients should be
hypothyroid with TSH>40 before
scanning
(b) whole body I-131 scans for mets and
recurrence for papillary
(i) Anaplastic and Medullary don't take
up I-131 therefore useless
(7) Post-ablation scans
(a) recomninant TSH (rhTSH) without
needing to withdrawal levo replacement
(b) give rhTST and check thryoglobulin
levels - Low or undetectable =
recurrence
(8) Radioiodine Therapy
(a) Anything >33mCi requires
hospitalization
(b) Make sure TSH>40 and patient avoid
iodine rich food/milk 1 wk prior to
rescan to ensure adequate iodine
uptake
(i) scan delays therapy by 23months!!
(c) Side-effects
(i) >100mCi saloadenitis and possible
permanent xerstomia
1. after treatment pt drink lots of
water and lozenges
PARATHYROID
a) Uptake T1-201 not Tc-99m (Thryoid uptakes both)
i)
Dual-Isotope imaging - Subtraction technique
b) Sestamibi/Tetrofosmin
i)
replaced by Tc/T1 subtraction technique
ii) Adenomas show delayed washout because of
high mitochondria content
c) Adenomas
i)
Uniform in appearance
d) Multiple Gland Disease
i)
parathryroid hyperplasia cannot be
differentiated from multiple adenomas by
imaging alone
e) Parathyroid Carcinoma
i)
at least 2cm in size
ii) heterogenous with cystic degeneration
f)
Ectopic Parathyroid

5.

i)
Tc-99m delayed scans
ADRENAL
a) I-131 MIBG Scans
i)
taken up by adrenal medullary -->
pheochomocytoma
ii) Also uptaken by neural crest cells -->
neuroblastomas and medullary thyroid cancer

b)

Indium-111 Pentetreotide
i)
Synthetic somatostatin
ii) imaging Neuroendocrine tumors --> carcinoid
and paraganglioma.

6.