Clinical Endocrinology (2010) 72, 122–127
ORIGINAL ARTICLE
The utility of radioiodine uptake and thyroid scintigraphy in the
diagnosis and management of hyperthyroidism
O. E. Okosieme*, D. Chan†, S. A. Price‡, J. H. Lazarus† and L. D. K. E. Premawardhana†,‡
*Department of Endocrinology and Diabetes, Prince Charles Hospital, Cwm Taff NHS Trust, Merthyr Tydfil, Mid Glamorgan, †Centre
for Endocrine and Diabetes Sciences, School of Medicine, Cardiff University, Cardiff, South Wales and ‡Department of Endocrinology
and Diabetes, Caerphilly District Miners’ Hospital, Caerphilly, UK
Summary
Background and objectives The value and practice of thyroid
radionuclide imaging in the diagnosis and management of hyper-
thyroidism is unsettled. Our objectives were to determine the influ-
ence of thyroid uptake and scintigraphy on the diagnosis of
hyperthyroidism and the prediction of outcome following radioio-
dine therapy.
Patients and design We reviewed records and scintigraphic
studies on 881 hyperthyroid patients carried out between 2000 and
2007. The agreement between the clinical and scintigraphic diagno-
sis was evaluated by kappa statistics. We determined the relation-
ship between 4-h 123I uptake and the outcome of 131I treatment in
626 patients. A multiple logistic regression model was used to
determine variables influencing treatment outcome in 1 year.
Results The diagnostic categories were Graves’ disease (GD,
n = 383), toxic multinodular goitre (n = 253), solitary toxic nod-
ule (n = 164) and Graves’ disease coexisting with nodules
(n = 81). The mean age of the patients was 58 ± 17, (M:F 160:721).
There was good agreement between clinical and scintigraph diag-
nosis (K = 0Æ60, 95% CI 0Æ57–0Æ64, P < 0Æ001); and they were cor-
rectly matched in 74%; mismatched in 6% and indeterminate in
20% of patients. Treatment outcome was not associated with scinti-
graph diagnosis (P = 0Æ98) or radioiodine uptake at 4 h (P = 0Æ2).
The use of antithyroid medications before treatment predicted
treatment failure (odds ratio 2Æ0, 95% CI 1Æ2–3Æ6, P = 0Æ01).
Conclusion Thyroid scintigraphy and uptake studies did not
influence diagnosis or treatment outcomes in most cases of hyper-
thyroidism. Our findings in this retrospective study do not justify
their routine use. Selective scanning will reduce cost and exposure
to radioisotopes without compromising diagnostic accuracy or
treatment outcomes.
(Received 29 March 2009; returned for revision 3 April 2009; finally
revised 25 April 2009; accepted 28 April 2009)
Correspondence: Dr Onyebuchi E. Okosieme, Department of Endocrino-
logy and Diabetes, Prince Charles Hospital, Cwm Taff NHS Trust, Merthyr
Tydfil, Mid Glamorgan, CF47 9DT, UK. Tel.: +44(0)1685 728353; Fax:
+44(0)1685 728448; E-mail: Onyebuchi.Okosieme@wales.nhs.uk
122
doi: 10.1111/j.1365-2265.2009.03623.
Background
Thyroid uptake and scintigraphy scans are widely employed in the
diagnosis and management of hyperthyroidism. They may be
indicated in the differentiation of Graves’ disease (GD) from toxic
nodular goitre (TNG), in the diagnosis of thyroiditis and as a guide
to radioiodine therapy for hyperthyroidism.1–3 The distinction
between GD and toxic nodules is essential as medical therapy with
thionamides may be offered as initial therapy for GD but is unlikely
to be effective in patients with toxic nodules, who ultimately
require radioiodine or surgical treatment. However, the value of
thyroid scintigraphy in the differential diagnosis of hyperthyroid-
ism is controversial. Current opinion suggests that with the advent
of modern sensitive thyrotropin receptor immunoassays for the
diagnosis of GD, the aetiology of hyperthyroidism can in most cases
be established on clinical and immunological grounds without
resorting to scintigraph studies. On the contrary, it is possible that
a significant number of patients with hyperthyroidism may be
misdiagnosed and subsequently mismanaged in the absence of rou-
tine scintigraphic assessments.4 Yet only few studies, mostly in
small groups of patients, have specifically addressed this issue to
date.5–7
Radioactive iodine uptake scans are also performed in the
assessment of patients prior to radioiodine therapy for hyper-
thyroidism.2 Radioiodine (131I) is now established as a safe and
effective treatment for hyperthyroidism.8–10 It is the treatment
of choice for solitary and multiple toxic nodules and is increas-
ingly being offered as first-line therapy in GD.8–10 A normal or
high isotope uptake is generally accepted as a prerequisite for
therapeutic efficacy while treatment is deemed unlikely to suc-
ceed in patients with low uptake.11,12 In addition, patients with
excessively high uptake levels appear to be more resistant to
radioiodine than those with less extreme uptake.13 However,
uptake thresholds for optimal therapeutic response are
unknown and dosimetric treatment protocols based on isotope
uptake have not offered significant advantages over fixed-dose
regimens in terms of outcome.14,15
It is therefore unclear as to what extent radioactive iodine uptake
scans influence the diagnosis and subsequent management of
patients with hyperthyroidism. It also remains unresolved whether
pretherapeutic uptake studies offer enough prognostic information
 2010 Blackwell Publishing Ltd

to justify their routine use in patients receiving radioiodine. These
considerations are relevant given that radionuclide imaging is
costly, often inconvenient to the patient and involves added expo-
sure to radioactive isotopes. To this end, we reviewed a large num-
ber of radioactive iodine uptake scans performed at the University
Hospital of Wales for hyperthyroidism between January 2000 and
December 2007. Our objectives were first, to ascertain the influence
of thyroid uptake and scintigraphic studies in the differential diag-
nosis and management of hyperthyroidism, and second, to deter-
mine their prognostic value in predicting outcome following
radioiodine therapy.
Methods
Patients
We studied the notes of consecutive patients with hyperthyroidism
who had radioactive iodine uptake studies in our institution
between January 2000 and December 2007. Patients were identified
through records in the nuclear medicine department and addi-
tional information was obtained from patient case records and
from the Welsh Automated Follow-up Registry (WAFUR). We
documented demographic and clinical data for each patient includ-
ing age at the time of treatment, gender, presence or absence of goi-
tre on clinical examination, clinical diagnosis and scintigraph
diagnosis. We also recorded thyroid functions (FT4 and TSH) and
thyroid antibody status, namely thyroid peroxidase (TPOAb) and/
or TSH receptor antibodies (TRAb).
Laboratory measurements
FT4 was measured with competitive labelled antibody assays and
TSH by a two-site immunochemiluminometric assay. These were
analysed on an automated immunoassay analyser, the ACS-180
Plus (Chiron Diagnostics Ltd, Halstead, Essex, UK). Reference
ranges were as follows: FT3, 3Æ5–6Æ8 pmol/l; FT4, 9Æ8–23 pmol/l
and TSH, 0Æ35–5Æ2 mU/l. Prior to October 2001, TPOAb was mea-
sured with a Roche ES300 automated immunoassay analyser
(Roche Diagnostics GmbH, Mannheim, Germany). After October
2001, TPOAb was measured with an ELISA method using a
competitive immunoassay on a Roche diagnostics Elecsys 2010
automated immunoassay analyser (Roche Diagnostics GmbH,
Mannheim, Germany). Reference values for TPOAb was
<19Æ4 kIU/l. Overt hyperthyroidism was defined as an elevated FT3
and/or FT4 with suppressed TSH, while subclinical hyperthyroid-
ism was defined as FT3 and FT4 within the reference range with
suppressed TSH. Overt hypothyroidism was defined as decreased
FT4 with elevated TSH, while subclinical hypothyroidism was
defined as FT4 within the reference range with elevated TSH.
Clinical diagnosis
Each patient was assigned a diagnosis based strictly on the clinical
and immunological findings at presentation regardless of the scin-
tigraphy studies. Patients were grouped into diagnostic categories
as follows: (1) GD, (2) TNG, (3) Graves’ disease coexisting with
 2010 Blackwell Publishing Ltd, Clinical Endocrinology, 72, 122–127
Radioiodine uptake scans and hyperthyroidism 123
toxic nodules (GDN) and (4) hyperthyroidism of indeterminate
aetiology (indeterminate). A diagnosis of GD was based on the
coexistence of biochemical hyperthyroidism and at least two of the
following features: a diffuse goitre, signs of Graves’ orbitopathy and
positive thyroid antibodies (TPOAbs and/or TRAbs). TNG was
diagnosed if there was biochemical hyperthyroidism associated
with a nodular goitre on clinical examination, and included
patients with solitary toxic nodules (STN) and toxic multinodular
goitres (TMNG). Those patients who fulfilled the criteria for GD
but in addition had palpable nodules, either single or multiple, were
diagnosed as GDN. Patients who fulfilled none of these diagnostic
criteria were classed as hyperthyroidism of indeterminate aetiology.
Thyroid scintigraphy scans
Thyroid scintigraphy was performed using a gamma camera with a
high resolution collimator. Images were acquired 4 h after oral
ingestion of 123I (administered activity: 10 MBq) on a 128-by-128
matrix. The acquisition parameters were 50,000 counts or after
10 min of imaging, whichever occurred first.
Post-scintigraphy diagnosis
A post-scintigraphy diagnosis was determined for each patient tak-
ing into account the scintigraphic pattern. Scintigraph scans were
examined by a single reviewer who was blinded to the clinical dia-
gnosis. GD was diagnosed if the uptake pattern was diffuse, while
toxic nodular disease was diagnosed if the uptake was patchy with
multiple areas of increased uptake (TMNG) or confined to a single
‘‘hot’’ area (STN). A diagnosis of GDN was made if patchy areas of
increased uptake were seen on a background of diffuse uptake. The
radioactive iodine uptake was measured 4 h after 123I uptake and
was expressed as a percentage of the administered dose. The refer-
ence range in our laboratory for the 4-h uptake was 5–25%.
Radioiodine treatment
In our clinic, radioiodine was used as first-line therapy for TNG and
was offered to patients with GD who relapsed following initial medi-
cal therapy. Depending on the severity of the clinical and biochemi-
cal features of thyrotoxicosis anti-thyroid medications were given
prior to radioactive iodine therapy and where possible were discon-
tinued 1 week before treatment. Majority of patients (97%) received
a fixed standard ablative dose of 555 MBq as is the policy in our unit.
A few patients received different empirical doses ranging from 400
to 800 MBq depending on the preferences of individual endocrinol-
ogists. Treatment was administered on an outpatient’s basis after a
radioactive iodine uptake scan performed on the same day.
Patient follow-up and outcome of treatment
Following radioiodine treatment, thyroid hormones were moni-
tored every 1–3 months for up to a year. Outcomes were defined at
the end of 12 months of follow-up as treatment success or treat-
ment failure. Treatment was judged to be successful if the patient
was euthyroid or hypothyroid at the end of the first year.
124 O. E. Okosieme et al.
Euthyroidism was diagnosed if patients had normal thyroid hor-
mones off all treatment, while hypothyroidism was diagnosed if
there was biochemical hypothyroidism, either overt or subclinical,
or if the patient was receiving treatment with thyroxine. In line
with our unit policy, we initiated thyroxine treatment in patients
with subclinical hypothyroidism. In some cases, this was stopped at
a later date to determine whether thyroid failure was transient or
permanent. Treatment was considered to have failed if the patient
had biochemical hyperthyroidism, or was receiving treatment with
antithyroid medications, or had received a second dose of radio-
iodine treatment within the first year of follow-up.
Statistical analysis
Values are presented as means (SD) except where otherwise stated.
All statistical analysis was performed using spss for windows, ver-
sion 16Æ0 (SPSS Inc., Chicago, IL, USA). Data were compared using
the chi-squared test for categorical data and the one-way anova
for continuous data with the Bonferroni correction applied for
multiple group comparisons. The agreement between the pre-
scintigraphy and post-scintigraphy diagnosis was examined using
the kappa statistics. Kappa values were interpreted according to
conventional grading as follows: 0–0Æ20 = poor agreement,
0Æ21–0Æ40 = regular agreement, 0Æ41–0Æ60 = moderate agreement,
0Æ61–0Æ80 = good agreement, 0Æ81–1Æ00 = very good agreement.16
Multiple logistic regression models were generated to examine the
variables associated with radioiodine treatment outcomes. The
level of statistical significance at which the null hypothesis was
rejected was chosen as 0Æ05.
Results
Patient characteristics
We reviewed 961 consecutive radioactive iodine uptake studies
performed for hyperthyroidism. We excluded 21 patients whose
clinical details were unavailable either because they had been
referred from neighbouring trusts (n = 16), or because their hospi-
tal records were untraceable (n = 5). We also excluded patients
with thyroiditis (n = 26), patients who had previously received 131I
therapy (n = 18), and those who had undergone thyroidectomy
(n = 15). A final number of 881 scintigraphy and uptake scans were
included in the study. Of these, 255 scans were performed for diag-
nostic purposes only while 626 scans were performed for patients
who in addition received 131I therapy. The clinical characteristics of
the patients is summarized in Table 1. As expected, the majority of
patients with hyperthyroidism were females, with GD accounting
for almost half of all cases of hyperthyroidism. In addition, patients
with GD were younger than those with single or multiple nodules
and had higher 4 h radioiodine uptake levels.
Relationship between clinical and post-scintigraphy
diagnosis
The relationship between the clinical and post-scintigraphy diagno-
sis is shown in Table 2. The clinical diagnosis was correctly matched
to the scintigraph diagnosis in 650 cases (73Æ8%), mismatched in 50
patients (5Æ7%) and was indeterminate in 181 patients (20Æ5%).
There was good overall agreement between clinical and post-
scintigraphy diagnosis with a kappa score of 0Æ60 (P < 0Æ001), 95%
CI (0Æ57–0Æ64). The agreement for GD was very good (K = 0Æ85;
P < 0Æ001), 95% CI (0Æ81–0Æ89), while the agreement for patients
with TNG was rated as good (K = 0Æ65; P < 0Æ001), 95% CI (0Æ60–
0Æ69). However, the kappa score for patients with mixed lesions was
rated as moderate (K = 0Æ45; P < 0Æ001), 95% CI (0Æ33–0Æ56).
Relationship between radioiodine uptake and outcome of
radioiodine therapy
Of the 626 patients who received radioiodine (131I) treatment, 91%
(571 patients) were successfully treated, 27% (169 patients) were
euthyroid and 64% (402 patients) had developed hypothyroidism
at 1 year. Table 3 shows the relationship between various clinical
and uptake characteristics and outcome of treatment (i.e. treat-
ment success or failure). Neither the scintigraph diagnosis nor the
radioiodine uptake was associated with treatment outcome. In the
univariate analysis, the only factor associated with treatment failure
was the use of antithyroid medications in the week before treat-
ment (P = 0Æ002). A stepwise logistic regression model was gener-
ated to examine the factors associated with treatment failure. The
factors which were fed into this model were age (>50 years or
£50 years), palpable goitre (absence or presence), gender and pre-
treatment with antithyroid medications (yes or no). Of these, only
pretreatment with antithyroid medications was significantly associ-
ated with treatment failure (estimated odds ratio 2Æ8, 95% CI 1Æ6–
5Æ0, P = 0Æ01).
In patients who were cured with a single dose of 131I, we exam-
ined the factors associated with the development of hypothyroid-
ism at 1 year (i.e. hypothyroidism or euthyroidism). We found no
association between hypothyroidism and age (P = 0Æ5), gender
(P = 0Æ3), the presence of goitre (P = 0Æ4), 4-h 123I uptake
(P = 0Æ5) or the use of anti-thyroid medications in the week before
treatment (P = 0Æ1). A scintigraph diagnosis of STN was associated
with a lower frequency of hypothyroidism at 1 year (estimated
odds ratio 0Æ26, 95% CI 0Æ15–0Æ43, P < 0Æ0001).
Discussion
The value of thyroid radionuclide imaging in the diagnosis and
management of hyperthyroidism has long been the subject of
debate. An unresolved issue is whether scintigraphic scans should
be performed routinely, selectively, or if they should be performed
at all in patients with hyperthyroidism. Despite a lack of consensus,
there are few detailed evaluations of the utility of scintigraphic
studies in hyperthyroidism. In the present study, we have reviewed
a large number of uptake studies performed in our institution, to
clarify the influence of thyroid uptake and scintigraphy scans on
the diagnosis and outcome of radioiodine therapy in patients with
hyperthyroidism. We found good agreement between the clinical
and scintigraphic diagnosis of hyperthyroidism. In most cases,
scintigraph studies provided little additional information over the
diagnosis obtained from standard clinical and immunological data.
 2010 Blackwell Publishing Ltd, Clinical Endocrinology, 72, 122–127
 Radioiodine uptake scans and hyperthyroidism 125

Table 1. Clinical characteristics of patients with hyperthyroidism

GD (n = 383) GDN (n = 81) TMNG (n = 253) STN (n = 164) Total (n = 881)

Age at RAI study (years) 50 ± 15* 63 ± 14 66 ± 15† 61 ± 16 58 ± 17

Gender
Male 63 (16%) 18 (22%) 46 (18%) 33 (20%) 160 (18%)
Female 320 (84%) 63 (78%) 207 (82%) 131 (80%) 721 (82%)
Palpable goitre
Absent 114 (29Æ8%) 2 (2Æ5%)‡ 66 (26Æ1%) 22 (13Æ4%)§ 202 (22Æ9%)
Present 269 (70Æ2%) 79 (97Æ5%) 187 (73Æ9%) 142 (86Æ6%) 679 (77Æ1%)
Thyroid antibody status
Positive 246 (64%)– 48 (59%)– 25 (10%) 24 (15%) 331 (38%)
Negative 22 (6%) 6 (8%) 131 (52%) 81 (49%) 230 (26%)
Unknown 115 (30%) 27 (33%) 97 (38%) 59 (36%) 320 (36%)
Percentage 4-h I123 uptake
Mean ± SD 43Æ7 ± 17Æ7** 33Æ1 ± 16Æ2†† 21Æ6 ± 12Æ2 21Æ4 ± 11Æ7 32Æ2 ± 18Æ4
Median 45** 32†† 20 17 28
Range 7–83 5–73 6–71 4–55 4–83

Patients with GD were significantly younger than those in other groups and together with patients with GDN had a significantly higher thyroid antibody
prevalence and RAI uptake.
GD, Graves’ disease; GDN, Graves disease and coexistent nodules; TMNG, toxic multinodular goitre; STN, solitary toxic nodule.
*P < 0Æ05 vs. GDN, TMNG and STN; †P < 0Æ05 vs. GD and STN; ‡P < 0Æ.05 vs. GD, TMNG and STN; §P < 0Æ.05 vs. GD, GDN and TMNG; –P < 0Æ05 vs.
STN and TMNG, **P < 0Æ05 vs. GDN, TMNG and STN; ††P < 0Æ.05 vs. GD, TMNG and STN.

Table 2. Relationship between clinical diagnosis and post-scintigraphy Table 3. The influence of clinical characteristics and radioiodine uptake on
diagnosis in patients with hyperthyroidism the outcome of radioiodine treatment

Post-scintigraphy diagnosis Treatment success; Treatment failure;

n = 571 (91Æ2%) n = 55 (8Æ8%) P-value
GD GDN TNG
Age
Clinical diagnosis >50 years 335 (89Æ8%) 38 (10Æ2%) 0Æ13
GD 347 (90Æ6%) 7 (8Æ6%) 9 (2Æ2%) £50 years 236 (93Æ3%) 17 (6Æ7%)
GDN 3 (0Æ8%) 25 (30Æ9%) 19 (4Æ6%) Gender
TNG 3 (0Æ8%) 9 (11Æ1%) 278 (66Æ7%) Male 97 (89Æ0%) 12 (11Æ0%) 0Æ12
Indeterminate 30 (7Æ8%) 40 (49Æ4%) 111 (26Æ6%) Female 474 (91Æ7%) 43 (8Æ3%)
Total 383 (100%) 81 (100%) 417 (100%) Palpable goitre
Absent 107 (94Æ7%) 6 (5Æ3%) 0Æ15
The clinical diagnosis was correctly matched to the scintigraph diagnosis in Present 464 (90Æ4%) 49 (9Æ6%)
650 patients (73Æ8%), mismatched in 50 patients (5Æ7%) and was indetermi- Scintigraph diagnosis
nate in 181 patients (20Æ5%). Data are presented as number of patients (per GD 201 (91Æ8%) 18 (8Æ2%) 0Æ95
cent of the total in each column). TMNG 177 (91Æ2%) 17 (8Æ8%)
STN 125 (91Æ2%) 12 (8Æ8%)
GD + nodules 68 (89Æ5%) 8 (10Æ5%)
Furthermore, the distinction between GD and toxic nodules was 4-h I123 uptake
resolved in 74% of cases without resorting to scintigraphy. £50% 433 (90Æ2%) 47 (9Æ8%) 0Æ2
Our findings are in agreement with previous studies which have >50% 138 (93Æ5%) 8 (6Æ5%)
shown good concordance between the scintigraphic and clinical ATD Pretreatment
Yes 111 (82Æ8%) 23 (17Æ2%) 0Æ002
diagnosis of GD.5,6 In line with these studies also, we found that
No 460 (91Æ5%) 32 (8Æ5%)
the diagnosis of toxic nodules was more difficult to establish clini-
cally. In one report, 20 out of 63 patients with toxic nodules would
The only factor associated with treatment failure was the use of antithyroid
have been misdiagnosed without the benefits of thyroid scintigra- medications in the week before treatment (P = 0Æ002; age, the presence of
phy.17 A third of patients with toxic nodules in our study were not palpable goitre and gender were also considered). Treatment outcome was
identified on clinical grounds alone. However, most of these were not associated with scintigraph diagnosis or radioiodine uptake.
patients with an indeterminate clinical diagnosis rather than
patients who were misdiagnosed. Clinically indeterminate have significantly reduced the number of scintigraph studies
hyperthyroidism accounted for 21% of our entire sample and performed without compromising-diagnostic accuracy.
comprised patients in all diagnostic categories. A strategy of selec- We also determined the prognostic value of pretherapeutic
tive radionuclide imaging in this indeterminate group alone would uptake scans in patients receiving 131I treatment. Numerous

 2010 Blackwell Publishing Ltd, Clinical Endocrinology, 72, 122–127

126 O. E. Okosieme et al.
studies have examined the relationship between uptake scans and
treatment outcome. These have given conflicting results, partly
because of differences in the treatment protocols used in individ-
ual studies. Some studies have demonstrated a higher rate of
treatment failure in patients with higher uptake levels13,18, while
other reports have not upheld this association.19 In the present
study, we found no relationship between radioiodine uptake and
treatment failure. One feature of our study is the ablative dose of
555 MBq used in the majority of patients. It is possible that this
relatively high dose could have eliminated any influence of pre-
therapeutic uptake on treatment outcome. Indeed, this could also
explain the lack of association between treatment failure in our
study and various radio-resistant characteristics identified in
some other studies, such as younger age, male gender and larger
thyroid volume.20,21 Interestingly, some of these studies have
used smaller radioiodine doses than ours, thus strengthening the
possibility that these effects were masked by the higher treatment
dose in our study.20,21
The only predictor of treatment failure observed in our study
was the use of antithyroid medications in the week before radioio-
dine treatment. The effect of antithyroid drugs on the efficacy of ra-
dioiodine treatment is contentious. Some studies have shown an
association between treatment failure and pretreatment with anti-
thyroid medications22–24, while other studies have failed to confirm
this association.25,26 Furthermore, it has been suggested that a
greater radio-protective effect is seen with propylthiouracil than
with methimazole.27 However, a meta-analysis of 14 randomized
controlled trials, involving 1306 participants showed that treat-
ment with antithyroid medications, either propylthiouracil or me-
thimazole, was associated with an increased risk of treatment
failure (relative risk 1Æ28).28 The mechanism of this radio-protec-
tive effect of antithyroid medications is unclear but may be related
to inhibition of iodine uptake by thyrocytes. In addition, it has
been postulated that antithyroid compounds prevent iodide
induced cell damage through the inhibition of TPOAb catalysed
synthesis of free oxygen radicals.29
The overriding consideration for patients receiving radioiodine
treatment is whether treatment will be successful or not. It is now
accepted that hypothyroidism is an inevitable consequence of treat-
ment which should be anticipated and actively corrected. There-
fore, the aim of treatment should be the elimination of
hyperthyroidism rather than prevention of hypothyroidism. How-
ever, there is wide variation in radioiodine treatment protocols30
ranging from fixed-dose regimens31,32 to protocols calculated on
the basis of radioiodine uptake18 and thyroid volume.3 Some have
proposed smaller-dose regimens, with incremental adjustments for
patients with radio-resistant clinical and uptake characteris-
tics.13,20,21 However, higher-dose regimens circumvent the need for
individual dose adjustments. As we show in this study, an ablative
dose of 555 MBq given to the majority of our patients was effective
in eliminating hyperthyroidism regardless of clinical or uptake
characteristics. Furthermore, our cure rate of 91% at 1 year was
comparable to the rates of others who have administered similar
131
I doses.30 In addition, two-thirds of our patients had become
hypothyroid within 1 year of treatment, thus facilitating early dis-
charge back to their primary care providers.
We acknowledge several limitations of our study. This was a ret-
rospective study with data spanning an 8-year period which saw
changes in antibody assay methods. Furthermore, antibody tests
were not always available, especially during the initial study period.
Nonetheless, the retrospective design of the study enabled the eval-
uation of a large number of patients which would have been logisti-
cally difficult to achieve prospectively. We also note that our study
group comprised only those patients with hyperthyroidism who
had undergone diagnostic or pretherapeutic uptake studies. Thus,
our sample may have been skewed towards clinically indeterminate
or radioiodine-treated cases of hyperthyroidism. Nevertheless, our
study population is likely to reflect the typical mix of patients with
hyperthyroidism undergoing radionuclide imaging in everyday
practice.
We conclude that in the majority of our patients with hyperthy-
roidism, thyroid scintigraphic studies did not provide additional
information over that obtained from clinical and laboratory exam-
inations. Based on our findings, we recommend restricting radio-
nuclide imaging to those hyperthyroid patients whose aetiological
diagnosis remains unclear from the clinical examination. Undoubt-
edly, thyroid uptake studies will continue to play a role in selected
clinical scenarios such as acute thyroiditis or factitious hyperthy-
roidism. While this strategy of selective use of thyroid scintigraphy
may be in line with the current practice of most clinicians, we pro-
vide evidence that such an approach is effective and will reduce
needless exposure to radioisotopes without affecting diagnostic
precision. The role of routine pretherapeutic uptake scans requires
re-examination. The revised Royal College of Physicians guidelines
no longer recommend treatment protocols based on uptake stud-
ies.10 In our experience, performance of such studies had no influ-
ence on the outcome of treatment. Rather, the more important
predictor of treatment failure was the continuation of antithyroid
medications before radioiodine treatment.
Acknowledgement
We thank Dr B Jones for help in performing the uptake and scinti-
graphy studies.
Competing interests/financial disclosure
All authors confirm that there are no conflicts of interests and no
financial disclosures.
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