Thyroid Diseases: Dietlein M

Luster M, Clarke SE, Dietlein M, Lassmann M, Lind P, Oyen WJ, Tennvall J, Bombardieri E, Anonymous00011. · Department of Nuclear Medicine, University of Würzburg, Josef-Schneider-Strasse 2, 97080 Würzburg, Germany. · Eur J Nucl Med Mol Imaging. · Pubmed #18670773 No free full text.

Abstract: INTRODUCTION: The purpose of the present guidelines on the radioiodine therapy (RAIT) of differentiated thyroid cancer (DTC) formulated by the European Association of Nuclear Medicine (EANM) Therapy Committee is to provide advice to nuclear medicine clinicians and other members of the DTC-treating community on how to ablate thyroid remnant or treat inoperable advanced DTC or both employing large 131-iodine ((131)I) activities. DISCUSSION: For this purpose, recommendations have been formulated based on recent literature and expert opinion regarding the rationale, indications and contraindications for these procedures, as well as the radioiodine activities and the administration and patient preparation techniques to be used. Recommendations also are provided on pre-RAIT history and examinations, patient counselling and precautions that should be associated with (131)I iodine ablation and treatment. Furthermore, potential side effects of radioiodine therapy and alternate or additional treatments to this modality are reviewed. Appendices furnish information on dosimetry and post-therapy scintigraphy.

Dietlein M, Dressler J, Farahati J, Grünwald F, Leisner B, Moser E, Reiners C, Schicha H, Schober O, Anonymous00006. · Klinik und Poliklinik für Nuklearmedizin, Universität zu Köln 50924 Köln. · Nuklearmedizin. · Pubmed #15316577 No free full text.

Abstract: The procedure guidelines for radioiodine therapy (RIT) of differentiated thyroid cancer (version 2) are the counter-part to the procedure guidelines for (131)I whole-body scintigraphy (version 2) and specify the interdisciplinary guidelines for thyroid cancer of the Deutsche Krebsgesellschaft and the Deutsche Gesellschaft für Chirurgie concerning the nuclear medicine part. Compared with version 1 facultative options for RIT can be chosen in special cases: ablative RIT for papillary microcarcinoma </=1 cm, ablative RIT for mixed forms of anaplastic and differentiated thyroid cancer, and RIT in patients with a measurable or increasing thyroglobulin concentration but without detectable metastases by imaging. The description of the pretherapeutic dosimetry now includes the isotopes (123)I and (124)I as well as a broader range of the activity of (131)I. Activities of 2-5 GBq (131)I are recommended for the first ablative RIT. If high accumulative activities of (131)I are expected, men who have not yet finished their family planning should be advised to the option of sperm cryoconservation. An interdisciplinary consensus is necessary whether the new TNM-classification (UICC, 6(th) edition, 2002) will lead to modified recommendations for surgical or nuclear medicine therapy, especially for the surgical completeness and for the ablative RIT of pT1 papillary cancer.

Dietlein M, Schober O, Schicha H. · Klinik und Poliklinik für Nuklearmedizin, Universität zu Köln 50924 Köln, · Nuklearmedizin. · Pubmed #15316576 No free full text.

Abstract: Papillary thyroid microcarcinomas </=1 cm have an excellent prognosis both in terms of overall and relapse-free survival. Their high prevalence in autopsy series suggests that most papillary microcarcinomas do not progress to clinically relevant cancer. The extent of surgery is still controversial. Lobectomy or subtotal resection are standard procedures, but multifocal microcarcinomas or lymph node metastases might be overlooked. The pros and cons of completion thyroidectomy and ablative radioiodine therapy are based on limited evidence due to heterogenous inclusion criteria in published series. The retrospective data analyses included subgroups with infiltration of the thyroid capsule, lymph node metastases or multifocal microcarcinomas at the primary staging. The local relapse rate reached approximately 7% after different therapeutic regimes. Radioiodine ablation decreased the recurrence rate in some retrospective studies, but data are inconsistent. Successful radioiodine ablation is possible also after less radical surgery without complete thyroidectomy with postoperative (131)I uptake of 10 to 20% or remnants of 3-8 ml. This concept was evaluated successfully in a monocentric series of patients with multifocal microcarcinomas. The therapeutic consideration should include the diameter of the carcinoma, neighbourhood to the thyroid capsule, histopathologic sub-groups, age, familiar occurrence, patient's informed consent and in future moleculargenetic tests, too. There-fore, limited surgical procedures for small papillary carcinomas as therapeutic standard, respectively thyroidectomy, lymph node dissection in the central compartment of the neck and ablative radioiodine therapy for individual cases are options for experienced surgeons and specialized tumour centers.

Dietlein M, Dressler J, Eschner W, Leisner B, Reiners C, Schicha H, Anonymous00372, Anonymous00373. · Klinik und Poliklinik für Nuklearmedizin der Universität zu Köln, 50924 Köln. · Nuklearmedizin. · Pubmed #12802477 No free full text.

Abstract: The version 2 of the procedure guideline for iodine-131 whole-body scintigraphy for differentiated thyroid cancer is an update of the procedure guideline published in 1999. The following statements are added or modified: The two alternatives of an endogenous TSH-stimulation by the withdrawal of the thyroidal hormone medication and of an exogenous TSH-stimulation by the injection of the recombinant human TSH (rhTSH) have an equal sensitivity for the diagnostic use of radioiodine and for the measurement of thyroglobulin. Image acquisition under rhTSH is obtained approximately 48 h after the radioiodine administration, while an interval of about 72 h is preferred under endogenous TSH-stimulation. If iodine-negative metastases are expected, the feasibility of scintigraphy using (99m)Tc sestamibi or preferably positron emission tomography using (18)F-fluorodeoxyglucose should be considered. The sensitivity of FDG-PET is increased by TSH-stimulation. Before planning the iodine-131 scintigraphy the patient has to avoid iodine-containing medication and the possibility of additives of iodine in vitamin- and electrolyte-supplementation has to be considered.

Dietlein M, Dressler J, Eschner W, Leisner B, Reiners C, Schicha H, Anonymous00370, Anonymous00371. · Klinik und Poliklinik für Nuklearmedizin der Universität zu Köln, 50924 Cologne. · Nuklearmedizin. · Pubmed #12802476 No free full text.

Abstract: The version 2 of the procedure guideline for thyroid scintigraphy is an update of the procedure guideline published in 1999. The procedure guideline considers the current amendment of legislative rules (Richtlinie Strahlenschutz in der Medizin 2002). Indication and use of radiopharmaceuticals have to be confirmed by the specialist in nuclear medicine. Activities of 75 MBq technetium-99m, respectively of 10 MBq iodine-123 should not be exceeded without an individual justification. The interpretation of the scintigraphy requires the knowledge of the patients' history, the palpation of the neck, the laboratory parameters, and of the sonography. The interpretation of the technetium-99m uptake requires the knowledge of TSH concentration.

Dietlein M, Dressler J, Eschner W, Lassmann M, Leisner B, Reiners C, Schicha H, Anonymous00368, Anonymous00369. · Klinik und Poliklinik für Nuklearmedizin der Universität zu Köln, 50924 Cologne. · Nuklearmedizin. · Pubmed #12802475 No free full text.

Abstract: The version 2 of the procedure guideline for radioiodine test is an update of the guideline published in 1999. The following statements were added or modified: The procedure guideline discusses the pros and cons of a single measurement or of repeated measurements of the iodine-131 uptake and their optimal timing. Different formulas are described when one, two or three values of the radioiodine kinetic are available. The probe with a sodium iodide crystal, alternative or additionally the gamma-camera using the ROI-technique are instrumentations for the measurement of iodine-131 uptake. A possible source of error is an inappropriate measurement (sonography) of the target volume. The patients' preparation includes the withdrawal of antithyroid drugs 2-3 days before radioiodine administration. The patient has to avoid iodine-containing medication and the possibility of additives of iodide in vitamin- or electrolyte-supplementation has to be considered.

Dietlein M, Dressler J, Grünwald F, Joseph K, Leisner B, Moser E, Reiners C, Rendl J, Schicha H, Schneider P, Schober O, Anonymous00367. · No affiliation provided · Nuklearmedizin. · Pubmed #12802474 No free full text.

Abstract: The version 2 of the guideline for diagnostic standards of thyroid disorders is an update of the guideline published in 1999 and describes standards of in vitro and in vivo procedures. The following statements are modified: In vitro procedures: When measurement of the TSH-receptor antibodies is indicated, the guideline recommends the use of a second generation assay (recombinant human TSH-receptor as antigen). The functional assay sensitivity for the measurement of thyroglobulin should reach a value < or =1 ng/ml. Molecular genetic tests (RET proto-oncogene) are indicated in patients with a newly diagnosed medullary thyroid cancer and in the relatives of patients with hereditary medullary thyroid cancer. In vivo procedures: The sonographic examination should use a probe with a frequency of at least 7.5 MHz. Indications for the thyroid scintigraphy: nodule size > or =1 cm in diameter, autonomous goitre/nodule with clinical or subclinical hyperthyroidism, necessity of a differentiation between Graves' disease and chronic lymphocytic thyroiditis, therapy control after a definitive treatment and - in individual cases - the follow-up of untreated autonomous nodules.

Verburg FA, Dietlein M, Lassmann M, Luster M, Reiners C. · No affiliation provided · Eur J Nucl Med Mol Imaging. · Pubmed #19050874 No free full text.

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Schmidt M, Huff W, Dietlein M, Kobe C, Schicha H. · Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Köln, Kerpener Str. 62, 50937 Köln. · Nuklearmedizin. · Pubmed #19057795 No free full text.

Abstract: Interactions between brain, psyche and thyroid are known from historical descriptions of thyroidectomy (Kocher) and hyperthyroidism. However, their importance is often underscored in clinical routine. Thyroid hormone deficiency during pregnancy may result in irreversible mental retardation and requires levothyroxine substitution. TSH screening after delivery must identify newborns with congenital hypothyroidism: An early levothyroxine substitution and long term therapy control are required. Hypothyroidism and depression have many symptoms in common. Cognitive deficits and depressive states are often found in overt hypothyroidism, psychotic derangements are rare. Levothyroxine improves hypothyroid symptoms and mental performance, mood and motivation. Psychic symptoms of hyperthyroidism include agitation, irritability, mood disturbances, hyperactivity, anxiousness and even panic attacks. Manic and delusional states are rare. In geriatric patients hyperthyroidism may be oligosymptomatic. In psychiatric patients more frequent but unspecific disturbances of thyroid laboratory values being reversible without specific therapy have to be distinguished from rather rare but causative organic thyroid diseases with therapeutic consequences. Some psychiatric drugs influence thyroid laboratory results. Hypothyroidism in depressive patients is a negative prognostic parameter and requires therapy. Psychiatric symptoms associated with hypothyroidism are usually reversible under levothyroxine within 4-8 weeks. The standard for hypothyroidism is mono-levothyroxine therapy.

Reiners C, Dietlein M, Luster M. · Department of Nuclear Medicine, University of Würzburg, Josef-Schneider-Strasse 2, 97080 Würzburg, Germany. · Best Pract Res Clin Endocrinol Metab. · Pubmed #19041827 No free full text.

Abstract: Post-surgical ablative iodine-131 therapy is recommended for all differentiated thyroid cancer primary tumors>1 cm in diameter. Regarding smaller primary tumors, 131I ablation may be helpful in special cases: tumor close to the thyroid capsule, previous percutaneous radiation to the neck, familial occurrence of thyroid cancer, tumor diameter 5-10 mm, and unfavorable histological variants. In this context, the patient's preferences for safety should be considered. In most centers, standard fixed activities of 1-3 GBq are used for 131I ablation. Preparation for the procedure with such activities requires a low-iodine diet for 2-3 weeks and stimulation of thyroid stimulating hormone (TSH) by withholding of thyroid hormone for 3 weeks following thyroidectomy or by use of recombinant human TSH. The advantages of recombinant TSH are avoidance of hypothyroid morbidity and consequently a better quality of life, as well as a lower radiation dose to extra-thyroidal compartments. To treat metastastic differentiated thyroid cancer, higher activities of radio-iodine (in the range 4-11 GBq) are necessary; if possible, individual dosimetry is recommended. The standard approach to preparation for 131I therapy in patients with metastases is endogenous hypothyroidism after thyroid hormone withdrawal.

Reiners C, Dietlein M, Luster M. · Klinik und Poliklinik für Nuklearmedizin, Universität Würzburg. · Dtsch Med Wochenschr. · Pubmed #18924056 No free full text.

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Dietlein M, Dederichs B, Kobe C, Theissen P, Schmidt M, Schicha H. · Klinik und Poliklinik für Nuklearmedizin der Universität zu Köln, 50924 Köln. · Nuklearmedizin. · Pubmed #16493511 No free full text.

Abstract: The need for therapy for nodular goiter results from the growth of thyroid nodules over decades and from the possibility of tracheal compression and worsening of respiratory function. Given the high prevalence of non-toxic goiter, the epidemiologically low incidence of clinically apparent thyroid cancer justifies non-surgical strategies. Randomised studies have shown that levothyroxine offers limited therapeutic effects and is inferior to radioiodine therapy regarding goiter shrinkage. When indication for a definitive therapy is given, the choice between resection and radioiodine therapy should consider volume of goiter, severity of clinical symptoms, thyroid uptake, patient's age, co-morbidity, previous resection of goiter, patient's profession and patient's wish. Even in large goiters between 100 and 300 ml radioiodine therapy showed consistent results with goiter size reduction from 35-40% one year and 40-60% two years after radioiodine therapy. Thyroid hormones to prevent recurrence of goiter are not necessary. Recurrent goiters were seldom observed after radioiodine therapy and resulted from initially very large goiters or uptake in dominate nodules or from low (131)I activities. Recombinant human TSH (rhTSH) offers the opportunity to enhance the effect of radioiodine therapy. Observational studies have shown that rhTSH increases low (131)I uptake in case of high alimentary iodine-supply by the factor 4, causes a more homogenous (131)I distribution within the goiter and improves goiter reduction. A phase I study for dose finding is running in the USA. Conclusion: Radioiodine therapy for shrinkage of large non-toxic goiter should not be restricted to elderly patients, or to patients with co-morbidity or high operative risk, but is an attractive alternative to surgery in patients with special professions (singer, teacher, speaker) or with the wish for a non-invasive treatment modality.

Dietlein M, Moka D, Schmidt M, Theissen P, Schicha H. · Klinik und Poliklinik für Nuklearmedizin der Universität zu Köln, 50924 Köln, Germany. · Nuklearmedizin. · Pubmed #14571314 No free full text.

Abstract: Cost-effectiveness analyses focused on benign thyroid diseases are under-represented in the literature. The calculation of costs per additionally gained life year is difficult: The benefit of prevention is shifted into the distant future. The influence of an untreated subclinical thyroid disease on life expectancy can only be demonstrated by a long-term follow-up and by epidemiological databases. Iodine supplementation and programs for the prevention of tobacco smoking (primary prevention) are very cost-effective. Smoking increases the risk both of multinodular goiter and of Graves' disease. Screening programs (secondary prevention) are discussed for the laboratory parameters thyrotropin (TSH), calcium and calcitonin. TSH testing seems to be very cost-effective for epidemiological considerations in a certain lifespan (newborn, pregnancy, postpartal, older persons, hospitalisation due to acute diseases) and in persons with previously elevated TPO-antibodies or TSH-values >2 mU/l, but dedicated cost-effectiveness analyses are lacking. On the other hand, the cost-effectiveness of a routine TSH testing beyond the age of 35 years has been shown by a high-quality decision analysis. Therapeutic strategies (tertiary prevention) aim at the avoidance of complications (atrial fibrillation, myocardial infarction, death for cardiac reasons) and of iatrogenic complications. Examples of a tertiary prevention are: firstly the definitive therapy of Graves' disease in patients who have an increased risk of relapse after antithyroid drugs (ATD), secondly the radioiodine therapy for subclinical hyperthyroidism and the radioiodine therapy of large goiters in older patients or in patients suffering from a relevant comorbidity. Cost-effectiveness analyses for different therapeutic strategies of Graves' disease were published using a lifelong time-horizon. The ablative radioiodine dose-regime is cost-effective as a first line therapy if the risk of relapse after ATD exceeds 60%.

Kahaly GJ, Dietlein M. · Department of Medicine I, Gutenberg-University Hospital, Mainz, Germany. · Thyroid. · Pubmed #12487774 No free full text.

Abstract: To assess the economic effects of thyroid disorder-related morbidity in Germany, a systematic review of national and international literature from 1981-2001 was performed. Data from insurance companies, the government department of public health, and the federal office of statistics helped characterize the situation in Germany. Being the most important thyroid disease, endemic iodine-deficiency goiter causes economic costs of approximately 2.1 billion DM per year or 1 billion Euros or 1 billion U.S. dollars. In recent years iodine supplementation of food became better accepted by the German population. This should significantly reduce the prevalence of goiter from 30%-40% to less than 10%. Functional thyroid disorders are observed in 5%-10% of the German population. A more differentiated view of these conditions should lead to specific guidelines for an economic screening and therapy of subpopulations. Lacking valuable data, an actual economic assessment of autoimmune or malignant thyroid diseases cannot be performed. On the other hand, with respect to the costs of specific thyroid therapy, e.g., radioiodine treatment of thyrotoxicosis (mainly toxic nodular goiter), the economic consequences of a new regulation for radiation protection in Germany have been demonstrated recently. Using the actual maximum permissible level of residual activity on discharge from the hospital after radioiodine therapy, length of hospitalization was shortened to 5.1 days in university hospitals and to 5.8 days in nonuniversity institutions. Payment per patient for radioiodine therapy was 1,856 and 1,530 Euros (median value) in university and nonuniversity hospitals, respectively. In conclusion, better prevention of iodine deficiency and its long-term consequences should effectively reduce direct as well as indirect costs and overall economic impact of endemic goiter as the most important thyroid disease in Germany. Sustainable elimination of iodine deficiency is technically possible, but it needs further commitment and support at all levels.

Moka D, Dietlein M, Schicha H. · Department of Nuclear Medicine, University of Cologne, Joseph Stelzmannstrasse 9, 50924 Köln, Germany. · Eur J Nucl Med Mol Imaging. · Pubmed #12192550 No free full text.

Abstract: Radioiodine therapy is now the most common definite treatment for persistent hyperthyroidism. The outcome of radioiodine therapy depends mainly on the absorbed energy dose in the diseased thyroid tissue. The administered activity and the resulting target dose in the thyroid depend on both the biokinetics of radioiodine and the actual therapeutic effect of radioiodine in the thyroid. Thyrostatic drugs have a major influence on the kinetics of radioiodine in the thyroid and may additionally have a radioprotective effect. Pre-treatment with thyrostatic medication lowers the effective half-life and uptake of radioiodine. This can reduce the target dose in the thyroid and have a negative influence on the outcome of the therapy. Discontinuation of medication shortly before radioiodine administration can increase the absorbed energy dose in the thyroid without increasing the whole-body exposure to radiation as much as would a higher or second radioiodine administration. Furthermore, administration of non-radioactive iodine-127 2-3 days after radioiodine administration can also increase the effective half-life of radioiodine in the thyroid. Thus, improving the biokinetics of radioiodine will allow lower activities to be administered with lower effective doses to the rest of the body, while achieving an equally effective target dose in the thyroid.

Schicha H, Dietlein M. · Klinik und Poliklinik für Nuklearmedizin, Universität zu Köln, Deutschland. · Nuklearmedizin. · Pubmed #11989300 No free full text.

Abstract: At the 15th conference on the human thyroid in Heidelberg in 2001 the following aspects of the radioiodine therapy of benign thyroid disorders were presented: General strategies for therapy of benign thyroid diseases, criterions for conservative or definitive treatment of hyperthyroidism as first line therapy and finally preparation, procedural details, results, side effects, costs and follow-up care of radioiodine therapy as well as legal guidelines for hospitalization in Germany. The diagnosis Graves' hyperthyroidism needs the decision, if rather a conservative treatment or if primary radioiodine therapy is the best therapeutic approach. In the USA 70-90% of these patients are treated with radioiodine as first line therapy, whereas in Germany the conservative therapy for 1-1.5 years is recommended for 90%. This review describes subgroups of patients with Graves' disease showing a higher probability to relapse after conservative treatment. Comparing benefits, adverse effects, costs, and conveniences of both treatment strategies the authors conclude that radioiodine therapy should be preferred as first line therapy in 60-70% of the patients with Graves' hyperthyroidism.

Dietlein M, Dederichs B, Weigand A, Schicha H. · Department of Nuclear Medicine, University of Cologne, Germany. · Exp Clin Endocrinol Diabetes. · Pubmed #10614920 No free full text.

Abstract: Whether or not thyroid-associated orbitopathy is exacerbated by radioiodine therapy is a matter of controversy. Several risk factors can be listed: pre-existing active ophthalmopathy, hypothyroidism following radioiodine therapy, elevated T3 levels during radioiodine therapy, recurrent or persisting hyperthyroidism after low-dose radioiodine therapy and smoking. Recent studies and own data demonstrate that worsening of pre-existing thyroid-associated orbitopathy after radioiodine therapy can be prevented by the administration of glucocorticoids. Even in patients without evident ophthalmopathy the prophylactic use of glucocorticoids is in our opinion justified to minimize a small but known risk of the development of ocular symptoms. Larger prospective randomized studies are needed to establish the optimal dose and duration of the required anti-inflammatory therapy.

Dietlein M, Moka D, Reinholz U, Schmidt M, Schomäcker K, Schicha H, Wellner U. · Department of Nuclear Medicine, University of Cologne, 50924 Cologne, Germany. · Nuklearmedizin. · Pubmed #17549318 No free full text.

Abstract: AIM: Graves' hyperthyroidism and antithyroid drugs empty the intrathyroid stores of hormones and iodine. The consequence is rapid 131I turnover and impending failure of radioiodine therapy. Can administration of additional inactive iodide improve 131I kinetics? PATIENTS, METHODS: Fifteen consecutive patients, in whom the 48 h post-therapeutically calculated thyroid dose was between 150 and 249 Gy due to an unexpectedly short half-life, received 3 x 200 microg inactive potassium-iodide (127I) daily for 3 days (Group A), while 17 consecutive patients with a thyroid dose of > or = 250 Gy (Group B) served as the non-iodide group. 48 hours after 131I administration (M1) and 4 or 5 days later (M2) the following parameters were compared: effective 131I half-life, thyroid dose, total T3, total T4, 131I-activity in the T3- and T4-RIAs. RESULTS: In Group A, the effective 131I half-life M1 before iodine (3.81 +/- 0.93 days) was significantly (p < 0.01) shorter than the effective 131I half-life M2 (4.65 +/- 0.79 days). Effective 131I half-life M1 correlated with the benefit from inactive 127I (r = -0.79): Administration of 127I was beneficial in patients with an effective 131I half-life M1 of <3 or 4 days. Patients from Group A with high initial specific 131I activity of T3 and T4 showed lower specific 131I activity after addition of inactive iodine compared with patients from the same group with a lower initial specific 131I activity of T3 and T4 and compared with the patient group B who was given no additional inactive iodide. This correlation was mathematically described and reflected in the flatter gradient in Group A (y = 0.5195x + 0.8727 for 131I T3 and y = 1.0827x - 0.4444 for 131I T4) and steeper gradient for Group B (y = 0.6998x + 0.5417 for 131I T3 and y = 1.3191x - 0.2901 for 131I T4). Radioiodine therapy was successful in all 15 patients from Group A. CONCLUSION: The administration of 600 microg inactive iodide for three days during radioiodine therapy in patients with Graves' hyperthyroidism and an unexpectedly short half-life of <3 or 4 days was a safe and effective alternative to the administration of a second radioiodine capsule.

Dietlein M, Luyken WA, Schicha H, Larena-Avellaneda A. · Department of Nuclear Medicine, University of Cologne, Cologne, Germany. · Nucl Med Commun. · Pubmed #15604941 No free full text.

Abstract: BACKGROUND: The extent of thyroid resection and the necessity of lymph node dissection has become an issue of controversy in patients with incidental multifocal papillary microcarcinoma. METHOD: Between 1993 and 2001 a total of 4120 patients underwent surgery for thyroid diseases: 142 patients showed papillary thyroid cancer of < or = 1 cm, multifocal microcarcinomas were found in 22 patients (15.5%). Twenty patients (17 women, three men, aged 26-71 years) met the inclusion criterion of having pre- and intraoperatively no indication of malignancy (incidentaloma). A limited surgical procedure ranging from bilateral subtotal (n=15), ipsilateral total, contralateral subtotal (n=4) to bilateral total (n=1) thyroidectomy without lymph node dissection was performed. The mean volume of thyroid remnants was 4.3 ml. RESULTS: In 16/20 (80%) patients, the thyroid remnant was ablated by the first dose of 131I, using 3.7 GBq 131I in 15 patients and 1.85 GBq 131I in one patient. Three patients received a second, and one patient a third radioiodine ablation. All 20 patients remained free from relapse or metastasis, documented by negative 131I whole-body scintigraphy and unmeasurable thyroglobulin levels after thyroid hormone withdrawal in hypothyroidism. One patient died 7 years after the diagnosis of thyroid cancer from primary lung cancer. Median follow-up was 65 months (range, 24-120 months). CONCLUSION: Subtotal thyroidectomy followed by radioiodine therapy without completion thyroidectomy and lymphadenectomy is a possible option in incidental multifocal microcarcinomas.

Dietlein M, Moka D, Scheidhauer K, Schmidt M, Theissen P, Voth E, Eschner W, Schicha H. · Department of Nuclear Medicine, University of Cologne, Germany. · Nucl Med Commun. · Pubmed #11192718 No free full text.

Abstract: The radioablation of thyroid remnants improves the prognosis of differentiated thyroid cancer. In our prospective study an activity of 3.7 GBq 131I failed to completely ablate the remnants in 46 out of 101 patients, but a 3-year follow-up period was uneventful. One other patient had a recurrence early after thyroidectomy. In view of possible stunning effects of 131I it might be advantageous to visualize such remnants by imaging modalities which do not emit beta-particles. Our data have revealed that neither magnetic resonance imaging (MRI), nor ultrasonography (US), nor 99Tcm-sestamibi scintigraphy, nor positron emission tomography could detect or reliably exclude minimal remnants. Such remnants did not produce thyroglobulin (Tg). A 123I and 131I uptake of> 10% after thyroidectomy was associated with about a 90% probability of persistent remnants. On the other hand, MRI was helpful in the patient group (n = 32) with Tg>4ng x ml(-1) at the second whole-body scintigraphy (TSH>30 mU x l(-1)) for planning the management of lymph node metastases (n = 15 patients): 12 patients had subsequent surgery and three patients radioiodine therapy. We recommend that MRI be used early in follow-up care when Tg is elevated. The decision of whether or not to treat persistent thyroid remnants should not be made on the basis of MRI, US or nonspecific scintigraphic methods. Complete ablation did not appear to have any clinical benefit in our study group.

Bachmann J, Kobe C, Bor S, Rahlff I, Dietlein M, Schicha H, Schmidt M. · Department of Nuclear Medicine, University Hospital of Cologne, Germany. · Nucl Med Commun. · Pubmed #19381116 No free full text.

Abstract: OBJECTIVE: To evaluate the effect of radioiodine therapy for volume reduction in large goitres. METHODS: A retrospective study was performed involving 88 patients treated between 2001 and 2007 with radioiodine for toxic or nontoxic goitres. The goitres were between 80 and 250 ml in volume (median 127 ml+/-38.57). Activities of I to be administered were calculated individually through radioiodine testing with uptake measurements over 5 days, the mean activity being 1721+/-440 MBq I (714-2395 MBq I), equivalent to a mean of 14+/-4.19 MBq I/g of thyroid tissue (6-24 MBq I/g of thyroid tissue). The designated dose was 150 Gy for the entire thyroid volume, and post-therapeutic dosimetry revealed a mean thyroid dose of 175+/-45.92 Gy (64-300 Gy). Control examinations were performed, including thyroid blood testing and thyroid ultrasound at 6 weeks and at 3, 6, 12, 24, 36, 48 and 72 months after radioiodine therapy. RESULTS: The mean volume reduction was 41.9% after 3 months and 65.9% after 1 year. Thyroid volume reduction was highly significant (P<0.001) in the first year after radioiodine therapy. No volume increase was observed in any patient during follow-up. Unfortunately, many patients were lost during follow-up (n = 84 after 3 months, n = 38 after 1 year). CONCLUSION: Radioiodine therapy is an effective treatment for both nontoxic and toxic goitres, resulting in a highly significant thyroid volume reduction of nearly 66% within 1 year.

Kobe C, Weber I, Eschner W, Sudbrock F, Schmidt M, Dietlein M, Schicha H. · Department of Nuclear Medicine, University of Cologne, Kerpener Strasse 62, Cologne, Germany. · Nuklearmedizin. · Pubmed #18690374 No free full text.

Abstract: AIM: This study was performed to analyse the impact of the choice of antithyroid drugs (ATD) on the outcome of ablative radioiodine therapy (RIT) in patients with Graves' disease. PATIENTS, MATERIAL, METHODS: A total of 571 consecutive patients were observed for 12 months after RIT between July 2001 and June 2004. Inclusion criteria were the confirmed diagnosis of Graves' disease, compensation of hyperthyroidism and withdrawal of ATD two days before preliminary radioiodine-testing and RIT. The intended dose of 250 Gy was calculated from the results of the radioiodine test and the therapeutically achieved dose was measured by serial uptake measurements. The end-point measure was thyroid function 12 months after RIT; success was defined as elimination of hyperthyroidism. The pretreatment ATD was retrospectively correlated with the results achieved. RESULTS: Relief from hyperthyroidism was achieved in 96% of patients. 472 patients were treated with carbimazole or methimazole (CMI) and 61 with propylthiouracil (PTU). 38 patients had no thyrostatic drugs (ND) prior to RIT. The success rate was equal in all groups (CMI 451/472; PTU 61/61; ND 37/38; p = 0.22). CONCLUSION: Thyrostatic treatment with PTU achieves excellent results in ablative RIT, using an accurate dosimetric approach with an achieved post-therapeutic dose of more than 200 Gy.

Schmidt M, Voell M, Rahlff I, Dietlein M, Kobe C, Faust M, Schicha H. · Department of Nuclear Medicine, University of Cologne, Cologne, Germany. · Thyroid. · Pubmed #18631004 No free full text.

Abstract: BACKGROUND: A number of studies show that the serum levels of antithyroid peroxidase antibodies (TPO-Ab) in patients with Hashimoto's thyroiditis decline during levothyroxine treatment, but do not provide quantitative data or report the fraction of patients in whom test for TPO-Ab became negative ("normalization percentage"). The objective of the present study was to provide this information. METHODS: This was a retrospective study of TPO-Ab concentrations in 36 women and 2 men (mean age 51 +/- 16 years; range 19-81 years) with Hashimoto's thyroiditis as defined by the following criteria: elevated plasma TPO-Ab and typical hypoechogenicity of the thyroid in high-resolution sonography at first presentation or during follow-up and low pertechnetate uptake in thyroid scintigraphy. When first studied 17 women and 1 man were not yet taking levothyroxine. The remaining 20 patients were receiving levothyroxine. At initial examination 18 patients had serum thyroid-stimulating hormone (TSH) concentrations above normal. Results of up to eight (mean = 5.8) measurements obtained over a mean period of 50 months while patients were receiving levothyroxine were analyzed. In addition, serum TSH, free triiodothyronine (fT3), and free thyroxine (fT4) were measured, and ultrasound of the neck was performed at each follow-up examination. RESULTS: In terms of TPO-Ab levels, 35 of 38 patients (92%) had a decrease, 2 patients had undulating levels, and 1 patient had an inverse hyperbolic increase in her TPO-Ab levels. In the 35 patients in whom there were decreasing TPO-Ab values, the mean of the first value was 4779 IU/mL with an SD of 4099 IU/mL. The mean decrease after 3 months was 8%, and after 1 year it was 45%. Five years after the first value, TPO-Ab levels were 1456 +/- 1219 IU/mL, a decrease of 70%. TPO-Ab levels became negative, < 100 IU/mL, in only six patients, a normalization percentage of 16%. There were no correlations between changes in thyroid volume and changes in TPO-Ab. CONCLUSION: Serum TPO-Ab levels decline in most patients with Hashimoto's thyroiditis who are taking levothyroxine, but after a mean of 50 months, TPO-Ab became negative in only a minority of patients.

Dietlein M, Wegscheider K, Vaupel R, Schmidt M, Schicha H. · Department of Nuclear Medicine, University of Cologne, Kerpener Str. 62, 50924 Cologne, Germany. · Nuklearmedizin. · Pubmed #18493687 No free full text.

Abstract: AIM: To compare the opinions of practitioners in primary care with those of thyroid specialists in Germany on the management of solitary thyroid nodules (Papillon 2005). METHODS: Questionnaires were filled in by 2,191 practitioners and 297 thyroid specialists between June 1 and September 30, 2005. The test cases and their modifications described a solitary thyroid nodule of 2-3 cm with different levels of thyroid function and a hypoechogenic nodule of 1 cm in diameter. RESULTS: TSH determination and sonography were found to be standard procedures, followed by scintigraphy (selected by 84.7% of practitioners and 95.1% of specialists, p < 0.001) and fine needle aspiration cytology (54.5% of practitioners, 57.4% of specialists). For a hypoechogenic nodule calcitonin determination was advocated by 54.0% of endocrinologists and by 32.2% of nuclear medicine physicians (p < 0.001). A euthyroid solitary thyroid nodule would be treated medically by 77.8% of practitioners and by 85.7% of specialists, the combination of levothyroxine and iodine being clearly preferred (60.9% of practitioners and 67.1% of specialists). For a hyperfunctioning nodule the preference of radioiodine therapy was significantly higher in the specialist group (88.8%) than among the practitioners (52.2%). CONCLUSIONS: The main differences of opinion between practitioners and specialists focused on calcitonin screening and referral to radioiodine therapy.

Dietlein M, Wieler H, Schmidt M, Schwab R, Goretzki PE, Schicha H. · Klinik und Poliklinik für Nuklearmedizin der Universität zu Köln, Köln, Germany. · Nuklearmedizin. · Pubmed #18392315 No free full text.

Abstract: In spite of the fact that the German Society of Endocrinology has recommended calcitonin as screening-parameter the majority of physicians in Germany do not routinely use calcitonin in patients with thyroid nodules to exclude medullary thyroid cancer (MTC). The future revision of the recommendation should describe reference values for each commercially available assay, separately for men and women (basal and after pentagastrin-stimulation), and should define sonomorphological inclusion criteria. The epidemiological database of the prevalence of MTC is controversial and the specificity of basal elevated calcitonin levels is limited up to the 5-fold of the upper reference level. If renal insufficiency, bacterial infection, and an alcohol- or drug-induced stimulation of calcitonin is excluded, hypercalcitoninaemia should be confirmed by a second measurement (if necessary using another assay). Stimulation of calcitonin by use of pentagastrin is mandatory prior to the decision on thyroidectomy. A stimulated calcitonin level < 100 pg/ml justifies "wait and see". If stimulated calcitonin levels range between 100 and 200 pg/ml or higher, the differentiation between C-cell hyperplasia and MTC remains uncertain, especially in men. The implementation of calcitonin-screening requires the definition of sonographic inclusion criteria and validation of each assay. Additional pre-requisites are excellent logistic (short period between blood sampling and start of the laboratory test), knowledge of differential diagnoses, knowledge of the consumption of drugs and alcohol, availability of pentagastrin-testing and of moleculargenetic testing with full information to the patients and sufficient time before the decision on surgery is made. All this and the choice of a skilled surgeon, experienced in thyroidectomy and lymphadenectomy with a low rate of local complications are the rationale to recommend calcitonin-screening primarily in centers for thyroid disorders.