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Review ArticleTeaching Case Studies

Management of Challenging Radioiodine Treatment Protocols: A Case Series and Review of the Literature

Joseph Waller, Courtney A. Lawhn-Heath, Cathleen Edmonds, Chloee Wendorf, Brandon Holmes, Michael White, Miguel Hernandez Pampaloni, Chienying Liu and Robert R. Flavell
Journal of Nuclear Medicine Technology June 2021, 49 (2) 180-185; DOI: https://doi.org/10.2967/jnmt.120.255307
Joseph Waller
1Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California;
2Drexel University College of Medicine, Philadelphia, Pennsylvania;
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Courtney A. Lawhn-Heath
1Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California;
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Cathleen Edmonds
3Radiation Safety and UCOP, University of California San Francisco, San Francisco, California; and
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Chloee Wendorf
1Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California;
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Brandon Holmes
3Radiation Safety and UCOP, University of California San Francisco, San Francisco, California; and
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Michael White
1Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California;
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Miguel Hernandez Pampaloni
1Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California;
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Chienying Liu
4Department of Medicine, University of California San Francisco, San Francisco, California
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Robert R. Flavell
1Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California;
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  • FIGURE 1.
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    FIGURE 1.

    Case 1 CT scan. Axial CT demonstrates lobulated and heterogeneous 3.4 × 2.9 × 3.3 cm mass in right thyroid and extending into right superior paratracheal space. Abnormal right cervical and bilateral paratracheal lymph nodes and nonspecific 2-mm nodule in left lower lobe of lung were also seen. Findings were suggestive of thyroid cancer with cervical nodal metastases.

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    FIGURE 2.

    Case 1 posttherapy scan. (A) Whole-body scan obtained after administration of 2,775 MBq (75 mCi) of 131I. (B) SPECT imaging of neck. These images are consistent with residual thyroid tissue, as focal tracer uptake was noted within thyroid resection bed.

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    FIGURE 3.

    Case 2 post-RAI therapy scan with intravenous administration of 131I. (A) Whole-body scan obtained after administration of 1,850 MBq (50 mCi) of 131I. (B and C) SPECT/CT imaging of neck obtained in axial and coronal planes, respectively, showing focal tracer uptake in thyroid bed, consistent with residual thyroid tissue. No distant metastases were observed.

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    FIGURE 4.

    Workflow for management of patients with end-stage renal disease (ESRD) who are on dialysis and referred for RAI.

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    FIGURE 5.

    Case 3 posttherapy scan. (A) Whole-body post-131I scan. (B–D) Axial SPECT/CT of the lower neck and mid neck, and coronal SPECT/CT of the neck and chest. These images show no evidence of distant metastatic disease. However, they did find 3 discrete regions of tracer activity within neck, consistent with iodine-avid tissue, likely residual thyroid tissue after thyroidectomy.

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    TABLE 1

    Other Studies on Liquid 131I Administration

    StudySummarySimilarities to case 1Differences from case 1
    Rini et al. ( 12 )Capsular 131I tracers exposed patients to higher-than-intended amounts of radiation, compared with liquid 131I tracersNot applicableInclusion criterion: Graves disease; radiation uptake compared
    Al Aamri et al. ( 9 )Several capsule-related mishaps were cited (i.e., acrylic-glass tube adherence, swallowing difficulty, radiation exposure)Pill dysphagiaRadioactive mishandling and misuse described
    Honour et al. ( 15 )Case series of 144 RAI patients documented minimal fluid intake for speedy recoveryNot applicableHigh-dose solid 131I therapy
    Shields and Johnson ( 11 )Novel presentation was made of capsular 131I administration via endoscopic stomach implantationSuccessful pill dysphagia workaroundEndoscopy required; capsule 131I administered
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    TABLE 2

    Other Studies on Oral 131I Administration for Dialysis Patients

    StudySummarySimilarities to case 3Differences from case 3
    Vermandel et al. ( 25 )Six ESRD patients were administered reduced RAI formulas to treat thyroid cancer; bone marrow toxicity was analyzed to define optimal dosimetryESRD; successful removal of 131I remnantsDosimetry used to minimize toxicity
    Magné et al. ( 21 )Hemodialysis was safe and effective during oral 131I RAI treatment of differentiated thyroid carcinomaESRD; metastases; successful excretionPapillary thyroid carcinoma; metastases in 9 of 16 cervical nodes
    Shields et al. ( 11 )Safe hemodialysis techniques and protocol were shared for minimizing radiation risks and maintaining RAI treatmentESRD; successful excretion; patient interaction minimizedNot applicable
    Bhat et al. ( 17 )Radioactive ablation in ESRD patient after complete thyroidectomy remained successful 4 y laterESRD; history of hypertension, diagnostic prescan with 123IGoiter; presented with shortness of breath after left thyroidectomy
    • ESRD = end-stage renal disease.

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Journal of Nuclear Medicine Technology: 49 (2)
Journal of Nuclear Medicine Technology
Vol. 49, Issue 2
June 1, 2021
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Management of Challenging Radioiodine Treatment Protocols: A Case Series and Review of the Literature
Joseph Waller, Courtney A. Lawhn-Heath, Cathleen Edmonds, Chloee Wendorf, Brandon Holmes, Michael White, Miguel Hernandez Pampaloni, Chienying Liu, Robert R. Flavell
Journal of Nuclear Medicine Technology Jun 2021, 49 (2) 180-185; DOI: 10.2967/jnmt.120.255307

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Management of Challenging Radioiodine Treatment Protocols: A Case Series and Review of the Literature
Joseph Waller, Courtney A. Lawhn-Heath, Cathleen Edmonds, Chloee Wendorf, Brandon Holmes, Michael White, Miguel Hernandez Pampaloni, Chienying Liu, Robert R. Flavell
Journal of Nuclear Medicine Technology Jun 2021, 49 (2) 180-185; DOI: 10.2967/jnmt.120.255307
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Keywords

  • radioactive iodine
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  • patient care
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