Cases reported "Thyroid Neoplasms"

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1/17. radiation protection consequences of the care of a terminally ill patient having received a thyroid ablation dose of 131I-sodium iodide.

    The death of a patient soon after an ablation dose of 131I-sodium iodide is a rare occurrence. We report a case of a patient who died, following emergency surgery to treat gastric bleeding, whilst still radioactive. The doses received by clinical staff involved in management of the patient were measured and were found to be within acceptable limits. However, there was an appreciable level of unsealed radioactivity in the intensive care Unit. The issues raised by this case are discussed in the context of legislative requirements and the worst case scenario. The event highlights the need for close liaison between the different specialities to ensure that clinical staff are properly advised and that necessary safety precautions are taken to avoid compromising the safety of staff or the care of the patient.
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2/17. Thyroid carcinoma with high levels of function: treatment with (131)I.

    In some patients with well-differentiated thyroid carcinoma, dosimetry is necessary to avoid toxicity from therapy and to guide prescription of the administered activity of radioiodine. methods: The presentations and courses of 2 patients exemplify the points. In the second patient, the clues to the need for dosimetry were the large size of the tumor and high circulating levels of thyroxine in the absence of exogenous hormone. The other patient manifested hyperthyroidism from stimulation of the tumors by thyroid-stimulating immunoglobulin. Dosimetry was performed by published methods. RESULTS: Dosimetry of radioactivity in the body and blood warned of increased irradiation per gigabecquerel of administered (131)I. In each patient, the tumors sequestered a substantial amount of administered (131)I and secreted (131)I-labeled hormones that circulated for days. In 1 patient, the blood time--activity curve was complex, making a broad range of predictions for irradiation to blood and bone marrow. Still, dosimetry gave information that helped to avoid severe toxicity. At, respectively, 1.85 and 2.2 GBq (131)I, initial treatments were relatively low. There was a modest escalation in subsequent administered activities. leukopenia with neutropenia developed in each patient, and one had moderate thrombocytopenia and anemia, but toxicity appeared to be transient. Each patient had a marked increase in well-being and evidence of reduced tumor function and volume. CONCLUSION: Two patients with advanced, well-differentiated thyroid carcinoma illustrate the need for dosimetry to help prevent toxicity to normal tissues from therapeutic radioiodine. Conversion of radioiodide to circulating radiothyroxine by functioning carcinomas increases the absorbed radiation in normal tissues. Yet, dosimetric data acquired for 4 d or more may be insufficient for accurate calculations of absorbed radiation in blood. Guidelines suggested for avoiding toxicity are based on the circulating thyroxine concentrations, the presence of thyroid stimulators, the amount of radioactivity retained in the body at 48 h, and the general status of the patient.
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3/17. Radioguided parathyroidectomy for reexploration of primary hyperparathyroidism-- a case report.

    BACKGROUND: We report a case of radioguided parathyroidectomy using a hand-held gamma probe for the reexploration of primary hyperparathyroidism. CASE REPORT: The patient was a 66-year-old Japanese woman. She had previously undergone surgical exploration for primary hyperparathyroidism due to a left inferior parathyroid tumor detected by 99mTc-methoxyisobutylisonitrile (MIBI) scintigraphy. However, the pathological diagnosis of the resected tumor was adenomatous goiter. 99mTc-MIBI scintigraphy was performed again and revealed an abnormal uptake close to the right lower lobe of the thyroid. However, venous sampling for PTH measurements did not support this finding. Sestamibi was injected and the radioactivity was measured pre- and intraoperatively with a hand-held gamma probe. With the patient under general anesthesia, the tumor, which was adjacent to the right recurrent laryngeal nerve, was resected, but it contained only a low level of radioactivity ex vivo, indicating that it was not a parathyroid tumor. A hand-held gamma probe accurately located the radioactive parathyroid tumor in the right lower neck. The resected tumor measured 15 x 6 mm and weighed 331 mg. The pathological diagnosis was parathyroid adenoma. CONCLUSIONS: Radioguided parathyroidectomy is useful to localize parathyroid tumors not only in primary hyperparathyroidism at the initial neck exploration but also for reexploration.
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4/17. Disposition of radioiodine (131)I therapy for thyroid carcinoma in a patient with severely impaired renal function on chronic dialysis: a case report.

    The aim of this study was to analyze the disposition of radioiodine used for the ablation of thyroid remnants after radical surgery for a differentiated thyroid carcinoma in a patient on chronic hemodialysis in order to deliver the optimal (131)I dose to improve the healing rate in these rare cases and to serve as a useful reference to other health care professionals who might face a similar dilemma. A 50 mCi dose of (131)I was administered orally and dialysis sessions were performed 24, 72 and 144 h after therapy. Patient effluent dialyzate waste samples were collected and blood radioactivity analyses were performed at each dialysis session. The (131)I disposition half-life was 2.7 /- 0.8 h. The amounts of remnant radioactivity in total body patient were 58.7, 38.9 and 27.1%, respectively, after each of the three dialysis sessions and the effective period calculated was 1.4 days. The extents of water purification in blood were 69.7, 47.9 and 22.7% at the beginning of each dialysis and 37.7, 42.8 and 18.1% at the end of each dialysis. Effective periods of radioiodine for thyroid cancer in a patient on hemodialysis resulted in rapid iodine clearance, thereby reducing the effective radiation dose and promoting the need to use larger treatment doses. Hemodialysis was safe and effective during treatment with radioiodine.
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5/17. Radioactive 131I use in end-stage renal disease: nightmare or nuisance?

    patients with end-stage renal disease (ESRD) are at risk of prolonged radiation exposure during therapy with radioactive iodine (131I) because it is normally renally excreted. However, 131I is dialyzable and exposure can be monitored with a standard Geiger counter during dialysis. We present two cases of thyroid carcinoma in patients with ESRD who were treated successfully with 131I while continuing chronic hemodialysis (HD). In each case, single HD treatments of 3 and 4 hours performed approximately 20 hours after the administration of 131I resulted in an 80% and 70% reduction in total body radiation levels, respectively. In both cases, Geiger counter measurements after HD following 131I administration revealed levels less than 3 mR/hr, allowing safe discharge from the hospital in a timely manner. All contaminated waste was disposed of by the hospital's Department of Radiation safety. Postdialysis monitoring revealed no residual radiation contamination of the HD machine or radiation exposure to the dialysis staff. Hemodialyzer reuse was suspended until monitoring demonstrated no appreciable evidence of radioactivity in these spent supplies. HD is a critical aspect in the treatment of patients with ESRD receiving 131I and can safely be administered with close planning between the HD staff and the staff of radiation safety.
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6/17. gallium-67 accumulation to the tumor thrombus in anaplastic thyroid cancer.

    A sixty-five-year-old woman was hospitalized for examination of swelling in the left arm. gallium-67 scintigraphy showed the same radioactivity in the left lobe of the thyroid gland and the junction of the internal jugular vein and the subclavian vein. Operation then proved obstruction of the left internal jugular vein and subclavian vein due to tumor thrombus accompanied by anaplastic thyroid cancer. gallium-67 scintigraphy was extremely useful in grasping the extent and feature of the tumor.
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7/17. Solitary liver metastasis from Hurthle cell thyroid cancer: a case report and review of the literature.

    Metastasis to the liver from thyroid cancer is a rare event with a reported frequency of 0.5%. Metastatic liver involvement from differentiated thyroid cancer (DTC) is nearly always multiple or diffuse and usually found along with other distant metastases (lung, bone and brain). The authors describe a patient with a solitary liver metastasis from Hurthle cell thyroid cancer, which appeared during long-term follow-up. The lesion was diagnosed by progressive increase of thyroglobulin in the serum and imaged with I-131 whole body scan, ultrasonography, magnetic resonance imaging (MRI) and F-18 fluoro-deoxyglucose positron emission tomography (FDG-PET) scan. For patients with a Tg level above some arbitrary limit, the administration of a large dose (3.7-5.5 GBq; 100-150 mCi) of I-131, in order to obtain a highly sensitive Tx whole body scan (WBS), remains the best diagnostic strategy. However, on very rare occasions, physiological enteric radioactivity can hide possible abdominal lesions and further indepth studies, such as FDG-PET scans, are sometimes necessary.
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8/17. Radioguided neck dissection in recurrent metastatic papillary thyroid carcinoma.

    Although radioguided surgery has been used for the excision of sentinel nodes in breast cancer and melanoma, sparse literature exists describing its use in thyroid cancer. We report a 69-year-old patient with a previous total thyroidectomy and lymph node dissection for papillary carcinoma who was subsequently found to have recurrent metastatic disease. After a therapeutic dose of radioactive iodine, a hand-held gamma-probe was used to selectively dissect the neck. The patient was offered radioguided revision neck dissection to remove the disease using residual radioactivity of the original therapeutic iodine 131 dose. Our case report seeks to demonstrate a recent example of our use of the gamma-probe in radioguided surgical excision of recurrent metastatic papillary thyroid carcinoma.
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9/17. Secondary lymphoma of the thyroid in 99mTc-pertechnetate scintigraphy.

    We present markedly decreased radioactivity in the right on a 99mTc-pertechnetate thyroid image in a patient with secondary lymphoma of the thyroid. At autopsy, the right lobe of the thyroid was replaced by lymphoma tissue. Markedly decreased radioactivity on the images may be explained by lymphoma cell infiltration or replacement of thyroid tissue with a resultant attenuation effect as well as interference of the trapping mechanism of the thyroid folicular cell. While cold areas in a radionuclide scintigram may present difficulties in interpretation, a high index of secondary lymphoma suspicion should be made by a combination of the scintigraphic findings and history of malignant lymphoma.
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10/17. Accumulation of radioactively labeled antithyroglobulin antibody by thyroid carcinoma.

    The present experiments were undertaken to investigate (1) accumulation of radioactively labeled anti-thyroglobulin antibody by thyroid carcinomas and (2) the mechanism by which radioactively labeled antibody reaches to and stays in carcinoma cells. Anti-thyroglobulin antibody was purified by affinity chromatography using serum obtained from a patient with Hashimoto's disease. 125I-labeled anti-thyroglobulin antibody was injected into nude mice bearing transplanted human thyroid carcinomas. Scintigrams were taken 3 and 7 days after injection. mice were killed thereafter and the radioactivity in each tissue and in serum was analyzed by gel filtration and affinity column chromatography of thyroglobulin, anti-thyroglobulin antibody and anti-human IgG antibody. In a total thyroidectomized patient with a metastatic thyroid carcinoma of the lymph node, 131I-labeled antibody was injected and scintigraphy and blood sampling performed for 7 days after injection. Scintigrams of the mice clearly showed the highest density over the transplanted carcinoma. Most radioactivity in the carcinoma was found to be in the thyroglobulin-antibody immune complex, while in other tissues, including serum samples, the radioactively was in free anti-thyroglobulin antibody. Scintigrams of the patient also showed a hot area over a metastatic carcinoma of the lymph node. It is concluded that (1) radioactively labeled anti-thyroglobulin antibody is accumulated by thyroid carcinoma in spite of the presence of thyroglobulin in blood and stays in cells as thyroglobulin-antibody immune complex, and (2) radioimmunodetection of thyroid carcinomas using labeled anti-thyroglobulin antibody is useful especially for patients with metastases which produces thyroglobulin and do not take up radioiodide.
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