86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Correlation of US with radionuclide scans
Susan J Mandel MD MPHProfessor of Medicine and Radiology
Perelman School of MedicineUniversity of Pennsylvania
Philadelphia, PA
ATA 2016Ultrasound Course
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Disclosure of ABIM Service: Susan Mandel, MD
I am a current member of the Endocrinology, Diabetes, and Metabolism Board.
To protect the integrity of certification, ABIM enforces strict confidentiality and ownership of exam content.
As a current member of the Endocrinology, Diabetes, and Metabolism Board, I agree to keep exam information confidential.
As is true for any ABIM candidate who has taken an exam for certification, I have signed the Pledge of Honesty in which I have agreed to keep ABIM exam content confidential.
No exam questions will be disclosed in my presentation.
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
I-123 scan
• Half life of 13 hours; 159 keV• 200-500 micro-Curies, orally• Imaging acquired at 24 hours
– Uptake– Anterior and oblique images
• Pinhole collimator--increased magnification and spatial resolution
• Trapped AND organified by thyroid cells
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Pinhole collimator Parrallel=hole collimator
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
AnteriorUptakeScintillation counter
Gamma camera
Oblique
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
23hr RAIU 34%May 2016
24hr RAIU 41%Jan 2016
Pinhole collimator
Parrallel-hole collimator
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
44y.o. woman TSH 0.38mIU/L1.9cm isthmus nodule and subcm nodules
RAO LAOAnterior
How oblique views alter nodule imaging
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
A thyroid nodule may appear on I-123 scan as…….
• Homogenously functioning (“hot”) with or without suppression of the extranodular thyroid parenchyma
• Heterogeneously functioning (“hot and cold”) with or without suppression of the extranodular thyroid parenchyma
• Non-functioning (“cold”)• Not detectable (due to position and/or
size)
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Autonomously functioning nodules“hot”
TSH 0.03
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Nonfunctioning nodule
TSH 1.1mU/L
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Anatomy vs. Function• Sonography provides anatomic detail
about location of nodules and morphologic features (consistency, calcifications, borders, etc)
• I-123 scan provides a 2D function map of activity from different regions of the thyroid
• Both types of information may be necessary for nodule evaluation
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Sagittal
Transverse
trachea
41y.o. woman with 3.6cm left thyroid nodule, reported “warm” on I-123 scan
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Transverse
upper
mid
lower
trachea
trachea
tracheaLAO
48 y.o. woman with 3.4cm left nodule
anterior
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Transverse
upper
mid
lower
trachea
trachea
tracheaLAO
48 y.o. woman with 3.4cm left nodule
anterior
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
THERE IS NO SUCH THING AS AN ISOFUNCTIOING NODULE.
This is simply the scan of a nonfunctioning nodule surrounded
by normal thyroid tissue.
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
41 y.o woman with 1.6 cm right thyroid nodule, TSH 0.9 mU/L
Anterior
RAO
sagittal transverse
trachea
Hyperfunctioning nodule without suppression of extranodular thyroid
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Right sagittal Left sagittal
inferiorinferior
44 y.o. woman with TSH 0.07mU/L
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
50 yo woman, TSH 0.23mIU/LRight nodules: RU 10x12x18, RM 10x10x11, RL 12x11x14Left nodules: LU 16x18x22“Normal I-123 uptake (20%) with homogenous distribution”
Anterior
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
TSH 0.01mIU/LI-123 uptake 35% at 24 hours
Anterior
RAO LAO
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Anterior
RAOR mid R lower
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
56y.o. woman with 3 right nodules,TSH 1.3mU/L
RU 1.9cm, RM 1.4cm, RL 1.7cm
Right sagittal
inferior
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Right sagittal Left sagittal
inferior inferior
47 y.o. woman with TSH 0.22 mU/L
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
16 y.o. girl, complex RL 2.4 cm nodule, TSH 0.81mIu/L
Transverse
trachea
Sagittal
lateral, superior solid area is functioning
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
40 yo man with LL 3cm mixed cystic solid nodule
TSH 0.63mIU/L
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
56 y.o. woman taking amiodaronefor 4 months, TSH 0.03mIU/L, 3
nodules, 24 hour RAIU 1.7%
sagittal
transverse
trachea
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
33 yo womanTSH <0.01, FT4 1.54ng/dl, TT3 2.3ng/ml
I123 RAIU 26 hrs 42.6%.
There is a focus of increased radiotracer uptake in the right upper lobe of the thyroid. The uptake in the remainder of the thyroid is otherwise diffusely decreased
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
HUP US report: Diffusely heterogeneous and hypervascular thyroid, 2.5 cm solid R upper pole nodule
TRAb 2.83 (NL<1.75)
Graves’ with RU functioning nodule
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
What is the risk of cancer in a autonomously
functioning nodule?
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Reports of cancer in AFN• Overall malignancy risk variable• 14 case series: 0-12% weighted total of
3%• Confounding factors in literature--
– Inclusion of cancers adjacent to a functioning nodule
– Use of Tc-99m and not I-123– US not generally performed
• Beware- heterogeneous I-123 uptake in solid component of a nodule
Mirfakhraee Thyroid Research 2013; 6:7
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
54 yo man with TSH 0.01mIU/L,
US: R superior thyroid hypoechoic 1.1cm nodule with infiltrating margins
24hr RAIU 16%“There is increased radiotracer uptake in the right thyroid lobe most intense in the upper mid aspect, note there is mismatch in the size of the nodule seen on the ultrasound and the area of increased uptake seen in the right thyroid lobe”
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
47 y.o. womanTSH 0.82mIU/LOutside US reported “multinodular goiter . . . largest nodule on right 2cm, on left 1.5cm”
Anterior
RAO LAO
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
I-123 scan in patient with “MNG”
Left sagittalRight sagittal
trachea
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
2.7cm right lower thyroid noduleTSH 0.81mIU/L
technetiumpertechnetatescan
anterior marker
LAO RAODoes this patient require FNA?
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
I-123 scan
2.7cm right lower thyroid noduleTSH 0.81mIU/L
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Technetium-99m pertechnetate
• Half life of 6 hours; 140Kev• 10mCi, IV administration• Images acquired at 10-20min• Parallel hole so larger field of view
[salivary glands], lower resolution • Trapped but not organified by thyroid
cells
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
How common is “trapping only”?
• Prospectively study of 140 EUTHYROID pts with hot or warm thyroid nodules on Tc-99m scan
• 5% (7pts) nodules COLD on Iodine scan• Pathology:
– 5 adenomas (follicular, Hürthle)– 2 cancers (follicular, papillary/follicular)
Reschini, E et al. Thyroid. August 2006, 16(8): 757-762.
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
86th Annual Meeting of the American Thyroid Association, September 21, 2016, Denver, ColoradoNOT FOR REPRODUCTION – FOR ATA ULTRASOUND COURSE USE ONLY
Thanks to Peter Singer!
