Endocrine System

XIE XIN LI
Department of Nuclear Medicine,
First Affiliated Hospital,
Zhengzhou University
HYPOTHALAM
US
TRH

PITUITAR
Y
TS ﹢ --
H

10% FT3

I- T3-TBG 99.5%
99m
TcO4
90% FT4
T4-TBG 99.95%
I-→ I2 → Hormone Synthesis
 Thyroid
 Physiology
– Thyroid Hormone Synthesis
• Iodide trapping
• Organification (iodine and tyrosine)
• Coupling
• Proteolysis or Release
– Classification of Thyroid Hormone
• T3(accounts for 10% of thyroid hormone , 99. 5% bound
and 0.5% free,more potent)
• T4(accounts for 90% of thyroid hormone ,99.95% bound
and 0.05% free)
• rT3(inactive)
Thyroid
 Physiology
– Pertinent Hormone
• TRH (synthesized in hypothalamus,can
stimulate synthesis and release of thyrotropin)
• TSH (synthesized in the pituitary, can
stimulate thyroid gland growth and thyroid
hormone synthesis)
In Vivo Thyroid Function Tests
RAIU(Radioactive Iodine Uptake Test)
 Thyroid uptake determination is the measurement of the fraction of
an administered amount of radioactive iodine that accumulates in
the thyroid at selected times following ingestion.
 Common Indications
– To confirm hyperthyroidism and determine the cause
of thyrotoxicosis
– Assist in determining the amount of 131 I to be
administered to patients for therapy of
hyperthyroidism or for ablation of thyroid remnants
– RAIU is of limited value in diagnosing hypothyroidism
In Vivo Thyroid Function Tests
 Procedure
– Patient preparation
– Avoidance of interfering materials
» medications such as thyroid hormones and
antithyroidal drugs,
» Iodine containing food such as kelp and lobster
» Medications such as iodinated contrast,
amiodarone ,betadine
• Empty stomach
In Vivo Thyroid Function Tests
 Radiophamaceutical
– 131
I : 5~10 uCi
– 123
I :200~300 uCi
 Data acquisition
– Instumentation (an probe)
– Measurement of uptake
 Processing
– %uptake=[(neck counts － net thigh counts) ×100]
÷(net standard counts)
In Vivo Thyroid Function Tests
 Clinical interpretation
– Normal range
• 4h: 6~18%
• 24h: 10~35%

The RAIU test provides a useful

assessment of thyroid function: in general
,the higher the iodine uptake,the more active
the gland.
In Vivo Thyroid Function Tests
 Etiologies resulting in an increased RAIU
– Hyperthyroidism
– Rebounding following abrupt withdrawal of antithyroidal
drugs
– Long term antithytoid therapy
– Enzyme defects
– Iodine starvation
– Lithium therapy
– Early hashimoto’s thyroiditis
– Rebound during recovery from subacute thyroiditis
In Vivo Thyroid Function Tests
 Etiologies resulting in a decreased RAIU
– Blocked trapping
• Iodine load
• Exogenous thyroid hormone replacement depressing TSH
levels
• Ectopic thyroid : Struma Ovarii
– Blocked organification
– Parenchymal destruction
– Hypothyroidism
• Primary and secondary
• Surgical / radioiodine ablation of thyroid
In Vitro Thyroid Function Tests

 TT3

– Bounded T3
– Unbounded T3 (FT3)
 TT4

– Bounded T4
– Unbounded T4 (FT4)
 TSH
 Thyroid Scintigraphy
Common Indications
 To relate the general structure of the thyroid gland to its
function(such as nodular or diffuse enlargement)
 To correlate thyroid palpation with scintigraphic findings to determine
whether the degree of function in a clinically defined area or nodule
 To locate ectopic thyroid tissue or determine whether a suspected
“thyroglossal duct cyst” is the only functioning thyroid tissue present
 To assist in evaluation of congenital hypothyroidism
 To evaluate a neck or substernal mass
 To differentiate thyroiditis and factitious hyperthyroidism from
Grave’s disease and other form of hyperthyroidism
Thyroid Scintigraphy
radiopharmaceuticals
 
Administrtion dose Imaging time
I-123 po 200-400μCi 3~4h
I-131 po 25~100μCi 16~24h
Tc-99m po 5 mCi 1h
iv 3 mCi 15~30min
  
Imaging the Thyroid

normal appearances
The normal thyroid image is variable.
Commonly, the lobes are asymmetrical and
the isthmus is not always fully visible.
Thyroid Scintigraphy
 Clinical applications
– Ectopic thyroid tissue
• Lingual thyroid
• Thyroglossal duct cyst
• Substernal thyroid
• Stuma ovarii
Thyroid Scintigraphy
Clinical Application
 thyroid nodules
“hot nodule” :has greater or more radioactivity than
the normal surrounding thyroid tissue,
Benign
Autonomous (50%)
Adenomatous hyperplasia
Compensatory hypertrophy
Physiologic thyroid hyperplasia
Malignant
Thyroid carcinoma (less than 4%)
 Thyroid Scintigraphy
Clinical Application
 thyroid nodules
“cold nodule” : has less activity than the normal surrounding thyroid
tissue,
Benign (80~85%)
Simple cyst
Adenomatous hyperplasia
Focal hemorrhage
Inflammatory
Parathyroid adenoma
Malignant(20%)
Thyroid carcinoma
Parathyroid adenoma/ carcinoma
Thyroid lymphoma
Metastatic disease
Thyroid Scintigraphy

Clinical Application
 thyroid nodules
“indeterminate nodule” : has activity equal to the
adjacent thyroid gland

A thyroid suppression test may be performed to

determine if the nodule is autonomous or cold . Cold
nodules require further evaluation to exclude
malignancy.
Extended scintigraphy for
differentiated thyroid cancer

 Radiophamacerticals
– 131I or 123I
– 201TL
– 99mTc-MIBI
Extended scintigraphy for
differentiated thyroid cancer
 Common indications
– To determine the presence and location of residual
functioning thyroid tissue and/or functioning thyroid
cancer/metastases.
 Patient preparation
– Avoidance of interfering materials
• medications such as thyroid hormones and antithyroid drugs,
• Iodine containing food such as kelp and lobster
• Medications such as iodinated contrast, amiodarone
,betadine
Extended scintigraphy for
differentiated thyroid cancer
 Image acquisition
– Whole body imaging
131
I-whole body imaging
99m
Tc-MIBI Imaging
99m
Tc-MIBI Imaging
Diseases pertinent to thyroid
Diffuse Toxic Goiter (Grave’s Disease)
 Defination
– An autoimmune disorder characterized by the presence of a
TSH receptor antibody.
 Symptom
– Goiter,exophthalmos,tachycardia,weight loss,heat
intorlerance,hyperactive reflexes ,warm skin ,lid lag,tremor
 Sign
– Increased levels of thyroid hormone and decreased level of
TSH , elevated RAIU, the scan demonstrates a uniform
distribution of increased activity in an enlarged gland ,with
decreased background activity
Diseases pertinent to thyroid
 Toxic nodular goiter(plummer’s disease)
– Autonomous function nodules
– Signs
• Elevated T3,T4, decreased TSH, Elevated
RAIU, “hot” nodule
Diseases pertinent to thyroid
 Thyroiditis
– Acute thyroiditis
– Subacute thyroiditis
– Chronic lymphocytic thyroiditis(hashimoto’s
disease)
Diseases pertinent to thyroid
 Hypothyroidism
– Primary hypothyroidism
– Secondary hypothyroidism
Diseases pertinent to thyroid
 Thyroid cancer
– Papillary thyroid carcinoma(60%)
– Follicular thyroid carcinoma(20%)
– Anaplastic/poorly differentiated
carcinoma(5%)
– Medullary thyroid carcinoma (1~5%)
Treatment for Graves disease
 Antithyroidal drugs
Antithyroid drugs such as the thionamides
Propylthiouracil and Tapazole (Methimazole)
act by blocking the intrathyroidal
organification (iodination) of the tyrosine
residues on the thyroglobulin molecule by
interacting with the enzyme thyroid
peroxidase- thereby inhibiting thyroid
hormone formation.
Treatment for Graves disease
 Surgery
Sufficient thyroid tissue is removed to reduce
overall hormone output.
Treatment for Graves disease
 I-131 Therapy for Hyperthyroidism
 Technique
I-131 is the treatment of choice for patients
over the age of 30, or those with medical
complications of their thyroid disease. The
dose of I-131 is approximately 80-200 uCi per
gram of thyroid.
Treatment for Graves disease
 I-131 Therapy for Hyperthyroidism
Dose Determination: Dose= (Thyroid
mass[gms] x 80-200 uCi/gm)/ Percent
uptake
 Amiodarone
An antianginal and antiarrhythmic drug.
It increases the duration of ventricular
and atrial muscle action by inhibiting
Na,K-activated myocardial adenosine
triphosphatase. There is a resulting
decrease in heart rate and in vascular
resistance.
 Struma Ovarii
A rare teratoid tumor of the ovary composed
almost entirely of thyroid tissue, with large
follicles containing abundant colloid.
Occasionally there are symptoms of
hyperthyroidism. 5-10% of struma ovarii become
malignant, the only absolute criterion for which
is the presence of metastasis. (Dorland, 27th
ed; Segen, Dictionary of Modern Medicine,
1992)
 Propylthiouracil
A thiourea antithyroid agent. Propylthiouracil
inhibits the synthesis of thyroxine and inhibits
the peripheral conversion of throxine to tri-
iodothyronine. It is used in the treatment of
hyperthyroidism. (From Martindale, The Extra
Pharmacopeoia, 30th ed, p534)
 Myxedema
A condition characterized by a dry, waxy type of
swelling with abnormal deposits of mucin in the skin
and other tissues. It is produced by a functional
insufficiency of the thyroid gland, resulting in
deficiency of thyroid hormone. The skin becomes
puffy around the eyes and on the cheeks and the
face is dull and expressionless with thickened nose
and lips. The congenital form of the disease is
CRETINISM.