Giovanella L, De Palma D, Ceriani L, Vanoli P, Garancini S, Tordiglione M, Tarolo G L
Dipartimento di Diagnostica per Immagini e Radioterapia, Unità Operativa di Medicina Nucleare, Azienda Ospedaliera Universitaria, Ospedale di Circolo e Fondazione Macchi, Varese.
Radiol Med. 2000 Dec;100(6):480-3.
To evaluate the clinical effectiveness of a simplified dosimetric approach to the iodine-131 treatment of hyperthyroidism due to Graves' disease or uninodular and multinodular toxic goiter.
We enrolled 189 patients with biochemically confirmed hyperthyroidism and performed thyroid ultrasonography and scintigraphy obtaining the diagnosis of Graves' disease in 43 patients, uninodular toxic goiter in 57 patients and multinodular toxic goiter in 89 patients. In 28 patients we found cold thyroid nodules and performed fine-needle aspiration with negative cytology for thyroid malignancy in all cases. Antithyroid drugs were stopped 5 days till radioiodine administration and, if necessary, restored 15 days after the treatment. Radioiodine uptake test was performed in all patients and therapeutic activity calculated to obtain a minimal activity of 185 MBq in the thyroid 24 hours after administration. The minimal activity was adjusted based on clinical, biochemical and imaging data to obtain a maximal activity of 370 MBq after 24 hours.
Biochemical and clinical tests were scheduled at 3 and 12 months posttreatment and thyroxine treatment was started when hypothyroidism occurred. In Graves' disease patients a mean activity of 370 MBq (distribution 259-555 MBq) was administered. Three months after treatment and at least 15 days after methimazole discontinuation 32 of 43 (74%) patients were hypothyroid, 5 of 43 (11%) euthyroid and 6 of 43 (15%) hyperthyroid. Three of the latter were immediately submitted to a new radioiodine administration while 32 hypothyroid patients received thyroxine treatment. One year after the radioiodine treatment no patient had hyperthyroidism; 38 of 43 (89%) were on a replacement treatment while 5 (11%) remained euthyroid. In uni- and multinodular toxic goiter a mean activity of 444 MBq (distribution 259-555 MBq) was administered. Three months posttreatment 134 of 146 (92%) patients were euthyroid and 12 of 146 (8%) patients hyperthyroid. Two patients were immediately submitted to a new radioiodine administration. One year posttreatment 142 of 146 (97%) patients were euthyroid while only 4 of 146 (3%) patients showed TSH levels above the normal range. Only 2 of them required thyroxine treatment.
The simplified dosimetric method illustrated in our paper is very effective in clinical practice because it permits to avoid resorting to sophisticated but also imprecise quantitative methods. Hypothyroidism should not be considered as a major collateral effect of radioiodine treatment, particularly in Graves' disease. In fact, the pathogenesis of the disease requires an ablative treatment with both surgery and radioidine treatment and the control of hyperthyroidism and the prevention of relapse are the major clinical targets. Vice versa, hypothyroidism was very uncommon in uni- and multinodular toxic goiter when our dosimetric approach was applied.
评估一种简化剂量测定方法对格雷夫斯病或单结节及多结节毒性甲状腺肿所致甲状腺功能亢进进行碘 - 131治疗的临床效果。
我们纳入了189例经生化确诊的甲状腺功能亢进患者，进行了甲状腺超声检查和闪烁扫描，其中43例诊断为格雷夫斯病，57例为单结节毒性甲状腺肿，89例为多结节毒性甲状腺肿。在28例患者中发现了甲状腺冷结节，并对所有病例进行了细针穿刺，甲状腺恶性肿瘤细胞学检查均为阴性。抗甲状腺药物在放射性碘给药前5天停用，必要时在治疗后15天恢复使用。对所有患者进行了放射性碘摄取试验，并计算治疗活性，以使给药后24小时甲状腺内的最小活性达到185 MBq。根据临床、生化和影像学数据调整最小活性，以使24小时后最大活性达到370 MBq。
治疗后3个月和12个月安排了生化和临床检查，甲状腺功能减退发生时开始甲状腺素治疗。在格雷夫斯病患者中，平均给予370 MBq的活性（分布范围为259 - 555 MBq）。治疗后3个月且在甲巯咪唑停药至少15天后，43例患者中有32例（74%）出现甲状腺功能减退，5例（11%）甲状腺功能正常，6例（15%）甲状腺功能亢进。后6例中的3例立即接受了新的放射性碘给药，而32例甲状腺功能减退患者接受了甲状腺素治疗。放射性碘治疗1年后，无患者出现甲状腺功能亢进；43例中的38例（89%）接受替代治疗，5例（11%）仍甲状腺功能正常。在单结节和多结节毒性甲状腺肿患者中，平均给予444 MBq的活性（分布范围为259 - 555 MBq）。治疗后3个月，146例患者中有134例（92%）甲状腺功能正常，12例（8%）甲状腺功能亢进。2例患者立即接受了新的放射性碘给药。治疗1年后，146例患者中有142例（97%）甲状腺功能正常，而146例中只有4例（3%）患者的促甲状腺激素水平高于正常范围。其中只有2例需要甲状腺素治疗。
我们论文中阐述的简化剂量测定方法在临床实践中非常有效，因为它避免了采用复杂但也不准确的定量方法。甲状腺功能减退不应被视为放射性碘治疗的主要副作用，尤其是在格雷夫斯病中。事实上，该疾病的发病机制需要手术和放射性碘治疗的消融性治疗，控制甲状腺功能亢进和预防复发是主要的临床目标。相反，当应用我们的剂量测定方法时，甲状腺功能减退在单结节和多结节毒性甲状腺肿中非常罕见。
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