The SNMMI Practice Guideline For Therapy Of Thyroid .
Downloaded from jnm.snmjournals.org by David Schuster on December 21, 2017. For personal use only.The SNMMI Practice Guideline for Therapy of ThyroidDisease with 131I 3.0*Edward B. Silberstein1 (Chair), Abass Alavi2, Helena R. Balon3, Susan E.M. Clarke4, Chaitanya Divgi5, Michael J. Gelfand6,Stanley J. Goldsmith7, Hossein Jadvar8, Carol S. Marcus9, William H. Martin10, J. Anthony Parker11, Henry D. Royal12,Salil D. Sarkar13, Michael Stabin14, and Alan D. Waxman151UCHealth University Hospital, Cincinnati, Ohio; 2Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania;Health System, Royal Oak, Michigan; 4Guy’s Hospital, London, United Kingdom; 5Columbia University Medical Center,New York, New York; 6Cincinnati Children’s Medical Center, Cincinnati, Ohio; 7New York–Presbyterian/Weill Cornell MedicalCenter, New York, New York; 8University of Southern California, Los Angeles, California; 9University of California at Los Angeles,Los Angeles, California; 10Vanderbilt University Medical Center, Nashville, Tennessee; 11Beth Israel Deaconess Medical Center,Boston, Massachusetts; 12Mallinckrodt Institute of Radiology, St. Louis, Missouri; 13Jacobi Medical Center, Bronx, New York;14Vanderbilt University, Nashville, Tennessee; and 15Cedars-Sinai Medical Center, Los Angeles, California3Beaumont3. Information required by the physicianperforming the procedure: blood tests . . . 104. Selection of activity. . . . . . . . . . . . . . . . 115. Therapeutic procedure for administrationof 131I . . . . . . . . . . . . . . . . . . . . . . . . . 126. Follow-up. . . . . . . . . . . . . . . . . . . . . . . 12C. Radiation safety issues, patient discharge,home instructions . . . . . . . . . . . . . . . . . . . 12D. Interactions of 131I with other forms ofdiagnosis or treatment . . . . . . . . . . . . . . . . 14E. Radiopharmaceuticals. . . . . . . . . . . . . . . . . 15F. Issues requiring further clarification. . . . . . . 15VII. Documentation/reporting . . . . . . . . . . . . . . . . . . 15VIII. Equipment specification. . . . . . . . . . . . . . . . . . . 16IX. Quality control and improvement . . . . . . . . . . . . 16X. Safety, infection control, and patienteducation concerns . . . . . . . . . . . . . . . . . . . . . . 16XI. Radiation dosimetry. . . . . . . . . . . . . . . . . . . . . . 16XII. Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . 16XIII. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16XIV. Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19INDEXPreamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I.Introduction: patient management, licensure. . . . .II. Goals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .III. Definitions: risk levels. . . . . . . . . . . . . . . . . . . .IV. Common clinical indications . . . . . . . . . . . . . . .V. Qualifications and responsibilities of personnel(in the United States). . . . . . . . . . . . . . . . . . . . .VI. Procedure/specifications of the examination . . . . .A. Therapy of Graves disease, toxic nodules,and nontoxic nodular goiter . . . . . . . . . . . .1. Goals. . . . . . . . . . . . . . . . . . . . . . . . . .2. Patient preparation: thionamides, consentform, rhTSH use. . . . . . . . . . . . . . . . . .3. Information required by the physicianperforming the procedure; scintigraphy;pregnancy and lactation . . . . . . . . . . . . .4. Selection of administered activity . . . . . .5. Therapeutic procedure for administrationof 131I . . . . . . . . . . . . . . . . . . . . . . . . .6. Follow-up. . . . . . . . . . . . . . . . . . . . . . .B. 131I therapy of thyroid cancer to ablate postthyroidectomy remnants and destroy residualor recurrent tumor . . . . . . . . . . . . . . . . . . .1. Indications for treatment with 131I:relationship to staging . . . . . . . . . . . . . .2. Patient preparation and informationthe patient needs: diet, TSH level,informed consent, side effects. . . . . . . . .12223344445666PREAMBLE778Received Feb. 27, 2012; accepted Feb. 27, 2012.For correspondence or reprints contact Edward B. Silberstein, Departmentof Nuclear Medicine, University of Cincinnati Medical Center, 234 GoodmanSt., Room G026, Mont Reid Pavilion, Cincinnati, OH 45219.E-mail: edward.silberstein@uchealth.com*NOTE: YOU CAN ACCESS THIS GUIDELINE THROUGH THE SNMMIWEBSITE (http://www.snmmi.org/guidelines).Published online Jul. 11, 2012.COPYRIGHT ª 2012 by the Society of Nuclear Medicine and MolecularImaging, Inc.DOI: 10.2967/jnumed.112.105148THERAPYThe Society of Nuclear Medicine and Molecular Imaging(SNMMI) is an international scientific and professionalorganization founded in 1954 to promote the science,technology, and practical application of nuclear medicine.Its 16,000 members are physicians, technologists, and scientists specializing in the research and practice of nuclearmedicine. In addition to publishing journals, newsletters, andbooks, the SNMMI also sponsors international meetings andworkshops designed to increase the competencies of nuclearmedicine practitioners and to promote new advances in thescience of nuclear medicine.The SNMMI will periodically define new guidelines fornuclear medicine practice to help advance the science ofnuclear medicine and to improve the quality of service toOFTHYROID DISEASEWITH 131I Silberstein et al.1633
Downloaded from jnm.snmjournals.org by David Schuster on December 21, 2017. For personal use only.patients throughout the United States. Existing practiceguidelines will be reviewed for revision or renewal, asappropriate, on their fifth anniversary or sooner, if indicated.Each practice guideline, representing a policy statementby the SNMMI, has undergone a thorough consensusprocess in which it has been subjected to extensive review,requiring the approval of the Committee on Guidelinesand SNMMI Board of Directors. The SNMMI recognizesthat the safe and effective use of diagnostic nuclearmedicine imaging requires specific training, skills, andtechniques, as described in each document. Reproduction ormodification of the published practice guideline by thoseentities not providing these services is not authorized.These guidelines are an educational tool designed toassist practitioners in providing appropriate care forpatients. They are not inflexible rules or requirements ofpractice and are not intended, nor should they be used, toestablish a legal standard of care. For these reasons andthose set forth below, the SNMMI cautions against the useof these guidelines in litigation in which the clinicaldecisions of a practitioner are called into question.The ultimate judgment regarding the propriety of anyspecific procedure or course of action must be made by thephysician or medical physicist in light of all the circumstances presented. Thus, there is no implication that anapproach differing from the guidelines, standing alone, wasbelow the standard of care. To the contrary, a conscientiouspractitioner may responsibly adopt a course of actiondifferent from that set forth in the guidelines when, in thereasonable judgment of the practitioner, such course ofaction is indicated by the condition of the patient, limitationsof available resources, or advances in knowledge ortechnology subsequent to publication of the guidelines.The practice of medicine involves not only the science, butalso the art, of dealing with the prevention, diagnosis,alleviation, and treatment of disease. The variety andcomplexity of human conditions make it impossible to alwaysreach the most appropriate diagnosis or to predict withcertainty a particular response to treatment. Therefore, itshould be recognized that adherence to these guidelines willnot ensure an accurate diagnosis or a successful outcome. Allthat should be expected is that the practitioner will followa reasonable course of action based on current knowledge,available resources, and the needs of the patient to delivereffective and safe medical care. The sole purpose of theseguidelines is to assist practitioners in achieving this objective.I. INTRODUCTIONOral administration of 131I has been a commonly accepted procedure for treatment of benign and malignantdisorders of the thyroid since the 1940s. Physicians responsible for treating such patients should have an understanding of the clinical pathophysiology and natural history ofthe disease processes, should be familiar with alternativeforms of therapy, and should be able to collaborate closely1634THE JOURNALOFwith other physicians involved in the management of thepatient’s condition. The treating physician should either seepatients in consultation with the physician assuming overallmanagement of the patient’s condition or be preparedto assume that role. In the United States, the treating physician should be board-certified in nuclear medicine or be ableto document equivalent training, competency, and experiencein the safe use and administration of therapeutic 131I.Licensure to possess 131I and regulations regarding therelease of patients treated with radioiodine vary from jurisdiction to jurisdiction. Physicians engaged in therapy with131I must be knowledgeable about, and in compliance with,all applicable laws and regulations. The facility in whichtreatment is performed must have appropriate personnel,radiation safety equipment, and procedures available forwaste handling and disposal, monitoring personnel for accidental contamination, and controlling spread of 131I toconform to state and federal regulations. All physiciansengaged in therapy have a duty to ensure that their knowledge and competencies are up to date.II. GOALSThe purpose of this guideline is to assist trainedpractitioners in evaluating patients for therapy with 131I(sodium iodide) for benign or malignant diseases of thethyroid gland, performing this treatment in a safe and appropriate manner, understanding and evaluating the sequelae of therapy, and reporting the results of therapy.III. DEFINITIONSSee also the SNMMI Guideline for General Imaging.131I is a b-emitting radionuclide with a physical half-lifeof 8.1 d; a principal g-ray of 364 keV; and a principalb-particle with a maximum energy of 0.61 MeV, an averageenergy of 0.192 MeV, and a mean range in tissue of 0.4 mm(1,2). Therapy means the oral administration of 131I as sodium iodide to treat papillary and follicular thyroid cancer,hyperthyroidism, or nontoxic nodular goiter, in contrast tothe diagnostic use of radioiodine to detect functioning thyroid tissue. Benign diseases include Graves disease (toxicdiffuse goiter) and toxic or nontoxic nodular goiter. Malignant diseases in this guideline indicate papillary andfollicular types of thyroid cancer that are sufficiently differentiated to be able to synthesize thyroglobulin and, inmost cases, accumulate radioiodine. Ablation refers to theuse of 131I to eliminate residual normal thyroid tissuedetected after thyroidectomy.The risk to the thyroid cancer patient of recurrence anddeath varies from very low to high (3,4). Classifying theprognosis for the risk of recurrence and dying from thyroid cancer has also been performed by the American JointCommittee on Cancer (AJCC), in detailed stages I–IV (5).The following systems of risk evaluation are similar to oneanother but not identical, indicating our lack of preciselong-term outcome data for all the variables. They remainNUCLEAR MEDICINE Vol. 53 No. 10 October 2012
Downloaded from jnm.snmjournals.org by David Schuster on December 21, 2017. For personal use only.valuable for prognostic purposes and in considering therapeutic options.variation from AJCC (T1–3 N1b M0) (3); and tumorswith a MACIS score of more than 6 (7). In patientsover the age of 45 y this category includes tumors withan aggressive histologic type (as listed above), witha minimally (i.e., microscopic) invasive follicular carcinoma smaller than 4 cm (3), with AJCC stage III (T3N0 M0 or T1–T3 N1a M0) (5)), or with a MACISscore of more than 6 (7).According to Cooper et al. (4), patients are in theintermediate-risk category if they have microscopicinvasion of tumor into the perithyroidal soft tissuesat initial surgery or a tumor with aggressive histologyor vascular invasion.A. Very low riskThe very-low-risk category excludes cancers withhigh-risk histopathology (e.g., tall cell, insular, columnar, diffuse sclerosing, trabecular, solid, poorly differentiated papillary carcinoma, and the Hürthle cellvariant of follicular carcinoma) and cancers with vascular invasion (3).In patients under the age of 45 y, this categoryincludes unifocal or multicentric microcarcinoma(,1.0 cm), tumors smaller than 4 cm confined to thethyroid (3) (tumors . 1.0 cm are seen by some asmore risky (6)), a stage I variation from AJCC (T1–2 N0 M0) (2), and tumors with a MACIS (metastases,age, completeness of resection, invasiveness, and size)score of less than 6 (7). In patients over the age of 45y, this category includes unifocal or multicentricmicrocarcinomas, a stage I variation from AJCC(T1–2 N0 M0) (3), and tumors with a MACIS scoreof less than 6 (7).D. High riskPatients under the age of 45 y are in the high-riskcategory if they have distant metastases; extension tomuscle; invasion of prevertebral fascia, subcutaneoussoft tissues, the larynx, the trachea, the esophagus, orrecurrent laryngeal nerve; encasement of the carotidartery or mediastinal vessels; a stage I variation fromAJCC (T4a or T4b any N M0) (3); AJCC stage II (anyT any N M1) (5); or a MACIS score of more than 6 (7).Patient over the age of 45 y are in the high-riskcategory if they have tumor extension to muscle; invasion of subcutaneous soft tissues, the larynx, thetrachea, the esophagus, or recurrent laryngeal nerve;invasion of prevertebral fascia or encasement of thecarotid artery or mediastinal vessels; central- or lateral-compartment lymph node metastases; distant metastases; macroscopic invasive follicular carcinoma ora follicular carcinoma larger than 4 cm (3); AJCCstage IVA (T4a any N M0 or T1–T3 N1b M0), IVB(T4b any N M0), or IVC (any T any N M1) (5); ora MACIS score of more than 6 (7).B. Low riskThere are 2 definitions for the low-risk category(3,4).According to Sacks et al. (3), in patients under theage of 45 y this category includes tumors smaller than4 cm with or without microscopic central-compartment lymph node metastases but no distant metastases(3); a stage I variation from AJCC (T1–T2 N0–N1aM0) (3); AJCC stage I (any T any N M0) (5); tumorswith a MACIS score of less than 6 (7). In patients overthe age of 45 y this category includes tumors smallerthan 4 cm confined to the thyroid with no node involvement (3) (i.e., AJCC stage II [T2 N0 M0] (5))and tumors with a MACIS score of less than 6 (7).According to Cooper et al. (4), patients are in thelow-risk category if they have no local or distant metastases after thyroidectomy and remnant ablation, ifall macroscopic tumor was resected, and if there is notumor invasion of locoregional tissues or structures, noaggressive histology, no vascular invasion, and, if 131Iis given, no 131I uptake outside the thyroid bed on theposttreatment whole-body scan.C. Moderate riskThere are 2 definitions for the moderate-risk category (3,4).According to Sacks et al. (3), in patients under theage of 45 y this category includes tumors larger than 4cm; macroscopic (.1 cm) central-compartment or lateral lymph node metastases; an aggressive histologictype; a minimally invasive (i.e., microscopic capsular,but not vascular, invasion) follicular carcinomasmaller than 4 cm (minimally invasive follicular carcinoma is seen by some as low risk) (3); a stage ITHERAPYIV. COMMON CLINICAL INDICATIONSCommon indications for therapy of thyroid diseases withinclude, but are not limited to, benign diseases such ascertain types of hyperthyroidism (131I may be indicated forthe treatment of Graves disease and toxic nodular [uninodular or multinodular] disease (8)) and nontoxic nodulargoiter (131I therapy may be used successfully to diminishthe size of nontoxic nodular goiters, especially when surgery is contraindicated or refused (9,10)), and differentiatedpapillary and follicular thyroid cancer (131I therapy is theprincipal treatment of residual thyroid tissue after thyroidectomy [thyroid remnant ablation], of residual or recurrentthyroid cancer, and of metastatic disease after near-totalthyroidectomy).131IV. QUALIFICATIONS AND RESPONSIBILITIES OFPERSONNEL (IN THE UNITED STATES)See also the SNMMI Guideline for General Imaging.The SNMMI believes that training and experience according to the nuclear medicine program requirements of theOFTHYROID DISEASEWITH 131I Silberstein et al.1635
Downloaded from jnm.snmjournals.org by David Schuster on December 21, 2017. For personal use only.TABLE 1Pharmaceuticals Blocking Radioiodine UptakeType of medicationThionamide medications (e.g., propylthiouracil,methimazole carbimazole)Multivitamins containing iodideNatural or synthetic thyroid hormonesKelp, agar, carrageenan, Lugol solutionSaturated solution of potassium iodideTopical iodine (e.g., surgical skin preparation)Intravenous radiographic contrast agentsWater solubleLipophilicAmiodaroneAccreditation Council for Graduate Medical Education(11), or the equivalent, are necessary for physicians to provide appropriate and effective therapy with unsealed radiopharmaceuticals. These requirements go beyond those ofthe U.S. Nuclear Regulatory Commission (NRC) for authorized users, which provide only for the safe handling anddelivery of radiopharmaceuticals. The minimum requirementsfor supervision and administration of radiopharmaceuticals (12) include the supervised, independent evaluationand treatment with 131I of a minimum of 10 patients forhyperthyroidism and a minimum of 5 patients for thyroidcarcinoma.VI. PROCEDURE/SPECIFICATIONS OFTHE EXAMINATIONSee also the SNMMI Guideline for General Imaging.A. Therapy of Graves disease, toxic nodules, andnontoxic nodular goiter1. GoalsThe goal of therapy for hyperthyroidism is toachieve a nonhyperthyroid status—either a euthyroid state or iatrogenic hypothyroidism that hasbeen completely compensated to the euthyroid statewith oral levothyroxine. The goal of therapy fora large nontoxic nodular goiter is the reduction ofthyroid volume to relieve symptoms caused bycompression of the goiter on structures in the neck.2. Patient preparationFor a sufficient time before therapy, patientsmust discontinue use of iodide-containing medications and preparations that could potentially affectthe ability of thyroid tissue to accumulate iodide(Table 1).Pretreatment of selected patients with thionamides (methimazole [Tapazole; Eli Lilly and Co.]or propylthiouracil) to deplete thyroid hormonestores may be helpful, although there must beawareness of uncommon adverse reactions to thionamides, including agranulocytosis and hepatotox-1636THE JOURNALOFRecommended time of withdrawal3d7–10 d10–14 d for triiodothyronine3–4 wk for thyroxine2–3 wk, depending on iodide content2–3 wk2–3 wk6–8 wk, assuming normal renal function1–6 mo3–6 mo or longer (100)icity (13). 131I therapy can cause radiation-inducedthyroiditis with release of stored thyroid hormoneinto the circulation, resulting in occasional transientworsening of hyperthyroidism and, rarely, precipitation of thyroid storm. This is more likely to occurin patients with a large, iodine-avid thyroid glandwho are given higher activities of 131I. Accordingly,elderly patients and patients with significant preexisting heart disease, severe systemic illness, ordebility may benefit from pretreatment with thionamides. The thionamide should be discontinued for3–5 d before the radioiodine therapy is given and canbe resumed 2–3 d afterward. Some experts recommend administering a higher activity of 131I inpatients who have been pretreated with a thionamide.Although some studies suggest that radioresistanceis more likely with propylthiouracil than methimazole, the issue remains unsettled (14,15). A randomized study found no effect of pretreatment of Gravesdisease with methimazole on outcome (16). In another study, thionamides had no effect on the outcome of Graves disease, but the outcome ofradioiodine therapy for toxic nodular goiter was adversely affected. Large goiters and severe hyperthyroidism may also be associated with radioresistanceand require a higher 131I administered activity (15).Other groups of patients for whom a higher activity(kBq [mCi]/g) has been recommended include pediatric patients and patients with rapid turnover, suchas when the radioiodine uptake at 4 h exceeds that at24 h. Treatment with b-blockers can be helpful forsymptomatic control. b-blockers need not be discontinued before treatment with 131I.The treating physician must explain the procedure, treatment, complications, side effects, therapeutic alternatives, and expected outcome to thepatient. Written information must be provided tothe patient according to the NRC (17). The treatingphysician should obtain written informed consentbefore therapy. The consent form should includeNUCLEAR MEDICINE Vol. 53 No. 10 October 2012
Downloaded from jnm.snmjournals.org by David Schuster on December 21, 2017. For personal use only.several items specific to the therapy of hyperthyroidism. The form should state that more than one131I treatment may be necessary and that long-termfollow-up is necessary, that recurrent laryngealnerve palsy and dysgeusia (altered or distortedsense of taste) are very uncommon side effects,and that there is a small (1%–5%) chance ofa mildly painful radiation thyroiditis after treatmentbut that acetaminophen or other nonnarcotic analgesic therapy usually suffices and corticosteroidsare rarely required. The form should also explainthat the likelihood of eventual hypothyroidism ishigh in Graves disease and somewhat lower withnodular goiters. It can occur within the first fewmonths after therapy or even decades later, witha small, ongoing annual incidence. Lifelong thyroidhormone supplementation would then become necessary.Other information to be included on the consent form is that ophthalmopathy may worsen ordevelop after 131I therapy for Graves’ disease,especially in smokers. High levels of pretreatmentserum triiodothyronine, posttherapy hypothyroidism, and thyroid-stimulating hormone (TSH)receptor antibody are also associated with an increased risk of the development or progression ofophthalmopathy (18). In addition, the form shouldstate that patients with severe hyperthyroidismmay occasionally experience an exacerbation ofsymptoms within the first 2 wk after 131I therapy.These symptoms usually respond to short-termb-blocker therapy and a thionamide but rarelymay progress to frank thyroid storm. Patientsshould be instructed to seek immediate medicalcare should such symptoms occur. The consentform should also mention that, on the basis ofprevious multicenter trials, there is no evidenceof an increased risk of thyroid carcinoma or othermalignancy, an increased risk of infertility, or anincreased incidence of birth defects caused by 131Itherapy for hyperthyroidism. There does exista small risk of preexisting or coexisting thyroidcancer in patients with toxic nodular goiter andGraves disease unrelated to 131I therapy (19,20).A final item to consider including on the informedconsent form is that most experts recommendwaiting 6–12 mo after 131I therapy before tryingto conceive a child (although there are no scientific data on the subject).The patient’s ability to comply with the prescribed radiation precautions should be ascertained,and travel precautions should be reviewed anda card or letter documenting the therapy shouldbe provided to the patient.Recombinant human TSH (rhTSH; Thyrogen[Genzyme Corp.]) has been used (in an off-labelTHERAPYuse) in patients with nontoxic or toxic nodular goiter with low iodine uptake to maximize thyroidgland uptake and minimize the radiation dose tothe rest of the body. An effective rhTSH dose tostimulate uptake and not increase circulating thyroid hormone has been reported as 0.03 mg givenonce or twice (21,22).3. Information required by the physician performingthe procedureThe treating physician should obtain the patient’sthyroid-related medical history and perform a directed physical examination. The cumulative administered activity of 131I should be reviewed andentered in the patient’s record. The patient’s identity must be confirmed in accordance with institutional policy before administration of 131I. Forpatients with a history of renal disease or diabetes,renal function should be assessed. Peritoneal or hemodialysis is not a contraindication to 131I therapy(32), and dosimetry should be helpful to determinethe maximum tolerated dose.The results from recent measurements of thyroid hormone levels (free T4, total or free T3)and TSH should be available and reviewed. Theavidity of the thyroid gland for iodide must beestablished. This should be accomplished quantitatively using a recent radioiodine uptake measurement with 123I or 131I, combined witha thyroid scan (especially in the presence of a nodule) or a stimulating TSH receptor antibody study,either of which usually can distinguish betweenGraves disease, a toxic multinodular goiter, anda uninodular adenoma. These procedures will alsodifferentiate silent thyroiditis and thyrotoxicosisfactitia from other forms of hyperthyroidism. Ifradioiodine is unavailable for scintigraphy,99mTc-pertechnetate is an option and 99mTc uptakecan be determined quantitatively (23,24), althoughthe correlation of 99mTc-pertechnetate uptake with123I uptake is not perfect since the former is notorganified. In the presence of an elevated level ofanti-TSH receptor antibody, orbitopathy, and pretibial myxedema, a thyroid scan may be unnecessary, and an uptake measurement with 185–370kBq (5–10 mCi) of 131I may suffice. Ultrasonography generally does not contribute to the differential diagnosis of thyrotoxicosis (25).131I therapy is always contraindicated in pregnant women. The fetal thyroid gland concentratesiodine by weeks 10–13 (26). Female patients whohave the potential to be pregnant must always betested for pregnancy using a urine or serumb–human chorionic gonadotropin (hCG) test, ideally within 24 h of treatment, as the pregnancy testmay remain negative for up to 7–10 d after fertilization (27). The urine b-hCG test can rarely detectOFTHYROID DISEASEWITH 131I Silberstein et al.1637
Downloaded from jnm.snmjournals.org by David Schuster on December 21, 2017. For personal use only.hormone levels less than 20–25 mIU/mL, whereasserum testing is sensitive to 10 mIU/mL or lower.Caution is therefore advised in treating patientswho have had unprotected intercourse in the 10 dbefore treatment, and the treating physician shouldconsider discussing the limitation of the pregnancytest with the patient, which could include consideration of delaying the therapy until the beginning ofthe next cycle.Before omitting a pregnancy test in women ofchildbearing age, some institutions may requirewritten historical confirmation of hysterectomy (apregnancy test is still required in some institutionsdespite a history of tubal ligation). In some cases inwhich the patient has declared that pregnancy isimpossible and the b-hCG test is consequentlyomitted, the patient has in fact been pregnant(27,28). If inadvertent administration of 131I toa pregnant patient does occur, information on counseling patients about the significance of accidentaladministrations of 131I is available from thepatient’s obstetrician and a reference provided atthe end of this guideline (29).All potentially breastfeeding or lactating womenmust be asked if they are lactating. If so, they mustbe advised to stop breastfeeding, and therapy mustbe delayed until lactation ceases, in orderto minimize the radiation dose to the breast (30).Lactation (and the ability of the breast to concentrate large amounts of iodine) usually ceases 4–6wk after birth (with no breastfeeding) or 4–6 wkafter breastfeeding stops. Documentation in thepatient’s record that the patient denies breastfeeding is suggested. If there is uncertainty as towhether the previously lactating breasts still concentrate iodine, this may be assessed by noting theabsence of uptake on pretherapy scintigraphy(28,31) with 123I or 99mTc-pertechnetate. Severalapproaches are available to speed the cessation oflactation, but these are beyond the scope of thisguideline. The patient may not resume breastfeeding for that child. Nursing may resume with thebirth of another child.If the patient’s mental status prevents the signing of an informed consent form, a guardian orclose family member can sign the form and shouldbe present during 131I therapy. Some patients withcognitive impairment may not be able to tolerateadmission and isolation in a hospital or to followinstructions necessary to allow the patient to be treated at home with 131I. Treatment in these cases mustbe carefully individualized. With incontinence, diapering the patient and bagging the contaminated material may be necessary, but waste disposal must bedone in cooperation with relevant local authorities soas not to set off alarms at waste facilities.1638THE JOURNALOF4. Selection of administered activityA variety of methods has been used to select theamount of administered activity (33–35). The thyroid radiation dose depends on the radioiodine uptake measurement, gland size, and biologic half-lifeof the radioiodine in the thyroid gland, which canvary widely. Although it is reasonable to base 131Iactivity on the radiation dose delivered to the thyroidgland rather than administered activity, there are fewpublications documenting or confirming this unequivocally (34,36). Dosimetry for the 131I treatmentof thyrotoxicosis has not been standardized.One nondosimetric method is to use the estimatedthyroid gland size and the results of a 24-h radioiodine uptake measurement to calculate the therapeutic activity of 131I in ord
detected after thyroidectomy. The risk to the thyroid cancer patient of recurrence and death varies from very low to high (3,4). Classifying the prognosis for the risk of recurrence and dying from thy-roid cancer has also been performed by the American Joint
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practical application of nuclear medicine. Its 16,000 members are physicians, technologists, and scientists specializing in the re-search and practice of nuclear medicine. In addition to publishing journals, newsletters, and books, the SNMMI also sponsors international meetings and workshops designed to increase the competencies of nuclear medicine practitioners and to promote new advances in .
