Session Title:
Maximal Tolerated Activity of Radioactive Iodine for Metastatic Thyroid Cancer
Presented at the Annual Meeting of the Society of Nuclear Medicine and Molecular Imaging in Denver, CO on Wednesday, June 14, 8:00AM–9:30AM
Side Effects of I-131: Preventive Measures and Management When Side Effects O...Mark Tulchinsky
This document summarizes a presentation given by Mark Tulchinsky on preventing and managing side effects related to radioiodine (I-131) therapy, with a focus on salivary gland complications. Some key points:
1. I-131 peaks in the salivary glands within the first 2-3 hours after administration and remains at high levels during the first night, so prophylaxis should start within 3 hours and continue through the first night.
2. Acute salivary gland inflammation is a common early side effect, which can progress to chronic sialadenitis and xerostomia if untreated. Sialendoscopy has shown promise in treating radioiodine-induced sial
Myths Surrounding Preparation for I-131 Evaluation and TreatmentMark Tulchinsky
This document summarizes a presentation on myths surrounding the preparation and use of radioactive iodine in differentiated thyroid cancer treatment. The presentation discusses several myths, including that rhTSH preparation is sufficient for diagnostic scans and will only miss 5% of cases, that the 2015 ATA guidelines on rhTSH use are trustworthy, and that patients should wait 24 hours after radioactive iodine treatment to start salivary gland protection. The presentation provides evidence against these myths, showing that rhTSH misses more cases than withdrawal, the guidelines panel had many conflicts of interest, and that starting protection earlier than 24 hours may better protect salivary glands.
Session Title:
Radionuclide Therapy Basics, General Regulations and Update on I-131 Rx
Presented at the Annual Meeting of the Society of Nuclear Medicine and Molecular Imaging in Denver, CO on Sunday, June 11, 3:00PM–4:30PM
Session Title:
Radioiodine Therapy for Hyperthyroidism: The State of the Art
Presented at the Annual Meeting of the Society of Nuclear Medicine and Molecular Imaging in Denver, CO on Tuesday, June 13, 4:45PM–6:15PM
Radioiodine therapy uses radioactive iodine to treat hyperthyroidism and thyroid cancer. Iodine concentrates in the thyroid gland where it delivers radiation to ablate residual or cancerous thyroid tissue. For therapy, patients prepare with a low iodine diet and medication withdrawal before receiving doses ranging from 5-200 mCi orally. Strict radiation safety precautions are required during and after treatment due to iodine excretion. Whole body imaging with 1-5 mCi I-131 or I-123 sodium iodide is performed 48-72 hours later to identify residual thyroid tissue or cancer metastases and guide further treatment. Sources of error include contamination, stunning from prior I-131 doses, and saliv
PowerPoint. Nonradioactive iodine competes with radioactive iodine. This has implications for the use of recombinant human TSH (rhTSH) when preparing differentiated thyroid cancer patients for radioiodine scanning with continued levothyroxine, because the latter contains iodine.
Interstitial cystitis (IC), also known as bladder pain syndrome, is a chronic condition characterized by pelvic pain perceived to be related to the bladder along with urinary symptoms. The cause is multifactorial and likely includes alterations in bladder permeability and neurogenic inflammation. Diagnosis involves ruling out other causes through history, exam, cystoscopy, and urine testing. Treatment is individualized and may include conservative measures, oral medications like amitriptyline, intravesical therapies, minimally invasive procedures, and rarely surgery. Management aims to control symptoms and improve quality of life through a stepwise approach utilizing various options.
This document discusses the management of low risk prostate cancer. It outlines the natural history of untreated low risk prostate cancer and the problems of overdiagnosis and overtreatment. Active surveillance is presented as a management option for low risk prostate cancer, with the rationale being to avoid unnecessary treatment and preserve quality of life. Results from active surveillance studies show low rates of cancer progression and metastasis, with 62% free from intervention at 10 years in one study. Triggers for intervention on active surveillance like rising PSA, grade progression, or tumor volume increase are discussed.
Side Effects of I-131: Preventive Measures and Management When Side Effects O...Mark Tulchinsky
This document summarizes a presentation given by Mark Tulchinsky on preventing and managing side effects related to radioiodine (I-131) therapy, with a focus on salivary gland complications. Some key points:
1. I-131 peaks in the salivary glands within the first 2-3 hours after administration and remains at high levels during the first night, so prophylaxis should start within 3 hours and continue through the first night.
2. Acute salivary gland inflammation is a common early side effect, which can progress to chronic sialadenitis and xerostomia if untreated. Sialendoscopy has shown promise in treating radioiodine-induced sial
Myths Surrounding Preparation for I-131 Evaluation and TreatmentMark Tulchinsky
This document summarizes a presentation on myths surrounding the preparation and use of radioactive iodine in differentiated thyroid cancer treatment. The presentation discusses several myths, including that rhTSH preparation is sufficient for diagnostic scans and will only miss 5% of cases, that the 2015 ATA guidelines on rhTSH use are trustworthy, and that patients should wait 24 hours after radioactive iodine treatment to start salivary gland protection. The presentation provides evidence against these myths, showing that rhTSH misses more cases than withdrawal, the guidelines panel had many conflicts of interest, and that starting protection earlier than 24 hours may better protect salivary glands.
Session Title:
Radionuclide Therapy Basics, General Regulations and Update on I-131 Rx
Presented at the Annual Meeting of the Society of Nuclear Medicine and Molecular Imaging in Denver, CO on Sunday, June 11, 3:00PM–4:30PM
Session Title:
Radioiodine Therapy for Hyperthyroidism: The State of the Art
Presented at the Annual Meeting of the Society of Nuclear Medicine and Molecular Imaging in Denver, CO on Tuesday, June 13, 4:45PM–6:15PM
Radioiodine therapy uses radioactive iodine to treat hyperthyroidism and thyroid cancer. Iodine concentrates in the thyroid gland where it delivers radiation to ablate residual or cancerous thyroid tissue. For therapy, patients prepare with a low iodine diet and medication withdrawal before receiving doses ranging from 5-200 mCi orally. Strict radiation safety precautions are required during and after treatment due to iodine excretion. Whole body imaging with 1-5 mCi I-131 or I-123 sodium iodide is performed 48-72 hours later to identify residual thyroid tissue or cancer metastases and guide further treatment. Sources of error include contamination, stunning from prior I-131 doses, and saliv
PowerPoint. Nonradioactive iodine competes with radioactive iodine. This has implications for the use of recombinant human TSH (rhTSH) when preparing differentiated thyroid cancer patients for radioiodine scanning with continued levothyroxine, because the latter contains iodine.
Interstitial cystitis (IC), also known as bladder pain syndrome, is a chronic condition characterized by pelvic pain perceived to be related to the bladder along with urinary symptoms. The cause is multifactorial and likely includes alterations in bladder permeability and neurogenic inflammation. Diagnosis involves ruling out other causes through history, exam, cystoscopy, and urine testing. Treatment is individualized and may include conservative measures, oral medications like amitriptyline, intravesical therapies, minimally invasive procedures, and rarely surgery. Management aims to control symptoms and improve quality of life through a stepwise approach utilizing various options.
This document discusses the management of low risk prostate cancer. It outlines the natural history of untreated low risk prostate cancer and the problems of overdiagnosis and overtreatment. Active surveillance is presented as a management option for low risk prostate cancer, with the rationale being to avoid unnecessary treatment and preserve quality of life. Results from active surveillance studies show low rates of cancer progression and metastasis, with 62% free from intervention at 10 years in one study. Triggers for intervention on active surveillance like rising PSA, grade progression, or tumor volume increase are discussed.
Nomograms provide predictions of outcomes for prostate cancer patients based on known treatment outcomes of similar patients. However, nomograms have several limitations including bias from the development cohort, lack of external validation, and lack of updates using contemporary patient populations. Additionally, nomograms often use surrogate endpoints rather than clinically meaningful endpoints and predictive accuracy is not 100%. While nomograms can help guide clinical decision making, good clinical judgement is still needed and nomograms may not accurately capture all risk factors or change clinical decisions for individual patients.
The document discusses screening and active surveillance for prostate cancer. It summarizes that screening with PSA testing can reduce prostate cancer mortality by 20% but also leads to overdiagnosis of indolent cancers. Active surveillance is presented as an alternative to immediate treatment for selected low-risk prostate cancer patients with criteria such as Gleason score ≤6, PSA<10ng/ml, and limited cancer in biopsy cores. Studies found that 29-50% of patients identified by screening as low-risk were found to have more aggressive cancer upon undergoing radical prostatectomy.
This document summarizes risk stratification and treatment options for prostate cancer. It discusses using risk prediction models to stratify patients into low, intermediate, and high risk groups to help determine appropriate initial treatment. Options include active surveillance, radical prostatectomy, radiotherapy, and hormone therapy depending on risk level. Treatment selection involves weighing factors like life expectancy, disease control, and side effects.
1) The document discusses management of advanced prostate cancer, focusing on high risk disease. Treatment options for high risk prostate cancer include radiotherapy, androgen deprivation therapy, surgery, or a combination approach.
2) Studies have shown that dose escalated external beam radiotherapy improves outcomes for high risk prostate cancer when combined with androgen deprivation therapy. Moderate hypofractionation is a reasonable alternative to standard fractionation.
3) For high risk disease, long term androgen deprivation therapy of 2 years or more is superior to short term therapy when combined with radiotherapy. However, reducing the duration of long term androgen deprivation may be considered.
1. Several randomized controlled trials have consistently shown that the addition of neoadjuvant hormonal therapy (NHT) to external beam radiotherapy (EBRT) improves outcomes for men with intermediate-risk or high-risk localized prostate cancer.
2. The optimal timing and duration of NHT is still unclear, but most evidence suggests that 2-3 months of NHT combined with EBRT is adequate for intermediate-risk patients. Longer adjuvant hormonal therapy may benefit high-risk patients.
3. While the sequence of NHT relative to EBRT may impact outcomes, short-term NHT combined with EBRT appears beneficial overall based on multiple randomized trials.
This presentation was delivered during a webinar held by the association of anaesthetists in association with RA-UK entitled "New Blocks - Friend or Foe?".
This took place on 19th October 2021.
In this short presentation - Dr Pawa covers: a brief overview of the history of Paravertebral blocks; how he got introduced to them; some updates on our understanding on the anatomy; and whether they still have a role in modern anaesthetic practice.
Talk on Kidney Transplant Fibrosis by Maarten NaesensMaarten Naesens
0.75
0.75
0.75
0
6
24
0
6
24
0
6
24
Time after transplantation
Time after transplantation
(months)
(months)
Time after transplantation
(months)
1. The document discusses kidney transplant fibrosis and chronic allograft damage. It presents data on kidney transplantation rates and outcomes.
2. It analyzes the development and progression of interstitial fibrosis/tubular atrophy (IF/TA) in transplant recipients over time using protocol biopsies. Early IF/TA within the first year is associated with significantly reduced long-term graft
The document summarizes research on active surveillance for prostate cancer. It discusses definitions of clinically significant prostate cancer, criteria for active surveillance candidacy, biomarkers like PSA kinetics and PCA3, and outcomes of patients on surveillance like cancer-specific survival rates and rates of remaining free from intervention. It concludes that active surveillance appears safe in the intermediate term but challenges remain in identifying higher risk disease and validating triggers for intervention.
Fast-track surgery - the role of the anaesthesiologist in ERASscanFOAM
A presentation by Narinder Rawal at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Hormonal Manipulations in Early Prostate Cancer Apollo Hospitals
This document discusses hormonal manipulation in early prostate cancer. It begins with an overview of the prostate cancer treatment continuum and various treatment options including radical prostatectomy, radiotherapy, hormonal therapy, and watchful waiting. It then focuses on the luteinizing hormone-releasing hormone (LHRH) agonist Zoladex (goserelin), reviewing its efficacy as neoadjuvant therapy prior to radical prostatectomy, and as adjuvant therapy following both radical prostatectomy and radiotherapy. Long-term clinical trial data is presented demonstrating improved survival outcomes when Zoladex is used as an adjuvant therapy. Other LHRH agonists such as leuprolide are also discussed. The mechanisms of action and clinical benefits
Advances in the diagnosis and treatment for benign and malignant thyroid diseaseHealthXn
Thyroid disorders are common. This presentation reviews the causes of benign thyroid disease as well as therapy, including new therapies for advanced thyroid cancer.
Mr. Yousef Sa'afeen, a 65-year-old previously healthy non-smoker, was diagnosed with prostate cancer after presenting with urinary symptoms. Biopsy showed adenocarcinoma with a Gleason score of 4+5=9, positive perineural invasion and lymphovascular space invasion, and PSA of 147 ng/ml. He also presented with bone metastases. After evaluation, he was determined to be a high-risk patient appropriate for management of his metastatic disease. Treatment options were discussed including surgery, radiation, hormone therapy and chemotherapy based on his risk category and stage of disease.
Prostate cancer is the second most common cancer in men and the second leading cause of cancer death in men worldwide. Maintaining low testosterone levels through medical or surgical castration is integral to treating prostate cancer across all disease stages. Clinical trials have shown that long-term androgen deprivation therapy in combination with radiation therapy improves survival outcomes for patients with high-risk or locally advanced prostate cancer compared to short-term therapy. Emerging evidence also supports the use of chemotherapy in combination with androgen deprivation for select non-metastatic prostate cancer patients. As the disease progresses to castration-resistant stages, novel anti-androgen and cytotoxic agents that target different pathways have improved outcomes compared to androgen deprivation alone.
Whole body retention of I-131 at 24hr vs 48hr as a predictor of maximum tole...Michael
This study evaluated using the 24-hour whole body retention (WBR) of I-131 as a predictor of the maximum tolerated activity (MTA) for radioactive iodine treatment, as an alternative to the standard 48-hour time point. For 99 thyroid cancer patients, the 24-hour and 48-hour WBR were highly correlated. A model using 24-hour WBR predicted MTA well when retention was <35%, which applied to about half of patients prepared with recombinant human thyroid stimulating hormone. For other patients, the 48-hour measurement was still needed. Using the 24-hour time point could simplify dosimetry for some patients but not replace the 48-hour measurement entirely.
Surgery vs IMRT for High Risk Prostate Cancer Debate - ACRO 2015drewzer
This document summarizes key points about treatment options for high risk prostate cancer. It discusses controversies around using androgen deprivation therapy alone versus tri-modality treatment with surgery, radiotherapy and ADT. Clinical trial data is presented showing improved survival with radiotherapy alone or with ADT compared to ADT alone. Challenges with surgery are noted along with long term functional outcomes data with radiotherapy. The importance of a multi-disciplinary approach and shared decision making is emphasized. While further randomized controlled trial data is still needed, the document argues against avoiding radiotherapy in high risk prostate cancer treatment.
Molecular biology of Prostate cancer. There are three major pathways - the androgen receptor pathway, PI3K/Akt pathway, and Rb pathway. Other factors include TMPRSS2-ETS fusion, TGF-b1, PTEN loss, and aberrant E-cadherin expression. Risk factors include age, ethnicity, genetic mutations like BRCA1/2, and environmental exposures. Prostate cancer can metastasize, with bone and lymph nodes being common sites. Diagnosis involves tests like DRE, PSA, biopsy, and imaging. Hormone therapy targets the androgen receptor and includes surgical or medical castration as well as antiandrogens, but resistance eventually develops
Radiation Therapy 101.5"-ONS Talk Jan2009Spectrum Health
The document provides an overview of radiation therapy presented by Joe Meadows to Hope Lodge. It defines ionizing and non-ionizing radiation and their sources. It discusses the basic mechanisms of radiobiology, contemporary radiation therapy technologies like IMRT and IGRT, and developing technologies like proton beam therapy. Meadows notes challenges in treating cancers like lung cancer and the high costs of emerging technologies.
Presentation by David J. Eschelman, MD, FSIR. Presented at the 2018 Eyes on a Cure: Patient & Caregiver Symposium, hosted by the Melanoma Research Foundation's CURE OM initiative.
Nomograms provide predictions of outcomes for prostate cancer patients based on known treatment outcomes of similar patients. However, nomograms have several limitations including bias from the development cohort, lack of external validation, and lack of updates using contemporary patient populations. Additionally, nomograms often use surrogate endpoints rather than clinically meaningful endpoints and predictive accuracy is not 100%. While nomograms can help guide clinical decision making, good clinical judgement is still needed and nomograms may not accurately capture all risk factors or change clinical decisions for individual patients.
The document discusses screening and active surveillance for prostate cancer. It summarizes that screening with PSA testing can reduce prostate cancer mortality by 20% but also leads to overdiagnosis of indolent cancers. Active surveillance is presented as an alternative to immediate treatment for selected low-risk prostate cancer patients with criteria such as Gleason score ≤6, PSA<10ng/ml, and limited cancer in biopsy cores. Studies found that 29-50% of patients identified by screening as low-risk were found to have more aggressive cancer upon undergoing radical prostatectomy.
This document summarizes risk stratification and treatment options for prostate cancer. It discusses using risk prediction models to stratify patients into low, intermediate, and high risk groups to help determine appropriate initial treatment. Options include active surveillance, radical prostatectomy, radiotherapy, and hormone therapy depending on risk level. Treatment selection involves weighing factors like life expectancy, disease control, and side effects.
1) The document discusses management of advanced prostate cancer, focusing on high risk disease. Treatment options for high risk prostate cancer include radiotherapy, androgen deprivation therapy, surgery, or a combination approach.
2) Studies have shown that dose escalated external beam radiotherapy improves outcomes for high risk prostate cancer when combined with androgen deprivation therapy. Moderate hypofractionation is a reasonable alternative to standard fractionation.
3) For high risk disease, long term androgen deprivation therapy of 2 years or more is superior to short term therapy when combined with radiotherapy. However, reducing the duration of long term androgen deprivation may be considered.
1. Several randomized controlled trials have consistently shown that the addition of neoadjuvant hormonal therapy (NHT) to external beam radiotherapy (EBRT) improves outcomes for men with intermediate-risk or high-risk localized prostate cancer.
2. The optimal timing and duration of NHT is still unclear, but most evidence suggests that 2-3 months of NHT combined with EBRT is adequate for intermediate-risk patients. Longer adjuvant hormonal therapy may benefit high-risk patients.
3. While the sequence of NHT relative to EBRT may impact outcomes, short-term NHT combined with EBRT appears beneficial overall based on multiple randomized trials.
This presentation was delivered during a webinar held by the association of anaesthetists in association with RA-UK entitled "New Blocks - Friend or Foe?".
This took place on 19th October 2021.
In this short presentation - Dr Pawa covers: a brief overview of the history of Paravertebral blocks; how he got introduced to them; some updates on our understanding on the anatomy; and whether they still have a role in modern anaesthetic practice.
Talk on Kidney Transplant Fibrosis by Maarten NaesensMaarten Naesens
0.75
0.75
0.75
0
6
24
0
6
24
0
6
24
Time after transplantation
Time after transplantation
(months)
(months)
Time after transplantation
(months)
1. The document discusses kidney transplant fibrosis and chronic allograft damage. It presents data on kidney transplantation rates and outcomes.
2. It analyzes the development and progression of interstitial fibrosis/tubular atrophy (IF/TA) in transplant recipients over time using protocol biopsies. Early IF/TA within the first year is associated with significantly reduced long-term graft
The document summarizes research on active surveillance for prostate cancer. It discusses definitions of clinically significant prostate cancer, criteria for active surveillance candidacy, biomarkers like PSA kinetics and PCA3, and outcomes of patients on surveillance like cancer-specific survival rates and rates of remaining free from intervention. It concludes that active surveillance appears safe in the intermediate term but challenges remain in identifying higher risk disease and validating triggers for intervention.
Fast-track surgery - the role of the anaesthesiologist in ERASscanFOAM
A presentation by Narinder Rawal at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Hormonal Manipulations in Early Prostate Cancer Apollo Hospitals
This document discusses hormonal manipulation in early prostate cancer. It begins with an overview of the prostate cancer treatment continuum and various treatment options including radical prostatectomy, radiotherapy, hormonal therapy, and watchful waiting. It then focuses on the luteinizing hormone-releasing hormone (LHRH) agonist Zoladex (goserelin), reviewing its efficacy as neoadjuvant therapy prior to radical prostatectomy, and as adjuvant therapy following both radical prostatectomy and radiotherapy. Long-term clinical trial data is presented demonstrating improved survival outcomes when Zoladex is used as an adjuvant therapy. Other LHRH agonists such as leuprolide are also discussed. The mechanisms of action and clinical benefits
Advances in the diagnosis and treatment for benign and malignant thyroid diseaseHealthXn
Thyroid disorders are common. This presentation reviews the causes of benign thyroid disease as well as therapy, including new therapies for advanced thyroid cancer.
Mr. Yousef Sa'afeen, a 65-year-old previously healthy non-smoker, was diagnosed with prostate cancer after presenting with urinary symptoms. Biopsy showed adenocarcinoma with a Gleason score of 4+5=9, positive perineural invasion and lymphovascular space invasion, and PSA of 147 ng/ml. He also presented with bone metastases. After evaluation, he was determined to be a high-risk patient appropriate for management of his metastatic disease. Treatment options were discussed including surgery, radiation, hormone therapy and chemotherapy based on his risk category and stage of disease.
Prostate cancer is the second most common cancer in men and the second leading cause of cancer death in men worldwide. Maintaining low testosterone levels through medical or surgical castration is integral to treating prostate cancer across all disease stages. Clinical trials have shown that long-term androgen deprivation therapy in combination with radiation therapy improves survival outcomes for patients with high-risk or locally advanced prostate cancer compared to short-term therapy. Emerging evidence also supports the use of chemotherapy in combination with androgen deprivation for select non-metastatic prostate cancer patients. As the disease progresses to castration-resistant stages, novel anti-androgen and cytotoxic agents that target different pathways have improved outcomes compared to androgen deprivation alone.
Whole body retention of I-131 at 24hr vs 48hr as a predictor of maximum tole...Michael
This study evaluated using the 24-hour whole body retention (WBR) of I-131 as a predictor of the maximum tolerated activity (MTA) for radioactive iodine treatment, as an alternative to the standard 48-hour time point. For 99 thyroid cancer patients, the 24-hour and 48-hour WBR were highly correlated. A model using 24-hour WBR predicted MTA well when retention was <35%, which applied to about half of patients prepared with recombinant human thyroid stimulating hormone. For other patients, the 48-hour measurement was still needed. Using the 24-hour time point could simplify dosimetry for some patients but not replace the 48-hour measurement entirely.
Surgery vs IMRT for High Risk Prostate Cancer Debate - ACRO 2015drewzer
This document summarizes key points about treatment options for high risk prostate cancer. It discusses controversies around using androgen deprivation therapy alone versus tri-modality treatment with surgery, radiotherapy and ADT. Clinical trial data is presented showing improved survival with radiotherapy alone or with ADT compared to ADT alone. Challenges with surgery are noted along with long term functional outcomes data with radiotherapy. The importance of a multi-disciplinary approach and shared decision making is emphasized. While further randomized controlled trial data is still needed, the document argues against avoiding radiotherapy in high risk prostate cancer treatment.
Molecular biology of Prostate cancer. There are three major pathways - the androgen receptor pathway, PI3K/Akt pathway, and Rb pathway. Other factors include TMPRSS2-ETS fusion, TGF-b1, PTEN loss, and aberrant E-cadherin expression. Risk factors include age, ethnicity, genetic mutations like BRCA1/2, and environmental exposures. Prostate cancer can metastasize, with bone and lymph nodes being common sites. Diagnosis involves tests like DRE, PSA, biopsy, and imaging. Hormone therapy targets the androgen receptor and includes surgical or medical castration as well as antiandrogens, but resistance eventually develops
Radiation Therapy 101.5"-ONS Talk Jan2009Spectrum Health
The document provides an overview of radiation therapy presented by Joe Meadows to Hope Lodge. It defines ionizing and non-ionizing radiation and their sources. It discusses the basic mechanisms of radiobiology, contemporary radiation therapy technologies like IMRT and IGRT, and developing technologies like proton beam therapy. Meadows notes challenges in treating cancers like lung cancer and the high costs of emerging technologies.
Presentation by David J. Eschelman, MD, FSIR. Presented at the 2018 Eyes on a Cure: Patient & Caregiver Symposium, hosted by the Melanoma Research Foundation's CURE OM initiative.
Overview of radiology basics, scan types and pros and cons of each, presented by David J. Eschelman, MD, FSIR, Professor of Radiology, Sidney Kimmel Medical College of Thomas Jefferson University, Co-Director of Interventional Radiology, Thomas Jefferson University Hospital.
Quantitative methods of data collection and its importance
The document discusses quantitative methods of data collection, which use numerical and statistical processes to answer specific questions. It describes several types of quantitative data collection, including census, sample surveys, experiments, and observational studies. The document also outlines some key methods used in cancer diagnosis, such as imaging procedures, biopsies, and the significance of environmental and genetic factors in cancer causation. Treatment methods for cancer discussed include surgery, radiation therapy, chemotherapy, immunotherapy, targeted therapy, and hormone therapy.
Nuclear medicine uses radioactive tracers and imaging techniques like PET and SPECT to produce functional images of the body. It has many clinical applications in areas like oncology, cardiology, and neurology. PET radiotracers like FDG are used to study glucose metabolism that can help identify cancer and other diseases. Nuclear medicine also has an important role in drug development by evaluating whether experimental drugs reach their targets and have the intended biological effect. It helps make drug development more efficient and cost-effective. However, expanding nuclear medicine in India faces challenges in training sufficient technical expertise across various disciplines needed to advance personalized medicine.
Nuclear medicine is a medical specialty that uses small amounts of radioactive tracers and imaging technologies to diagnose and treat diseases. It allows physicians to obtain medical information noninvasively that may otherwise require surgery or more invasive tests. Nuclear medicine procedures can identify abnormalities early in the progression of diseases and allow for earlier treatment when prognosis is better. Over 18 million nuclear medicine procedures are performed annually in the United States to diagnose and treat many different types of diseases.
Radioiodine ablation of normal remnants after less-than-total thyroidectomy f...Herbert Klein
After less-than-total thyroidectomy for thyroid cancer, I-131 is commonly used to ablate the remnant, as distinct from treatment of metastases. This PowerPoint discusses the rationale for ablation and the evidence in the medical literature regarding this, with clinical examples.
The use of whole body irradiation to reduce tumour development in a mouse mod...Leishman Associates
This document summarizes a study investigating the effects of whole body irradiation on tumor development in a mouse model of prostate cancer. The study aims to explore the radiation adaptive response by examining how low doses of radiation may modulate biological processes like cancer. Specifically, the study will use the TRAMP mouse model of prostate cancer to determine how different doses and timings of radiation exposure impact prostate weight, tumor development, proliferation, and other endpoints. The results could increase understanding of prostate cancer processes and identify new treatment strategies.
Role of Radiotherapy in HCC. What do the guidelines say ? A comprehensive review of guidelines and other studies on role of radiotherapy in hepatocellular carcinoma.
Radioactive ablation in thyriod cancersDR Saqib Shah
This document discusses radioactive iodine ablation in thyroid cancers. It provides background on the discovery of thyroid cancer, epidemiology showing it is the most common endocrine malignancy. It reviews the classification, causes, risk factors, evaluation and guidelines for treatment of differentiated thyroid cancers. It discusses the use, goals, effectiveness and factors impacting decision making for radioactive iodine remnant ablation after surgery. It also covers administration, patient preparation, dosimetry approaches and uptake differences between cancer and normal thyroid tissue.
Medical scans that use radiation, such as CT scans, X-rays, mammograms, and PET scans, expose patients to ionizing radiation that can increase cancer risks. While doctors maintain the benefits of these scans outweigh the risks, the document argues that multiple scans or frequent scans unnecessarily increase radiation exposure and may cause or worsen cancers. It recommends only undergoing medical scans deemed absolutely necessary by doctors and exploring alternative testing methods that do not use radiation when possible. The document also provides natural strategies like consuming certain foods that can help protect against radiation exposure and remove radioactive isotopes from the body after undergoing scans.
Radiation therapy involves using ionizing radiation to treat diseases, especially cancer. It works by damaging tumor cells' DNA and preventing their growth and spread. There are two main types: external beam radiation therapy which uses a machine to aim high-energy beams at the tumor, and brachytherapy which places radioactive material inside or near the tumor site. The goals of radiation therapy are to determine the optimal radiation dose to damage the tumor while minimizing harm to surrounding tissues, through careful patient examination, treatment planning and monitoring during and after treatment.
This seminar paper discusses radiation therapy and its use in cancer treatment. It defines radiation therapy and its goals, which include curing early-stage cancer, preventing metastasis, and treating symptoms from advanced cancer. The paper describes the mechanism of action of radiotherapy by explaining how it causes double-stranded DNA breaks in cells. It also outlines the different types of radiation therapy including photon and particle radiation. Additionally, it discusses the principles of radiation therapy such as precisely locating the tumor, immobilizing the patient, accurately aiming the radiation beams, shaping the beams, and delivering an optimal therapeutic dose.
Uveal melanoma commonly spreads to the liver. This document discusses uveal melanoma (MUM) that has metastasized to the liver. It provides background on MUM, noting that half of patients develop metastases, usually first appearing in the liver. It describes genetic risk factors for metastasis and different risk classifications. The document advocates for locoregional therapies for liver metastases since there are no effective systemic therapies. It presents evidence that liver-directed therapies may prolong survival more than systemic treatments or surveillance alone.
Lecture metastatic breast carcinoma to the spine (final version)Spiro Antoniades
This document discusses a case of metastatic breast cancer to the thoracic spine in a 74-year-old woman. She presented with mid-thoracic back pain and was later found to have a 5.5 cm breast mass, confirmed to be stage 4 breast cancer with metastases to the spine, ribs, and femur. The document provides historical background on cancer terminology and discusses treatment options and outcomes for spinal metastases, including surgery versus radiation. Prognostic scoring systems like Tokuhashi are mentioned. Overall, the summary discusses evaluation and management of a patient presenting with spinal metastases from breast cancer.
How might basic research on low dose ionizing radiation influence future radi...Leishman Associates
This document discusses how basic research on low dose ionizing radiation could influence future radiation protection programs. It outlines the speaker's research interests in understanding the biological effects of exposure to low doses of radiation and how to translate this data to radiation risk assessments. It notes that the current paradigm for radiation risk extrapolates from high dose exposures, but low dose exposures are typically chronic and low dose rate, calling this approach into question. Non-targeted effects like bystander effects and genomic instability are discussed as important considerations. The complexity of communicating radiation risk when the scientific understanding remains uncertain is also addressed.
Brief history and current status of sirt agentsmadhavmb
This document provides a history and overview of selective internal radiation therapy (SIRT) agents that have been developed over the last seven decades to treat cancers like hepatocellular carcinoma (HCC). It discusses early microsphere-based agents in the 1960s/1970s made of 90Y2O3 and 90Y that showed tumor responses but also caused myelosuppression. 90Y-glass microspheres were introduced in the 1980s that did not leach 90Y and thus did not cause myelosuppression. 90Y-resin microspheres and 166Ho-PLA microspheres were also discussed along with their clinical studies. It provides a comparison of the three main commercial SIRT agents -
Whole body screening using CT involves risks and benefits that are debated. While it may detect some cancers early, many abnormalities detected may not be life-threatening. Following up on these abnormalities could lead to patient anxiety, additional testing with radiation exposure or other risks, and overdiagnosis of inconsequential findings. Current policies support targeted CT screening for certain high-risk individuals but do not recommend whole body screening for healthy asymptomatic people due to a lack of evidence for clear benefits outweighing the risks.
Similar to Effectiveness of Empirical and Maximal Tolerated Activity in I-131 Therapy (20)
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
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Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Effectiveness of Empirical and Maximal Tolerated Activity in I-131 Therapy
1. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 1
Effectiveness of Empirical and Maximal
Tolerated Activity (MTA) in I-131 Therapy
Mark Tulchinsky, MD, FACNM, CCD
Professor of Radiology and Medicine
Division of Nuclear Medicine
Penn State University Hospital
Mark.Tulchinsky@gmail.com
Mark Tulchinsky, MD, FACNM, CCD
Professor of Radiology and Medicine
Division of Nuclear Medicine
Penn State University Hospital
Mark.Tulchinsky@gmail.com
No Conflict of Interests to Declare
The First 131I Administration
for Graves’ Disease:
Theronostics’ Birthplace
• Saul Hertz, M.D. (April
20, 1905 – July 28, 1950)
laid the foundation of
iodine physiology that
made radioactive iodine
therapy possible
• Dr. Hertz (at age 35)
performed the first 131I
treatment, administering
2.1 mCi to a patient with
Grave’s disease on
March 31st, 1941
• Saul Hertz, M.D. (April
20, 1905 – July 28, 1950)
laid the foundation of
iodine physiology that
made radioactive iodine
therapy possible
• Dr. Hertz (at age 35)
performed the first 131I
treatment, administering
2.1 mCi to a patient with
Grave’s disease on
March 31st, 1941
2. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 2
Samuel M. Seidlin, M.D.
The First I-131 Treatment
Montefiore Medical Center, Bronx, NY
The Most Important Nuclear
Medicine Paper Ever Written*
JAMA, Dec. 7, 1946
*according to
Marshall Brucer
3. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 3
Celebrated Patient BB
Siegel E. Cancer Biother Radiopharm 1999
Seidlin et al. JAMA 1946
1943
Prior to Radioiodine Tx
1949
After Radioiodine Tx
BB
“...a Brooklyn shoe salesman ... destined to become
one of the most famous patients in medical history
... is the first person known to be cured of
metastatic cancer… Metastatic cancer has always
been 100% fatal. But ... tumors were destroyed in a
simple, almost miraculous way: by the drinking of
four doses of radioactive iodine. …he appeared to
be suffering from an overactive thyroid gland … he
was weak and emaciated. … his thyroid gland …
had been removed by surgery. ...Radioiodine was
given on the theory that his thyroid tumors would
absorb the drug. ...If they did, they would be
destroyed. ...Three months after he drank his first
glass of tasteless, colorless liquid ... he started to
put on weight. …After three additional doses the
tumors ... eventually disappeared altogether.
“...a Brooklyn shoe salesman ... destined to become
one of the most famous patients in medical history
... is the first person known to be cured of
metastatic cancer… Metastatic cancer has always
been 100% fatal. But ... tumors were destroyed in a
simple, almost miraculous way: by the drinking of
four doses of radioactive iodine. …he appeared to
be suffering from an overactive thyroid gland … he
was weak and emaciated. … his thyroid gland …
had been removed by surgery. ...Radioiodine was
given on the theory that his thyroid tumors would
absorb the drug. ...If they did, they would be
destroyed. ...Three months after he drank his first
glass of tasteless, colorless liquid ... he started to
put on weight. …After three additional doses the
tumors ... eventually disappeared altogether.
Life Magazine 1949
4. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 4
Brucer’s Vignettes in Nuclear
Medicine
5. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 5
Brucer’s Vignettes in Nuclear
Medicine
Learning Objectives
• Treatment options terminology for Differentiated
Thyroid Cancer (DTC)
Based on target tissue definition
Based on activity selection approach
• The state of determining the best administered
activity (AA)
• Evidence
• Acceptable, logical practice today
• Treatment options terminology for Differentiated
Thyroid Cancer (DTC)
Based on target tissue definition
Based on activity selection approach
• The state of determining the best administered
activity (AA)
• Evidence
• Acceptable, logical practice today
6. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 6
Target-Based RAIT: ATA Terminology
Cooper, DS et al. 2009 ATA guidelines. Thyroid (DOI: 10.1089/thy.2009.0110)
Van Nostrand, D 2009 The benefits and risks … Thyroid (DOI: 10.1089/thy.2009.1611)
Haugen, BR et al. 2015 ATA guidelines. Thyroid (DOI: 10.1089/thy.2015.0020)
• Ablation or ablation therapy: Eradicating
remnant, benign thyroid tissue post-TT
• Adjuvant therapy: Eradicating suspected
microscopic metastases. Usually, first post-TT.
Also applies to later visits, e.g. –DxRAIS/+Tg
• RAI therapy of metastatic DTC: RAIT of
anatomically defined metastatic DTC
• Ablation or ablation therapy: Eradicating
remnant, benign thyroid tissue post-TT
• Adjuvant therapy: Eradicating suspected
microscopic metastases. Usually, first post-TT.
Also applies to later visits, e.g. –DxRAIS/+Tg
• RAI therapy of metastatic DTC: RAIT of
anatomically defined metastatic DTC
Abbreviations: –DxRAIS = negative radioactive iodine scan; +Tg = positive
thyroglobulin; ATA = American Thyroid Association; DTC = differentiated thyroid
cancer; RAIT = radioactive iodine treatment; TT = total thyroidectomy
Radioiodine Treatment Options
• Empiric Activities/”Standard” Activity
1. Give empirical activities, amounts scaled to the type of
thyroid cancer, metastatic spread and location1,2
2. Give a “standard” amount, 100 mCi, to all for as long as
post-treatment scan remains positive (Schlumberger et al.)
• Lesion-Based (“Lesional”) Dosimetry
Administering activity that delivers a lethal dose to the
lesion(s)3
• Maximum Tolerated Activity Therapy (MTAT), based on
Dosimetry
Determining the maximum activity the patient can
tolerate, sparing pts fatal radiation induced side effects4
• Empiric Activities/”Standard” Activity
1. Give empirical activities, amounts scaled to the type of
thyroid cancer, metastatic spread and location1,2
2. Give a “standard” amount, 100 mCi, to all for as long as
post-treatment scan remains positive (Schlumberger et al.)
• Lesion-Based (“Lesional”) Dosimetry
Administering activity that delivers a lethal dose to the
lesion(s)3
• Maximum Tolerated Activity Therapy (MTAT), based on
Dosimetry
Determining the maximum activity the patient can
tolerate, sparing pts fatal radiation induced side effects4
1. Deandreis D. et al. (2016). JNM. https://doi.org/10.2967/jnumed.116.179606
2. Lassmann M. et al. (2010). Endocrine-Related Cancer. https://doi.org/10.1677/ERC-10-0071
3. Maxon H.R. et al. (1983). The New England Journal of Medicine. https://doi.org/10.1056/NEJM198310203091601
4. Benua, R. S. et al. (1962). AJR, 82, 171–182.
7. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 7
56 year old woman
1.2 cm PTC, no extra thyroidal
extension
+0/3 central lymph nodes
Tg 5.6, Tg Ab 1, TSH 48.6
pT1b, N0, M0. AJCC Stage I
Diagnostic RAI Scan (DxRAIS)
1mCi of 131I, 24 hr. delay, Ant View
ATA 2015 – “low risk”
Case 1 Case Courtesy of Dr. Anca M. Avram
Restaging
T1b, N0, M1; Stage IV C
2015 ATA “High Risk”
SPECT/CT
Liver metastasis
Case 1 Case Courtesy of Dr. Anca M. Avram
Right thyroid remnant
8. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 8
Empirical I-131 Administered
Activities (AA)
• No metastatic disease
30 – 100 mCi for Ablation
• Regional lymph node (LN) metastases
100 – 150 mCi for Therapy
• Distant metastatic disease
200 – 250 mCi for Therapy
• Exclusions (move to dosimetry):
Renal insufficiency or failure
Age ≥ 70 y/o
? Pediatric patients
• No metastatic disease
30 – 100 mCi for Ablation
• Regional lymph node (LN) metastases
100 – 150 mCi for Therapy
• Distant metastatic disease
200 – 250 mCi for Therapy
• Exclusions (move to dosimetry):
Renal insufficiency or failure
Age ≥ 70 y/o
? Pediatric patients
“It ain't what you don't know that gets
you [or your patient] into trouble. It's
what you know for sure [about your
patient] that just ain't so.”
Mark Twain
9. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 9
Diagnostic (1 mCi) 131I scan at 6 mo.
after 200 mCi RAI Rx:
Interval resolution of liver metastasis
and of thyroid remnant tissue
Theranostics principle – risk
stratify based on surgical pathology,
withdrawal Tg + I-131 scan – treat
with commensurate I-131 activity
Case 1 Case Courtesy of Dr. Anca M. Avram
It’s not the size of the primary that defines DTC
aggressiveness (i.e. the “risk”), it’s the metastatic
aggressiveness in DTC!
DxRAIS is the most direct and specific way of
determining I-131 avidity and the
aggressiveness of IODINE-AVID DTC
“It's not the size of the dog in the fight,
it's the size of the fight in the dog.”
Mark Twain
10. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 10
Empiric Fixed‐Activities Method
• Beierwaltes WH. The treatment of thyroid
carcinoma with radioactive iodine. Semin Nucl
Med. 1978 Jan;8(1):79‐94.
• Cervical lymph nodes metastases: 150‐175
mCi
• Lung metastases: 175‐200 mCi
• Bone metastases: 200 mCi
• 2012 SNM Practice Guideline for Therapy of
Thyroid Disease with I‐131
• Postoperative ablation: 30‐100 mCi
• Cervical or mediastinal lymph node
metastases: 150‐200 mCi
• Distant metastases: 200 mCi or higher
cervical
node
mets
lung
mets
Slide courtesy of Jennifer Kwak, MD
Haugen BR, et al. 2015 American Thyroid Association Management Guidelines for
Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The
American Thyroid Association Guidelines Task Force on Thyroid Nodules and
Differentiated Thyroid Cancer. Thyroid 2016;26(1):1-133.
11. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 11
Administered Dose Thresholds At
≥80% CR
• Lymph node 85 1, 2
• Thyroid Remnant 300 1
• Bone 350-650 3
• Lymph node 85 1, 2
• Thyroid Remnant 300 1
• Bone 350-650 3
Metastatic Sites AD (Gy) Ref.#
1. Maxon HR, 3rd, et al. Radioiodine-131 therapy for well-differentiated thyroid
cancer--a quantitative radiation dosimetric approach: outcome and validation in
85 patients. J Nucl Med 1992;33(6):1132-6.
2. Jentzen W, et al. Assessment of lesion response in the initial radioiodine
treatment of differentiated thyroid cancer using 124I PET imaging. J Nucl Med
2014;55(11):1759-65.
3. Jentzen W, et al. 124I PET Assessment of Response of Bone Metastases to Initial
Radioiodine Treatment of Differentiated Thyroid Cancer. J Nucl Med
2016;57(10):1499-504.
Abbreviations: AD = Administered Activity
Treat with 150 mCi –
post treatment scan to
follow
DTC with Small Post-TT remnant or
Re-Evaluation
Risk Assessment
Known or Suspected Mets?
Risk & Distribution
Based Treatment
HighLow
ThyroglobulinDone,
F/U in
1 Year
Abnormal Uptake
HighLow
No Yes
I-131
1-5 mCi
Scan
No Abnormal Uptake
Dosimetry
PET, Tc-99m MIBI
or Tl-201
?
Authored by Mark Tulchinsky, MD, FACNM
12. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 12
The
Bad
“Magicbullet”
2015 ATA vs. Theranostics
• 2015 ATA Guidelines - the “Magic bullet”?
Risk stratification for RAI Rx selection is
based on surgical pathology + Tg, ignores
full body imaging => 60% ↓ in WBS/RAIT
131I Activity / DTC response, ignored
DxRAIS is discounted, RxRAIS substituted
This approach can
easily miss the target
This approach can
easily miss the target
2015 ATA vs. Theranostics
• Theranostics
Interrogate the target with a tracer
Determine adm. activity appropriate for the target
Deliver targeted radiation therapy to the lesion(s)
• Theranostics
Interrogate the target with a tracer
Determine adm. activity appropriate for the target
Deliver targeted radiation therapy to the lesion(s)
The Good
Theranosticsprinciple
13. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 13
Selecting Patients for MTAT
• Indications
Metastasis beyond regional LN known or
highly suspected
Regional lymph node involvement
Follicular CA or Tall Cell Variants
• Concerning variables
Tumor at the inked margins
Gross extrathyroidal invasion
PTC, size greater than 3.5 cm
≥70 y/o, renal dysfunction
• Indications
Metastasis beyond regional LN known or
highly suspected
Regional lymph node involvement
Follicular CA or Tall Cell Variants
• Concerning variables
Tumor at the inked margins
Gross extrathyroidal invasion
PTC, size greater than 3.5 cm
≥70 y/o, renal dysfunction
1. Macroscopic invasion into
perithyroidal soft tissues
(gross extrathyroidal
extension)
2. Incomplete tumor
resection
3. Distant metastases
4. Post-operative serum Tg
suggestive of distant
metastases
5. Pathologic N1 with any
metastatic lymph node > 3
cm in largest dimension
6. Follicular thyroid with
extensive vascular
invasion (>4 foci of
vascular invasion)
ATA 2015 Guidelines:
Risk Stratification – High Risk
MTAT Indicated
14. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 14
1. Microscopic invasion of
tumor into the perithyroidal
soft tissue
2. RAI avid metastatic foci in
neck on first post- tx whole
body scan
3. Aggressive histology
4. Papillary thyroid cancer
with vascular invasion
5. Clinical N1 or > 5
pathological N1 with all
lymph nodes < 3 cm in
largest dimension.
6. Multifocal papillary
microcarcinoma with
extrathyroidal extension
and BRAF V600E.
ATA 2015 Guidelines:
Risk Stratification – Intermediate
Risk
MTAT Should be Considered
1st Presentation
Post-TT
40.4% uptake
15. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 15
1st Presentation
Post-TT
Treated with a MTAT = 150 mCi dose.
TREATMENT #1
16. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 16
4.6%
uptake
2nd Presentation
1 year later
Treated with MTAT = 250 mCi dose.
TREATMENT #2
17. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 17
0.15%
uptake
3rd Presentation
2 year later
2.44%
Uptake
0.369 rads/mCi
Posterior ViewAnterior View
18. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 18
TREATMENT #3
Treated with MTAT = 503 mCi dose.
1 year after, only 2 nodes remained in the neck,
resected, remaining with stable low-abnormal Tg
for the past 6 years (9 years since first visit)
19. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 19
Critique
• Overall Survival was compared
French women happen to overall live longer
• “Dosimetry” group was older than “One-
size-fit-all” group
• “Dosimetry” was done in ALL pts with
rhTSH stimulation
>99% of Dosimetry is done with THW
• Etc. …
• Not a valid comparison study –
result are not valid
• Overall Survival was compared
French women happen to overall live longer
• “Dosimetry” group was older than “One-
size-fit-all” group
• “Dosimetry” was done in ALL pts with
rhTSH stimulation
>99% of Dosimetry is done with THW
• Etc. …
• Not a valid comparison study –
result are not valid
20. Effectiveness of Empirical and Maximal
Tolerated Activity in I-131 Therapy
Wednesday, June 14, 8:00AM–9:30AM
Mark Tulchinsky, MD, FACNM, CCD 20
Conclusions
• As of today, there is no evidence on which
therapeutic approach to follow
• The expertize in Nuclear Medicine and
observations by those experts
If you can resect isolated conspicuous
lesion(s) – do it
Before resecting – establish iodine avidity
If you cannot resect all tumor
Treat surprises with lesion-adjusted activity
Expected distant disease – MTAT
• As of today, there is no evidence on which
therapeutic approach to follow
• The expertize in Nuclear Medicine and
observations by those experts
If you can resect isolated conspicuous
lesion(s) – do it
Before resecting – establish iodine avidity
If you cannot resect all tumor
Treat surprises with lesion-adjusted activity
Expected distant disease – MTAT