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
Radioactivity is the spontaneous disintegration of unstable atomic nuclei. It was discovered in 1896 and results in the emission of radiation. The number of neutrons and protons in a nucleus determines its stability, with heavier elements above atomic number 82 generally being radioactive. Radioactive decay occurs through different types of emission and can be used for medical applications like radiation therapy or diagnostic imaging. Proper patient preparation and safety precautions are important when using radiopharmaceuticals like iodine-131 to optimize treatment and minimize radiation exposure.
Step-by-Step Stereotactic Radiotherapy Planning of Vestibular Schwannoma: A G...Kanhu Charan
This document provides a step-by-step guide to stereotactic radiotherapy planning for vestibular schwannoma. It describes the case of a 40-year-old male patient presenting with symptoms of tinnitus, dizziness, and facial twitching. Imaging including CT and MRI confirmed a right-sided vestibular schwannoma. The tumor was graded and treatment options were discussed. The patient was planned for fractionated stereotactic radiotherapy to a dose of 25Gy in 5 fractions based on guidelines. The planning process is then described in detail, including CT simulation, MRI protocol, contouring of targets and organs at risk, plan evaluation criteria, and subsequent treatment.
PET imaging is useful for cancer diagnosis and management. It provides functional information about glucose metabolism in tumors that can help establish prognosis, guide treatment decisions, and assess response. PET using 18F-FDG has high sensitivity and specificity for detecting cancer. It has applications in staging, restaging, and monitoring treatment response for many cancer types including lung cancer, lymphoma, and head and neck cancers. PET can identify tumor involvement that may be missed by anatomical imaging alone.
This document discusses radiopharmaceutical imaging of neuroendocrine tumors. It begins by defining neuroendocrine tumors and their most common sites of origin. It then discusses the radiopharmaceuticals used in imaging NETs, including somatostatin analogues that target somatostatin receptors, catecholamine analogues that target sympathetic nervous system tumors, and FDG that targets glucose metabolism. The document provides examples of different radiopharmaceutical scans and their findings in common NETs like carcinoid tumors, pheochromocytomas, and paragangliomas. It also discusses the added value of SPECT/CT in image interpretation.
Radioactivity is the spontaneous disintegration of unstable atomic nuclei. It was discovered in 1896 and results in the emission of radiation. The number of neutrons and protons in a nucleus determines its stability, with heavier elements above atomic number 82 generally being radioactive. Radioactive decay occurs through different types of emission and can be used for medical applications like radiation therapy or diagnostic imaging. Proper patient preparation and safety precautions are important when using radiopharmaceuticals like iodine-131 to optimize treatment and minimize radiation exposure.
Step-by-Step Stereotactic Radiotherapy Planning of Vestibular Schwannoma: A G...Kanhu Charan
This document provides a step-by-step guide to stereotactic radiotherapy planning for vestibular schwannoma. It describes the case of a 40-year-old male patient presenting with symptoms of tinnitus, dizziness, and facial twitching. Imaging including CT and MRI confirmed a right-sided vestibular schwannoma. The tumor was graded and treatment options were discussed. The patient was planned for fractionated stereotactic radiotherapy to a dose of 25Gy in 5 fractions based on guidelines. The planning process is then described in detail, including CT simulation, MRI protocol, contouring of targets and organs at risk, plan evaluation criteria, and subsequent treatment.
PET imaging is useful for cancer diagnosis and management. It provides functional information about glucose metabolism in tumors that can help establish prognosis, guide treatment decisions, and assess response. PET using 18F-FDG has high sensitivity and specificity for detecting cancer. It has applications in staging, restaging, and monitoring treatment response for many cancer types including lung cancer, lymphoma, and head and neck cancers. PET can identify tumor involvement that may be missed by anatomical imaging alone.
This document discusses radiopharmaceutical imaging of neuroendocrine tumors. It begins by defining neuroendocrine tumors and their most common sites of origin. It then discusses the radiopharmaceuticals used in imaging NETs, including somatostatin analogues that target somatostatin receptors, catecholamine analogues that target sympathetic nervous system tumors, and FDG that targets glucose metabolism. The document provides examples of different radiopharmaceutical scans and their findings in common NETs like carcinoid tumors, pheochromocytomas, and paragangliomas. It also discusses the added value of SPECT/CT in image interpretation.
This document discusses the radiobiological basis of fractionated radiation therapy. It covers the classic "4 R's" of radiobiology - repair, reassortment, repopulation and reoxygenation. Repair and reoxygenation make tumor cells more sensitive to radiation between fractions, while repopulation and reassortment make them more resistant. The document also proposes a "5th R" of radiossensitivity based on tissue maturity and metabolism. Finally, it briefly mentions the potential "6th R" of bystander effects and abscopal effects, where radiation triggers immune responses against distant tumor cells. Fractionation exploits repair in normal tissues while counteracting resistance mechanisms in tumors through its scheduling over multiple doses.
1. There are multiple methods for labeling red blood cells with Tc-99m, including in vivo, in vitro, and modified techniques.
2. GI bleeding studies are best done with Tc-99m RBCs prepared using the packed cell or UltraTag kit techniques to achieve high labeling efficiency.
3. White blood cells can be easily labeled with either Tc-99m or In-111 by isolating WBCs and incubating them with a lipophilic intermediate.
4. Red blood cell labeling with Cr-51 is very simple, not requiring isolation of RBCs, just incubation of blood with Cr-51.
This document discusses various aspects of fractionation in radiotherapy. It begins by describing early experiments by Regaud showing that fractionated doses achieved tumor sterilization without excessive skin damage, compared to single high doses. It then discusses the four R's of radiobiology - repair, repopulation, redistribution and reoxygenation - which form the basis for fractionated regimens. Various fractionation schedules are described, including conventional, hyperfractionation, accelerated fractionation and hypofractionation. The advantages and disadvantages of different approaches are summarized.
Introduction
Time dose & fractionation
Therapeutic index
Four R’s Of Radiobiology
Radiation response
Survival Curves Of Early & Late Responding Cells
Various fractionation schedules
Clinical trials of altered fractionation
Hemostatic radiotherapy uses single high doses or fractionated lower doses of external beam radiation to control tumor bleeding. Radiation works by shrinking the tumor and relaxing its aggressiveness, which stops bleeding in 80% of patients within 24-48 hours of treatment starting. Studies have found hemostatic radiotherapy effective at controlling hemorrhaging in 78-100% of advanced cancer patients, usually with doses of 4-10 Gy in a single fraction or 30 Gy over 10 fractions. While radiation achieves short-term hemostasis, most patients experience local recurrence or metastases within two years.
1) Radioiodine treatment (RAI) utilizes the ability of thyroid cancer cells to absorb iodine to effectively treat well-differentiated thyroid cancer. However, less differentiated cancers may not absorb iodine and become resistant to RAI treatment.
2) The document discusses the physics and physiology of radioactive iodine treatment, factors that influence treatment effectiveness like stunning, and guidelines around patient preparation and follow up including dosimetry approaches and activity levels for treatment.
3) Optimal RAI treatment requires differentiating cancer cells to absorb sufficient iodine doses without exceeding radiation safety limits, and the document discusses approaches and considerations for individualizing safe and effective treatment.
Radionuclides are unstable atoms that can emit radiation through alpha, beta, or gamma decay. Beta-emitting radionuclides like iodine-131 and strontium-89 are commonly used for radiation therapy. Iodine-131 is used to treat thyroid conditions like Graves' disease and thyroid cancer by inhibiting thyroid cell growth. Strontium-89 localizes to bone metastases and provides palliative pain relief through tumor cell destruction. Phosphorus-32 can be used to treat chronic myeloid leukemia or malignant effusions by accumulating in bone marrow, spleen, liver, or cavity surfaces. Proper patient preparation and dosing is needed to maximize treatment effect while minimizing side effects.
1) Radiotherapy plays an important role in managing carcinoma of the cervix by delivering high doses through a combination of external beam radiotherapy and brachytherapy.
2) The disease has central and peripheral components - the central component confined to the cervix is best treated with brachytherapy, while the peripheral component involving surrounding tissues is treated with both external beam radiotherapy and brachytherapy.
3) External beam radiotherapy techniques include 3D conformal radiotherapy and IMRT to improve dose distribution and spare surrounding organs-at-risk.
This document provides information about total body irradiation (TBI). It discusses that TBI uses megavoltage photon beams to destroy the recipient's bone marrow and tumor cells prior to bone marrow transplantation. It is used to treat various diseases like leukemia, lymphoma, and multiple myeloma. TBI can be delivered at high or low doses, to half the body, or total nodes. Techniques include parallel opposed beams from linear accelerators or cobalt-60 machines. Dosimetry and in vivo dosimetry are important due to the large fields and difficulty achieving uniform dose. Complications can include sterility, secondary cancers, and growth issues.
This document discusses the use of stereotactic body radiation therapy (SBRT) for liver tumors. It provides details on common liver tumors including hepatocellular carcinoma and metastases. It describes SBRT as a treatment option for inoperable early stage tumors, as a bridge to transplant, and for intermediate or locally advanced stages. Key factors for patient selection and treatment planning such as tumor size, number and location, as well as liver function are summarized. The document also briefly discusses proton beam therapy and current clinical trials investigating SBRT for liver cancer.
Radiotherapy in hepatocellular carcinomasPratap Tiwari
External Radiotherapy in hepatocellular carcinomas (HCC). A brief summary of the guidelines statements on radiotherapy role in hepatocellular carcinoma (hcc).
This document discusses normal tissue tolerance doses from radiation therapy. It describes the formation of a task force to establish tolerance protocols, with an emphasis on partial volume effects. The earliest publication of tolerance doses is cited from 1972. 28 critical organ sites were included and considered in terms of dose, time factors, and partial volumes irradiated. The significance of these parameters and a quantitative model for normal tissue complication probability are provided. Limitations of the available data and ongoing areas of research are also outlined.
The document discusses craniospinal irradiation (CSI), which delivers radiation to the entire cranial-spinal axis to treat intracranial tumors. It was pioneered in the 1950s and is commonly used to treat tumors that may spread through the cerebrospinal fluid such as medulloblastoma. The document outlines the techniques, challenges, indications, and evolving approaches for CSI such as reduced dose protocols and hyperfractionated regimens. It discusses topics like patient positioning, target volumes, critical structures, field arrangements, and the use of newer technologies like virtual simulation.
Radiotherapy plays an important role in the management of urinary bladder cancers. It can be used as part of bladder-preserving protocols for muscle-invasive bladder cancer or as palliative treatment in elderly patients. Combined modality treatment with transurethral resection and concurrent chemoradiotherapy provides 5-year overall survival of 50-65% and bladder preservation in 38-43% of patients. External beam radiotherapy is typically delivered with a 4-field box technique to the whole pelvis at 45-50 Gy followed by a bladder boost to 60-65 Gy.
The 5 R's of radiobiology are repair, reoxygenation, redistribution, repopulation, and radiosensitivity. They explain why radiotherapy is fractionated into multiple smaller doses. Repair allows cells to recover from sublethal damage between fractions. Repopulation and redistribution impact how radiation sensitivity changes over time. Reoxygenation improves oxygenation of hypoxic tumor cells between fractions. Together these concepts maximize cancer cell killing while minimizing damage to normal tissues.
PET - Production of [18F] PET tracers: Beyond [18F]FDG@Saudi_nmc
This document summarizes the production of [18F] PET tracers beyond [18F]FDG. It discusses the major positron emitting radionuclides used in PET imaging and why 18F is commonly used. The document then describes the automated synthesis of two specific 18F labeled tracers - [18F]fluorocholine and [18F]-L-DOPA. For [18F]fluorocholine, it outlines the multi-step synthesis and purification process. For [18F]-L-DOPA, it compares electrophilic and nucleophilic synthesis and details the automated nucleophilic synthesis approach. Finally, it discusses the clinical applications of these two 18F labeled tracers
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
* Case presentation: hyperosmolar hyperglycemic state (HHS)
Mortality attributed to hyperosmolar hyperglycemic state (HHS) is considerably higher than that attributed to DKA, with recent mortality rates of 5–20%.
* Agenda:
Historical perspectives and diagnosis.
Pathophysiology.
Treatment issues.
Rhabdomyolysis: an overlooked complication.
Final bottom line and take home message.
This document discusses the radiobiological basis of fractionated radiation therapy. It covers the classic "4 R's" of radiobiology - repair, reassortment, repopulation and reoxygenation. Repair and reoxygenation make tumor cells more sensitive to radiation between fractions, while repopulation and reassortment make them more resistant. The document also proposes a "5th R" of radiossensitivity based on tissue maturity and metabolism. Finally, it briefly mentions the potential "6th R" of bystander effects and abscopal effects, where radiation triggers immune responses against distant tumor cells. Fractionation exploits repair in normal tissues while counteracting resistance mechanisms in tumors through its scheduling over multiple doses.
1. There are multiple methods for labeling red blood cells with Tc-99m, including in vivo, in vitro, and modified techniques.
2. GI bleeding studies are best done with Tc-99m RBCs prepared using the packed cell or UltraTag kit techniques to achieve high labeling efficiency.
3. White blood cells can be easily labeled with either Tc-99m or In-111 by isolating WBCs and incubating them with a lipophilic intermediate.
4. Red blood cell labeling with Cr-51 is very simple, not requiring isolation of RBCs, just incubation of blood with Cr-51.
This document discusses various aspects of fractionation in radiotherapy. It begins by describing early experiments by Regaud showing that fractionated doses achieved tumor sterilization without excessive skin damage, compared to single high doses. It then discusses the four R's of radiobiology - repair, repopulation, redistribution and reoxygenation - which form the basis for fractionated regimens. Various fractionation schedules are described, including conventional, hyperfractionation, accelerated fractionation and hypofractionation. The advantages and disadvantages of different approaches are summarized.
Introduction
Time dose & fractionation
Therapeutic index
Four R’s Of Radiobiology
Radiation response
Survival Curves Of Early & Late Responding Cells
Various fractionation schedules
Clinical trials of altered fractionation
Hemostatic radiotherapy uses single high doses or fractionated lower doses of external beam radiation to control tumor bleeding. Radiation works by shrinking the tumor and relaxing its aggressiveness, which stops bleeding in 80% of patients within 24-48 hours of treatment starting. Studies have found hemostatic radiotherapy effective at controlling hemorrhaging in 78-100% of advanced cancer patients, usually with doses of 4-10 Gy in a single fraction or 30 Gy over 10 fractions. While radiation achieves short-term hemostasis, most patients experience local recurrence or metastases within two years.
1) Radioiodine treatment (RAI) utilizes the ability of thyroid cancer cells to absorb iodine to effectively treat well-differentiated thyroid cancer. However, less differentiated cancers may not absorb iodine and become resistant to RAI treatment.
2) The document discusses the physics and physiology of radioactive iodine treatment, factors that influence treatment effectiveness like stunning, and guidelines around patient preparation and follow up including dosimetry approaches and activity levels for treatment.
3) Optimal RAI treatment requires differentiating cancer cells to absorb sufficient iodine doses without exceeding radiation safety limits, and the document discusses approaches and considerations for individualizing safe and effective treatment.
Radionuclides are unstable atoms that can emit radiation through alpha, beta, or gamma decay. Beta-emitting radionuclides like iodine-131 and strontium-89 are commonly used for radiation therapy. Iodine-131 is used to treat thyroid conditions like Graves' disease and thyroid cancer by inhibiting thyroid cell growth. Strontium-89 localizes to bone metastases and provides palliative pain relief through tumor cell destruction. Phosphorus-32 can be used to treat chronic myeloid leukemia or malignant effusions by accumulating in bone marrow, spleen, liver, or cavity surfaces. Proper patient preparation and dosing is needed to maximize treatment effect while minimizing side effects.
1) Radiotherapy plays an important role in managing carcinoma of the cervix by delivering high doses through a combination of external beam radiotherapy and brachytherapy.
2) The disease has central and peripheral components - the central component confined to the cervix is best treated with brachytherapy, while the peripheral component involving surrounding tissues is treated with both external beam radiotherapy and brachytherapy.
3) External beam radiotherapy techniques include 3D conformal radiotherapy and IMRT to improve dose distribution and spare surrounding organs-at-risk.
This document provides information about total body irradiation (TBI). It discusses that TBI uses megavoltage photon beams to destroy the recipient's bone marrow and tumor cells prior to bone marrow transplantation. It is used to treat various diseases like leukemia, lymphoma, and multiple myeloma. TBI can be delivered at high or low doses, to half the body, or total nodes. Techniques include parallel opposed beams from linear accelerators or cobalt-60 machines. Dosimetry and in vivo dosimetry are important due to the large fields and difficulty achieving uniform dose. Complications can include sterility, secondary cancers, and growth issues.
This document discusses the use of stereotactic body radiation therapy (SBRT) for liver tumors. It provides details on common liver tumors including hepatocellular carcinoma and metastases. It describes SBRT as a treatment option for inoperable early stage tumors, as a bridge to transplant, and for intermediate or locally advanced stages. Key factors for patient selection and treatment planning such as tumor size, number and location, as well as liver function are summarized. The document also briefly discusses proton beam therapy and current clinical trials investigating SBRT for liver cancer.
Radiotherapy in hepatocellular carcinomasPratap Tiwari
External Radiotherapy in hepatocellular carcinomas (HCC). A brief summary of the guidelines statements on radiotherapy role in hepatocellular carcinoma (hcc).
This document discusses normal tissue tolerance doses from radiation therapy. It describes the formation of a task force to establish tolerance protocols, with an emphasis on partial volume effects. The earliest publication of tolerance doses is cited from 1972. 28 critical organ sites were included and considered in terms of dose, time factors, and partial volumes irradiated. The significance of these parameters and a quantitative model for normal tissue complication probability are provided. Limitations of the available data and ongoing areas of research are also outlined.
The document discusses craniospinal irradiation (CSI), which delivers radiation to the entire cranial-spinal axis to treat intracranial tumors. It was pioneered in the 1950s and is commonly used to treat tumors that may spread through the cerebrospinal fluid such as medulloblastoma. The document outlines the techniques, challenges, indications, and evolving approaches for CSI such as reduced dose protocols and hyperfractionated regimens. It discusses topics like patient positioning, target volumes, critical structures, field arrangements, and the use of newer technologies like virtual simulation.
Radiotherapy plays an important role in the management of urinary bladder cancers. It can be used as part of bladder-preserving protocols for muscle-invasive bladder cancer or as palliative treatment in elderly patients. Combined modality treatment with transurethral resection and concurrent chemoradiotherapy provides 5-year overall survival of 50-65% and bladder preservation in 38-43% of patients. External beam radiotherapy is typically delivered with a 4-field box technique to the whole pelvis at 45-50 Gy followed by a bladder boost to 60-65 Gy.
The 5 R's of radiobiology are repair, reoxygenation, redistribution, repopulation, and radiosensitivity. They explain why radiotherapy is fractionated into multiple smaller doses. Repair allows cells to recover from sublethal damage between fractions. Repopulation and redistribution impact how radiation sensitivity changes over time. Reoxygenation improves oxygenation of hypoxic tumor cells between fractions. Together these concepts maximize cancer cell killing while minimizing damage to normal tissues.
PET - Production of [18F] PET tracers: Beyond [18F]FDG@Saudi_nmc
This document summarizes the production of [18F] PET tracers beyond [18F]FDG. It discusses the major positron emitting radionuclides used in PET imaging and why 18F is commonly used. The document then describes the automated synthesis of two specific 18F labeled tracers - [18F]fluorocholine and [18F]-L-DOPA. For [18F]fluorocholine, it outlines the multi-step synthesis and purification process. For [18F]-L-DOPA, it compares electrophilic and nucleophilic synthesis and details the automated nucleophilic synthesis approach. Finally, it discusses the clinical applications of these two 18F labeled tracers
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
* Case presentation: hyperosmolar hyperglycemic state (HHS)
Mortality attributed to hyperosmolar hyperglycemic state (HHS) is considerably higher than that attributed to DKA, with recent mortality rates of 5–20%.
* Agenda:
Historical perspectives and diagnosis.
Pathophysiology.
Treatment issues.
Rhabdomyolysis: an overlooked complication.
Final bottom line and take home message.
This is a PDF of a presentation given to the Radiation Oncology department at the University of Minnesota in October 2015. This PDF focuses on evaluation, management, and state-of-the-art approach to gliomas from a medical neuro-oncology perspective.
Memorias Conferencia Científica Anual sobre Síndrome Metabólico 2017 - Programa Científico
Futuro en el tratamiento de la DM2
Dr. Guillermo E. Umpierrez
Professor of Medicine in the Division of Endocrinology at Emory University School of Medicine, Section Head, Diabetes and Endocrinology. USA. Editor en Jefe del BJM Open Diabetes Research and Care
Weight diabetes and metabolic problems in patients taking atypical antipsycho...Alex J Mitchell
Free slide show on weight gain, diabetes and metabolic problems in those taking atypical antipsychotic medication in schizophrenia, bipolar disorder and related conditions. Image credits retained by original authors. Please give correct acknolwedgements if you present any material from here.
This document summarizes lessons from studies on type 2 diabetes (DM2), including the UK Prospective Diabetes Study (UKPDS). The UKPDS found that intensive glucose control reduced long-term risk of microvascular complications and myocardial infarction compared to conventional treatment. These benefits persisted for over a decade after the trial. The study also found metformin treatment reduced cardiovascular events compared to sulfonylurea/insulin. Overall, the UKPDS provides evidence that earlier and tighter glucose control has long-term benefits in preventing diabetes complications.
1. Neuroendocrine tumors (NETs) are increasing in incidence and are often metastatic at diagnosis. They originate from neuroendocrine cells and secrete hormones.
2. Somatostatin analogues are first-line treatment for symptomatic control in NETs but resistance can develop. Chemotherapy has limited efficacy except in high-grade tumors.
3. Emerging biomarkers and molecular targeted therapies such as inhibitors of angiogenesis are improving outcomes beyond traditional approaches.
This document discusses drug risk assessment and pharmacoepidemiology. It notes that clinical trials prior to drug approval are limited in detecting uncommon or long-term side effects. Observational studies using large patient populations are needed to further evaluate drug safety issues and understand rare or long-term side effects. The document compares different pharmacoepidemiological study designs like cohort studies and case-control studies that can be used to investigate drug safety questions following a drug's approval and entry into widespread use.
Treating Cholesterol in Asian Patients: Balancing the Risk and Benefitsahvc0858
This document summarizes a presentation on treating cholesterol in Asians given by Dr. Jeremy Chow. It discusses the prevalence of hyperlipidemia in Singapore, challenges with statin usage in Asians including common myths, and new cholesterol targets for high-risk patients. It provides examples of managing different patient cases, including lifestyle modifications, medications such as statins and PCSK9 inhibitors, and balancing risks and benefits of treatment.
Ueda2015 diabetes control dr.lobna el-toonyueda2015
This document discusses diabetes control and treatment challenges. It summarizes:
1) Traditional oral antidiabetic medications can cause hypoglycemia, weight gain, beta-cell exhaustion, and uncertainties around cardiovascular safety which challenge achieving optimal diabetes control and treatment goals.
2) Clinical trials studying the effects of intensive glycemic control on cardiovascular outcomes have had mixed results, with some trials showing benefits and others showing potential harms, highlighting the need for safer antidiabetic therapies.
3) Newer antidiabetic drug classes like DPP-4 inhibitors have shown comparable or improved efficacy and safety profiles over traditional medications in clinical trials, though long-term outcomes data is still emerging.
Ueda2015 diabetes control dr.lobna el-toonyueda2015
This document discusses diabetes control and treatment challenges. It summarizes:
1) Traditional oral antidiabetic medications can cause hypoglycemia, weight gain, beta-cell exhaustion, and uncertainties around cardiovascular safety which challenge achieving optimal diabetes control and treatment goals.
2) Clinical trials studying the effects of intensive glycemic control on cardiovascular outcomes have had mixed results, with some trials showing benefits and others showing potential harms, highlighting the need for safer antidiabetic therapies.
3) Newer antidiabetic drug classes like DPP-4 inhibitors have shown comparable or improved efficacy and safety profiles over traditional medications in clinical trials, though long-term outcomes data is still emerging.
Ponencia presentada por la Dra. Lina Badimon Maestro en el directo online ‘Estudio ODYSSEY OUTCOMES: los expertos opinan’, realizado el 20 de noviembre de 2018 en la Casa del Corazón
1. Tuberculosis remains a major global health problem, with an estimated 2 billion people infected and 10 million new active cases each year resulting in 1.5 million deaths.
2. Standard short course DOTS therapy involves a combination of drugs administered over 6-9 months depending on the category of TB. Adverse effects of the main anti-TB drugs are discussed.
3. Multidrug resistant TB and extensively drug resistant TB present significant treatment challenges, requiring prolonged courses of second-line drugs and close monitoring given their increased toxicity. Preventing further emergence of drug resistance is critical.
1. The document discusses the management of tuberculosis, including the history, statistics, principles of treatment, protocols, side effects of drugs, and the Revised National Tuberculosis Control Programme in India.
2. It covers topics like tuberculosis and diabetes, tuberculosis and HIV co-infection, multi-drug resistant tuberculosis, and paradoxical reactions seen with antituberculosis treatment and antiretroviral therapy.
3. Guidelines are provided for treatment of different categories of tuberculosis patients, management of drug interactions and adverse effects, and regimens for multi-drug resistant cases.
This document discusses the importance of clinical trials for developing new medicines and treatments. It notes that clinical trials contribute to scientific advances in areas like cancer genomics and new drug technologies. However, clinical trial activity has been lower in Greece compared to similar EU countries due to inadequate regulatory and administrative support. The document advocates for partnerships between government and industry to improve the clinical trial environment and facilitate access to innovative medicines. It outlines Roche's investments in clinical trials and new cancer treatments in Greece.
The TENIS syndrome refers to patients with elevated thyroglobulin levels but negative iodine scans after treatment for thyroid cancer. This can occur for several reasons including loss of function of genes involved in iodine uptake and thyroglobulin production, false positive thyroglobulin assays, or metastatic cancer that is no longer able to concentrate iodine. When TENIS syndrome is present, further investigation is needed including ultrasound, PET/CT scans, and measurement of stimulated thyroglobulin levels to attempt to locate any metastatic thyroid tissue for possible surgical removal or treatment with high doses of radioactive iodine. Several targeted drugs and other treatments are also being investigated for their ability to restore iodine uptake in
The document discusses diabetes and glycemic control. It notes that 7 in 10 people with diabetes do not achieve desired treatment outcomes. By 2045, it is estimated that over 736 million people globally will have diabetes. Currently, over 425 million people have diabetes and about half of people with type 2 diabetes do not know they have it. Intensive treatment can help reduce complications, but tight control is difficult to achieve due to hypoglycemia risk, which poses a considerable burden. New basal insulins like degludec aim to provide improved glycemic control and lower hypoglycemia risk compared to older insulins like glargine.
1) Minimal change disease (MCD) is mediated by cytokines like IL-13 and local factors like ANGPTL4 that alter podocyte structure and function, leading to proteinuria.
2) Treatment with corticosteroids is usually effective for MCD, but evidence for second-line therapies is limited. Rituximab shows promise but requires approval through an individual funding request process.
3) While MCD commonly presents as nephrotic syndrome, it can also present as acute kidney injury (AKI) or overlap with other diseases like IgA nephropathy. Recovery is generally good even in complicated cases of MCD.
Thuốc điều trị tăng huyết áp trên bệnh thận đái tháo đường - BS Phạm Văn Bù...cacao83
This document discusses hypertension and its effects on the kidney. It provides an overview of key considerations in the pathophysiology of hypertension, including the roles of the renin-angiotensin-aldosterone system and other factors. Several studies are summarized that examine the use of diuretics and other antihypertensive drugs to control blood pressure and reduce proteinuria in patients with chronic kidney disease. Angiotensin receptor blockers are highlighted as effective treatments for slowing the progression of kidney disease through blood pressure control and additional renoprotective effects.
A 63-year-old man with a history of IHD, 1VD, HTN, hyperlipidemia, and an HbA1c of 8.2% is taking 26 units of insulin glargine daily. His LDL is 80 mg/dL and TG is 160 mg/dL. His BMI is 26. The document discusses treatment options with pioglitazone given his medical history and risk factors. Pioglitazone has been shown to improve insulin sensitivity and reduce cardiovascular events and microvascular complications in patients with type 2 diabetes when used as monotherapy or in combination with other antidiabetic agents. However, pioglitazone can cause side effects like edema,
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- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
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
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
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.
Cell Therapy Expansion and Challenges in Autoimmune Disease
I-131 Therapy: Current Practice and Updates
1. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 1
I-131 Therapy:
Current Practice and Updates
Mark Tulchinsky, MD, FACNM, CCD
Professor of Radiology and Medicine
Division of Nuclear Medicine
Penn State University Hospital
Mark Tulchinsky, MD, FACNM, CCD
Professor of Radiology and Medicine
Division of Nuclear Medicine
Penn State University Hospital
No Conflict of Interests to Declare
Disclosure:
I will use
characters
from my
favorite
movie to
highlight
salient points
Blondie TucoAngelEyes
2. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 2
Learning Objectives
• Historical background of I-131 therapy
• Benign Conditions Amenable to Radioactive Iodine
Therapy (RAIT)
• Thyroid Cancer, 2015 ATA Guidelines – “The Good,
The Bad and The Ugly”
Risk-based approach to RAI treatment
Preparation for RAI – Low Iodine Diet, Withdrawal
vs. Thyrogen®
RAI treatment – the ATA “Cookbook”
• Impact of imaging with SPECT-CT on staging
• Effect of ATA Guidelines on practice and patients
• Historical background of I-131 therapy
• Benign Conditions Amenable to Radioactive Iodine
Therapy (RAIT)
• Thyroid Cancer, 2015 ATA Guidelines – “The Good,
The Bad and The Ugly”
Risk-based approach to RAI treatment
Preparation for RAI – Low Iodine Diet, Withdrawal
vs. Thyrogen®
RAI treatment – the ATA “Cookbook”
• Impact of imaging with SPECT-CT on staging
• Effect of ATA Guidelines on practice and patients
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
3. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 3
Benign Conditions Amenable to RAIT
Condition Etiology
Graves’ disease (GD) (~80%) TSH-R-Ab stimulation of thyrocyte
Toxic Multinodular Goiter (NMNG)
Toxic Adenoma (TA)
mutation → TSH-R-Ab activation →
autonomous function
Hashimoto’s Thyroiditis (HT) in
productive phase (“Hashi-
toxicosis”, overlaps Graves’)
autoimmune disease - a variety of
cell- and antibody-mediated
immune processes
Intermittent/recurrent Thyroiditis* Unknown
Amiodarone thyroiditis Multifactorial
Abbreviations: TSH-R-Ab = thyroid stimulating hormone
receptor autoantibobdy, RAIT = RAI treatment
*RAIT in recovery phase, prevents recurrences
Typical Approach to GD in the USA:
First Decade of 21st Century
• Anti-thyroid Drugs ± beta blocker for 1-2 years
• Stop ATD therapy to check for remission
• If no remission or patient recurs after short
remission → RAIT or Surgery
• Euthyroid RAIT used in early days, hypothyroid
RAIT (ablation) becoming dominant after 2005
study that showed its mortality advantage*
• No standardization of hypo-RAIT technique,
approaches vary widely
• Anti-thyroid Drugs ± beta blocker for 1-2 years
• Stop ATD therapy to check for remission
• If no remission or patient recurs after short
remission → RAIT or Surgery
• Euthyroid RAIT used in early days, hypothyroid
RAIT (ablation) becoming dominant after 2005
study that showed its mortality advantage*
• No standardization of hypo-RAIT technique,
approaches vary widely
* Franklyn JA, Sheppard MC, Maisonneuve P. Thyroid function and mortality in
patients treated for hyperthyroidism. JAMA. 2005;294:71-80.
4. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 4
Disadvantages of RAIT When
Compared to Long-term ATDT:
Realizations of 1990’s and 2000’s
• RAI may induce or worsen Graves’
Orbitopathy (GO) in 15-33%
• RAIT practice not standardized with erratic
clinical & biochemical outcomes
Euthyroid (Eu) goal
multiple, fixed, activities
Multiple, mCi/g thyroid calculated activity
Hypothyroid (hypo) goal (aka Ablation)
single fixed activity (15 mCi)
Radiation dose to thyroid, single administration
Activity per g of thyroid, single administration
• RAI may induce or worsen Graves’
Orbitopathy (GO) in 15-33%
• RAIT practice not standardized with erratic
clinical & biochemical outcomes
Euthyroid (Eu) goal
multiple, fixed, activities
Multiple, mCi/g thyroid calculated activity
Hypothyroid (hypo) goal (aka Ablation)
single fixed activity (15 mCi)
Radiation dose to thyroid, single administration
Activity per g of thyroid, single administration
Graves’ Orbitopathy (GO), aka
Graves Ophthalmopathy, Thyroid-Associated Orbitopathy
(TAO), Thyroid Eye Disease (TED)
Progression is the
natural course of GO
Clinical Incidence: ~ 20% of GD
Imaging Reveals: > 60% of GD
Severe in ≤ 5%
Predisposing factors:
Smoking
Older age
Male sex
Diabetes
Hypothyroidism after RAIT
1 year
5. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 5
What Do We Know About Risk of GO
as Relevant to Therapy of GD?
• Known risk factors = remove whichever
possible, i.e. smoking, post RAIT TSH
elevation/hypo (replace early)
• Higher the T3, the greater GO occurrence-
progression probability for all treatments
(especially for RAIT) = pretreat with ATD’s
• Higher the TSH-R-Ab & inflammation in
thyroid, the greater GO risk => suppress
autoimmune response with steroids
• GO progression after RAIT starts early =>
preventive measures must start early
• Known risk factors = remove whichever
possible, i.e. smoking, post RAIT TSH
elevation/hypo (replace early)
• Higher the T3, the greater GO occurrence-
progression probability for all treatments
(especially for RAIT) = pretreat with ATD’s
• Higher the TSH-R-Ab & inflammation in
thyroid, the greater GO risk => suppress
autoimmune response with steroids
• GO progression after RAIT starts early =>
preventive measures must start early
Initial Experience: Basics
Tallstedt L, et al. Occurrence of ophthalmopathy after treatment for Graves'
hyperthyroidism. The Thyroid Study Group. N Engl J Med. 1992;326:1733-1738.
Iodine Group – 39 pts, initial dose
120 Gy → 13/39 worsening / de
novo GO, 18/39 were given more
than 1 dose, 12/18 developed
worsening or de novo GO (in 2)
Lesson 1: “Gentle” RAIT is
rough on the eye! Ablate
with single administration!
>1RAIT, 67% → ↑GO
1 RAIT, 5% → ↑GO
6. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 6
Prevention of Post-RAIT GO:
Three-tier, Risk-adjusted Approach
• No GO findings, no risk factors → no
prophylaxis
• No GO findings or Mild GO, + risk factor(s)
Prednisone 0.2 mg/kg/d, tapered over the 4-5
weeks, starting on the day of RAIT
• Mild to Moderate GO, + risk factor(s)
Prednisone 0.4-0.5 mg/kg/d, tapered over 3
months, starting on the day of RAIT
• Moderate to Severe GO → no RAIT
• No GO findings, no risk factors → no
prophylaxis
• No GO findings or Mild GO, + risk factor(s)
Prednisone 0.2 mg/kg/d, tapered over the 4-5
weeks, starting on the day of RAIT
• Mild to Moderate GO, + risk factor(s)
Prednisone 0.4-0.5 mg/kg/d, tapered over 3
months, starting on the day of RAIT
• Moderate to Severe GO → no RAIT
Shiber S, et al. Glucocorticoid regimens for prevention of Graves' ophthalmopathy
progression following radioiodine treatment: systematic review and meta-analysis.
Thyroid. 2014;24:1515-1523. DOI: 10.1089/thy.2014.0218
2011 Survey of Clinical Practice Patterns in the Management of Graves' Disease
J Clin Endocrinol Metab. 2012;97(12):4549-4558. doi:10.1210/jc.2012-2802
Differences in the selection of primary treatment modality for the index case of
uncomplicated GD
RAIT as the primary
treatment choice:
Changes between
7. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 7
2011 Survey of Clinical Practice Patterns in the Management of Graves' Disease
J Clin Endocrinol Metab. 2012;97(12):4549-4558. doi:10.1210/jc.2012-2802
Case Presentation
without GO
Case Presentation
with mild GO
Choice of Primary Treatment in GD
Abbreviations: GD = Graves’ disease; CS = corticosteroids
Abbreviation: MMI = Methimazole
RAIT n=102 pts MMI n=114 pts
8. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 8
Expectations
• The RAIT of benign conditions has
definitely declined for reasons that are not
favorable for patients
Endocrinologists – biased in favor of ATDT
Public – radiation phobia has increased
• The volumes of studies and therapy will
decline, unless we – Nuclear Medicine
community of professionals and relevant
patient groups – dedicate greater efforts to
change negative perceptions
• The RAIT of benign conditions has
definitely declined for reasons that are not
favorable for patients
Endocrinologists – biased in favor of ATDT
Public – radiation phobia has increased
• The volumes of studies and therapy will
decline, unless we – Nuclear Medicine
community of professionals and relevant
patient groups – dedicate greater efforts to
change negative perceptions
9. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 9
The data now indicates that rising PTC incidence is
not just due to better detection of microscopic disease
Differentiated Thyroid Cancer
Case 1
88.0%
90.0%
92.0%
94.0%
96.0%
98.0%
100.0%
5-Year Relative Survival
Haymart MR, et al. JAMA. 2011; 306(7): 721–728.
TheGoodIf it ain't broke, don't fix it
10. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 10
We Now Rarely See
Advanced (The Bad)
Disease … Case 1
or Severe (The Ugly)
Complications
Endocrinology Surgery, Endo Pathology 19 Oncology 14 Nuclear Med (Fr)1
• 133 pages document, 1078 references, graded
qualitatively for evidence strength
good, moderate, weak
• Made 101 recommendations (strong, weak, none)
21 were diametrically changed from 2009
11. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 11
7 have no COI, 9 (>50%) with COI
Chair
12. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 12
2015 ATA Guidelines
• 133 pages document
• Reviewed 1078 references, grading of the
evidence qualitatively
good, moderate, weak
• Made 101 recommendations, using
modified ACP system
strong, weak, no recommendation
• There is a broad range of new or modified
recommendations
21 were diametrically changed from 2009
• 133 pages document
• Reviewed 1078 references, grading of the
evidence qualitatively
good, moderate, weak
• Made 101 recommendations, using
modified ACP system
strong, weak, no recommendation
• There is a broad range of new or modified
recommendations
21 were diametrically changed from 2009
Abbreviations: ACP = American College of Physicians
Stated Aim versus Recommendation
Haugen BR et al. 2015 ATA guidelines. Thyroid
DOI: 10.1089/thy.2015.0020
• AIM: “A major goal of these guidelines is to
minimize potential harm from overtreatment in
a majority of patients at low risk for disease-
specific mortality and morbidity, while
appropriately treating and monitoring those
patients at higher risk.” [AJCC/UICC staging?]
• RECOMMENDATION 48: “The 2009 ATA Initial
Risk Stratification System is recommended for
DTC patients treated with thyroidectomy, based
on its utility in predicting risk of disease
recurrence and/or persistence.”
• AIM: “A major goal of these guidelines is to
minimize potential harm from overtreatment in
a majority of patients at low risk for disease-
specific mortality and morbidity, while
appropriately treating and monitoring those
patients at higher risk.” [AJCC/UICC staging?]
• RECOMMENDATION 48: “The 2009 ATA Initial
Risk Stratification System is recommended for
DTC patients treated with thyroidectomy, based
on its utility in predicting risk of disease
recurrence and/or persistence.”
13. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 13
Sizing up Patients’ Risk for Bad
Outcomes and RAIT Needs
• The tumor size is at the hart of risk
assessment, referral to RAI imaging, etc.
• Regional metastasis – important but not
critical in risk assessment
• Distant metastasis are very important in risk
assessment
One has to look for them to know whether or
not they exist
Based on pathology a lot of patients never
will get imaged with RAI
• The tumor size is at the hart of risk
assessment, referral to RAI imaging, etc.
• Regional metastasis – important but not
critical in risk assessment
• Distant metastasis are very important in risk
assessment
One has to look for them to know whether or
not they exist
Based on pathology a lot of patients never
will get imaged with RAI
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 Whole Body Scan (DxWBS)
After 1mCi of 131I, 24 hr. delay, Ant View
ATA 2015 – “low risk”
Case 2 Slide Courtesy of Dr. Anca M. Avram
14. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 14
Restaging
T1b, N0, M1; Stage IV C
2015 ATA “High Risk”
SPECT/CT
Liver metastasis
Case 2 Slide Courtesy of Dr. Anca M. Avram
Right thyroid remnant
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 2 Slide Courtesy of Dr. Anca M. Avram
15. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 15
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
16. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 16
Target-Based RAIT Terms
Cooper DS et al. 2009 ATA guidelines. Thyroid
DOI: 10.1089/thy.2009.0110
Haugen BR et al. 2015 ATA guidelines. Thyroid
DOI: 10.1089/thy.2015.0020
• Ablation or ablation therapy: Eradicating
remnant post-op benign thyroid tissue
• Adjuvant therapy: Eradicating suspected
microscopic metastases
• RAI therapy: Eradicating anatomically
defined (imaged) persistent/recurrent disease
o We should commit to one of the specific terms
above in our reports – avoid using general
terms like “radioactive iodine treatment”, etc.
• Ablation or ablation therapy: Eradicating
remnant post-op benign thyroid tissue
• Adjuvant therapy: Eradicating suspected
microscopic metastases
• RAI therapy: Eradicating anatomically
defined (imaged) persistent/recurrent disease
o We should commit to one of the specific terms
above in our reports – avoid using general
terms like “radioactive iodine treatment”, etc.
TheGood
Abbreviations: RAIT = radioactive iodine treatment
2015 ATA Guidelines:
Major Changes
• “2015 ATA Risk” stratification is based on
“Recurrence Risk” (NOT mortality risk)
New approach, no direct data support
Extrapolated from studies where patients had
been treated with RAI
Observation of good outcome led to
classification of “low risk”; hence, those
were assumed would do well without RAI
The problem with this assumption is just
exactly that … it’s an assumption that
patients would do just as well without RAI
• “2015 ATA Risk” stratification is based on
“Recurrence Risk” (NOT mortality risk)
New approach, no direct data support
Extrapolated from studies where patients had
been treated with RAI
Observation of good outcome led to
classification of “low risk”; hence, those
were assumed would do well without RAI
The problem with this assumption is just
exactly that … it’s an assumption that
patients would do just as well without RAI
17. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 17
Thyrogen®
Case 3
Thyroid Hormone
Withdrawal (THW)≠
Freudenberg LS et al. Lesion dose in differentiated thyroid
carcinoma metastases after rhTSH or thyroid hormone
withdrawal: 124I PET/CT dosimetric comparisons.
Eur J Nucl Med Mol Imaging (2010) 37:2267–2276
Case 4
≠
Thyrogen®
Thyroid Hormone
Withdrawal (THW)
18. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 18
rhTSH versus THW
• The I-131 uptake is equal in remnant
normal tissue with rhTSH versus THW
stimulation1
• The I-131 uptake and dose to metastatic
tissue is GREATER with THW versus
rhTSH stimulation. Uptake of I-131 was on
average almost twice as high under THW
as compared to rhTSH.2
• The I-131 uptake is equal in remnant
normal tissue with rhTSH versus THW
stimulation1
• The I-131 uptake and dose to metastatic
tissue is GREATER with THW versus
rhTSH stimulation. Uptake of I-131 was on
average almost twice as high under THW
as compared to rhTSH.2
1. Zanotti-Fregonara P et al. On the effectiveness of recombinant human TSH
as a stimulating agent for 131-I … Eur J Nucl Med Mol Imaging (2010)
DOI: 10.1007/s00259-010-1608-9
2. Freudenberg LS et al. …Dosimetric Comparison of rhTSH versus Thyroid
Hormone Withholding… Exp Clin Endocrinol Diabetes 2010
DOI: 10.1055/s-0029-1225350
2015 ATA Guidelines:
Recommendation 54
• rhTSH (Thyrogen®) preparation can be
used as an alternative to thyroxine
withdrawal (THW) for remnant ablation or
adjuvant therapy
• The only category where THW gets some
preference is metastatic disease
• Benefits of rhTSH emphasized, but issues
(poor DxWBS sensitivity for mets and poor
uptake in mets) are de-emphasized
• rhTSH (Thyrogen®) preparation can be
used as an alternative to thyroxine
withdrawal (THW) for remnant ablation or
adjuvant therapy
• The only category where THW gets some
preference is metastatic disease
• Benefits of rhTSH emphasized, but issues
(poor DxWBS sensitivity for mets and poor
uptake in mets) are de-emphasized
Abbreviations: rhTSH = recombinant human Thyroid Stimulating Hormone
19. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 19
Preparing Patients for RAIT
RECOMMENDATION 57
• A low iodine diet (LID) for approximately 1–2
weeks should be considered for patients
undergoing RAI remnant ablation or treatment.
(Weak recommendation, Low-quality evidence)
• “There are no studies examining whether the
use of a LID in preparation for RAI remnant
ablation or treatment impacts long-term
disease related recurrence or mortality rates.”
• Should we also do studies examining whether
the use of a parachute impacts on mortality of
paratroopers … drop a few “control subjects”?!
• A low iodine diet (LID) for approximately 1–2
weeks should be considered for patients
undergoing RAI remnant ablation or treatment.
(Weak recommendation, Low-quality evidence)
• “There are no studies examining whether the
use of a LID in preparation for RAI remnant
ablation or treatment impacts long-term
disease related recurrence or mortality rates.”
• Should we also do studies examining whether
the use of a parachute impacts on mortality of
paratroopers … drop a few “control subjects”?!
Preparing Patients for RAIT
RECOMMENDATION 57
• A low iodine diet (LID) for approximately 1–2
weeks should be considered for patients
undergoing RAI remnant ablation or treatment.
(Weak recommendation, Low-quality evidence)
• “There are no studies examining whether the
use of a LID in preparation for RAI remnant
ablation or treatment impacts long-term
disease related recurrence or mortality rates.”
• Should we also do studies examining whether
the use of a parachute impacts on mortality of
paratroopers … drop a few “control subjects”?!
• A low iodine diet (LID) for approximately 1–2
weeks should be considered for patients
undergoing RAI remnant ablation or treatment.
(Weak recommendation, Low-quality evidence)
• “There are no studies examining whether the
use of a LID in preparation for RAI remnant
ablation or treatment impacts long-term
disease related recurrence or mortality rates.”
• Should we also do studies examining whether
the use of a parachute impacts on mortality of
paratroopers … drop a few “control subjects”?!
placebo
Application of the logic used in this recommendation to
examining need for parachutes.
20. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 20
Ultrasound (US) is Promoted:
RECOMMENDATION 65
• (A) Following surgery, cervical US to evaluate the
thyroid bed and central and lateral cervical nodal
compartments should be performed at 6–12
months and then periodically, depending on the
patient’s risk for recurrent disease and Tg status.
Strong recommendation, Moderate-quality evidence
• (C) Suspicious lymph nodes less than 8–10mm in
smallest diameter may be followed without biopsy
with consideration for FNA or intervention if there is
growth or if the node threatens vital structures.
Weak recommendation, Low-quality evidence
• (A) Following surgery, cervical US to evaluate the
thyroid bed and central and lateral cervical nodal
compartments should be performed at 6–12
months and then periodically, depending on the
patient’s risk for recurrent disease and Tg status.
Strong recommendation, Moderate-quality evidence
• (C) Suspicious lymph nodes less than 8–10mm in
smallest diameter may be followed without biopsy
with consideration for FNA or intervention if there is
growth or if the node threatens vital structures.
Weak recommendation, Low-quality evidence
21. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 21
http://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=115450
22. Dr. Mark Tulchinsky (2017 SNMMI
Annual meeting)
6/13/2017
CE88: Radioiodine Therapy for
Hyperthyroidism: The State of the Art 22
• Drastic reductions in RAI pre-Rx scans & Rx
• Poor prep (rhTSH for stimulation, ±LID) =
poor scan (if done) = poor RAI Rx
• Authorized users responsible mostly for
dispensing RAI, if and when it’s ordered
• It may save $ for 3rd party payers … but at
what (or whose)?
• Drastic reductions in RAI pre-Rx scans & Rx
• Poor prep (rhTSH for stimulation, ±LID) =
poor scan (if done) = poor RAI Rx
• Authorized users responsible mostly for
dispensing RAI, if and when it’s ordered
• It may save $ for 3rd party payers … but at
what (or whose)?
The Good
“You can always count on Americans [American
Thyroid Association] to do the right thing - after
they've tried everything else.” Winston Churchill
The End?
131I