Skip to main content
SpringerLink
Log in

Radioiodine Therapy for Benign Thyroid Disease

  • Chapter
  • First Online:
Clinical Nuclear Medicine

Abstract

The success rate of radioiodine (I-131) therapy for toxic goiter and solitary hyperfunctioning nodules depends on thyroid volume, compensation of hyperthyroidism, timing of the withdrawal of antithyroid drugs, alimentary iodine intake, and the dose concepts in the different thyroid diseases. The aim of treatment with I-131 is to achieve a non-hyperthyroid status, which can be euthyroid or hypothyroid, recompensated by levothyroxine medication. Studies with an intended dose of about 120 Gy to the toxic multinodular goiter reported a success rate of more than 90%. The successful elimination of hyperfunctioning nodules occurred in 90% of patients receiving 300 Gy to the nodule volume and in 94% of patients receiving 400 Gy to the nodule volume. There is an emerging role for I-131 in the treatment for so-called subclinical hyperthyroidism.

The success of I-131 treatment in reducing the size of nontoxic goiters depends on the applied I-131 activities per gram thyroid tissue and the distribution of I-131 within the goiter. Disadvantageous are large cystic and fibrotic areas. Most of the shrinkage occurs within the first year, and goiter volumes are decreasing continuously for several years to about 30% of the initial size. With more effective strategies for goiter shrinkage—including the additive use of modified recombinant human thyrotropin in clinical trials—more patients will require levothyroxine medication. Radioiodine therapy for reducing the goiter size can be recommended especially for elderly people, for those with comorbidity and for patients who want to avoid surgery.

Radioiodine therapy due to Graves’ disease is recommended for patients with persistence of Graves’ thyrotoxicosis after 12–24 months of antithyroid drugs or relapse of thyrotoxicosis. In a subgroup of patients with an initially high risk of recurrent thyrotoxicosis (young patients, thyroid volume of >40 mL, TSH-receptor antibodies >10 IU/L after 6 months of antithyroid drugs), radioiodine therapy should be discussed as first-line treatment. For the elimination of Graves’ thyrotoxicosis, an ablative concept is preferred (intended dose of 300 Gy) with the aim of replacing thyroid hormone by levothyroxine medication.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 149.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Abbreviations

Ab:

Antibody

ATD:

Antithyroid drug

FNAB:

Fine needle aspiration biopsy

fT4:

Free levothyroxine in serum

fT3:

Free triiodothyronine in serum

I-131:

Iodine-131 (radioiodine)

LT4:

Levothyroxine medication

mrhTSH:

Modified recombinant human TSH

PTU:

Propylthiouracil

rhTSH:

Recombinant human TSH

SD:

Standard deviation

Tg:

Thyroglobulin

TPO:

Thyroidal peroxidase

Xe-131:

Xenon-131

References

  1. Stokkel M, Handkiewicz J, Lassmann M, Dietlein M, Luster M. EANM procedure guidelines for therapy of benign thyroid disease. Eur J Nucl Med Mol Imaging. 2010;37:2218.

    Article  PubMed  Google Scholar 

  2. Col NF, Surks MI, Daniels GH. Subclinical thyroid disease. Clinical applications. JAMA. 2004;291:239–43.

    Article  CAS  PubMed  Google Scholar 

  3. McDermott MT, Woodmansee WW, Haugen BR, Smart A, Ridgway EC. The management of subclinical hyperthyroidism by thyroid specialists. Thyroid. 2003;13:1133–9.

    Article  PubMed  Google Scholar 

  4. Surks MI, Ortiz E, Daniels GH, et al. Subclinical thyroid disease. Scientific review and guidelines for diagnosis and management. JAMA. 2004;291:229–38.

    Article  Google Scholar 

  5. Gammage MD, Parle JV, Holder RL, Roberts LM, Hobbs FDR, Wilson S, Sheppard MC, Franklyn JA. Association between serum free thyroxine concentration and atrial fibrillation. Arch Intern Med. 2007;167:928–34.

    Article  CAS  PubMed  Google Scholar 

  6. Heeringa J, Hoogendoorn EH, van der Deure WM, Hofman A, Peeters RP, Hop CJ, den Heijer M, Visser TJ, Witteman JCM. High-normal thyroid function and risk of atrial fibrillation - The Rotterdam Study. Arch Intern Med. 2008;168:2219–24.

    Article  PubMed  Google Scholar 

  7. Weetman AP. Radioiodine treatment for benign thyroid diseases. Clin Endocrinol (Oxf). 2007;66:757–64.

    Article  CAS  Google Scholar 

  8. Freitas JE. Therapeutic options in the management of toxic and nontoxic nodular goiter. Semin Nucl Med. 2000;30:88–97.

    Article  CAS  PubMed  Google Scholar 

  9. Fast S, Nielsen V, Bonnema S, Hegedus L. Time to reconsider nonsurgical therapy of benign nontoxic multinodular goiter. Focus on recombinant human TSH (rhTSH) augmented radioiodine therapy. Eur J Endocrinol. 2008;160:517–28.

    Article  PubMed  CAS  Google Scholar 

  10. Papini E, Petrucci L, Guglielmi R, Panunzi C, Rinaldi R, Bacci V, Crescenzi A, Nardi F, Fabbrini R, Pacella CM. Long-term changes in nodular goiter: a 5-year prospective randomized trial of levothyroxine suppressive therapy for benign cold thyroid nodules. J Clin Endocrinol Metab. 1998;83:780–3.

    Article  CAS  PubMed  Google Scholar 

  11. Wesche MF, Tiel-V Buul MM, Lips P, Smits NJ, Wiersinga WM. A randomized trial comparing levothyroxine with radioactive iodine in the treatment of sporadic nontoxic goiter. J Clin Endocrinol Metab. 2001;86:998–1005.

    Article  CAS  PubMed  Google Scholar 

  12. Dietlein M, Grünwald F, Schmidt M, Schneider P, Verburg FA, Luster M. Guideline for radioiodine therapy for benign thyroid diseases (version 5). [German]. Nuklearmedizin. 2016;55:213–20.

    Article  PubMed  Google Scholar 

  13. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward DL, Tuttle RM, Wartowsky L. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26:1–133.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maria AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Malter MA. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2015;26:1343–421.

    Article  PubMed  Google Scholar 

  15. Cappelen T, Unhjem JF, Amundsen AL, Kravdal G, Følling I. Radiation exposure to family members of patients with thyrotoxicosis treated with iodine-131. Eur J Nucl Med Mol Imaging. 2006;33:81–6.

    Article  CAS  PubMed  Google Scholar 

  16. Dillehay GL, Ellerbroek NA, Balon H, Brill DR, Grigsby PW, Macklis RM, Mauch PM, Mian TA, Potters L, Silberstein EB, Williams TR, Wong JC, Gaspar LE. American Society for Therapeutic Radiology and Oncology. Practice guideline for the performance of therapy with unsealed radiopharmaceutical sources. Int J Radiat Oncol Biol Phys. 2006;64:1299–307.

    Article  PubMed  Google Scholar 

  17. International Commission on Radiological Protection. Release of patients after therapy with unsealed radionuclides. Ann ICRP. 2004;34:1–79. Erratum in: Ann ICRP 34(3–4): 281.

    Google Scholar 

  18. Koch W, Rosa F, Knesewitsch P, Hahn K. Guideline on radiation protection in medicine requires documentation of radioiodine therapy and follow-up: what are the benefits of an electronic database? Nuklearmedizin. 2005;44:49–55.

    Article  CAS  PubMed  Google Scholar 

  19. Eskes SA, Wiersinga WM. Amiodarone and thyroid. Best Pract Res Clin Endocrinol Metab. 2009;23:735–51.

    Article  CAS  PubMed  Google Scholar 

  20. Brunn J, Block U, Ruf G, Bos I, Kunze WP, Schriba PC. Volumetric analysis of thyroid lobes by real-time ultrasound. Dtsch Med Wschr. 1981;106:1338–40.

    Article  CAS  PubMed  Google Scholar 

  21. Moschetta M, Ianora AA, Testini M, Vacca M, Scardapane A, Angelelli G. Multidetector computed tomography in the preoperative evaluation of retrosternal goiters: a useful procedure for patients for whom magnetic resonance imaging is contraindicated. Thyroid. 2010;20:181–7.

    Article  PubMed  Google Scholar 

  22. Moka D, Dietlein M, Schicha H. Radioiodine therapy and thyrostatic drugs and iodine. Eur J Nucl Med Mol Imaging. 2002;29(Suppl 2):S486–91.

    Article  CAS  PubMed  Google Scholar 

  23. Bonnema SJ, Bennedbaek FN, Veje A, Marving J, Hegedus L. Propylthiouracil before I-131 therapy of hyperthyroid diseases; effect on cure rate evaluated by a randomized clinical trial. J Clin Endocrinol Metab. 2004;89:4439–44.

    Article  CAS  PubMed  Google Scholar 

  24. Braga M, Walpert N, Burch HB, Solomon BL, Cooper DS. The effect of methimazole on cure rates after radioiodine treatment for Graves’ hyperthyroidism: a randomized clinical trial. Thyroid. 2002;12:135–9.

    Article  CAS  PubMed  Google Scholar 

  25. Santos RB, Romaldini JH, Ward LS. Propylthiouracil reduces the effectiveness of radioiodine treatment in hyperthyroid patients with Graves’ disease. Thyroid. 2004;14:525–30.

    Article  CAS  PubMed  Google Scholar 

  26. Kobe C, Eschner W, Sudbrock F, Weber I, Marx K, Dietlein M, Schicha H. Graves’ disease and radioiodine therapy: is success of ablation dependent on the achieved dose above 200 Gy? Nuklearmedizin. 2008a;47:13–7.

    Article  CAS  PubMed  Google Scholar 

  27. Kobe C, Weber I, Eschner W, Sudbrock F, Schmidt M, Dietlein M, Schicha H. Graves’ disease and radioiodine therapy: is success of ablation dependent on the choice of thyreostatic medication? Nuklearmedizin. 2008b;47:153–66.

    Article  CAS  PubMed  Google Scholar 

  28. Bogazzi F, Bartalena L, Brogioni S, Scarcello G, Burelli A, Compomori A, Manetti L, Rossi G, Pinchera A, Martino E. Comparison of radioiodine with radioiodine plus lithium in the treatment of Graves’ hyperthyroidism. J Clin Endocrinol Metab. 1999;84:499–530.

    CAS  PubMed  Google Scholar 

  29. Bal CS, Kumar A, Pandey RM. A randomized controlled trial to evaluate the adjuvant effect of lithium on radioiodine treatment of hyperthyroidism. Thyroid. 2002;12:399–405.

    Article  CAS  PubMed  Google Scholar 

  30. Fast S, Nielsen VE, Grupe P, Bonnema SJ, Hegedus L. Optimizing 131I uptake after rhTSH stimulation in patients with nontoxic multinodular goiter: evidence from a prospective, randomized, double-blind study. J Nucl Med. 2009;50:732–7.

    Article  CAS  PubMed  Google Scholar 

  31. Nielsen VE, Bonnema SJ, Hegedus L. Transient goiter enlargement after administration of 0.3 mg of recombinant human thyrotropin in patients with benign non-toxic nodular goiter: a randomized, double-blind, cross-over trial. J Clin Endocrinol Metab. 2006a;91:1317–22.

    Article  CAS  PubMed  Google Scholar 

  32. Nielsen VE, Bonnema SJ, Boel-Jorgensen H, Grupe P, Hegedus L. Stimulation with 0.3 mg recombinant human thyrotropin prior to iodine 131 therapy to improve the size reduction of benign non-toxic nodular goiter: a prospective randomized double-blind trial. Arch Intern Med. 2006b;166:1476–82.

    Article  CAS  PubMed  Google Scholar 

  33. Silva MN, Rubió IG, Romão R, Gebrin EM, Buchpiguel C, Tomimori E, Camargo R, Cardia MS, Medeiros-Neto G. Administration of a single dose of recombinant human thyrotropin enhances the efficacy of radioiodine treatment of large compressive multinodular goiters. Clin Endocrinol (Oxf). 2004;60:300–8.

    Article  CAS  Google Scholar 

  34. Bockisch A, Jamitzky T, Derwanz R, Biersack HJ. Optimized dose planning of radioiodine therapy of benign thyroidal diseases. J Nucl Med. 1993;34:1632–8.

    CAS  PubMed  Google Scholar 

  35. Marinelli LD, Quimby EH, Hine G. [Dosimetry of radioactive isotopes; biological observations and practical applications]. Strahlentherapie 1950;81:587–594

    Google Scholar 

  36. Hegedus L, Bonnema SJ, Bennedbaek FN. Management of simple nodular goiter: current status and future perspectives. Endocr Rev. 2003;24:102–32.

    Article  PubMed  Google Scholar 

  37. Nieuwlaat WA, Huysmans DA, van den Bosch HC, Sweep CG, Ross HA, Corstens FH, Hermus AR. Pretreatment with a single, low dose of recombinant human thyrotropin allows dose reduction of radioiodine therapy in patients with nodular goiter. J Clin Endocrinol Metab. 2003;88:3121–9.

    Article  CAS  PubMed  Google Scholar 

  38. Boeleart K, Syed AA, Manji N, Sheppard MC, Holder RL, Gough SC, Franklyn JA. Prediction of cure and risk of hypothyroidism in patients receiving I-131 for hyperthyroidism. Clin Endocrinol (Oxf). 2009;70:129–38.

    Article  Google Scholar 

  39. de Rooy A, Vandenbroucke JP, Smit JW, Stokkel MP, Dekkers OM. Clinical outcomes after estimated versus calculated activity of radioiodine for the treatment of hyperthyroidism: systematic review and meta-analysis. Eur J Endocrinol. 2009;161:771–7.

    Article  CAS  Google Scholar 

  40. Dietlein M, Dressler J, Eschner W, Lassman M, Leisner B, Reiners C, Schicla H. Procedure guideline for radioiodine test (version 3). [German]. Nuklearmedizin. 2007;46:198–202.

    Article  CAS  PubMed  Google Scholar 

  41. Kobe C, Eschner W, Wild M, Rahlff I, Sudbrock F, Schmidt M, Dietlein M, Schicha H. Radioiodine therapy of benign thyroid disorders: what are the effective thyroidal half-life and uptake of I-131. Nucl Med Commun. 2010;31:201–5.

    Article  CAS  PubMed  Google Scholar 

  42. Leslie WD, Ward L, Salamon EA, Ludwig S, Rowe RC, Cowden EA. A randomized comparison of radioiodine in Graves’ hyperthyroidism. J Clin Endocrinol Metab. 2003;88:978–83.

    Article  CAS  PubMed  Google Scholar 

  43. Salvatori M, Luster M. Radioiodine therapy dosimetry in benign thyroid disease and differentiated thyroid carcinoma. Eur J Nucl Med Mol Imaging. 2010;37:821–8.

    Article  PubMed  Google Scholar 

  44. Sisson JC, Avram AM, Rubello D, Gross MD. Radioiodine treatment of hyperthyroidism: fixed or calculated doses; intelligent design of science? Eur J Nucl Med Mol Imaging. 2007;34:1129–30.

    Article  PubMed  Google Scholar 

  45. Stabin MG, Brill AB. State of the art in nuclear medicine dose assessment. Semin Nucl Med. 2008;38:308–20.

    Article  PubMed  Google Scholar 

  46. Kaptein EM, Levenson H, Siege ME, Gadallah M, Akmal M. Radioiodine dosimetry in patients with end-stage renal disease receiving continuous ambulatory peritoneal dialysis therapy. J Clin Endocrinol Metabol. 2000;85:3058–64.

    CAS  Google Scholar 

  47. Hall P, Holm LE. Late consequences of radioiodine for diagnosis and therapy in Sweden. Thyroid. 1997;7:205–8.

    Article  CAS  PubMed  Google Scholar 

  48. Schmidt M, Gorbauch E, Dietlein M, Faust M, Stützer H, Eschner W, Theissen P, Schicha H. Incidence of postradioiodine immunogenic hyperthyroidism/Graves’ disease in relation to a temporary increase in thyrotropin receptor antibodies after radioiodine therapy for autonomous thyroid disease. Thyroid. 2006;16:281–8.

    Article  CAS  PubMed  Google Scholar 

  49. Hall P, Lundell G, Holm LE. Mortality in patients treated for hyperthyroidism with iodine-131. Acta Endocrinol. 1993;128:230–4.

    Article  CAS  Google Scholar 

  50. Boice JD Jr. Radiation induced thyroid cancer – what’s new? J Natl Cancer Inst. 2005;97:703–5.

    Article  PubMed  Google Scholar 

  51. Dickman PW, Holm LE, Lundell G, Boice JD Jr, Hall P. Thyroid cancer risk after thyroid examination with I-131: a population-based cohort study in Sweden. Int J Cancer. 2003;106:580–7.

    Article  CAS  PubMed  Google Scholar 

  52. Dobyns BM, Sheline GE, Workman JB, Tompkins EA, McConahey WM, Becker DV. Malignant and benign neoplasms of the thyroid in patients treated for hyperthyroidism: a report of the cooperative thyrotoxicosis therapy follow-up study. J Clin Endocrinol Metab. 1974;38:976–98.

    Article  CAS  PubMed  Google Scholar 

  53. Franklyn JA, Maisonneuve P, Sheppard M, Betteridge J, Boyle P. Cancer incidence and mortality after radioiodine treatment for hyperthyroidism: a population based cohort study. Lancet. 1999;353:2111–5.

    Article  CAS  PubMed  Google Scholar 

  54. Lucignani G. Long-term risks in hyperthyroid patients treated with radioiodine: is there anything new? Eur J Nucl Med Mol Imaging. 2007;34:1504–9.

    Article  PubMed  Google Scholar 

  55. Dunkelmann S, Endlicher D, Prillwitz A, Rudolph F, Groth P, Schuemichen C. Results of a TcTUs-optimized radioiodine therapy of multifocal and disseminated functional thyroid autonomy. Nuklearmedizin. 1999;38:131–9.

    Article  CAS  PubMed  Google Scholar 

  56. Reinhardt MJ, Joe A, von Mallek D, Zimmerlin M, Manka-Waluch A, Palmedo H, Krause TM. Dose selection for radioiodine therapy of borderline hyperthyroid patients with multifocal and disseminated autonomy on the basis of 99mTc-pertechnetate thyroid uptake. Eur J Nucl Med Mol Imaging. 2002;29:480–5.

    Article  CAS  PubMed  Google Scholar 

  57. Walter MA, Crist-Crain M, Schindler C, Mueller-Brand J, Mueller B. Outcome of radioiodine therapy without, on or 3 days off carbimazole: a prospective interventional three-group comparison. Eur J Nucl Med Mol Imaging. 2006;33:730–7.

    Article  CAS  PubMed  Google Scholar 

  58. Reiners C, Schneider P. Radioiodine therapy of thyroid autonomy. Eur J Nucl Med. 2002;29(Suppl 2):S471–8.

    Article  CAS  Google Scholar 

  59. Reinhardt MJ, Kim B, Wissmeyer M, Juengling F, Brockmann H, von Mallek D, Ezziddin S, Joe AY, Krause T. Dose selection for radioiodine therapy of borderline hyperthyroid patients according to thyroid uptake of 99mTc-pertechnetate: applicability to unifocal thyroid autonomy? Eur J Nucl Med Mol Imaging. 2006;33:608–12.

    Article  CAS  PubMed  Google Scholar 

  60. Manders JMB, Corstens FHM. Radioiodine therapy of euthyroid multinodular goiters. Eur J Nucl Med. 2002;29(Suppl 2):S466–70.

    Article  CAS  Google Scholar 

  61. Bachmann J, Kobe C, Bor S, Rahlff I, Dietlein M, Schicha H, Schmidt M. Radioiodine therapy for thyroid volume reduction of large goiters. Nucl Med Commun. 2009;30:466–71.

    Article  PubMed  Google Scholar 

  62. Bonnema SJ, Andersen PB, Knudsen DU, Hegedus L. MR Imaging of large multinodular goiters: observer agreement on volume versus observer disagreement on dimension of the involved trachea. Am J Roentgenol. 2002;179:259–66.

    Article  Google Scholar 

  63. Bonnema SJ, Nielsen VE, Boel-Jørgensen H, Grupe P, Andersen PB, Bastholt L, Hegedus L. Improvement of goiter volume reduction after 0.3mg recombinant human thyrotropin-stimulated radioiodine therapy in patients with a very large goiter: a double-blinded, randomized trial. J Clin Endocrinol Metab. 2007;92:3424–34.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany

    Markus Dietlein

Authors
  1. Markus Dietlein
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Markus Dietlein .

Editor information

Editors and Affiliations

  1. Department of Nuclear Medicine, Klinikum Westfalen - Knappschaftskrankenhaus Academic teaching hospital of the Ruhr University, Dortmund, Nordrhein-Westfalen, Germany

    Hojjat Ahmadzadehfar

  2. Department of Nuclear Medicine, Beta Klinik Bonn, Bonn, Germany

    Hans-Jürgen Biersack

  3. Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, Bronx, NY, USA

    Leonard M. Freeman

  4. Albert Einstein College of Medicine, Bronx, NY, USA

    Lionel S. Zuckier

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Dietlein, M. (2020). Radioiodine Therapy for Benign Thyroid Disease. In: Ahmadzadehfar, H., Biersack, HJ., Freeman, L., Zuckier, L. (eds) Clinical Nuclear Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-39457-8_28

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-39457-8_28

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-39455-4

  • Online ISBN: 978-3-030-39457-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation