Diagnosis and Treatment > Medication > Radioiodine

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Haruhiko Yamazaki Department of Breast and Endocrine Surgery, Kanagawa Cancer Center, Yokohama, Japan

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Hiroyuki Iwasaki Department of Breast and Endocrine Surgery, Kanagawa Cancer Center, Yokohama, Japan

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Yoichiro Okubo Department of Pathology, Kanagawa Cancer Center, Yokohama, Japan

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Nobuyasu Suganuma Department of Breast and Endocrine Surgery, Kanagawa Cancer Center, Yokohama, Japan

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Katsuhiko Masudo Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, Yokohama, Japan

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Hirotaka Nakayama Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan

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Yasushi Rino Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan

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Munetaka Masuda Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan

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Summary

The objective this study is to report two cases of thyroid gland invasion by upper mediastinal carcinoma. Mediastinal tumors are uncommon and represent 3% of the tumors seen within the chest. In reports on mediastinal masses, the incidence of malignant lesions ranged from 25 to 49%. The thyroid gland can be directly invaded by surrounding organ cancers. We report these cases contrasting them to the case of a thyroid cancer with mediastinal lesions. Case 1 was a 73-year-old woman who was diagnosed with papillary thyroid carcinoma, and she underwent surgery and postoperative radioactive iodine. Case 2 was a 74-year-old man who was diagnosed with non-small-cell lung carcinoma, favor squamous cell carcinoma, and he underwent chemoradiotherapy. Case 3 was a 77-year-old man who was diagnosed a thymic carcinoma based on pathological findings and referred the patient to thoracic surgeons for surgical management. The images of the three cases were similar, and the differential diagnoses were difficult and required pathological examination. Primary thyroid carcinoma and invading carcinoma originating from the adjacent organs need to be distinguished because their prognoses and treatment strategies are different. It is important to properly diagnose them by images and pathological findings.

Learning points:

  • The thyroid gland in the anterior neck can be directly invaded by surrounding organ cancers.

  • Primary thyroid carcinoma and invading carcinoma originating from the adjacent organs need to be distinguished because their prognoses and treatment strategies are different.

  • It is important to properly diagnose by images and pathological findings.

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Mallika Bhat Division of Endocrinology, Department of Medicine

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Matty Mozzor Department of Radiology

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Savneek Chugh Division of Nephrology, New York Medical College, Westchester Medical Center, Valhalla, New York, USA

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Vamsi Buddharaju Division of Nephrology, New York Medical College, Westchester Medical Center, Valhalla, New York, USA

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Monica Schwarcz Division of Endocrinology, Department of Medicine

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Guy Valiquette Division of Endocrinology, Department of Medicine

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Summary

We describe detailed administration of thyroidal and extrathyroidal doses of radioiodine to a patient with end-stage renal disease on hemodialysis. A thorough description of area under curve measurements in a patient with compromised renal function has rarely been described in the literature. Few publications have described thyroid cancer management of patients on hemodialysis, and we believe our management will aid in patient treatment in the future.

Learning points:

  • Scheduling of hemodialysis is important when administering radioactive iodine.

  • Treatment of thyroid cancer with radioiodine in patients with end-stage renal disease requires multidisciplinary approach coordinating dialysis, nuclear medicine and endocrinologists care.

  • Balancing ideal dosage of I131 and the timing of dialysis to insure maximal thyroidal uptake and minimal extra thyroidal I131 concentration is necessary.

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Kursad Unluhizarci Department of Endocrinology

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Hulya Akgun Department of Pathology

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Bahadır Oz Department of Surgery, Erciyes University Medical School, Kayseri, Turkey

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Zuleyha Karaca Department of Endocrinology

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Fatih Tanriverdi Department of Endocrinology

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Fahrettin Kelestimur Department of Endocrinology

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Summary

Among various substances produced by C-cells, the most important one is calcitonin (CT) that is used for detection, post-operative follow-up and evaluation of individuals at risk of developing medullary thyroid carcinoma (MTC). However, the role of serum CT measurement in the evaluation of thyroid nodules has been widely discussed, and there is still no consensus about the role of CT in the initial evaluation of all thyroid nodules. Two patients with thyroid nodules whose fine-needle aspiration results were compatible with benign cytology besides having mildly elevated basal serum calcitonin levels were reported. Calcitonin responses (peak levels were 313 and 229 pg/mL, respectively) to calcium stimulation test were compatible with the possible diagnosis of MTC. However, the final diagnosis was papillary thyroid carcinoma of the thyroid gland. There are limited numbers of case reports showing such an increased serum calcitonin responses to calcium stimulation test associated with papillary or follicular thyroid carcinoma of the thyroid. We suggest to measure serum CT level once and in case of normal levels, no further CT measurement is necessary. Physicians should keep in mind that thyroid carcinomas other than MTCs may also be associated with high serum CT levels.

Learning points:

  • Although serum calcitonin is a valuable tumor marker for MTC, it is well known that mild elevations may be seen in some other diseases such as Hashimoto thyroiditis, neuroendocrine tumors or due to medications such as proton pump inhibitors, calcium salts, beta blockers and glucocorticoids.

  • Those two cases indicate that high calcitonin responses to calcium stimulation test, mimicking MTC, may also be seen in patients with papillary thyroid carcinoma although the mechanism is not clear.

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Tsung-Chun Huang Departments of Plastic and Reconstructive Surgery

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Yu-Kai Cheng Departments of Neurosurgery

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Tsung-Wei Chen Departments of Pathology, China Medical University Hospital, China Medical University, Taichung, Taiwan

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Yung-Chang Hsu Departments of Plastic and Reconstructive Surgery

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En-Wei Liu Departments of Plastic and Reconstructive Surgery

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Hsin-Han Chen Departments of Plastic and Reconstructive Surgery

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Summary

Thyroid cancer with cranial metastasis in a pregnant woman is very rare. In the literature, most cases are diagnosed early from neurogenic signs or symptomatic thyroid gland. Pregnancy also contributes to a hesitation toward early surgical and medical treatments. We reported a scalp tumor in a physically healthy 37-year-old pregnant female with a follicular thyroid carcinoma (FTC) with lung, bone and cranial metastasis in initial presentation. Silent neurogenic and physical examinations make an early diagnosis very challenging. Resection of scalp and intracranial tumor, a thyroidectomy, post-operative radioactive iodine therapy and tyrosine kinase inhibitors were employed as treatment. The scalp tumor was confirmed as a metastatic follicular thyroid carcinoma via positive immunoreactivity for thyroglobulin and thyroid transcription factor 1 in tumor cells. Blood examination revealed an elevated thyroglobulin level (>5335 ng/mL). The patient was discharged without any neurological deficit. An asymptomatic scalp tumor in a pregnant woman with a normal thyroid disease history needs differential diagnosis from intracranial origin. Rapid progression and an elevated thyroglobulin level are the indicators that further image study is needed. Aggressive surgical excision of resectable thyroid gland and metastatic tumor are essential for a longer survival rate. There is nothing to indicate that a post-partum operation will worsen prognosis.

Learning points:

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Christopher W Rowe Departments of Endocrinology and Diabetes
Schools of Medicine and Public Health

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Kirsten Murray Departments of Endocrinology and Diabetes

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Andrew Woods Maternity and Gynaecology, John Hunter Hospital, Newcastle, New South Wales, Australia

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Sandeep Gupta Department of Nuclear Medicine & PET, Hunter New England Imaging, John Hunter and Calvary Mater Hospital, Newcastle, New South Wales, Australia
Health Sciences, University of Newcastle, Newcastle, New South Wales, Australia

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Roger Smith Departments of Endocrinology and Diabetes
Schools of Medicine and Public Health

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Katie Wynne Departments of Endocrinology and Diabetes
Schools of Medicine and Public Health

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Metastatic thyroid cancer is an uncommon condition to be present at the time of pregnancy, but presents a challenging paradigm of care. Clinicians must balance the competing interests of long-term maternal health, best achieved by iatrogenic hyperthyroidism, regular radioiodine therapy and avoidance of dietary iodine, against the priority to care for the developing foetus, with inevitable compromise. Additionally, epidemiological and cellular data support the role of oestrogen as a growth factor for benign and malignant thyrocytes, although communicating the magnitude of this risk to patients and caregivers, as well as the uncertain impact of any pregnancy on long-term prognosis, remains challenging. Evidence to support treatment decisions in this uncommon situation is presented in the context of a case of a pregnant teenager with known metastatic papillary thyroid cancer and recent radioiodine therapy.

Learning points:

  • Pregnancy is associated with the growth of thyroid nodules due to stimulation from oestrogen receptors on thyrocytes and HCG cross-stimulation of the TSH receptor.

  • Thyroid cancer diagnosed during pregnancy has not been shown to be associated with increased rates of persistent or recurrent disease in most studies.

  • There is little evidence to guide the management of metastatic thyroid cancer in pregnancy, where both maternal and foetal wellbeing must be carefully balanced.

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Marco Russo Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy

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Ilenia Marturano Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy

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Romilda Masucci Surgical Oncology, Garibaldi-Nesima Hospital, Catania, Italy

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Melania Caruso Gynecology and Obstetrics, Garibaldi-Nesima Hospital, Catania, Italy

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Maria Concetta Fornito Nuclear Medicine, Garibaldi-Nesima Hospital, Catania, Italy

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Dario Tumino Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy

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Martina Tavarelli Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy

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Sebastiano Squatrito Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy

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Gabriella Pellegriti Endocrinology, Garibaldi-Nesima Hospital, Catania, Italy

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Summary

Struma ovarii is a rare ovarian teratoma characterized by the presence of thyroid tissue as the major component. Malignant transformation of the thyroidal component (malignant struma ovarii) has been reported in approximately 5% of struma ovarii. The management and follow-up of this unusual disease remain controversial. We report the case of a woman with a history of autoimmune thyroiditis and a previous resection of a benign struma ovarii that underwent hystero-annexiectomy for malignant struma ovarii with multiple papillary thyroid cancer foci and peritoneal involvement. Total thyroidectomy and subsequent radioiodine treatment lead to complete disease remission after 104 months of follow-up. The diagnosis and natural progression of malignant struma ovarii are difficult to discern, and relapses can occur several years after diagnosis. A multidisciplinary approach is mandatory; after surgical excision of malignant struma, thyroidectomy in combination with 131I therapy should be considered after risk stratification in accordance with a standard approach in differentiated thyroid cancer patients.

Learning points

  • Malignant struma ovarii is a rare disease; diagnosis is difficult and management is not well defined.

  • Predominant sites of metastasis are adjacent pelvic structures.

  • Thyroidectomy and 131I therapy should be considered after risk stratification in accordance with standard approaches in DTC patients.

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Eva Krčálová Nuclear Medicine Department, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
Academic Department of Internal Medicine, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic

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Jiří Horáček 4th Department of Internal Medicine, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
Academic Department of Internal Medicine, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic

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Lubomír Kudlej Internal Medicine Department, Hospital Trutnov, Trutnov, Czech Republic

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Viera Rousková Nuclear Medicine Department, Hospital Trutnov, Trutnov, Czech Republic

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Blanka Michlová Nuclear Medicine Department, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic

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Irena Vyhnánková Nuclear Medicine Department, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic

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Jiří Doležal Nuclear Medicine Department, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic

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Jaroslav Malý 4th Department of Internal Medicine, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
Academic Department of Internal Medicine, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic

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Pavel Žák 4th Department of Internal Medicine, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
Academic Department of Internal Medicine, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic

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Summary

Radioiodine (RAI) has played a crucial role in differentiated thyroid cancer treatment for more than 60years. However, the use of RAI administration in patients with papillary thyroid microcarcinoma (even multifocal) is now being widely discussed and often not recommended. In accordance with European consensus, and contrary to the American Thyroid Association (ATA) guidelines, we recently performed RAI thyroid remnant ablation in a patient with differentiated papillary multifocal microcarcinoma. The post-therapeutic whole-body scan and SPECT/CT revealed the real and unexpected extent of disease, with metastases to upper mediastinal lymph nodes. This finding led to the patient’s upstaging from stage I to stage IVa according to the American Joint Committee on Cancer/International Union Against Cancer criteria.

Learning points

  • 131I is a combined beta–gamma emitter, thus allowing not only residual thyroid tissue ablation but also metastatic tissue imaging.

  • RAI remnant ablation omission also means post-treatment whole-body scan omission, which may lead to disease underestimation, due to incorrect nodal and metastatic staging.

  • RAI should be considered also in “low-risk” patients, especially when the lymph node involvement is not reliably documented.

  • Lower administered RAI activity (30mCi, 1.1GBq) may be a workable compromise in low-risk patients, not indicated for RAI remnant ablation according to ATA guidelines.

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Anastasia Dimakopoulou
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Karunakaran Vithian Colchester Hospital University NHS Foundation Trust, Colchester, UK

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David Gannon Colchester Hospital University NHS Foundation Trust, Colchester, UK

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Allan Harkness Colchester Hospital University NHS Foundation Trust, Colchester, UK

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Summary

A 55-year-old female patient presented to the endocrine clinic with Grave's disease. She was initially treated with carbimazole. After an early relapse, a decision was made to proceed with radioactive iodine therapy. Four days after radioiodine administration, she presented to the emergency department with chest tightness and dyspnea due to heart failure. Biochemistry revealed thyrotoxicosis and significantly elevated Troponin-T. There was ST segment elevation on electrocardiography. However, coronary angiography was normal. Ventricular function was fully restored after 6 weeks of supportive medical management. A diagnosis of stress cardiomyopathy following radioactive iodine therapy was made. This is the second case reported in the literature so far to the best of our knowledge.

Learning points

  • Stress cardiomyopathy in the context of radiation thyroiditis is a rare complication following radioiodine therapy.

  • A degree of awareness is essential because the approach is multidisciplinary. Management is mainly supportive and cardiac dysfunction is completely reversible in most cases.

  • The pathogenesis of this condition remains unclear. Post-menopausal women and susceptible individuals appear to be pre-disposed.

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Lauren J Baker Endocrinology Department, Concord Hospital, Sydney, New South Wales, Australia

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Anthony J Gill Pathology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia

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Charles Chan Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
Anatomical Pathology Department, Concord Hospital, Sydney, New South Wales, Australia

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Betty P C Lin Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
Anatomical Pathology Department, Concord Hospital, Sydney, New South Wales, Australia

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Bronwyn A Crawford Endocrinology Department, Concord Hospital, Sydney, New South Wales, Australia
Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia

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Summary

In 2006, a 58-year-old woman presented with thyrotoxicosis. She had undergone left hemithyroidectomy 14 years before for a benign follicular adenoma. Ultrasound imaging demonstrated bilateral cervical lymphadenopathy with enhanced tracer uptake in the left lateral neck on a Technetium-99m uptake scan. Fine-needle aspiration biopsy of a left lateral neck node was insufficient for a cytological diagnosis; however, thyroglobulin (Tg) washings were strongly positive. The clinical suspicion was of functionally active metastatic thyroid cancer in cervical lymph nodes. A completion thyroidectomy and bilateral cervical lymph node dissection were performed. Histology demonstrated benign multinodularity in the right hemithyroid, with bilateral reactive lymphadenopathy and 24 benign hyperplastic thyroid nodules in the left lateral neck that were classified as parasitic thyroid nodules. As there had been a clinical suspicion of thyroid cancer, and the hyperplastic/parasitic thyroid tissue in the neck was extensive, the patient was given ablative radioactive iodine (3.7 GBq). After 2 years, a diagnostic radioactive iodine scan was clear and the serum Tg was undetectable. The patient has now been followed for 7 years with no evidence of recurrence. Archived tissue from a left lateral neck thyroid nodule has recently been analysed for BRAF V600E mutation, which was negative.

Learning points

  • Thyrotoxicosis due to functional thyroid tissue in the lateral neck is very rare and may be due to metastatic thyroid cancer or benign parasitic thyroid tissue.

  • Parasitic thyroid nodules should be considered as a differential diagnosis of lateral neck thyroid deposits, particularly where there is a history of prior thyroid surgery.

  • Parasitic thyroid nodules may occur as a result of traumatic rupture or implantation from a follicular adenoma at the time of surgery.

  • The use of ablative radioactive iodine may be appropriate, as resection of all parasitic thyroid tissue can prove difficult.

  • BRAF mutational analysis of parasitic thyroid tissue may provide extra reassurance in the exclusion of papillary thyroid carcinoma.

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Adam R Puchalski Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine at UCLA, 24-130 Warren Hall, 900 Veteran Avenue, Los Angeles, California 90095, USA

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Inder J Chopra Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine at UCLA, 24-130 Warren Hall, 900 Veteran Avenue, Los Angeles, California 90095, USA

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Summary

Radioiodine (131I) is a critical component in the treatment of differentiated thyroid cancer. We recently saw a patient with thyroid cancer who was hesitant to take 131I treatment because he had previously encountered an allergic reaction to administration of iodine-containing radiocontrast agent for computed tomography (CT) scanning. We were able to administer 131I treatment after discussion that his anaphylactic reaction was not due to iodine and that radioiodine (131I) treatment is unlikely to cause a reaction in the patient.

Learning points

  • An allergy to iodine itself does not exist.

  • When patients claim that they have an ‘iodine allergy’, ask them what substances they are allergic to and what kind of reaction occurred during use of such substances.

  • Radioactive iodine is not a contraindication for patients who claim an ‘allergy to iodine’.

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