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ASSESSMENT of THYROID FUNCTION and ANATOMY with TECHNETIUM-99M AS PERTECHNETATE

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ASSESSMENT of THYROID FUNCTION and ANATOMY with TECHNETIUM-99M AS PERTECHNETATE ASSESSMENT OF THYROID FUNCTION AND ANATOMY WITH TECHNETIUM-99m AS PERTECHNETATE Harold 1. Atkins and Powell Richards Brookhaven National Laboratory, Upton, New York A number of elements other than iodine are se The patient was placed supine, and a suitably lectively concentrated by the thyroid gland (1—7). collimated 2 x 2-in. NaI(Tl) crystal scintillation de Among these are elements in the periodic group tector was placed over the neck 25 cm from the skin VIIa (manganese, technetium and rhenium) which surface. The detector signal was fed through a dis are taken up by the thyroid gland but, in contra criminator and ratemeter to a strip-chart paper distinction to iodine, are not organically bound. recorder. The radioactivity in the neck was con Technetium is not a naturally occuring element tinuously recorded after the intravenous administra and exists only in radioactive form. One of the iso tion of 2.0—2.6mc [email protected] amount topes of technetium is o9mTc which is available as of activity, which is suitable for scintillation scanning, the daughter product of 99Mo in a generator system produced counting rates too high for a flat-field (8). Its physical characteristics make it particularly collimator. Therefore 2.5 cm of Lucite were inserted suitable for scintillation scanning; it has a short half over the end of the detector collimator which reduced life of 6 hr, virtually no beta emission and a mod the sensitivity by 30% and eliminated errors due to erately low-energy gamma emission ( 140 key) that the resolving-time capability of the detector. The can be efficiently collimated. The possibility of ad settings were : 300,000 counts/min scale, 1-sec time ministering millicurie quantities of activity without constant and 12-in./hr paper speed. delivering a high radiation dose to the patient allows After the initial peak caused by the bolus of studies to be performed rapidly and accurately. Be activity passing through the neck and great vessels, cause of these characteristics, the isotope has been the counting rate dropped rapidly to a minimum widely used as a scanning agent (9—11). value within 1 mm after injection. There was then a Because the uptake of technetium in the thyroid gradual rise in counting rate over the next 15—20 reflects the state of the trapping function of the mm to a maximumvalue. The countingrate then gland, its use in studying thyroid physiology has been remained fairly constant with only a slow diminution suggested (12,13 ) . It is the purpose of this study (Fig. 1) . A “trappingindex―was determined by to evaluate the thyroidal uptake of o9mTc@pertechne@dividing the minimum counting rate into the maxi tate in relation to the clinical state and to make an mum. An “accumulation gradient― was determined intercomparison with other tests of thyroid function. by measuring the average slope of the curve from Several parameters of technetium uptake have been the minimum to the half-maximum value. A modifi measured and correlated with each other as well as cation was introduced after the study had been started with the results of @@1Juptake and serum protein which reduced the size of the initial “spike―of activity bound iodine. so that the recording needle would not go off scale. A %6-in. lead sheet was placed over the neck and METHOD upper chest with an opening 4-in. in diameter over The patients included referrals from the Industrial the thyroid area. This sheet reduced extraneous Medicine Clinic at the Medical Research Center, counts from activity in the heart and great vessels. Brookhaven, patients hospitalized at the Medical After recording over the neck, a recording was Research Center primarily for other reasons than made over the thigh for 1 mm. When this value was disturbances of the thyroid and referrals from sev subtracted from the maximum and minimum values, era! outside physicians who questioned abnormal thyroid function or the presence of palpable nodules. Received Nov. 9, 1966; revision accepted April 4, 1967. Volume 9, Number 1 7 ATKINS AND RICHARDS The vial, made of 1.5-mm-thick Lucite, was inserted into a Lucite cylindrical neck phantom 1 2.7 cm in diameter and 12.7 cm high. The center of the vial (J@ I— was 2.2 cm from the anterior surface of the neck z 0 phantom (Fig. 2). 0 w We performed a scan of the phantom immediately > after completing the patient study using the same -J parameters. The uptake of 9amTc in the gland was U then determined by counting dots on the teledeltos recording over the thyroid, subtracting background and comparing the results with the standard that con tamed 3 % of the injected activity (Fig. 3 ) . This method is similar to that of Andros et al (12 ) , but we made no corrections for size and depth of the gland because these estimates have a high degree of error, and we felt that the phantom represented a good average. The determination of thyroidal uptake TIME using the “dot―scan is more accurate than the usual FIG.1. Immediateuptakeof°@mTc-pertechnetateinthyroidafter method because of the rather low uptake of tech intravenousinjection.Traceproceedsintimefromrighttoleft. netium in the thyroid and the high background level Traces are on individuals with hyperthyroidism (middle), normal function (above) and hypothyroidism (below). of radioactivity, including localization in salivary glands. Nearly all patients had a PBI determination on a “corrected trapping index― was determined. It had the day of the B9mTcstudy. If it was not inconvenient been determined previously that the activity level for the patient, an oral dose of 131!was administered over the thigh did not change during this time interval. after the scan was completed, and a 24-hr uptake A neck-to-thigh ratio was also computed. in the thyroid was determined. The BBmTcdid not When these steps were completed (about 15—20 interfere with this study because the activity level mm) , the patient was placed under a rectilinear had decreased by a factor of I 6 in 24 hr, about 30% scanner (Picker Magnascanner, 3 x 2-in. NaI(Tl) had been excreted and the discriminator setting of crystal) , and the isotope distribution in the neck the detector effectively eliminated the 140-key pho was determined. Focusing collimators with I ,045 tons. Special studies, such as a BE! or a T-3 resin holes, developed in the Brookhaven Hot Laboratory, uptake, were performed as indicated. are used for scanning (14) . Depending on the count In 47 patients the following procedure was used: ing rate, one of the two collimator thicknesses is A sample of blood was drawn at the end of the scan, used. The most often used is a I .3-in. collimator with a resolution of 0.16 in. (4 mm) at the 50% isoresponse level and 3.5-in. focal depth. When the counting rate is low, as in hypothyroidism or after suppression by exogenous thyroid medication, a 1-in. collimator is used. Its resolution is 0.23 in. (6 mm), but the sensitivity is about 40% greater. Maximum counting rates over the thyroid ranged from 20,000 to 40,000 counts/mm for euthyroid patients. Scan ning speeds of 30—50 cm/mm with indexing steps of 0. 15 cm are the usual scanning parameters. These provide a maximum counting rate density of 3,750— 5,625 per square centimeter. The duration of the scan was 5—15mm. c A standard was prepared in the following way. A quantity of 99―Tcequivalent to that injected into the patient (0.3—0.7 ml) was diluted to 100 ml. Three milliliters of this standard were then added to 20 ml of water in a Lucite vial cylinder with an FIG.2. Luciteneckphantomandvialrepresentingthyroidare inner diameter of 2.3 cm and a length of 6.3 cm. used for determining thyroid accumulation of @@mTc. 8 JOURNAL OF NUCLEAR MEDICINE @ : J 0:: ; @: e C C C C • C C V S 4 C • C C • C C C a * C C C C C C S S . C S I C C C S C C C C b S S S S • e a C 0 5 5 C S a C S C 0 5 S C S S C C S C S @ C C C S C S S C • •@S S S • C S C C • C e C C C • C • • • S C S C C S S S C C a a a a . S 4 C S S C C @ S C C C . S • S a C S S S S a S • S S S S C S C S L • S S C C C C a . tc@ FIG.3. Exampleofcalculationofthy. roidal concentration of @@mTcfrom tele = deltos scans of neck and phantom. Back ground is measured in rectangular region @ and multiplied by 8 to compensate for st@0@Z&@L2,o7xz difference in area. d.f. refers to dot scaling @ factor used in making scan. 1'@@i@@.;&tt@,t&b;L:I ;‘@.i:@7@ and the 99mTcactivity per milliliter of plasma was pothyroidism were studied, and they all had uptakes determined. The size of the thyroid was calculated below 0.5% . In the diagnosis of the hyperthyroid from the scan using the method developed by Good state, two of I 5 patients whose thyroids were defi win et a! ( 15), and the ratio [TcO;] thyroid/[TcO4@] nitely overactive had technetium uptakes below , plasma as well as the thyroidal technetium space 4.0% for a diagnostic accuracy of 87%.
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