available from on-site generators. Iodine-123, however,is cyclotron-produced, considerably more expensive,and, with a 13-hr physical half-life, presents significantlogistical problems. Finally, the issue is further compli

cated by the fact that the value of thyroid scanningforcancer detection has been challenged and its clinicalusefulness questioned (12,13)

Since the introduction of [99mTcjpertechfletate forroutine thyroid imaging, a number of cases of thyroidcarcinoma appearing scintigraphically hot with [@mTc]pertechnetate and cold with radioiodine have beenrather dramatically reported (14—21).The result ofthese findings has been the frequent recommendationthat nodules appearing hot with pertechnetate shouldbe re-imaged with an isotope ofiodine in order that thediagnosis of thyroid malignancy is not overlooked.However, other case reports (22-29) and comparativestudies ofthe two radionucides (9,30,31) indicated thatbenign thyroid lesions are the more likely cause ofdiscrepant findings. Thyroid carcinoma has also beenfound with another, less frequent type of discrepancy,increased iodine uptake relative to pertechnetate (32).

The BureauofRadiologicalHealth (BRH),Food andDrug Administration (FDA), being interested in reduction of radiation dose delivered to the organs duringnuclear imaging procedures, appointed an AdvisoryTask Force on Short-LivedRadionuclidesfor MediCalApplications. This group recommended that comparative studies of [99mTc]pertechnetateand 1231as imagingagents for nodular goiter be undertaken to clarify differences between these two radionucides. The BRHdesigned a comprehensive study ofthis issue using theseradiopharmaceuticals, including cytologic or histologicfollow-up(33).

MATERIALSANDMEThODSThe study was conducted in the University Hospital “Dr.

Mladen Stojanovié―in Zagreb, Yugoslaviaaccording to aprotocol developed by the BRH FDA's Nuclear Medicine

Threehundredandsixteenpatientswith solitaryor dominant thyroidnoduleswere imagedboth with technetium99m- (@“Tc)pertechnetateand iodine-i23 (1231).The imageswere independentlyinterpretedbyfivereaders.Iodinescanswere preferred,but differenceswere smalland in27%—58%of the casesthere was no differencein qualitybetween the two radionuclides. Discrepancies between99mTcand 1231imageswere found in 5%—8%of cases,twiceas oftenin multinodulargoitersas in singlenodules.Cytologic/histologicexaminationwas performedon allnodulesbut nocorrelationwasfoundbetweenthe pathologyandthetypeof discrepancy.Twelvecarcinomaswerefound (4%) but none in nodulesshowinga discrepancy.There was great variationamongthe observersaboutthepreferencefor radionuclidesand about the existenceortypeof discrepancies.Theslightlybetteroverallqualityof1231 scans is probably not of diagnostic significance and

does not justify the routineuse of@ insteadof @“Tc.Routinereimagingof @“Tchot noduleswith radioiodinefor cancerdetectiondoesnot appearto be necessary.

JNucIMed1990;31:393—399

everal systematic comparative studies using technetium-99m- (99mTc)pertechnetate and radioiodine(@@‘I,1251 1231)have been performed in attempts toclarify their respective roles in thyroid imaging. Someshowed definite superiority of radioiodine (1—4),butother authors found the results so similar that they werenot able to choose one radionuclide as better (5—11).There is similar disagreement about the clinical significance of discrepant scan findings. The controversybecomes even more complex if economic factors areconsidered. Technetium is inexpensive and readily

ReceivedJuly5, 1989;revisionacceptedNov.21, 1989.For reprintscontact: ZvonkoKusi@,MD,Departmentof NuclearMedI

one andOncology,UniversityHospital@Dr.M. Stojanoviô,―Vinogradska29,41000Zagreb,Yugoslavia.

393Technetium-99m and Iodine-i 23 Thyroid Scans Comparison •Kusic et al

Comparison of Technetium-99m and Iodine123 Imaging of Thyroid Nodules: Correlationwith Pathologic FindingsZvonko Kusié,David V. Becker, Eugene L. Saenger, Peter Paras, Peter Gartside, Terry Wessler andSime Spaventi

DepartmentofNuclear Medicine and Oncology, UniversityHospital “Dr.M. Stojanoviê'@Zagreb, Yugoslavia;DivisionofNuclear Medicine, Department ofRadiology, The New York Hospital-CorneilMedical Center, New York; E. L.Saenger Radioisotope Laboratory, Department ofRadiology and Division ofEpidemiology and Biostatistics,University ofCincinnati Medical Center, Cincinnati, Ohio; and National Centerfor Devices and Radiological Health,FDA, Silver Spring, Maryland

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Laboratoryin collaborationwith the Universityof CincinnatiMedicalCenter.

Entry into the study was limited to patients with a solitaryor dominant nodule on palpation of the thyroid, which wasperformed by two experienced thyroid specialistsprior toimaging. Three hundred and sixteen patients (283 women and33 men, mean age 42 yr) came from the northwest part ofYugoslavia,which, until recently,wasan areaofmild endemicgoiter.No patienthad a historyofchildhood neckirradiation.The procedureand purpose of the study were explained andindividual signed consent was obtained. Controls were 20clinically and biochemically euthyroid women, mean age 35with normal thyroidson palpationand no historyof thyroiddisease.

The initial image was obtained 20 to 30 mm after aninjection of 185 MBq of [@mTc]pertechnetate.Two-hundredthousand counts were collected using the l40-keV photopeakand 20% window on a scintillation camera (GE 400T, Milwaukee, WI) with a 5-mm pinhole collimator. Images wererecorded on x-ray film. A skin-to-aperturedistance was recorded (in the majority ofcases it was 7 cm). An anterior viewwith a marker on the thyroid cartilage and suprasternal notchalso was obtained. The image was repeated with additionalmarkers on any palpable nodules. Oblique views at 45°wereobtained in all patients.

Within 1 wk, the patients were again studied, using an oraldose of 14.8—18.5MBq of 1231.This preparation(provided byMalhinckrodt, Vienna, Austria) was free of 1241and had <2%contamination with 1251Patients had only liquids for 4 hrprior to administration of activity. Images and uptakes wereobtainedat 1hrand 20—24hrafteradministrationof 1231Thesame instrument, imaging view, and distance was used forboth radionuclides.Imageswith 1231wereobtainedwitha totalof 100,000counts or an imagingtime of 10 mm, whichevercame first,usingthe l59-keVphotopeakand 20%window.

Cytologic examinations of all palpable nodules were performed subsequent to imaging studies. Sixty patients, whowere subsequentlytreated surgically,had histologicfindingsavailable. The locations of the abnormalities found on palpation and areas biopsied were marked on anatomic drawingsof the thyroid and correlation with scan findings was established by one of the physicians who had originally examinedthe patients.

In addition to the medical history and physicalexamination, laboratory tests were obtained including serum thyroxme, triiodothyronine, thyrotropin, TRH test, antithyroid antibodies, and ultrasound for the majority of patients. Hyperthyroidism was diagnosed in 18 patients, the rest wereeuthyroid.

Imageswerereadindependentlyby five experiencedreaders(DVB, RSB,ZL, WPL,and ELS)qualifiedin nuclearmedicineimage analysis who were not familiar with the patients orimages. The images were presented to them without medicalhistory, laboratory, cyto-histologicor technical data. All ofthe readers routinely use [@mTc]pertechnetate as a thyroidimaging agent in their institutions. The observations of thefive readerswere recordedon a form, which requiredcategorized notations of: image quality (on a five-level scale fromexcellent to unusable); image thyroid size; image thyroidsymmetry;image distributionofactivity, iflocalized; locationofirregularity; image interpretation (on a five-level scale from

definitely normal to definitely abnormal); impression (normal,multinodular goiter, cold nodule, hot nodule, and diffusegoiter); discrepant area; comparison of @mTcand 1231scan;and comparison of 1231(l-hr) and 123!(20-hr) scans.

Each patient had three films, one each for [@mTcJpertech@netate, 1231at 1 hr, and 1231at 20—24hr. Each film containedfour scans:

1. Anterior view with a marker on thyroid cartilage andsuprasternal notch.

2. Sameviewwith a marker on the nodule.3. Right oblique view.4. Left oblique view.

The 1,008 films (three films for each of the 336 subjects:316 patients and 20 controls) were coded, randomized, andgrouped into five batches. In addition, for the first trial, thescanswiththe markeron the noduleweremasked.It consistedof two readings, and was double blinded with respect toradionuclide and patient. Each reader read one batch (201films) in the first reading. In the second reading, the readerschanged batches so that each film was seen by 2 differentreadersconstitutingone pair. Five batcheswere read by fivedifferentpairsof readers,as follows:AB,CA, BD, EC, DE.

In the second trial, the films were unmasked and eachreader read the same batch as in the first reading.

The third trial consisted of direct (simultaneous) comparison ofthe three films ofeach patient (99mTc,123Jl-hr, 123!20-hr). For this trial, the films were decoded, unmasked, andreorganized, and identified by patient and radionuclide.

There was no attempt to impose rules of interpretation orcriteria evaluation on the readers because it was deemedimportant that each reader represent his individual experienceand attitude. If rules of interpretationhad been imposed, anyconclusion of the study might have been less applicable togeneral(usual)clinicalpractice.

StatisticalMethodsThe data from the image readingforms for all 336 patients

and controls were keyed with verification into a permanentcomputer file. The study was organized to follow a balancedincomplete block design (34). This method permitted the fivereaders to read only 40% ofthe films to complete the study.

Frequency tabulations and percentages were obtained bycreating contingency tables. The amount of association representedby the data containedin the tableswascomputed bychi-squareanalysis using the method of Cramer (35). Thepresence of significant heterogeneity among readers for thesetabulations was determined by log-linear model analyses.

The data for image quality and image interpretationwereanalyzed by variance analysis. The values that were not available due to the design ofthe study were estimated by the leastsquaresmethod for theseentries.

RESULTS

When [99mTc]pertechfletateand 1231scans were evaluated simultaneously for each patient (Trial 3) therewas almost general agreement that 123!scans were “better―than 99mTc@ (Table 1). The number of casesreported as showing no difference was large (27%—

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TABLEIComparisonof [@“‘Tc]Pertechnetateand 123IScans1@I

better99mTc

betterthanthan@ % @Tc,%NodifferenceReader

of cases of cases% ofcasesA

273835l>TcB383527Tc>iC24058I>TctD25147l>TCtE

144145I>TCt.

Nonsignificantdifference.t

Significant difference.

1231better@“Tc

betterthanthan1231,%@‘Tc, %NodifferenceImpressionof

casesof cases% ofcasesNormal31681Multinodular

goiter185032Coldnodule194239Hotnodule235324Diffuse

goiter93457

TABLE2Association of Image Interpretation with th

of @“Tcand 1231ScanseComparison1231

better99mTc

betterthanImagethan1231% @“Tc,%Nodifferenceinterpretation

of cases of cases% ofcasesDefinitely

normal 01486Probablynormal 32176Indeterminate

42274Probablyabnormal 233641Definitelyabnormal 19 4635

TABLE3Associationof DiagnosticImpressionwith the

Comparison of @Tcand 1@lScans

nuclides. The reading was double blinded with respectto radionuclides and patient identification and with amask obscuring scans showing location of the palpablenodules. All readers preferred 20-hr 123!scans to [99mTc]pertechnetate scans; four readers also preferred 1-hr 1231scans over [@mTc]pertechnetate scans. The same comparison with unmasked films demonstrated that knowing the location ofthe nodule did not make a substantialchange in the preference for radionuclide.

Interobserver agreement did not differ significantlyfor @mTcand 123!scans in categories of image quality,image interpretation, and diagnostic impression. Therewas no correlation between uptake values (32%-55%at 20 hr) and preference for radionucides. Correlationof location of palpable nodules with location of scanabnormality did not show significant difference between99mTcand 1231images.

Evaluation of categories of diagnostic impressionbased on 99mTcand 1231scintigraphy was done blindlywithout knowledge of location of nodule. There wasgreat variation among the readers, but every readerfound the lowest percentage of normals and the highestpercentage of multinodular goiter on @mTcscintigraphy. This observation is in accordance with the findingthat 99mTcimages of abnormal glands were more likelyto be classified as abnormal than were 1231scans (on ascale from definitely normal to definitely abnormal).Both radionucides were similar in demonstratingcoldand hot nodules.

Because of the crossover nature of the trial, whichprecluded each reader from seeing all images, it is onlypossible to estimate the overall frequency of discrepancies at 5%—8%.Of the discrepancies reported, therewas agreement about the type of discrepancy betweentwo readers who saw the same cases in only one-fifth ofthese instances. In as many as two-thirds ofthe discrepant cases, there was disagreement about the very existence of a discrepancy. Some readers were more likelyto find discrepancies than others—but most often indifferent images. The most frequent type of discrepancywas technetium, normal or cold with iodine, cold ornormal. Technetium hot/iodine cold was somewhat lessfrequent. In one-sixth of the cases, discrepant scan

58%). Among the reasons mentioned for preference ofone radionuclide were: lower background, sharper edgesresulting in better contrast, and absence of esophagealactivity.

In a comparison of 1-hr and 20-hr 123!scans, the 20-hr 1231scans were preferred in a significant number ofinstances by all observers, but in 35%—58%ofcases nodifference was indicated.

Association ofimage interpretation with the comparison of[@mTcJpertechnetate and 123!scans for all readerscombined is summarized in Table 2. For the majorityofglandsjudged as normal, no difference between @mTcand 1231scans was found. However, for abnormal glandsit was apparently easier to choose one radionucide asbetter, and the 1231images were generally preferred,although there remained a large number of cases inwhich no difference was indicated. Comparison of diagnostic “impression―for scans made with the tworadionuclides (Table 3) shows a preference for 1231in allcategories, although there are large numbers of caseswhere no difference was noted, especially for glandsconsidered “normal―or a “diffusegoiter.―In all categories of image interpretation and impression, 20-hr

23! images were considered better than 1-hr 1231 images

but with a large percentage ofcases reported as showingno difference.

Independent evaluation of each film based on imagequality produced a ranking of preference for radio

Technetium-99m and Iodine-i 23 Thyroid Scans Comparison •Kusic et al 395

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findings did not correspond to the palpated nodule.Discrepancies were found twice as often in multinodular than in solitary nodule goiter.

Examples of the types of discrepancies found areshown in Figures 1 through 3.

Table 4 lists cytologic or histologic findings of lesionswith discrepant scan findings. There is no correlationbetween the observed type of discrepancy and cytologyor histology of the nodule. There were 12 carcinomasfound in the study, but none of them was found in thenodules showing discrepancy. Two cancers were foundin the glands with discrepant images but did not correlate with scintigraphic discrepancy.

In two patients with technetium hot/iodine cold discrepancy, the TRH test was normal. In three patientswith technetium hot/iodine normal discrepancy, TRHtests were: normal, blunted, and flat. In two patientswith iodine hot/technetium normal discrepancy, TRHtest was normal as well as in one patient with iodinehot/technetium cold discrepancy.

DISCUSSION

The overall quality of 1231thyroid scans has beenjudged better than @mTcscans in some reported comparative studies (1,4), although the clinical significanceof such findings has not been conclusively demonstrated. In the present study, all readers showed a general preference for 1231,but the differences betweeniodine and technetium images were small and couldnot be considered to be of diagnostic importance. In alarge proportion of cases (27%—58%)scans with bothradionuclides were judged by the different readers to beequal in quality. Differences between average scores forquality of 99mTcand 123!scans were very small, but thelarge number of cases contributed to their significance.

The major reasons for preference of 123!in this andother studies were lower background and the greaterclarity of the picture, but images obtained with bothradionuclides yielded essentially the same information.

A

FIGURE1Palpablenoduleintheisthmuswasaboutequalinfunctiontothe remainderof the glandon [@TcJpertechnetatescan(A)andcoldon1231scan(B).Histology:follicularadenoma

A @‘@- B

FIGURE2Palpablenodulein the left lobe.(A)Nonfunctioningregionon[@“Tc]pertechnetatescan.(B)Increaseduptakeinthenoduleon 1@lscan. Histology:follicularadenoma

Only two pairs of readersin our study had statisticallysignificant agreement in preference for one radionuclidewhile three did not. There seemed a greater variationamong the observersthan between the radionuclides.

The 20-hr 123!scans were preferred in our study to 1-hr scans, but the differences were small and there werea large number of cases in which no difference wasnoted. The relatively high uptake at 1 hr in our patients(5%—15%) and large dose (14.8—18.5 MBq) may account in part for the good quality of early 123!scans,which were satisfactoryfor clinical purposes. To obtain100,000 counts with 1231at 1 and 20 hr required < 10mm in almost all our patients. Ryo et al. (11) found 1-hr 1231scans of poor quality. The 4-hr and 24-hr scanswith 1231were found to be of equal diagnostic value(36). Our study indicates the possibility of obtainingsatisfactory 123!images in even shorter time if uptake ishigh. Normal values are still rather high in Yugoslavia(25%—45%at 24hr).

The prevalence of reported discrepancies between99mTc and radioiodine scintigrams varies (1,2,3,7,8,10,11,37) and probably depends on many factors: se

FIGURE 3Palpable nodule in the lower part of the left lobe correspondedto anareaof apparentlynormal[@“Tc]pertechnetateconcentration(A)butabsent1231concentration(B).Histology:follicularadenoma

;@ .@ -@

A BB

396 TheJournalof NudearMedicine•Vol.31 •No.4 •April1990

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DiscrepantImagesTABLE: Cytolog4icor HistologicFindingsNumberType

of discrepancyof casesCytology orhistology@‘Tc

hot/1231normal2111Colloid

goiterHemorrhagiccysttSevereacuteinfiammationtColloid goiter withcysf99mTc

hOt/1@Icold11112Colloid

goitertHemorrhagiccysttLymphocyticthyroiditistColloid goiter with cystColloidgoiter9smTc

normal/1231cold4111Colloid

goitertNormalthyroid@Lymphocyticthyroiditi&Follicularadenom&s9mTc

normal/123Ihot1Follicularadenom&99mTccold/'231normal4

321Colloid

goitertHemorrhagiccysttFollicularadenomaFollicularneoplasmt99mTc

coid/'@I hot111ColIold

goitertHemorrhagiccysttFollicularadenoma.

Histology.t

Cytology.

omous nodules may have different degrees of functionseen in the relatively suppressed normal thyroid tissue(38). One autonomous nodule with significantly betterfunction in the suppressed tissue with 1231as comparedto 99mTcwas found in the present study. In somepatients with scan discrepancy and hot nodule seenonly with one radionuclide, a TRH test was performed.In one-third of the cases with positive [@mTcJpertech@netate uptake and negative 1231uptake, the TRH testwas abnormal (flat or blunted). In all cases with apositive 1231uptake and negative [@Tc]pertechnetateuptake, the TRH test was normal. Although the mostsensitive study (the suppression test) was not performed,the results suggest that not all nodules which are hotonly with one radionuclide show autonomous function.There seems a greaterprobability of autonomy in nodules appearing hot only with @mTcthan in nodulesappearing hot only with 1231but the number of suchcases was rather small.

In the present study, the @“Tcimages were morelikely to be described as abnormal and classified asrepresentingmultinodular goiters than 123!scans. Thepathophysiology and significance of such findings hasnot been clarified. In 1983, Ryo et al. reported thatmore lesions with increased uptake can be demonstrated on 99mTcscintigraphythan on 1231scintigraphy(1 1). They concluded that the sensitivity of@mTc scanfling in detecting lesions is higher than that of 123!.Inour study, the frequency of that kind of discrepancy,however, was not high. The use of ultrasound is probably desirable to assist in establishing the diagnosis insuch situations. Occurrence of the multinodular imagepattern in a palpatory uninodular goiter is not uncommon (11,39). The value of finding multiple scan abnormalities in palpatory uninodular goiter has beenquestioned. Such findings may make cancer in thenodule less likely.

Few discrepancies between 1-hrand 20-hr 123!scanswere noted, although there were some variations in thedegree of function in the present study. In two cases, 1-hr 1231scans were more similar to 99mTcthan to the 20-hr 1231scans. The quantitative differences between areasof normal and deficient organic binding may increasewith time (9).

Oblique views generally were felt to minimize theincidence ofdiscrepancies in the present study. On rareoccasions, however, oblique views introduced a discrepancy which was not seen on the anterior view. Inmultinodular goiters, different areas sometimes showeddifferent kinds of discrepancies.

Cytologic and histologic examinations of noduleswith discrepantimages have revealeda varietyof lesions(9,14—16,19,22,26,27,29,30). The lack of correlation

reported in the literature between the type of discrepancy observed and histology ofthe nodule is confirmedin the presentstudy. Microscopic foci ofcarcinoma that

lection of patients, the imaging procedures (timing ofthe images, scanning equipment), use of 1311or 1231,criteria used for evaluating images, etc. Usually 24-hrradioiodine images were reported, although some authors used earlier times, even 20 mm after i.v. administration (4). In some studies, a large proportion of thesubjects had no thyroid abnormality or had Graves'disease (1,3) and a low frequency of discrepancy wasfound. This is in contrast to the studies where a highproportion of the patient population had nodular ormultinodular goiter (2,11,20). It appears in all studiesthat the patients with multinodular goiter have thehighest frequency of discrepancy. In the present study,patients were selected for inclusion because of findingon palpation of a solitary or dominant nodule withpresumed greater risk ofmalignancy. In addition, imageevaluation and precise correlation of the pathologic orcytologic findings with scan abnormalities in multinodular goiter is usually difficult. However, a number ofmultinodular goiters were inevitably included. The relatively low frequency of discrepancies (5%—8%)in thepresent study, is probably due to patient selection.Discrepancies were found twice as often in multinodular image patterns than in images showing a solitaryabnormality.

The radioiodine scan and technetium scan of auton

Technetium-99m and Iodine-i 23 Thyroid Scans Comparison •Kusic et aJ 397

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could not be the cause of the discrepant scan findinghave been reported (30). In the present study, a similarcase of lack of correspondence of carcinoma and scandiscrepancy in the same gland was found.

The most frequent explanation for positive @mTcuptake and negative radioiodine uptake has been thatthese nodules retain the ability to concentrate monovalent anions (pertechnetate and iodine) but have lostthe ability to organify iodine (23), allowing it to bereadily discharged. Some lesions which are hot on 99mTcscan and not visualized on radioiodine scan may beautonomous and have a rapid iodine turnover in thenodule (24). In the present study, no malignancy wasfound in patients with 99mTcpositive and radioiodinenegative scans. Detailed review ofthe literature suggeststhat the frequency of thyroid carcinoma with suchdiscrepancy is very low. In addition to four case reports(14,16,1 7,18) in three studies comparing the two

radionuclides (15,20,21), only three cases were reported. In all of these studies, ‘@‘Iwas used for radioiodine scintigraphy with the relatively poor resolutionof the rectilinear scans in some studies. In one study,the unusually high number of discrepancies caused bycancers particularly follicular (twice as many as all casesreported in the literature) remains unexplained (19).These cases, however, heavily influence literature recommendations for managing discrepant nodules.

Although these and similar findings are frequentlyquoted as the basis for the recommendation that nodules with positive [@mTc]pertechnetate uptake be reimaged with radioiodine, this may not be optimumstrategy for evaluation of such findings. Since autonomous nodules are almost never malignant, the mostappropriate next step would probably be the TRH test(40), measurement of TSH with sensitive assay, or

suppression test to define possible autonomy in thenodule.

The present study and careful review ofthe literaturelead to the conclusion that the slightly better overallquality of 1231scans does not in itselfprovide sufficientadvantage to justify recommendation of the use of 1231over [99mTc]pertechfletatefor routine thyroid imaging.This is particularly true in view ofthe present tendencyto consider the usefulness of thyroid imaging limitedwhere its principal benefit is to differentiate cold fromhot nodules. In addition, @mTcmay be a more practicalagent than 1231for general use. Discrepancies in imagesare rare and appear most often in multinodular goiterwhere they are probably of only minimal importance.There is no correlation between the type of discrepancyand the histology of the lesions. Discrepancies are farmore likely to be caused by benign thyroid disordersthan malignancy. The risk ofcancer in nodules appearing hot with 99mTcand cold with radioiodine is probablyso low that routine re-imaging of hot nodules on the99mTcscan with radioiodine is not necessary.

ACKNOWLEDGMENTSPresented in part at the 35th Annual Meeting ofThe Society

of Nuclear Medicine, San Francisco, June 14—17,1988.The authors thank Dr. Richard S. Benua, Dr. James R.

Hurley, Dr. Zeljka Labar, Dr. Paul W. Lee, Dr. Harry R.Maxon, Dr. Hiroshi Nishiyama, Dr. Ivo Padovan, and Dr.Ivo @lausfor their cooperationand Dr. David N. Charkesforhis criticalreviewof the manuscript.The authors are gratefulto Mallinckrodt Diagnostica (Byk Sangtec), Vienna, Austria,for generouslydonating the initial supply of 1231.This studywould not have been possible without the cooperation of thetechnical staff and secretarial expertise of Miijana Ivathéfrom the Department of Nuclear Medicine and Oncology,University Hospital “Dr.M. Stojanoviá,―Zagreb, Yugoslavia.

This material is based on work supported by the U.S.-YugoslavJoint Fund for Scientificand TechnologicalCooperation, in cooperation with DHHS/FDA under Grant No.02-660-F.

REFERENCES

1. Atkins HL, Klopper JF, Lambrecht RM, Wolf AP. A comparison of technetium-99m and iodine-l23 for thyroid imaging.AmiRoentgen1973;117:195—201.

2. Gorowski T, Chomicki OA. Some comparative studies using99mTcand ‘@‘Iin thyroid scanning. Nuk/earmedizin 1976;15:268—272.

3. Prince JR. Zubi SM, Haag BL. Thyroid imagingwith iodine125 and technetium-99m. Eur J Nuc/ Med 1979; 4:37—41.

4. Shapiro B, Britton K, Fountos A, et al. A multiobservercomparison of@mTcO4and 231thyroid imaging. Eur. J Nuc/Med 1981;6:135—138.

5. Schultz JL, Hanner TG, Witcofski RL, Maynard CD. Comparison of@―Tcand 125!thyroid scans [Abstract]. J Nucl Med1966; 7:797.

6. Weber PM, Dos Remedios L, Fish M, PollycoveM. Thyroidimaging 1311or @mTc:a clinical comparison [Abstract). JNuclMed 1969; 10:451.

7. Marion MA, Ronai PM, Pain RW, Wise PH. Simultaneousassessment ofthyroid structure and function with the gammacamera using pertechnetate: a comparison with radioiodineand biochemicaldiagnosis.Aust N Z iMed 1974;4:379—384.

8. Arnold JE, PinskyS. Comparison of@mTcand 1231for thyroidimaging.JNuclMed1976;17:261—267.

9. Dige-PetersenH, Kroon S, Vadstrup 5, Andersen ML, RoyPoulsen NO. A comparison of@mTcand 123!scintigraphy innodular thyroid disorders. Eur J NucIMed 1978;3:1—4.

10. Kalk WJ, Van Drimmellan M, Klugman L, Silberman R,Levin J. Comparison of @mTcand 1311scans in thyroidfunction studies. S Afr Med J 1979; 56:839—840.

11. Ryo UY, Vaidya PV, Schneider AB, Bekerman C, PinskySM. Thyroid imaging agents: a comparison ofl-l23 and Tc99m pertechnetate. Radiology 1983; 148:819—822.

12. Miller JM. Evaluation of thyroid nodules. Accent on needlebiopsy. Med C/in North Am 1985; 69:1063—1077.

13. Rojeski MT, Gharib H. Nodular thyroid disease. Evaluationandmanagement.NEnglJMed 1985;313:428—436.

14. SteinbergM, Cavalieri RR, Choy SH. Uptake of technetium99m pertechnetate in a primary thyroid carcinoma: need forcaution in evaluatingnodules.J C/in Endocrinol 1970;31:81—84.

15. Shambaugh GE, Quinn JL, Oyasu R, Freinkel N. Disparatethyroid imaging. Combined studies with sodium pertechnetate Tc-99m and radioactiveiodine. JAMA 1974;228:866—869.

16. Turner JW, Spencer RP. Thyroid carcinoma presenting as a

398 TheJournalof NuclearMedicine•Vol.31 •No.4 •April1990

by on June 13, 2017. For personal use only. jnm.snmjournals.org Downloaded from

pertechnetate “hot―nodule, but without 131juptake: casereport. J NucIMed 1976; 17:22—23.

17.QuinnJL,HenkinRE.Scanningtechniquestoassessthyroidnodules. Ann Rev Med 1975; 26:193—201.

18. O'Connor MK, Cullen MJ, Malone iF. A kinetic study of(‘@‘l)iodide and (99mTc)pertechnetate in thyroid carcinomasto explain a scan discrepancy: case report. J Nucl Med 1977;18:796—798.

19. Erjavec M, Movrin T, Auersperg M, Golouh R. Comparativeaccumulation of99mTcand 1311in thyroid nodules: case report.JNuclMed 1977;18:346—347.

20. Massin JP, Planchon C, Accard JL, Perez R. Discordancesscintigraphiques entrele technetium 99m et l'iode 131 dansl'etude des nodules thyroidiens.NouvPresseMed 1977;6:97—100.

21. SzonyiG, BowersP. Allwright5, et al. Comparative study of99mTcand ‘@‘Iin thyroid scanning. Eur J Nucl Med 1982;7( 10):444—446.

22. Usher MS. Arzoumanion AY. Thyroid nodule scans madewith pertechnetate and iodine may give inconsistent results.JNuclMed 1971;12:136—137.

23. Demeester-Mirkine N, Van Sande J, Corvilain J, DumontJE. Benign thyroid nodule with normal iodide trap and defective organification. J C/in Endocrino/ Metab 1975;41:1169—1171.

24. Miller JM, Kasenter AG, Marks DS. Disparate imaging ofthe autonomous functioning thyroid nodule with @“Tcpertechnetate and radioiodine. Radiology 1976; 119:737—739.

25. Kim E, Kumar B. Discrepant imaging ofnodular hyperplasiawith pertechnetate and radioiodine. C/in Nucl Med 1976;1:204—205.

26. Hirabayashi 5, Koga Y, Kitahara T, Hishida T, Kiga M,Lindo S. Inconsistent images of thyroid nodule scintigramsmade with iodine and pertechnetate: case report. J NucIMed1975;16:918.

27. Barth JD, Bakker WH, Hennemann G. Discrepancies between iodine and technetium thyroid scintigraphy. JAMA1978: 240:463—464.

28. Thrall JH, Burman KD, WortofskyL, Corcoran Ri, JohnsonMC,GillinMT. Discordantimagingofa thyroidnodulewith

‘@‘Iand 99mTc:concordance of ‘@‘iand fluorescent scans.Radiology1978;128:705—706.

29. BrowneHG. Report ofa case ofdisparate imaging in thyroidscintigraphswith histopathologiccorrelation.J Tenn MedAssoc 1979; 72:368—370.

30. Ryo UY, Vaidya P, Schneider A, Pinsky SM. Histopathologyofthyroid lesionsthat caused discrepant findingsbetween Tc99m scanand 1-123scan [Abstract].JNuclMed 1979;20:678.

31. Tennvall J, Cederquist E, Moller T, Naversten Y, AkermanM. Preoperativescintigraphywithcorrelationto cytologyandhistopathologyin carcinoma ofthe thyroid. Ada Radio Oncol1983;22:183—191.

32. Vorne M, Jarvi K. @‘Tc-pertechnetatein the detection ofthyroid carcinoma in a ten year period. EurJ Nuc/Med 1987;I3:362—365.

33. Paras P, Saenger EL, Spaventi @,Kusiê Z. Comparativestudies of 1-123and Tc-99m as imaging agents for thyroiddisorders. Proceedings ofthe third world congress of nuclearmedicine and biology. Paris:Pergamon Press; 1982; 1:794—798.

34. Fisher RA, Yates F, eds. Statistical tables for biological,agriculturaland medical research.New York: Hafner PublishingCo.; 1953.

35. Mathematica/methodsforstatistics. Princeton, NJ: PrincetonUniversityPress; 1946.

36. Rosenthal SL, Hofeldt FD, Verdon TA. Comparison of 4-and 24-hr thyroid scans with 1231:concise communication. JNuc/Med 1976;17:1050—1052.

37. Strauss HW, Hurley PJ, Wagner HN. Advantages of @@mTcpertechnetateforthyroidscanningin patientswithdecreasedradioiodine uptake. Radiology 1970;97:307—310.

38. Massin JP, Planchon C, Perez R. Comparison of @mTc@pertechnetate and ‘@‘Iin scanning of thyroid nodules. C/inNuc/ Med 1977;2:324—333.

39. Alderson P0, Sumner MW, Segel BA. The single palpablethyroid nodule. Evaluation by 99mTcpertechnetate imaging.Cancer 1976; 37:258—265.

40. Ng Tang Fui S, Maisey MN. Thyroid disease. In: Maisey MN,Britton KE, Gilday DL, eds. Clinical nuclear medicine. Philadelphia-Toronto: WB Saunders Company; l985;197—247.

399Technetium-99m and Iodine-i 23 Thyroid Scans Comparison •Kusic et al

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1990;31:393-399.J Nucl Med.   Zvonko Kusic, David V. Becker, Eugene L. Saenger, Peter Paras, Peter Gartside, Terry Wessler and Sime Spaventi  Correlation with Pathologic FindingsComparison of Technetium-99m and Iodine 123 Imaging of Thyroid Nodules:

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