Radiology and Endocrinology

ANATOMY
Radiography
Ultrasound
CT
MRI

FUNCTION
Radionuclide
Imaging
- Scintigraphy
- PET

Radionuclide Imaging
Images metabolic pathways
Pharmaceutical which mimics a component of a
normal metabolic pathway is administered to the
patient
Pharmaceutical radiolabelled so that its
distribution in the patient can be visualised with a
gamma camera

Ideal Radionuclide
emits gamma radiation at suitable energy
for detection with a gamma camera
(60 - 400 kev, ideal 150 kev)
should not emit alpha or beta radiation
half life similar to length of test
cheap
readily available

Ideal radiopharmaceutical
cheap and readily available
radionuclide easily incorporated without
altering biological behaviour
radiopharmaceutical easy to prepare
localises only in organ of interest
t1/2 of elimination from body similar to
duration of test

Thyroid - radiography
Little role
Thyroid mass diagnosed incidentally on
chest radiograph
Thoracic inlet views may demonstrate
tracheal compression

Thyroid - ultrasound
High resolution (5 - 10 MHz)
Confirms - mass is thyroid
cystic or solid
single or multiple
cannot distinguish solid carcinoma from
solid dominant nodule
Not useful in hyperthyroidism

Thyroid - CT/MRI
Not as good as US at resolving lesions
within the thyroid
Best tests for assessing mediastinal
disease
CT better than MRI for calcification
MRI better than CT for distinguishing
between fibrosis and residual tumour

Thyroid - scintigraphy
PERTECHNETATE
Trapped but not organified
Competes with iodide for uptake
Cheap and readily available
IODINE (123I or 131 I)
Trapped and organified
Better for retrosternal goitres
Expensive, cyclotron generated
RECENT (10 days) IODINE CONTRAST BLOCKS UPTAKE
99m

Thyroid scintigraphy
Tc 123 NaI
ADMIN iv po/iv
99m

PATIENT withdraw thyroid Rx

PREP avoid high Iodine foods
IMAGING 15 min pi
24 hr po

1-2hr pi

Hyperthyroidism
RN uptake
1. Thyroid gland (>95%)
Toxic nodular goitre
Diffuse toxic goitre (Graves)
Thyroiditis

2. Exogenous T3/4/iodine
Iatrogenic
Iodine - induced
(XRay contrast, amiodarone)

Thyroid nodules
Risk of malignancy
Overall 10%
US - cystic 0.3 - 10%
US - solid
????
RNI - cold 16%
RNI - hot
4%
First line investigation: Cytology +/- US

RNI in thyroid disease

Investigation of hyperthyroidism
Location of ectopic thyroid tissue
(congenital hypothyroidism, retrosternal
goitre)
Little role in thyroid nodules

1ry Hyperparathyroidism

Adenomas
Hyperplasia
Carcinoma

Type

Single
Chief cell
Clear cell

80
15
1
4

RN parathyroid imaging
Tc / 201Tl 99mTc-MIBI
subtraction scansearly/late scans
99m

False positives: thyroid pathology

False negatives: parathyroid hyperplasia
Both good for ectopic parathyroids

Parathyroid imaging
US

not good at finding ectopic glands

CT

Contrast
Surgical artifacts

MRI Good for localisation and ectopic

glands

Imaging parathyroids
Uncomplicated 1ry hyperparathyroidsim
90 -95% surgical success rate without imaging
Recurrent/persistent hyperparathyroidism
surgical success rate without imaging -50%
with imaging - 90%
(combined RNI + MRI)

Adrenal glands
Cortex

aldosterone
cortisol
adrenal androgens

Medulla

adrenalin

Adrenal glands
AXR - may show calcification
US - large masses only (unless neonatal)
CT - can detect small lesions
- cannot distinguish metastases from nonfunctioning adenomas
MRI - small lesions
- may distinguish mets from
non-functioning adenomas

Adrenal cortical RNI

Radiolabelled cholesterol esters
(75 Seleno-methylnorcholesterol,
131 I - 6B iodomethyl-19-norcholesterol)
Image at 4 and 7 days
> 50% difference in activity between sides is
abnormal

RNI in Cushings syndrome

ACTH-dependent CS bilat
pituitary/ectopic
ACTH -independent CS
bilat nodular hyperplasia bilat
adrenocortical adenomauni
Adrenocortical carcinomabilat

Cushings syndrome
Diagnosis - biochemistry
Localisation - CT/MRI
for
1. Pituitary ACTH-dependent
2. Ectopic ACTH-dependant
3. ACTH - independant
RNI not usually necessary

RNI and Cushings syndrome

Used for
1. Finding residual functioning adrenal
remnants if recurrent disease after prior
bilateral adrenalectomy
2. Somatostatin receptor scanning for
ectopic ACTH from small bronchial
carcinoid tumours

Primary aldosteronism
small tumours may not be seen with
CT/MRI
RNI + dexamethasone suppression can
find tumours < 1cm
Adrenal visualisation before 5 days is
abnormal (bilateral/unilateral)

Adrenal medullary RNI

Phaeochromocytoma
Paraganglioma
Neuroblastoma
Ganglioneuroblastoma
Ganglioneuroma

Adrenal medullary RNI

Metaiodobenzylguanidine (MIBG)
- localises in catecholamine storage
vesicles of adrenergic nerve endings
- 123 I or 131 I
somatostatin receptor imaging
111 In octreotide

MIBG

phaeochromocytomas (95% sensitivity)

neuroblastoma
(80 - 90% sens)
carcinoid
medullary thyroid carcinoma

(MEN syndromes)

Phaeochromocytomas
10%

malignant
bilateral
extra- adrenal
paediatric

Phaeochromocytomas
Diagnosis - biochemistry
Localisation
CT if > 2cm
RNI to exclude - small tumours
- bilateral adrenal
- multifocal
- metastases

Incidentalomas
Incidental adrenal mass in patients
undergoing abdominal imaging (2%)
Q. Is it functioning?
Is it benign or malignant?

Functioning incidentalomas
Diagnosis
Clinical features
Biochmistry
Confirmation
RNI

Non-functioning
Non-functioning adenoma vs. metastasis
CT using attenuation values

MRI - chemical shift imaging

Radiology and Endocrinology

Localisation
not

Diagnosis

IMAGING
and the
ENDOCRINE SYSTEM