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Abstract Marine-Lenhart Syndrome is a rare entity, described as Graves' disease with coexisting functioning thyroid nodules. It is often diagnosed on thyroid scintigraphy as a cold nodule with surrounding extranodular hyperactivity initially and postradioiodine ablation, they regain function on the follow-up thyroid scintigraphy due to endogenous thyroid-stimulating hormone (TSH) stimulation. We retrospectively reviewed all thyroid scintigraphy database performed between January 2018 and March 2020 in our institute. We searched patients with Graves' disease with the following criteria to suggest Marine-Lenhart Syndrome: (a) initial thyroid scintigraphy showing features of Graves' disease with coexistent poorly functioning nodules (b) There is normalization of uptake within the nodule on thyroid scan after radioiodine ablation suggestive of endogenous TSH stimulation (this also indirectly proves nodules are TSH dependent), (c) nodule(s) is/are benign on fine-needle aspiration cytology. Four patients (1.46%) were confirmed as Marine-Lenhart Syndrome as per the criteria. Three patients were female, and one was male. The eye signs were present in two of four patients. Two patients had two hypofunctioning nodules, whereas the remaining two had a single nodule and required re-ablation with radioiodine. Marine-Lenhart Syndrome requires special attention as these patients are relatively radioiodine resistant, require higher activity for iodine-131; however, it is curable with radioiodine treatment.

Thyroid nodule is one of the most common endocrine diseases in the world; it occurs in 4-7% of the general population. Depending on the method of discovery, 4-8% nodules are discovered using palpation, 10-41% with ultrasound (US), and 50% through autopsy where only 20% or less of cold thyroid nodules are caused by cancerous lesions. The aim of this study was to assess US as supporting modality for thyroid scintigraphy to predict malignancy in patient with thyroid cold nodules. In a retrospective study between 2009 and 2013, we analyzed 399 subjects with cold thyroid nodule, where 39 subjects (36 women and 3 men) presented with malignant thyroid cold nodule and 19 subjects underwent US. The US showed malignancy parameters in 8 (42.11%) subjects, while the rest of the 11 (57.89%) subject were benign. Out of all the subjects who underwent US in this study, only 8 (42.11%) subjects shown malignancy characteristics in cold thyroid nodule with  papillary thyroid cancer (PTC). That means US parameters of malignant thyroid nodule do not always show up in malignant cold thyroid nodule.

Common causes of unilateral breast uptake of Tc-99m pertechnetate are predominant breast-feeding on one side, mastitis, and breast cancer. Uptake of Tc-99m pertechnetate in the epithelial cells of the breast, like that of iodide, depends on the transmembrane sodium/iodide symporter (NIS), the expression of which is known to be greatly enhanced during lactation and in breast cancer. The authors present an interesting case of predominant left breast uptake of Tc-99m pertechnetate detected incidentally during thyroid scintigraphy, for the evaluation of a nodule in the left lobe of thyroid.

Warthin-like Papillary thyroid carcinoma (WPTC) is a rare variant of papillary carcinoma of thyroid, PTC which derives its name by closely resembling Warthin's tumor of salivary gland. Hallmark histological feature of this variant is papillary folding lined by oncocytic neoplastic cells with clear nuclei and nuclear pseudoinclusions, accompanied by prominent lymphocytic infiltrate in the papillary stalks. It is thought to be one of those differentiated thyroid cancers with favorable prognosis. We report a case of Graves' disease with a cold nodule harboring WPTC with initial presentation of lymph nodal metastases. It is important to identify this peculiar variant of PTC as 5 to 10% of them undergo dedifferentiation and 30% have the lymph nodal metastases and extra thyroidal extension.

Abstract One of the treatment options for benign thyroid nodules is radioactive iodine (RAI). However, this treatment is more effective for hot/warm solid thyroid nodules. Cold thyroid solid nodules are characterized by the lack of iodine uptake compared to normal thyroid tissue. Oral retinoic acid (RA) is a synthetic derivative of Vitamin A. The effect of RA on the uptake of RAI is still controversial. The aim of this study was to evaluate the effect of RA in the ability of a cold solid thyroid nodule to take up RAI. Individuals with a cold solid thyroid nodule based on ultrasonography and thyroid scintigraphy were included. Participants with liver dysfunction, smokers, and pregnant patients were excluded from the study. Each participant underwent thyroid uptake scintigraphy twice (pre- and post-RA consumption) using 35–37 MBq NaI-131. Participants consumed RA at a dose of 1 mg/kg body weight (BW) followed with 1.5 mg/kg BW. This study was approved by Dr. Hasan Sadikin General Hospital Ethic Committee. A total of 12 cold thyroid solid nodules were evaluated. The mean percentage of the nodule uptake value pre- and post-intervention was 1.11% and 0.62%, respectively ( P = 0.004), while normal thyroid tissue uptake values pre- and post-intervention were 27.57% and 13.40%, respectively ( P = 0.002). The percentage alteration of nodules and normal thyroid tissue uptake value were 42.4% and 51.5% lower, respectively ( P = 0.354). This study showed that RA reduces the ability of cold solid thyroid nodule, as well as normal thyroid tissue, to take up RAI.

Secondary neoplasm of the thyroid mimicking a primary thyroid lesion is a rare finding, especially in an individual without a past history of malignancy. A case of squamous cell carcinoma metastatic to the thyroid (presenting as a solitary thyroid nodule), who had an unsuspected primary in the esophagus is described. Usually, multiple areas of the gland are involved in the secondary involvement of the thyroid. The clinical presentation of an apparently asymptomatic mass with neck lymphadenopathy, normal thyroid functions, and a cold nodule on 99mTcO4- thyroid scan can often lead to a misdiagnosis as primary thyroid neoplasm. The present case underscores the fact that due importance to the subtle signs and symptoms and a high degree of suspicion, whenever the histology is unusual for a thyroid primary, is needed and the workup should include ruling out other primary malignancies.

There is no consensus on the appropriate management of benign cold nodules of the thyroid gland. This study addresses the problem in an iodine-deficient area, evaluating the efficacy of levothyroxine suppression therapy on a 2-year course.  A total of 58 patients affected with benign cold nodules of the thyroid were enrolled. With a double-blind placebo-controlled design, levothyroxine (1.5-–2  μμg/kg/day) was delivered to the 31 cases over 2 years. The consequences of this treatment were compared with 27 controls. Nodule size was measured with high-resolution ultrasonography. In the treatment group, the mean volume on baseline was 12.8  ±± 11.9 ml and changed to 9.4 ±± 9.8, 12.4 ±± 16.7 and 10.8 ±± 9.7 ml in  months 6, 12 and 24, respectively. In the placebo group, these figures were 13.0 ±± 10.2, 11.5 ±± 8.0, 11.7 ±± 13.6 and 11.6 ±± 8.5 ml, respectively. No significant difference between the two groups was observed. Thyroid-stimulating hormone suppression with levothyroxine for 2  years was not effective in reducing the size of benign cold nodules of the thyroid gland.

Various diagnostic techniques have been successfully used in the clinical management of cold nodules; however, the decision on whether to employ surgery or a conservative treatment is not always easy. This study was designed to appraise the diagnostic value of technetium-99m methoxyisobutylisonitrile (MIBI) scintigraphy in the assessment of cold nodules detected using ^sup 99m^Tc-pertechnetate. Fifty-two patients were included in the study. All had already been selected for surgery, based on their clinical and laboratory findings, including fine-needle aspiration biopsy. The total number of cold nodules on ^sup 99m^Tc-pertechnetate scans was 59. The thyroid scan was performed 20-40 min after i.v. injection of 400 MBq of ^sup 99m^Tc-MIBI. Uptake of MIBI in thyroid nodules was compared with that in the surrounding normal thyroid tissue, and a score of between 0 and 3 was assigned to each nodule as follows: 0, cold; 1, decreased; 2, equal; 3, hot. Definitive histology revealed nodular goitre in 24 cases, adenoma in 19, thyroiditis in 1, differentiated cancer in 12, medullary cancer in 2, and anaplastic cancer in 1. None of the degenerative nodules were hot on MIBI scan, while the adenomas showed a variety of MIBI imaging patterns, most frequently the score 3 pattern. In the diagnosis of differentiated thyroid cancer the sensitivities of score 3 and score 2+3 MIBI uptake patterns were 83% (10/12) and 100%, respectively. The score 3 MIBI uptake pattern had a specificity of 100% and a positive predictive value of 100% with respect to thyroid (benign and malignant) neoplastic diseases, whereas a specificity of 72% and a positive predictive value of 43% were observed in the detection of differentiated cancer. After a cold nodule had been detected using ^sup 99m^Tc-pertechnetate, a second scan with high MIBI uptake increased by 7.8 times the probability that this nodule would be a differentiated cancer. In conclusion, ^sup 99m^Tc-MIBI scintigraphy is a useful method in the differential diagnosis of cold thyroid nodules if the primary aim is to differentiate degenerative from neoplastic diseases rather than to differentiate benign from malignant nodules. High MIBI uptake considerably increases the probability of a differentiated thyroid cancer and facilitates immediate surgical removal, while decreased uptake actually excludes it. We suggest a combination of fine-needle aspiration biopsy and MIBI scan as a routine diagnostic approach to cold thyroid nodules.[PUBLICATION ABSTRACT]

In current practice, thyroid scintigraphy is predominantly used for thyroid nodules in patients with subnormal TSH. We present radiopharmaceuticals used for imaging and therapy and describe imaging procedures and interpretation of findings. Differences between European and US practices are addressed. Patient preparation and instructions prior to nuclear thyroid imaging and therapy are described. We discuss the current indications for radioiodine therapy of benign nodular disease, how the administered dosage is determined, and the results and complications of radioiodine treatment. Nuclear medicine evaluation of nodular thyroid in children is addressed briefly. The potential role of nuclear medicine imaging in the differentiation of benign from malignant follicular lesions is reviewed. Lastly, how to approach incidental finding of increased uptake of 18F-FDG in a thyroid nodule is discussed.

Patients with Graves’ disease are common to all general endocrine outpatient clinics and management options for these individuals are generally straight forward. Thyroid nodules are also frequently encountered and can present more of a clinical challenge. Less common is the finding of thyroid nodules associated with Graves’ and these individuals may require greater consideration. This case addresses the treatment options available for Graves’ disease along with the management and investigation of thyroid nodules.