REPOST: Dr. Ain: Re: - Lithium Protocol --> Pam

December 17, 2002

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(Dr. Ain)

Date: Sun, 16 Jul 2000 14:04:22 -0500

Subject: Re: Lithium in Thyroid Cancer

In-reply-to: <010a01bfee32$03207ee0$2417173f@default>

> >From Werner & Ingbar's the Thyroid (textbook):

>

>LITHIUM. This drug enhances tumor I-131 retention by reducing release of

>iodine from normal thyroid and tumor tissue. In a dosage of 400 to 800 mg

>daily (10 mg/kg) for 7 days, lithium increases I-131 uptake in metastatic

>lesions while only slightly increasing I-131 uptake in normal tissue. Serum

>lithium concentrations should be measured frequently and maintained between

>0.8 and 1.2 mmol/L. Radiation of tumors in which the biologic half-life of

>iodine is short (<6 days) is maximized without increasing that to other

>organs.

>

>(Ref. Clin Nucl Med 1987;8:644)

Dear ThyCa Members:

The above comment is INCORRECT. Lithium does NOT enhance I-131 uptake into

tumors. Instead, it enhances I-131 RETENTION in tumors which have already taken

it up. This distinction is important because lithium is not capable of making a

negative I-131 scan into a positive scan. Rather, some patients with apparently

reasonable uptake of I-131 into their tumors fail to kill these tumors with

I-131 because the tumor discharges the I-131 before an effective radiation dose

is delivered. In these specific cases, lithium can cause the tumor to retain

the radioactive iodine longer and gain better effect of the administered I-131

dose. I participated in much of this research and co-authored the most recent

study with my NIH colleagues [Koong SS, Reynolds JC, Movius EG, Keenan AM, Ain

KB, Lakshmanan MC & Robbins JR (1999) Lithium as a potential adjuvant to 131I

therapy of metastatic, well differentiated thyroid carcinoma. J Clin Endocrinol

Metab 84, 912-916].

**************PLEASE BE ADVISED**********************

THE INFORMATION CONTAINED IN THIS COMMUNICATION IS INTENDED

FOR EDUCATIONAL PURPOSES ONLY. IT IS NOT INTENDED, NOR SHOULD

IT BE CONSTRUED, AS SPECIFIC MEDICAL ADVICE OR DIRECTIONS. ANY

PERSON VIEWING THIS INFORMATION IS ADVISED TO CONSULT THEIR OWN

PHYSICIAN(S) ABOUT ANY MATTER REGARDING THEIR MEDICAL CARE.

*************************************************

B. Ain, M.D.

Associate Professor of Internal Medicine

Director, Thyroid Nodule & Oncology Clinical Service

Director, Thyroid Cancer Research Laboratory

Division of Endocrinology and Molecular Medicine

Department of Internal Medicine, Room MN524

University of Kentucky Medical Center

800 Rose Street, Lexington, Kentucky 40536-0298

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(Dr. Ain)

Date: Sun, 16 Jul 2000 16:18:09 -0500

Subject: Re: Lithium in Thyroid Cancer #2

In-reply-to:

>Dr. Ain , Should everyone who is going in for I-131 take lithium to help with

>[retention], or is this used only in specific cases? I am asking because I go

in

>next week for a 150 mCi dose and I want it to be as effective as possible!

Bekki

>tg 88, clean scan

Dear ThyCa Members:

Only a portion of patients with thyroid cancer have rapid turnover of I-131 in

their tumor. It is my practice to do a 24 hour and a 48 hour whole body scan

after the administration of the I-131 tracer dose. This permits me to see if

the tumor sites are rapidly discharging their I-131 and would require lithium to

enhance the therapy. Sometimes, if previous treatments have been unsuccessful,

I both increase the administered dose of I-131 and give lithium carbonate for

the next I-131 treatment.

I do not routinely use lithium carbonate on ALL patients because: 1)

hypothyroid patients often have nausea due to delayed gastric emptying and

lithium can aggravate nausea; 2) there is a very narrow interval between

adequate blood levels of lithium and toxic blood levels of lithium, requiring

the dosage of lithium to be carefully adjusted for at least 3 days before the

I-131 is given, with measurements of the lithium level in the blood; and 3)

when lithium is used for this purpose, it must be started 3 days before

treatment and continued for 5 days after treatment to get the appropriate

possible benefit. On the other hand, I do not hesitate to use lithium in the

appropriate circumstances and with careful preparation of my patients and

documentation of its benefit with post-therapy whole body scans at 48 hours and

again (usually) at 4-5 days.

In the situation above, with a " clean " I-131 scan, lithium does not have any

specific indication. On the other hand, it would be critical to measure a

24-hour urine specimen to be sure that the cause of the " clean " scan is not due

to interfering non-radioactive iodine.

**************PLEASE BE ADVISED**********************

THE INFORMATION CONTAINED IN THIS COMMUNICATION IS INTENDED

FOR EDUCATIONAL PURPOSES ONLY. IT IS NOT INTENDED, NOR SHOULD

IT BE CONSTRUED, AS SPECIFIC MEDICAL ADVICE OR DIRECTIONS. ANY

PERSON VIEWING THIS INFORMATION IS ADVISED TO CONSULT THEIR OWN

PHYSICIAN(S) ABOUT ANY MATTER REGARDING THEIR MEDICAL CARE.

*************************************************

B. Ain, M.D.

Associate Professor of Internal Medicine

Director, Thyroid Nodule & Oncology Clinical Service

Director, Thyroid Cancer Research Laboratory

Division of Endocrinology and Molecular Medicine

Department of Internal Medicine, Room MN524

University of Kentucky Medical Center

800 Rose Street, Lexington, Kentucky 40536-0298

& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &

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(Dr. Ain)

Date: Tue, 17 Dec 2002 08:09:09 -0500

Subject: Assessing radioiodine retention in tumors

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>Dr. Ain;

>How is poor retention determined? Since my TT in '98 I've had 150mci

>(hypo after surgery). Uptake in thyroid bed w/ Thyrogen scan in '99,

>went hypo took 30mci. Uptake in thyroid bed w/ Thyrogen scan, went

>hypo took 210 mci in '00. Clean Thyrogen scan in '01, although I'm

>skeptical because the person doing the scan had trouble doing the

>neck scan & had to redo it, they did the scan on a Fri. & had me come

>back the following Wed. (in the past I'd come back on Mon.).

>The nuclear med. dr. reviewed my Thyrogen scan with me last week and

>it showed uptake in the thyroid bed again.

>How common is it to have taken 3 high RAI doses & still have tissue

>in the thyroid bed? In the past my Tg test has shown antibodies, I

>did have it done again last week when hyper, I have a call in to the

>endo. to discuss this whole situation.....I just dread going hypo

>again.

>Pam

>Rochester, NY

Dear ThyCa Members:

There are a wide variety of approaches to radioiodine scanning and

assessment. Some Nuclear Medicine sections rely upon a " cookbook "

approach, using techniques based upon " standard protocols, " while

others take a more analytical approach in order to obtain more useful

data. The method used at the University of Kentucky employs scans

obtained at both 24 and 48 hours after tracer dose administration in

order to directly evaluate the adequacy of radioactive iodine

retention in tumor tissue and determine whether use of lithium

carbonate would be helpful to enhance therapy effectiveness. For a

variety of reasons, we do not routinely use Thyrogen for these scans

(Thyrogen is not approved nor advised for radioiodine treatments) and

this technique is applied to patients prepared with hypothyroid

withdrawal. There are many other reasons, besides " poor retention, "

to account for poor treatment response and this is why some patients

require evaluation in more specialized clinical practices.

--

**************PLEASE BE ADVISED*********************

THE INFORMATION CONTAINED IN THIS COMMUNICATION IS INTENDED

FOR EDUCATIONAL PURPOSES ONLY. IT IS NOT INTENDED, NOR SHOULD

IT BE CONSTRUED, AS SPECIFIC MEDICAL ADVICE OR DIRECTIONS. ANY

PERSON VIEWING THIS INFORMATION IS ADVISED TO CONSULT THEIR OWN

PHYSICIAN(S) ABOUT ANY MATTER REGARDING THEIR MEDICAL CARE.

************************************************

B. Ain, M.D.

Professor of Medicine

Director, Thyroid Nodule & Oncology Clinical Service

Director, Thyroid Cancer Research Laboratory

Division of Endocrinology and Molecular Medicine

Department of Internal Medicine, Room MN524

University of Kentucky Medical Center

800 Rose Street, Lexington, Kentucky 40536-0298

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(Dr. Ain)

Date: Wed, 28 Apr 1999 17:16:31 -0400

Subject: Re: clearance of iodine

In-reply-to:

>Hi, I just had an IVP done with iodine based contrast due to blood in my

>urine. It was given IV and Xrays were taken of the kidneys,bladder.

>Does anyone know how long it takes for the iodine to clear from the

>body, for future scans/RAI txs?

> Now when I have a medical problem I think the worst and I never did

>this before!

>Thanks, Laurie Pap, TT 12-97, RAi 2-98, clean scan 2-99, 150 Synthroid

>and hx of kidney stones.

Dear ThyCa Members:

Unfortunately, most physicians (including nuclear medicine physicans and

radiologists) do not realize the severe interfence of iodine-based contrast in

radioiodine scanning and therapy. Although most assume that any interference is

gone in a few weeks, the fact is that this interference effectively lasts from

10 to 14 months. I have documented this effect in my patients with 24-hour

urine iodine studies while on a low-iodine diet, and some of them required at

least a year before they could resume I-131 scanning or treatments. I have also

been sent a number of patients with " dedifferentiated " tumors which were said to

no longer take up iodine. In many of these cases, they had been scanned within

several months of a contrast CT scan or IVP, causing false negative findings on

their nuclear studies. In these cases, waiting for the iodine to leave their

bodies resulted in restoration of their response to I-131. The only study

documenting the length of this effect is listed below. Additionally, a medical

student has started a project with me to further document this effect.

[spate VL, JS, Nichols TA, et al. 1998 Longitudinal study of iodine in

toenails following IV administration of an iodine-containing contrast agent. J

Radioanalyt Nucl Chem. 236:71-76.]

I must reiterate, that I have never met any other physician who had ever

evaluated this problem, most of them worked on an assumption that the effect was

trivial and short. I have found otherwise.

**************PLEASE BE ADVISED**********************

THE INFORMATION CONTAINED IN THIS COMMUNICATION IS INTENDED

FOR EDUCATIONAL PURPOSES ONLY. IT IS NOT INTENDED, NOR SHOULD

IT BE CONSTRUED, AS SPECIFIC MEDICAL ADVICE OR DIRECTIONS. ANY

PERSON VIEWING THIS INFORMATION IS ADVISED TO CONSULT THEIR OWN

PHYSICIAN(S) ABOUT ANY MATTER REGARDING THEIR MEDICAL CARE.

*************************************************

B. Ain, M.D.

Associate Professor of Internal Medicine

Director, Thyroid Nodule & Oncology Clinical Service

Director, Thyroid Cancer Research Laboratory

Division of Endocrinology and Molecular Medicine

Department of Internal Medicine, Room MN520

University of Kentucky Medical Center

800 Rose Street, Lexington, Kentucky 40536-0084

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>Date: Tue, 17 Dec 2002 02:27:48 +0000

> "

>Subject: Dr. Ain - Lithium Protocol