Background: Graves’ disease (GD) is an autoimmune disorder and the leading cause of hyperthyroidism. Antithyroid drugs (ATDs) are available treatment option. Agranulocytosis is a rare but potentially fatal complication of ATD in hyperthyroidism management. The study's objectives include clinical symptoms of ATD-induced agranulocytosis in Graves' illness and the difficulties in clinical care in addition to radioactive iodine therapy (RAIT). Methods: Twelve patients with ATD induced agranulocytosis referred to NINMAS between 2021to 2022 for RAIT therapy were included in this study. All the patients with hyperthyroidism and agranulocytosis or leukopenia were taken in this study. Results: The age of the 12 patients (female: male = 10:3) was 26 to 56 years (mean SD: 38.41±13.9 years). Among the twelve patients 10 were treated with carbimazole and two with PTU for Graves’ disease. Initial dose of ATD was 15-30 mg daily. The most common clinical manifestations were fever (100%), sore throat (41.6%), oral ulcer (16%), rash (41.66%), loose motion (16.66%) and atrial fibrillation (8.33%) with deep vein thrombosis (DVT). Agranulocytosis developed between 7th and 547th days after initiation of ATD; all of them developed early onset except one who developed agranulocytosis after 1.5 years of initiation of ATD. All 12 patients were treated immediately after diagnosis of agranulocytosis following prompt discontinuation of ATD, they were treated with antibiotic with 12 cases, G CSF in one case, KI in one case, glucocorticoid in two cases, and beta blocker in all cases. After intensive and supportive treatment in hospital, all the patients recovered with absolute neutrophil counts of more than 500/mm3 in 5 to 15 days (mean SD: 7.6 3.4 days). Nine patients were treated with lithium carbonate supplement to reduce FT3 level. Average dose of lithium carbonate was 600 mg. After that patients were referred for RAIT. TRAb were positive in seven patients and average were 4.2 U/L. Plasmapheresis was done in three patients and one patient in two times due to high FT4 level before RAIT. Lithium carbonate supplementation reduce thyroid hormone level but not to the optimum level. All the 12 patients were treated with RAIT. Average dose RAI 10.9 mCi, average follow up period 2.3 years. Two patients required second dose of RAIT due to persistent hyperthyroidism. Six patients became hypothyroid, two were in hyperthyroid state (on plan for second therapy), four patients are euthyroid at present and they are on follow up. No fatal condition was found in this study. Conclusion: The most cost-effective method of managing agranulocytosis induced by thionamide-derived ATD is that all patients with thyrotoxicosis must be informed that their white blood cells and differential counts should be checked immediately whenever the “common cold” symptoms occur during treatment, especially within the first three months of medication. Contraindication to ATDs; RAI is a safe and effective alternative. Bangladesh J. Nuclear Med. 26(1): 39-43, 2023

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Thyroglossal duct cyst (TGDC) is the most common developmental anomaly of the thyroid gland, while TGDC carcinoma with local infiltration to the hyoid bone is extremely rare. The reported case of papillary thyroid carcinoma (PTC) was diagnosed in TGDC along with local infiltration to the hyoid bone and needed individualized management. A 70-year-old male patient presented with a history of PTC arising in TGDC and locally infiltrated to the hyoid bone followed by total thyroidectomy and radical sistrunk operations and was referred to  National Institute of Nuclear Medicine and Allied Sciences (NINMAS) for radioactive iodine therapy (RAIT). His post-operative ultrasound of the neck revealed an irregular shaped, fungating, grossly non-homogenous mixed echogenic mass lesion invading the hyoid bone, measuring about 25 X 28 mm. Radioactive iodine(131I) of 150 mCi was administered because the residual hyoid bone mass was inoperable and he was on thyroxine suppression therapy. The post-therapy 131I scan (RxWBS) showed two intense foci of radiotracer concentration (RTC) in the upper area (above the thyroid bed) and an intense focal RTC in the fundal region of the stomach. The activity in the stomach region was evaluated by ultrasound imaging, which revealed a soft tissue mass or thickening of the mid-region of the posterior wall of the stomach (3.3 cm X 1.6 cm). A CT scan of the chest was also performed to rule out metastasis, and it revealed multiple nodular lesions in both lung fields (most likely secondary) as well as tiny subcentric lymphnodes in the lower pre- and right paratracheal regions after nearly one month of RAIT when the patient was stable for examination. EBRT is still under consideration as adjuvant therapy. Tyrosine kinase inhibitors (TKI) may be considered in cases of refractoriness to radioiodine and disease progression. Bangladesh J. Nuclear Med. 26(1): 67-70, 2023

Background: Radioiodine treatment in thyroidectomized differentiated thyroid carcinoma (DTC) patients was introduced in the world in 1940s and in Bangladesh in 1980. Long experience of treatment and lifelong follow up of DTC patients with proper documentation of medical records enriched the archive of the thyroid division of National Institute of Nuclear Medicine & Allied Sciences (NINMAS). Aims: To evaluate the response of radioiodine treatment in DTC patients at NINMAS and   analyze the outcome and prognostic factors in this cohort of patients in a single institute of a developing country. Patients and Methods: This is a retrospective cohort study. A total of 7525 patients with DTC received RAI ablation therapy from 1980-2021 at NINMAS, among them 5448 patients were treated with radioiodine from 1980-2017. Data were obtained from the medical records of 3482 DTC patients who were followed up until 2021 and all relevant data were available. Demographical, histopathological, surgical, radioiodine ablation doses of 131I, serum biomarkers thyroglobulin (Tg), antithyroglobulin antibody (TgAb) and biochemical investigation data were analyzed systematically. Age, gender, tumor size, presence of local and distant metastases at presentation, extrathyroidal extension (ETE), disease recurrence, and cancer-specific survival were also evaluated. Risk stratifications for recurrence and staging were calculated for dosing of radioiodine. The single dose of radioiodine ranged from 30 mCi to 200 mCi was given according to the postsurgical risk assessment. Repeated doses of radioiodine were given in the cases of persistent disease (PD) and recurrent disease (RD). Results: The median age of DTC patients was 38 years, with a range of 5-87 years (39.90± 12.67 years), with the majority of patients falling within the 30-39 age group. The ratio of female to male was 3.74:1. Compared to the previous decade, patient number increased about 72 and 16-folds in relation to the 1980s and 1990s respectively at this institute. Papillary thyroid carcinoma (PTC) and follicular variant of thyroid carcinoma (FVPTC) together were evaluated in 3311(95.09%) cases and follicular thyroid carcinoma (FTC) was diagnosed in 171(4.91%). Excellent response (ER) was observed by a single dose of radioiodine ablation in 2853(81.94%) and PD and RD were noted in 388(11.14%) and 241(6.92%) respectively. Tg and TgAb levels at pre-therapy state were significantly higher in patients who had PD (P <0.000) and RD (P <0.000). Conclusion: Significant increase in the number of DTC patients was observed in the last two decades. ER was noted in 81.94% with a single dose of radioiodine. Serum Tg and TgAb are two prognostic factors for disease outcomes showing high Tg and TgAb in PD and RD cases. Bangladesh J. Nuclear Med. 25(2): 81-87, 2022

Distant metastasis is more common in follicular thyroid carcinomas (FTC) than papillary thyroid carcinomas (PTC), as vascular invasion is often characteristic of FTC. Lung, bone, brain, liver, bladder, and skin are potential sites of distant metastases. On the other hand, lymph node involvement is much less common (8–10%) in cases of FTC compared to PTC. The therapy of patients may be significantly impacted by learning more about the epidemiological features of thyroid metastases at uncommon sites. In our experience, metastases in uncommon sites do not always indicate a poor prognosis for differentiated thyroid carcinoma (DTC), which might be due to the disease patterns. Every year, around 5% new FTC patients are registered, treated with radioiodine, and followed up in the thyroid division of National Institute of Nuclear Medicine and Allied Sciences (NINMAS). Four FTC patients (F=3, M=1) with skull bone and brain metastases are discussed in this case series. All of them were post thyroidectomized and were referred to NINMAS for radioiodine ablation therapy (RAIT). Two of them had skull and brain metastases, third patient had extensive skull, facial bone and pubic bone invasion, whereas, fourth patient had multiple skull metastases. Bangladesh J. Nuclear Med. 25(2): 128-137, 2022