Toxic Adenoma medical therapy: Difference between revisions
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{{CMG}} ; {{AE}} {{ADG}} | {{CMG}} ; {{AE}} {{ADG}} | ||
==Overview== | ==Overview== | ||
The mainstay of treatment for most patients with toxic adenoma includes [[Iodine-131|radioiodine]] | The mainstay of treatment for most patients with toxic adenoma includes [[Iodine-131|radioiodine]] and [[Antithyroid|anti thyroid drugs]]. In patients with overt [[thyrotoxicosis]], [[Beta blockers|beta blocker]] will alleviate the signs and symptoms mediated by the increased [[beta-adrenergic]] activity. Alternative treatment modalities include [[percutaneous]] [[Ethanol|ethanol injection]], thermoablation, or [[Radiofrequency ablation|radiofrequency]] ablation. [[Antithyroid agents|Antithyroid drugs]] are not routinely employed in the management of toxic adenoma. | ||
==Medical Treatment== | ==Medical Treatment== | ||
In patients with overt [[thyrotoxicosis]], [[Beta blockers|beta blocker]] will alleviate the signs and symptoms mediated by the increased [[beta-adrenergic]] activity. The mainstay of treatment for most patients with toxic adenoma includes treatment with [[radioiodine]] and [[surgery]]. Alternative treatment modalities include percutaneous [[Ethanol|ethanol injection,]] thermoablation, or [[radiofrequency ablation]]. [[Antithyroid agents|Antithyroid drugs]] are not routinely employed in the management of toxic adenoma. | In patients with overt [[thyrotoxicosis]], [[Beta blockers|beta blocker]] will alleviate the signs and symptoms mediated by the increased [[beta-adrenergic]] activity. The mainstay of treatment for most patients with toxic adenoma includes treatment with [[radioiodine]] and [[surgery]]. Alternative treatment modalities include percutaneous [[Ethanol|ethanol injection,]] thermoablation, or [[radiofrequency ablation]]. [[Antithyroid agents|Antithyroid drugs]] are not routinely employed in the management of toxic adenoma. | ||
===RADIOACTIVE IODINE=== | ===RADIOACTIVE IODINE=== | ||
In the United States, radioactive iodine is the preferred choice of treatment for patients with toxic adenoma.<ref name="pmid12192548">{{cite journal |vauthors=Reiners C, Schneider P |title=Radioiodine therapy of thyroid autonomy |journal=Eur. J. Nucl. Med. Mol. Imaging |volume=29 Suppl 2 |issue= |pages=S471–8 |year=2002 |pmid=12192548 |doi=10.1007/s00259-002-0910-6 |url=}}</ref><ref name="pmid486923">{{cite journal |vauthors=Bransom CJ, Talbot CH, Henry L, Elemenoglou J |title=Solitary toxic adenoma of the thyroid gland |journal=Br J Surg |volume=66 |issue=8 |pages=592–5 |year=1979 |pmid=486923 |doi= |url=}}</ref><ref name="pmid15310544">{{cite journal |vauthors=Duick DS, Baskin HJ |title=Significance of radioiodine uptake at 72 hours versus 24 hours after pretreatment with recombinant human thyrotropin for enhancement of radioiodine therapy in patients with symptomatic nontoxic or toxic multinodular goiter |journal=Endocr Pract |volume=10 |issue=3 |pages=253–60 |year=2004 |pmid=15310544 |doi=10.4158/EP.10.3.253 |url=}}</ref><ref name="pmid12846955">{{cite journal |vauthors=Abós MD, Banzo J, Razola P, Prats E, García F, Ubieto MA |title=[Treatment of hyperthyroidism with 131 I] |language=Spanish; Castilian |journal=Rev Esp Med Nucl |volume=22 |issue=4 |pages=262–76; quiz 277–81 |year=2003 |pmid=12846955 |doi= |url=}}</ref><ref name="pmid11443161">{{cite journal |vauthors=Burch HB, Solomon BL, Cooper DS, Ferguson P, Walpert N, Howard R |title=The effect of antithyroid drug pretreatment on acute changes in thyroid hormone levels after (131)I ablation for Graves' disease |journal=J. Clin. Endocrinol. Metab. |volume=86 |issue=7 |pages=3016–21 |year=2001 |pmid=11443161 |doi=10.1210/jcem.86.7.7639 |url=}}</ref><ref name="pmid10566642">{{cite journal |vauthors=Andrade VA, Gross JL, Maia AL |title=Effect of methimazole pretreatment on serum thyroid hormone levels after radioactive treatment in Graves' hyperthyroidism |journal=J. Clin. Endocrinol. Metab. |volume=84 |issue=11 |pages=4012–6 |year=1999 |pmid=10566642 |doi=10.1210/jcem.84.11.6149 |url=}}</ref><ref name="pmid10427153">{{cite journal |vauthors=Catargi B, Leprat F, Guyot M, Valli N, Ducassou D, Tabarin A |title=Optimized radioiodine therapy of Graves' disease: analysis of the delivered dose and of other possible factors affecting outcome |journal=Eur. J. Endocrinol. |volume=141 |issue=2 |pages=117–21 |year=1999 |pmid=10427153 |doi= |url=}}</ref><ref name="pmid23883244">{{cite journal |vauthors=Yu L, Fletcher JG, Grant KL, Carter RE, Hough DM, Barlow JM, Vrtiska TJ, Williamson EE, Young PM, Goss BC, Shiung M, Leng S, Raupach R, Schmidt B, Flohr T, McCollough CH |title=Automatic selection of tube potential for radiation dose reduction in vascular and contrast-enhanced abdominopelvic CT |journal=AJR Am J Roentgenol |volume=201 |issue=2 |pages=W297–306 |year=2013 |pmid=23883244 |doi=10.2214/AJR.12.9610 |url=}}</ref> | In the United States, [[radioactive iodine]] is the preferred choice of treatment for patients with toxic adenoma.<ref name="pmid12192548">{{cite journal |vauthors=Reiners C, Schneider P |title=Radioiodine therapy of thyroid autonomy |journal=Eur. J. Nucl. Med. Mol. Imaging |volume=29 Suppl 2 |issue= |pages=S471–8 |year=2002 |pmid=12192548 |doi=10.1007/s00259-002-0910-6 |url=}}</ref><ref name="pmid486923">{{cite journal |vauthors=Bransom CJ, Talbot CH, Henry L, Elemenoglou J |title=Solitary toxic adenoma of the thyroid gland |journal=Br J Surg |volume=66 |issue=8 |pages=592–5 |year=1979 |pmid=486923 |doi= |url=}}</ref><ref name="pmid15310544">{{cite journal |vauthors=Duick DS, Baskin HJ |title=Significance of radioiodine uptake at 72 hours versus 24 hours after pretreatment with recombinant human thyrotropin for enhancement of radioiodine therapy in patients with symptomatic nontoxic or toxic multinodular goiter |journal=Endocr Pract |volume=10 |issue=3 |pages=253–60 |year=2004 |pmid=15310544 |doi=10.4158/EP.10.3.253 |url=}}</ref><ref name="pmid12846955">{{cite journal |vauthors=Abós MD, Banzo J, Razola P, Prats E, García F, Ubieto MA |title=[Treatment of hyperthyroidism with 131 I] |language=Spanish; Castilian |journal=Rev Esp Med Nucl |volume=22 |issue=4 |pages=262–76; quiz 277–81 |year=2003 |pmid=12846955 |doi= |url=}}</ref><ref name="pmid11443161">{{cite journal |vauthors=Burch HB, Solomon BL, Cooper DS, Ferguson P, Walpert N, Howard R |title=The effect of antithyroid drug pretreatment on acute changes in thyroid hormone levels after (131)I ablation for Graves' disease |journal=J. Clin. Endocrinol. Metab. |volume=86 |issue=7 |pages=3016–21 |year=2001 |pmid=11443161 |doi=10.1210/jcem.86.7.7639 |url=}}</ref><ref name="pmid10566642">{{cite journal |vauthors=Andrade VA, Gross JL, Maia AL |title=Effect of methimazole pretreatment on serum thyroid hormone levels after radioactive treatment in Graves' hyperthyroidism |journal=J. Clin. Endocrinol. Metab. |volume=84 |issue=11 |pages=4012–6 |year=1999 |pmid=10566642 |doi=10.1210/jcem.84.11.6149 |url=}}</ref><ref name="pmid10427153">{{cite journal |vauthors=Catargi B, Leprat F, Guyot M, Valli N, Ducassou D, Tabarin A |title=Optimized radioiodine therapy of Graves' disease: analysis of the delivered dose and of other possible factors affecting outcome |journal=Eur. J. Endocrinol. |volume=141 |issue=2 |pages=117–21 |year=1999 |pmid=10427153 |doi= |url=}}</ref><ref name="pmid23883244">{{cite journal |vauthors=Yu L, Fletcher JG, Grant KL, Carter RE, Hough DM, Barlow JM, Vrtiska TJ, Williamson EE, Young PM, Goss BC, Shiung M, Leng S, Raupach R, Schmidt B, Flohr T, McCollough CH |title=Automatic selection of tube potential for radiation dose reduction in vascular and contrast-enhanced abdominopelvic CT |journal=AJR Am J Roentgenol |volume=201 |issue=2 |pages=W297–306 |year=2013 |pmid=23883244 |doi=10.2214/AJR.12.9610 |url=}}</ref> | ||
====Indications==== | ====Indications==== | ||
Radioactive iodine is generally preferred over surgery when there is | Radioactive iodine is generally preferred over surgery when there is | ||
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===Percutaneous ethanol injection=== | ===Percutaneous ethanol injection=== | ||
An alternative to surgery and 131 iodine therapy for toxic adenomas is the use of percutaneous [[Ethanol|ethanol injection]] into the nodule under ultrasound guidance. | An alternative to surgery and 131 iodine therapy for toxic adenomas is the use of percutaneous [[Ethanol|ethanol injection]] into the [[nodule]] under [[ultrasound guidance]]. | ||
*The injection results in necrosis and thrombosis of small vessels. | *The injection results in [[necrosis]] and [[thrombosis]] of small vessels. | ||
*Side effects include local pain and, in rare cases, [[Recurrent laryngeal nerve|recurrent nerve damage.]] | *Side effects include local pain and, in rare cases, [[Recurrent laryngeal nerve|recurrent nerve damage.]] | ||
*Results of ethanol injection in relatively large AFTNs (diameter 3 to 4 cm) are also favorable, particularly in patients with [[Hyperthyroidism|subclinical hyperthyroidism]]. | *Results of ethanol injection in relatively large AFTNs (diameter 3 to 4 cm) are also favorable, particularly in patients with [[Hyperthyroidism|subclinical hyperthyroidism]]. | ||
===Percutaneous laser thermal ablation (LTA)=== | ===Percutaneous laser thermal ablation (LTA)=== | ||
*Percutaneous laser thermal ablation (LTA) is a more recently introduced technique for the treatment of [[Thyroid nodule|thyroid nodules]]. | *Percutaneous laser thermal ablation (LTA) is a more recently introduced technique for the treatment of [[Thyroid nodule|thyroid nodules]]. | ||
*In hyperfunctioning nodules, LTA induced a nearly 50% volume reduction with a variable frequency of normalization of [[thyroid-stimulating hormone]] levels. | *In hyperfunctioning [[nodules]], LTA induced a nearly 50% volume reduction with a variable frequency of normalization of [[thyroid-stimulating hormone]] levels. | ||
*Ultrasound-guided laser or radiofrequency ablation are also used for symptomatic solid nodules with normal or abnormal thyroid function and appear safe and effective | *[[Ultrasound]]-guided laser or [[radiofrequency ablation]] are also used for symptomatic solid [[nodules]] with normal or abnormal [[thyroid]] function and appear safe and effective. | ||
====Complications==== | ====Complications==== | ||
Potential adverse effects of 131 | Potential adverse effects of 131 Iodine therapy for toxic nodular goiter include: | ||
*Radiation thyroiditis | *Radiation thyroiditis | ||
*Postablative [[Hypothyroidism|hypothyroidism.]] | *Postablative [[Hypothyroidism|hypothyroidism.]] | ||
| Line 36: | Line 36: | ||
*Radiation thyroiditis presents with anterior [[neck pain]] in the week after therapy and exacerbation of [[thyrotoxicosis]] because of the release of preformed [[thyroid hormone]] from the gland, which typically occurs 2 to 8 weeks after treatment. | *Radiation thyroiditis presents with anterior [[neck pain]] in the week after therapy and exacerbation of [[thyrotoxicosis]] because of the release of preformed [[thyroid hormone]] from the gland, which typically occurs 2 to 8 weeks after treatment. | ||
*Pretreatment with an [[Antithyroid agents|antithyroid drug]] has been shown to decrease the severity of [[thyrotoxicosis]] caused by radiation thyroiditis in [[Graves’ disease]], but this has not been established for toxic nodular goiter. | *Pretreatment with an [[Antithyroid agents|antithyroid drug]] has been shown to decrease the severity of [[thyrotoxicosis]] caused by radiation thyroiditis in [[Graves’ disease]], but this has not been established for toxic nodular goiter. | ||
*Thyroiditis-related gland swelling with potential worsening of compressive symptoms is a concern that has not actually been realized in studies of [[Radioiodine|radioiodine therapy]] for nodular goiter. | *[[Thyroiditis]]-related [[Glands|gland]] swelling with potential worsening of compressive symptoms is a concern that has not actually been realized in studies of [[Radioiodine|radioiodine therapy]] for nodular goiter. | ||
*Long term, thyroid volume typically decreases by about 40% after 131 | *Long term, [[thyroid]] volume typically decreases by about 40% after 131 Iodine treatment. | ||
====Postablative hypothyroidism==== | ====Postablative hypothyroidism==== | ||
| Line 47: | Line 47: | ||
===ANTITHYROID DRUGS=== | ===ANTITHYROID DRUGS=== | ||
*Unlike hyperthyroid conditions such as [[Graves’ disease|Graves’ diseas]]<nowiki/>e, thyroid autonomy in toxic nodular goiter rarely remits unless it has been provoked by an iodine load. | *Unlike hyperthyroid conditions such as [[Graves’ disease|Graves’ diseas]]<nowiki/>e, thyroid autonomy in toxic nodular goiter rarely remits unless it has been provoked by an iodine load. | ||
*Thionamide therapy alone may not control [[hyperthyroidism]] completely because of the substantial store of previously synthesized [[thyroid hormone]] that can be present in the large gland of a patient with toxic nodular goiter. | *Thionamide therapy alone may not control [[hyperthyroidism]] completely because of the substantial store of previously synthesized [[thyroid hormone]] that can be present in the large [[gland]] of a patient with toxic nodular goiter. | ||
*But still, antithyroid medications are indicated in situations which include | *But still, [[antithyroid]] medications are indicated in situations which include | ||
**Useful for the initial control of [[hyperthyroidism]] that is severe or complicates cardiac or other conditions in a fragile patient. | **Useful for the initial control of [[hyperthyroidism]] that is severe or complicates cardiac or other conditions in a fragile patient. | ||
**[[Propylthiouracil|PTU]] is the immediate treatment of choice for pregnant patients with [[hyperthyroidism]]. | **[[Propylthiouracil|PTU]] is the immediate treatment of choice for pregnant patients with [[hyperthyroidism]]. | ||
**Time-limited course of [[Antithyroid agent|antithyroid]] drugs can sometimes be useful to evaluate the clinical status of patients with subclinical [[hyperthyroidism]] who have nonspecific symptoms, such as [[nervousness]] or [[insomnia]], that may or may not improve with definitive treatment of mild hyperthyroidism. | **Time-limited course of [[Antithyroid agent|antithyroid]] drugs can sometimes be useful to evaluate the clinical status of patients with subclinical [[hyperthyroidism]] who have nonspecific symptoms, such as [[nervousness]] or [[insomnia]], that may or may not improve with definitive treatment of mild hyperthyroidism. | ||
**If a patient experiences an improvement in symptoms or sense of well-being when thyroid function has been restored to normal on thionamide therapy, then radioiodine therapy or surgery is indicated. | **If a patient experiences an improvement in symptoms or sense of well-being when [[thyroid]] function has been restored to normal on thionamide therapy, then [[radioiodine]] therapy or [[surgery]] is indicated. | ||
==Treatment options== | ==Treatment options== | ||
===Nonpregnant nonlactating adults without mass effect=== | ===Nonpregnant nonlactating adults without mass effect=== | ||
Latest revision as of 17:16, 19 October 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
The mainstay of treatment for most patients with toxic adenoma includes radioiodine and anti thyroid drugs. In patients with overt thyrotoxicosis, beta blocker will alleviate the signs and symptoms mediated by the increased beta-adrenergic activity. Alternative treatment modalities include percutaneous ethanol injection, thermoablation, or radiofrequency ablation. Antithyroid drugs are not routinely employed in the management of toxic adenoma.
Medical Treatment
In patients with overt thyrotoxicosis, beta blocker will alleviate the signs and symptoms mediated by the increased beta-adrenergic activity. The mainstay of treatment for most patients with toxic adenoma includes treatment with radioiodine and surgery. Alternative treatment modalities include percutaneous ethanol injection, thermoablation, or radiofrequency ablation. Antithyroid drugs are not routinely employed in the management of toxic adenoma.
RADIOACTIVE IODINE
In the United States, radioactive iodine is the preferred choice of treatment for patients with toxic adenoma.[1][2][3][4][5][6][7][8]
Indications
Radioactive iodine is generally preferred over surgery when there is
- No suspicion of coexisting thyroid malignancy
- No large goiter threatening local compressive symptoms
- No other reason for neck surgery (e.g., primary hyperparathyroidism)
- No imperative for an immediate cure, and whenever the patient’s general health makes him or her a poor candidate for surgery.
Contraindications
- Pregnant women
- Children and adolescents (associated with risk of thyroid cancer)
Percutaneous ethanol injection
An alternative to surgery and 131 iodine therapy for toxic adenomas is the use of percutaneous ethanol injection into the nodule under ultrasound guidance.
- The injection results in necrosis and thrombosis of small vessels.
- Side effects include local pain and, in rare cases, recurrent nerve damage.
- Results of ethanol injection in relatively large AFTNs (diameter 3 to 4 cm) are also favorable, particularly in patients with subclinical hyperthyroidism.
Percutaneous laser thermal ablation (LTA)
- Percutaneous laser thermal ablation (LTA) is a more recently introduced technique for the treatment of thyroid nodules.
- In hyperfunctioning nodules, LTA induced a nearly 50% volume reduction with a variable frequency of normalization of thyroid-stimulating hormone levels.
- Ultrasound-guided laser or radiofrequency ablation are also used for symptomatic solid nodules with normal or abnormal thyroid function and appear safe and effective.
Complications
Potential adverse effects of 131 Iodine therapy for toxic nodular goiter include:
- Radiation thyroiditis
- Postablative hypothyroidism.
Radiation thyroiditis
- Radiation thyroiditis presents with anterior neck pain in the week after therapy and exacerbation of thyrotoxicosis because of the release of preformed thyroid hormone from the gland, which typically occurs 2 to 8 weeks after treatment.
- Pretreatment with an antithyroid drug has been shown to decrease the severity of thyrotoxicosis caused by radiation thyroiditis in Graves’ disease, but this has not been established for toxic nodular goiter.
- Thyroiditis-related gland swelling with potential worsening of compressive symptoms is a concern that has not actually been realized in studies of radioiodine therapy for nodular goiter.
- Long term, thyroid volume typically decreases by about 40% after 131 Iodine treatment.
Postablative hypothyroidism
- The incidence of post ablative hypothyroidism after radioiodine therapy has been reported to be 25% to 50%.
- The development of hypothyroidism was not associated with age, sex, radioiodine dose, radioiodine uptake, or degree of suppression of the extranodal tissue.
- In patients treated with antithyroid drugs prior to radioiodine therapy, the increase in TSH may reactivate suppressed thyroid tissue and iodide uptake, resulting in damage by I-31 iodine.
- Therefore, some clinicians administer levothyroxine for 2 weeks prior to therapy in order to assure that the tissue surrounding the toxic adenoma is suppressed.
ANTITHYROID DRUGS
- Unlike hyperthyroid conditions such as Graves’ disease, thyroid autonomy in toxic nodular goiter rarely remits unless it has been provoked by an iodine load.
- Thionamide therapy alone may not control hyperthyroidism completely because of the substantial store of previously synthesized thyroid hormone that can be present in the large gland of a patient with toxic nodular goiter.
- But still, antithyroid medications are indicated in situations which include
- Useful for the initial control of hyperthyroidism that is severe or complicates cardiac or other conditions in a fragile patient.
- PTU is the immediate treatment of choice for pregnant patients with hyperthyroidism.
- Time-limited course of antithyroid drugs can sometimes be useful to evaluate the clinical status of patients with subclinical hyperthyroidism who have nonspecific symptoms, such as nervousness or insomnia, that may or may not improve with definitive treatment of mild hyperthyroidism.
- If a patient experiences an improvement in symptoms or sense of well-being when thyroid function has been restored to normal on thionamide therapy, then radioiodine therapy or surgery is indicated.
Treatment options
Nonpregnant nonlactating adults without mass effect
- Preferred regimen: Radioactive iodine therapy (I-131) Dose is generally calculated based on goiter size, or computed based on the amount of radiation to be delivered.
- Note: Pretreatment with antithyroid drugs
- Alternative regimen: Subtotal thyroidectomy
- Note: Pretreatment with antithyroid drugs
- Preferred regimen: Radioactive iodine therapy (I-131) Dose is generally calculated based on goiter size, or computed based on the amount of radiation to be delivered.
Nonpregnant nonlactating adults without mass effect and with moderate/severe symptoms involving cardiovascular
- Preferred regimen: Beta blockers
Nonpregnant nonlactating adults with mass effect
- Preferred regimen: Subtotal thyroidectomy
- Note: Pretreatment with antithyroid drugs
- Alternative regimen: Radioactive iodine therapy (I-131)
- Note: Pretreatment with antithyroid drugs
- Preferred regimen: Subtotal thyroidectomy
Pregnant or lactating
- Preferred regimen: Antithyroid drugs
- Note:- Methimazole 5-60 mg/day orally given once daily or in 2-3 divided doses; doses rarely exceed 40 mg/day in practice
- Note:- Propylthiouracil 50-400 mg/day orally given in 3 divided doses
- Preferred regimen: Antithyroid drugs
References
- ↑ Reiners C, Schneider P (2002). "Radioiodine therapy of thyroid autonomy". Eur. J. Nucl. Med. Mol. Imaging. 29 Suppl 2: S471–8. doi:10.1007/s00259-002-0910-6. PMID 12192548.
- ↑ Bransom CJ, Talbot CH, Henry L, Elemenoglou J (1979). "Solitary toxic adenoma of the thyroid gland". Br J Surg. 66 (8): 592–5. PMID 486923.
- ↑ Duick DS, Baskin HJ (2004). "Significance of radioiodine uptake at 72 hours versus 24 hours after pretreatment with recombinant human thyrotropin for enhancement of radioiodine therapy in patients with symptomatic nontoxic or toxic multinodular goiter". Endocr Pract. 10 (3): 253–60. doi:10.4158/EP.10.3.253. PMID 15310544.
- ↑ Abós MD, Banzo J, Razola P, Prats E, García F, Ubieto MA (2003). "[Treatment of hyperthyroidism with 131 I]". Rev Esp Med Nucl (in Spanish; Castilian). 22 (4): 262–76, quiz 277–81. PMID 12846955.
- ↑ Burch HB, Solomon BL, Cooper DS, Ferguson P, Walpert N, Howard R (2001). "The effect of antithyroid drug pretreatment on acute changes in thyroid hormone levels after (131)I ablation for Graves' disease". J. Clin. Endocrinol. Metab. 86 (7): 3016–21. doi:10.1210/jcem.86.7.7639. PMID 11443161.
- ↑ Andrade VA, Gross JL, Maia AL (1999). "Effect of methimazole pretreatment on serum thyroid hormone levels after radioactive treatment in Graves' hyperthyroidism". J. Clin. Endocrinol. Metab. 84 (11): 4012–6. doi:10.1210/jcem.84.11.6149. PMID 10566642.
- ↑ Catargi B, Leprat F, Guyot M, Valli N, Ducassou D, Tabarin A (1999). "Optimized radioiodine therapy of Graves' disease: analysis of the delivered dose and of other possible factors affecting outcome". Eur. J. Endocrinol. 141 (2): 117–21. PMID 10427153.
- ↑ Yu L, Fletcher JG, Grant KL, Carter RE, Hough DM, Barlow JM, Vrtiska TJ, Williamson EE, Young PM, Goss BC, Shiung M, Leng S, Raupach R, Schmidt B, Flohr T, McCollough CH (2013). "Automatic selection of tube potential for radiation dose reduction in vascular and contrast-enhanced abdominopelvic CT". AJR Am J Roentgenol. 201 (2): W297–306. doi:10.2214/AJR.12.9610. PMID 23883244.