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Presentation on theme: "Recent Advances IN THYROID IMAGING"— Presentation transcript:

1 Recent Advances IN THYROID IMAGING
Asia Oceania Thyroid Association Congress Bali, Indonesia October 22, 2012 Recent Advances IN THYROID IMAGING Emerita a. Barrenechea MD, FPCP, FPSNM Department of Nuclear Medicine St. Luke’s Medical Center Veterans Memorial Medical Center

2 Thyroid gland-very accessible

3 Mainstream Thyroid Imaging
Scintigraphy Sonography there have been several recent advances that are of interest to thyroidologists, radiologists and endocrinologists

4 What is available? Planar/SPECT/SPECT-CT imaging (e.g. 99mTc- based radiotracers,123I, 131I) Positron emission tomography ( PET) Ultrasonography (USG), USG elastography Computed tomography (CT) Magnetic resonance imaging (MRI) Optical coherence tomography

5 Ultrasonography Most common
Facilitate diagnosis of clinically apparent nodules Most affordable Primary imaging modality American Thyroid Association other authoritative bodies

6 Ultrasonography Patterns most frequently associated with thyroid CA
Microcalcifications Relative hypoechogenicity of the nodule Irregular margins or absent halo sign Solid pattern and taller-than-wide morphology Intranodular vascularization Should not be used singly

7 Normal echopattern

8 Suggestive of a follicular lesion

9 Hashimoto’s Thyroiditis

10 Thyroid Nodule Evaluation
Fine needle aspiration cytology is cornerstone Simple Useful Cost-effective BUT evaluation of non-diagnostic and insufficient FNA samples continues to be a problem

11 Elastography Sonographic estimation of rigidity/deformability of tissue change in Doppler signal after external application of pressure/vibrations by tracking shear wave propagation May correlate with: palpable consistency of goiter cytology of a nodule May enhance cancer-prediction in non-cystic, non-calcified thyroid nodules or inflammatory conditions

12 Computed Tomography 3D image of internal organs
Uses 2D X-ray images “Windowing” allows better visualization of targeted organs Cannot detect small nodules Uses: Detection of goiter or larger thyroid nodules Evaluation of cervical lymphadenopathy Local tumor extension Mediastinal/Retrotracheal extension

13 Substernal Thyroid (CT)

14 Magnetic Resonance Imaging
Anatomic imaging only Evaluation of thyroid size and shape Preferable than CT No patient exposure to radiation No need for contrast study

15 Magnetic Resonance Imaging
Arterial spin labeling (ASL) Differentiation of autoimmune thyroid conditions Treatment response evaluation in Graves disease Diffusion weighted imaging (DWI) Apparent diffusion coefficient (ADC) can be used to differentiate benign from malignant nodules (Schueller) Benign = low signal intensities on DWI + high ADC Malignant = high signal intensities on DWI + low ADC

16 MRI of thyroid gland

17 New Modalities Optical Coherence Tomography (OCT)
high-resolution, real-time, cross-sectional imaging of tissues Optical Coherence Microscopy (OCM) high magnification cellular imaging 1–15 µ resolution High-resolution images comparable with histopathologic images Both use infrared light

18 Radionuclide Imaging (Planar)
Standard views

19 Normal Variations

20 Graves’ disease

21 Thyroid Scan-UTS Correlation

22 “Cold” nodule = focal defect

23 Cold nodule, R lobe (99mTcO4)

24 Multinodular Goiter

25 Graves Disease 24/M (+) thyrotoxic symptoms 131I thyroid scan & uptake
Diffuse thyromegaly Elevated RAI uptake values

26 Diffuse Toxic Goiter 30/F
Palpitations, excessive sweating, irritability, anterior neck enlargement 99mTcO4 thyroid scan Diffuse thyromegaly Scintigraphic evidence of increased gland uptake function 38 sec acquisition time Reduced background tracer activity

27 Autonomous functioning thyroid adenoma

28 Subacute Thyroiditis 30/M Hyperthyroid symptoms 131I thyroid scan
Thyroid not visualized Only background radioactivity

29 Amiodarone Thyroiditis

30 Hashitoxicosis

31 Lingual thyroid

32 Whole Body 131I Scintigraphy

33 Remnant Thyroid Complete Ablation Complete ablation of Residual thyroid Tissue in neck Very low/ Undetectable Level of Tg

34 II III I IV Initial Presentation Post-SURGERY Post remnant Ablation
Functioning Mets In Both Lungs II III I I-131 Therapy of Functioning Metastases Proceed to to stage IV IV

35 SPECT/CT Improved detection and localization of disease (superior to SPECT alone) In radionuclide therapy, provides more insight into the effectiveness of targeting and may explain the observed response


37 Thyroid SPECT Agents 99mTcO4 99mTc sestamibi 99mTc tetrofosmi 201TlCl

38 131I SPECT/CT 131I SPECT-CT is more accurate than 18FDG PET-CT in well-differentiated thyroid cancer regional and distant metastasis residual/recurrent disease The most important advantage of fusion 18FDG PET-CT and 131I SPECT-CT is detection of metastasis in normal sized lymph nodes.

39 131I SPECT/CT

40 TCA with mets


42 99mTc sestamibi-Parathyroid

43 Medullary Thyroid Carcinoma


45 Whole body 131I Scintigraphy
78/M, (+) 13-year FU, (+) rising Tg up to 1447 µg/L

46 PET in TCA with increasing TG, negative TBS

47 18FDG PET/CT Well-established usefulness in WDTC if Tg (+) and WBS (–)
Helpful in anaplastic/medullary thyroid cancer May be complimented by PET studies using 68Ga-DOTATOC and 18F-DOPA when looking for recurrent disease

48 Indications of PET/CT residual or recurrent thyroid cancer WHEN elevated Tg + RAI scan (–) When localized, may require surgery or radiotherapy Extent of poorly differentiated TCAs & invasive Hurthle cell Cas Treatment response following systemic or local therapy

49 BNMS Guidelines on TCA Assessment of patients with elevated thyroglobulin levels and negative iodine scintigraphy with suspected recurrent disease. To evaluate disease in treated medullary thyroid carcinoma associated with elevated calcitonin levels with equivocal or normal cross-sectional imaging, bone and octreotide scintigraphy - for alternative PET imaging with 68Ga- DOTA- octreotate (DOTATATE), DOTA-1-NaI3- octreotide (DOTANOC) or DOTA- octreotide (DOTATOC).


51 Metastatic PTCA

52 Metastatic PTCA

53 131I WBS (–) 18FDG PET (–) ↑↑ Tg (56000 µg/L)


Somatostatin receptor expression in thyroid CA Patients with positive studies may be treated with Peptide Receptor Radionuclide Therapy (PRRT) 117Lu DOTA-TATE 90Y DOTA-TATE

56 18FDG Scan in Medullary TCA
PET only CT Only Intense FDG uptake in a hypodense nodule, L thyroid lobe Serum Calcitonin: 800 Final Diagnosis: Medullary TCA PET-CT Fusion

57 Other findings in PET ↑FDG uptake in thyroid nodule as part of whole body study for cancer imaging = moderately high risk of malignancy Require further evaluation Differentials = Graves' disease & thyroiditis Otherwise, thyroid gland should be normal in PET

58 Diffuse 18FDG uptake (benign)

59 Philippine Data (2002 to 2012) 170 18FDG PET on 105 patients from 2005 to 2012 72 ♀ and 33 ♂ 17- to 83-years old Indications 116 – disease recurrence 6 – staging 11 – residuals 21 – response to therapy 13 – monitoring

60 Case Profile (Philippines)
77 – papillary thyroid cancer 9 – follicular thyroid cancer 11 – medullary thyroid cancer 2 – anaplastic thyroid cancer 2 – insular thyroid cancer 2 – squamous cell carcinoma 1 – adenosquamous thyroid carcinoma 1 – Castle disease

61 Results 32 PTCA + 4 FTCA 14 PTCA Most frequent sites of metastases
↑Tg, (–) RAI scan, (+) 18FDG PET 14 PTCA Normal Tg, (–) RAI scan, (+) 18FDG PET Most frequent sites of metastases Neck area Cervical lymph nodes Pretracheal nodes Lungs

62 Results Most common resultant interventions: LN dissection
Gamma knife therapy EBRT Chemotherapy ↑dose RAI therapy

63 Advantages of PET/CT Can detect significantly more tumor sites
Only imaging modality that can screen for malignancy in multiple organs at once Can lead to more appropriate clinical management

64 Other uses of 18FDG PET Indeterminate thyroid nodules (3 cases)
Calcitonin-positive medullary TCA 18F-DOPA is superior to 18FDG for this One case was negative on 18FDG Anaplastic thyroid cancer Insular thyroid carcinoma

65 Summary of 18FDG PET Impact on Thyroid Cancer Management
Determination of definitive therapy for RAI scan (–) WDTCA with elevated Tg Evaluation of aggressive and difficult-to-treat TCA and poorly differentiated TCA Discrimination of malignancy from thyroiditis in questionable thyroid nodules

66 Greatest impact of PET/CT
For WDTCA whose I-131 WBS is negative with increasing thyroglobulin but positive in PET as therapy is more definitive For aggressive and difficult to treat TCA and undifferentiated TCA For questionable thyroid nodules differentiating malignancy and thyroiditis

67 Interesting Case CT (L) & fused PET/CT (R) in 56 y/o woman with lung cancer. Focal FDG uptake in R thyroid lobe with low CT attenuation (76 HU). PTCA on histopath.

68 Interesting Case CT (L) & fused PET/CT (R) in 65 y/o man with esophageal cancer. Focal FDG uptake in L thyroid lobe with very low CT attenuation (3.6 HU). Diffusely increased FDG uptake in surrounding gland tissue. Follicular adenoma with lymphocytic thyroiditis on histopath.

69 Interesting Case 63/M with PTCA, s/p thyroidectomy, RAI therapy, thoracotomy, and radiotherapy Neck MRI = L anterior neck nodule suspicious for recurrence (+) pulmonary nodules on CT Biopsy of thyroid & lung nodules = not malignant (+) RAI-avid right cervical lesion with elevated Tg

70 Interesting Case Calcified hypermetabolic R paratracheal node, multiple bilateral hypermetabolic non-calcified pulmonary nodules, multiple cervical, hilar and substernal nodes, and hypermetabolic lesions in a left rib and sternum, suspicious for metastases.

71 Interesting Case 65/F with PTCA, s/p thyroidectomy & multiple RAI therapies (cumulative dose = 1150 mCi) elevated Tg at >800 (+) nodules in both lungs and left adrenal (+) R lung base RAI-avid lesion on post- therapy whole body scan

72 Interesting Case Hypermetabolic right lung base mass corresponding to RAI-avid R lung base lesion seen on post-therapy scan, consistent with persistent metastatic thyroid cancer.

73 Interesting Case 67/F with PTCA, s/p thyroidectomy, L radical neck dissection, multiple RAI therapies & gamma knife treatment elevated Tg, (–) RAI whole body scan (+) nodules in both lungs and left adrenal (+) R lung base RAI-avid lesion on post- therapy whole body scan CT showed possible recurrence in L thyroid bed

74 Interesting Case FDG-avid right cavernous sinus mass involving the petrous part of the temporal bone is most likely metastatic in nature.

75 Interesting Case Hypermetabolic lesions/masses in the left neck extending to the thoracic inlet specifically to the left thyroid bed with hypermetabolic bilateral cervical lymphadenopathies are consistent with recurrent metastatic disease.

76 Interesting Case Hypermetabolic osseous metastases in the cervico thoracic spine.

77 Interesting Case 77/M with insular TCA, s/p thyroidectomy
L thyroid nodule and lung nodules on pre-op CT Post-op PET was requested for evaluation of disease extent

78 Interesting Case Hypermetabolic lesion in the left thyroid bed may be inflammatory but residual disease cannot be ruled out.

79 Interesting Case Hypermetabolic R hilar nodes. Differentials include inflammatory reaction vs. metastases.

80 TCA Staging

81 TCA Follow-up & Monitoring

82 Review of 2594 cases were reviewed for 1.5 years
Focal and diffuse thyroid FDG uptake were identified and were correlated with patholological diagnosis 3.8% (99/2594) showed incidental thyroid FDG uptake 46 diffuse (21 chronic thyroiditis) 53 focal 11/53 with focal FDG uptake FNAB results 4 benign 7 malignant (63.3%) Use of SUV to delineate benign from malignant uptake is still undetermined Chen, et al. Evaluation of thyroid FDG uptake incidentally identified on FDG imaging. NMC 2009 March 30(3):240-4

83 Conclusions Ultrasound and thyroid scans are still the mainstay in imaging the thyroid gland CT and MRI have limited values and can be utilized in identifying lymph nodes, local tumor extension, diff. thyroiditis and as FNA guide PET/CT is best for WDTCA that have dedifferentiated hence negative on I-131- WBS but increasing thyroglobulin as well as in aggressive and difficult cases of TCA and certain suspicious nodules by FNAB

84 Thanks you so much!

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