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Emerita a. Barrenechea MD, FPCP, FPSNM Department of Nuclear Medicine St. Luke’s Medical Center Veterans Memorial Medical Center Asia Oceania Thyroid Association.

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Presentation on theme: "Emerita a. Barrenechea MD, FPCP, FPSNM Department of Nuclear Medicine St. Luke’s Medical Center Veterans Memorial Medical Center Asia Oceania Thyroid Association."— Presentation transcript:

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

2 Thyroid gland-very accessible

3 Mainstream Thyroid Imaging SonographyScintigraphy

4 What is available? Planar/SPECT/SPECT-CT imaging (e.g. 99m Tc- based radiotracers, 123 I, 131 I) 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  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 New Modalities

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 ( 99m TcO 4 )

24 Multinodular Goiter

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

26 Diffuse Toxic Goiter  30/F  Palpitations, excessive sweating, irritability, anterior neck enlargement  99m TcO 4 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 131 I Scintigraphy

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

34 Functioning Mets In Both Lungs Initial Presentation Post-SURGERY Post remnant Ablation I II III Proceed to to stage IV I-131 Therapy of Functioning Metastases 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  99m TcO 4  99m Tc sestamibi  99m Tc tetrofosmi  201 TlCl  123 I  131 I

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

39 131 I SPECT/CT

40 TCA with mets


42 99m Tc sestamibi-Parathyroid

43 Medullary Thyroid Carcinoma


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

46 PET in TCA with increasing TG, negative TBS

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


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


55  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 18 FDG Scan in Medullary TCA  Intense FDG uptake in a hypodense nodule, L thyroid lobe  Serum Calcitonin: 800  Final Diagnosis: Medullary TCA PET onlyCT Only 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 18 FDG uptake (benign)

59 Philippine Data (2002 to 2012)  170 18 FDG 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  ↑ Tg, (–) RAI scan, (+) 18 FDG PET  14 PTCA  Normal Tg, (–) RAI scan, (+) 18 FDG 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 18 FDG PET  Indeterminate thyroid nodules (3 cases)  Calcitonin-positive medullary TCA  18 F-DOPA is superior to 18 FDG for this  One case was negative on 18 FDG  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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