1. Dr. LP Si Yan Chai Hospital

2. Background With the increasing use of imaging modalities, more and more clinically inconspicuous thyroid lesions are discovered These are termed as thyroid incidentalomas Also include asymptomatic thyroid lesions identified during non-thyroid neck surgery, eg. parathyroidecotmy, carotid endarterectomy

3. Prevalence USG: 67% CT / MRI: 16% Carotid duplex: 9.4% FDG -PET: 2-3% Increasing use of FDG-PET Thyroid carcinomas detected by FDG-PET is more aggressive than those detected by other imaging modalities

4. FDG-PET Fluorodeoxyglucose positron emission tomography Mostly commonly used for Disease staging for patients with known malignancy Malignancy screening in healthy individuals

5. Increase FDG uptake in metabolically active tissue, e.g. malignancy, infection, inflammation, etc Normal thyroid gland not shown up

6. FDG-PET detected thyroid incidentalomas Unsuspected, asymptomatic thyroid lesions discovered on FDG-PET Prevalence 1.2-4.8% Increasing incidence but no increase in disease specific mortality Risk of malignancy 14-74% higher than incidental thyroid nodules found by USG, CT, or MRI

7. Is the thyroid incidentaloma on FDG-PET benign or malignant?

8. Pattern of uptake Focal Increase i n radioactivity concentration compared to that of the thyroid parenchyma Clearly delineated from the surrounding thyroid gl and Diffuse Ev en distribution of FDG in the entire thyroid gland Radioactivity concentration is higher than th at of the surrounding soft tissue

9. Focal uptake

10. Diffuse uptake

11. Focal uptake of thyroid lesions on PET also known as PETomas PET-associated incidental neoplasms (PAINs) PET de tected thyroid incidentalomas (PETI) Associated with an increased risk of malignancy than diffuse uptake

12. 20 out of 27 patients who underwent operation proved to have thyroid malignancy (74%) Nishimori H et al. Incidental thyroid “PETomas”: clinical significance and novel description of the self-resolving variant of focal FDG-PET thyroid uptake. Can J Surg Vol. 54, No.2, April 2011

13. SUV Standardized uptake value Elevated in metabolically active tissue Controversies about the use of SUV as an adjunct to differentiate between benign or malignant No cut off value

14. Katz SC et al. PET-Associated Incidental Neoplasms of the Thyroid. J Am Coll Surg (2008) 259-264

15. SUV correlates with the size of the thyroid incidentaloma in focal uptake r = 0.64, p < 0.05 Nilsson IL et al. Thyroid Incidentaloma Detected by Flurordeoxyglucose Positron Emission Tomography/Computed Tomography: Practical Management Algorithm. World J Surg (2011) 35:2691-2697

16. Risk factors of malignancy Clinically apparent thyroid nodules are associated with 5% malignant rate Are et al. showed that risk of malignancy in the presence and absence of palpable thyroid nodule is 24% and 6.3% respectively (p = 0.01)

17. Focal FDG uptake and unilateral uptake are associated with higher malignancy rate Are C et al. FDG-PET Detected Thyroid Incidentalomas: Need for Further Investigation? Annals of Surgical Oncology (2006) 14(1): 239-247

18. FDG-PET detected incidental thyroid carcinomas Most are papillary thyroid carcinoma (PTC) Poor prognostic variants are more common Tall-cell variant papillary thyroid carcinoma (TCVPTC) Poorly differentiated thyroid carcinoma As high as 50% Extra-thyroidal extension is also more common Higher treatment failure rate Higher local, regional and distant recurrences Higher disease-specific mortality

19. TCVPTC More aggressive with a worse prognosis when compared to classical PTC (cPTC) High rate of extra-thyroidal extension Up to 90% in one series Commonly smaller than cPTC FNAC is warranted regardless of the size if the lesion is suspicious

20. Management Most of the patients already have a primary malignancy → the whole plan of management should depend on the overall prognosis and life expectancy USG thyroid is necessary for all patient No evident nodule → follow up Nodule ≥ 1cm or < 1cm with suspicious features → FNAC

21. Suspicious sonographic features Marked hypoechogenicity Taller than wide Irregular shape Ill-defined margin Punctate calcification Increase in vascularity

22. FNAC (Bethesda System) Nondiagnostic Benign Atypia of undetermined significance (AUS) Suspicious for follicular neoplasm / follicular neoplasm Suspicious for malignancy Malignant

23. FNAC resultsAction Non-diagnostic / AUSRepeat FNAC BenignFollow up Suspicious for follicular neoplasm / follicular neoplasm / suspicious for malignancy / malignant Operation

24. Conclusion FDG-PET detected thyroid incidentalomas harbour a significant risk of malignancy Thyroid carcinomas detected on FDG-PET are more aggressive and demonstrate poorer prognosis They should be investigated by USG +/- FNAC Definitive management plan depends on the overall prognosis and life expectancy of the patients

25. References American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (2009) Jin J et al. Thyroid incidentaloma. Best Practice & Research Clinical Endocrinology & Metabolism 26 (2012) 83-96 Nilsson IL et al. Thyroid Incidentaloma Detected by Flurordeoxyglucose Positron Emission Tomography/Computed Tomography: Practical Management Algorithm. World J Surg (2011) 35:2691- 2697 Ho TY et al. Prevalence and significance of thyroid uptake detected by 18 F-FDG PET. Endocrine (2011) 40:297-302 Bertagna F et al. F18-PDF_PET/CT thyroid incidentalomas and their benign of malignant nature: a critical and debated issue. Ann Nucl Med (2011) 25:151-152 Nishimori H et al. Incidental thyroid “PETomas”: clinical significance and novel description of the self-resolving variant of focal FDG-PET thyroid uptake. Can J Surg Vol. 54, No.2, April 2011 Law TT et al. Incidental Thyroid Carcinoma by FDG-PET/CT: A Study of Clinicopathological Characteristics. Ann Surg Oncol (2011) 18:472-478

26. Jin J et al. Incidental thyroid nodule: patterns of diagnosis and rate of malignancy. The American Journal of Surgery (2009) 197, 320-324 Kang BJ et al. Incidental thyroid uptake on F-18 FDG PET/CT: correlation with ultrasonography and pathology. Ann Nucl Med (2009) 23:729-737 Gough J et al. Thyroid Incidentaloma: An Evidence-based Assessment of Management Strategy. World J Surg (2008) 32:1264-1268 Katz SC et al. PET-Associated Incidental Neoplasms of the Thyroid. J Am Coll Surg (2008) 259- 264 Are C et al. Histological Aggressiveness of Fluorodeoxyglucose Positron-Emission Tomogram (FDG-PET)-Detected Incidental Thyroid Carcinomas. Annals of Surgical Oncology (2007) 14(11):3210-3215 Are C et al. FDG-PET Detected Thyroid Incidentalomas: Need for Further Investigation? Annals of Surgical Oncology (2006) 14(1): 239-247