A new method for radioguided occult lesion localization using a

PET e Tiroide
Raffaele Giubbini
Cattedra ed U.O. di Medicina Nucleare
Università & Spedali Civili
Centro PET della Fondazione Guido Berlucchi
Brescia
[email protected]
PET & Thyroid
Specificity of PET/CT in DTC:
1. high resolution (theoretically < 3 mm)
enphasize by hybrid imaging with CTCT
2. use of tracers with different targets:



18F-FDG
124I
68Ga-Dotanoc
Detection of Residual Lymph Node Metastases in
High-Risk Papillary Thyroid Cancer
Kaneko K. Et al Clin Nucl Med 2010;35: 6–11
TG=57 ng/ml
18F-FDG PET/CT
131I-WBS
F-18 FDG-PET/CT Evaluation of Ptss With DTCWith Negative I-131 Total Body
Scan and High Thyroglobulin Level.
ROC curves showing PET/CT results correlated with Tg
levels in terms of sensibility and specificity.
Bertagna F; Giubbini R et al. Clinical Nuclear Medicine 2009 34(11):756-761.
2
Bertagna F; Giubbini R et al. Clinical Nuclear Medicine 2009 34(11):756-761.
Thyrotropin Stimulates Glucose Transport
in Cultured Rat Thyroid Cells
TSH stimulates the glucose transport system
by an enhancement of the number of
functional glucose transporters in the
thyroid plasma membrane.
The TSH effect was dose dependent
Filetti S et al. Endocrinology 120: 2576–2581,1987
high Tg levels with negative 131I-WBS
Is sensitivity of 18FDG PET/CT
enhanced by TSH stimulus ?
Results of FDG PET during thyroid
stimulating hormone (TSH) stimulation and
TSH suppression
F-18 FDG-PET/CT Evaluation of Ptss With DTCWith Negative I-131 Total Body
Scan and High Thyroglobulin Level.
Bertagna F; Giubbini R et al. Clinical Nuclear Medicine 2009 34(11):756-761.
2
The incidentalomas!
Diagnostic and clinical significance of F18-FDG-PET/CT thyroid
incidentalomas. A critical review of the literature.
Francesco Bertagna1, Giorgio Treglia2, Arnoldo Piccardo3, Raffaele Giubbini1.
1Nuclear Medicine, University of Brescia and Spedali Civili di Brescia, Brescia, Italy.
2Nuclear Medicine, Catholic University of Sacred Heart, Rome, Italy.
3 Nuclear Medicine, Galliera Hospital, Genoa, Italy.
JCEM 2012, in press
Author
Year
N.
N.TI (%)
N.TIFI (%)
N.Mal (%)
Cohen et al.
Kang et al.
Hsieh et al.
Ishimori et al.
Chen et al.
Kim et al.
Chu et al.
Even-Sapir et al.
Choi et al.
Nam et al.
Bogsrud et al.
Are et al.
King et al.
Kwak et al.
Chen et al.
Bae et al.
Eloy et al.
Kang et al.
Zhai et al.
Nishimori et al.
Kim et al.
Ohba et al.
Nilsson et al.
Ho et al.
Pagano et al.
Bonabi et al.
Pampaloni et al.
2001
2003
2003
2005
2005
2005
2006
2006
2006
2007
2007
2007
2007
2008
2009
2009
2009
2009
2010
2010
2010
2010
2011
2011
2011
2012
2012
4525
1330
477
1912
4803
4136
6241
2360
1763
689
7347
8800
15711
14434
2594
3379
630
12840
3600
4726
11623
1501
3641
5877
11040
3062
8464
102 (2.3)
29 (2.2)
12 (2.5)
29 (1.5)
60 (1.2)
94 (2.2)
76 (1.2)
59 (2.5)
70 (4)
19 (2.8)
79 (1.1)
263 (2.9)
22 (0.2)
88 (0.6)
99 (3.8)
285 (8.4)
30 (4.8)
1151 (8.9)
115 (3.2)
160 (3.38)
159 (1.4)
20 (1.3)
64 (1.8)
220 (3.7)
191 (1.8)
75 (2.4)
156 (1.8)
15 (15)
15 (52)
10 (83)
11 (38)
50 (83)
32 (34)
14 (18)
41 (70)
44 (63)
12 (63)
48 (61)
84 (32)
22 (100)
85 (97)
11 (11)
99 (35)
18 (60)
190 (16)
96 (83)
50 (31)
140 (88)
20 (100)
27 (42)
55 (25)
37 (19)
42 (56)
40 (71)
7 (47)
4 (27)
1 (8)
6 (24)
7 (14)
16 (50)
4 (29)
13 (32)
17 (39)
5 (42)
15 (35)
44 (52)
3 (14)
42 (49)
7 (64)
22 (23)
5 (28)
57 (30)
48 (50)
9 (18)
37 (26)
11 (55)
16 (59)
8 (15)
15 (40)
10 (24)
15 (38)
Diagnostic and clinical significance of F18-FDG-PET/CT thyroid
incidentalomas. A critical review of the literature.
Francesco Bertagna1, Giorgio Treglia2, Arnoldo Piccardo3, Raffaele Giubbini1.
1Nuclear Medicine, University of Brescia and Spedali Civili di Brescia, Brescia, Italy.
2Nuclear Medicine, Catholic University of Sacred Heart, Rome, Italy.
3 Nuclear Medicine, Galliera Hospital, Genoa, Italy.
Author
total
Year
2012
JCEM 2012, in press
N.
N.TI (%)
N.TIFI (%)
N.Mal (%)
147506
3657(2.47)
1308 (35.8)
444 (40)
incidence of thyroid cancer in focal thyroid
incidentaloma
detected by 18F-fluorodexyglucose positron
emission
Incidence; 20 /1501 normal volunteers
Ohba K. Et al. Endocr J. 2010 Feb 17. [Epub ahead of print]
(a) Therapeutic central-compartment (level VI) neck dissection for pts with clinically
involved central or lateral neck lymph
(b) Prophylactic central-compartment neck dissection for advanced primary tumors (T3
or T4)
(c) Near-total or total thyroidectomy without prophylacticcentral neck dissection may
be appropriate for small (T1 or T2), noninvasive, clinically node-negative PTCs and
most follicular cancer.
(d) Therapeutic lateral neck compartmental lymph node dissection for pts with biopsy
provenmetastatic lateral cervical lymphadenopathy
29/12/2011
near total
thyroidectomy
(2012/2/22)
histology: invasive
follicular carcinoma
with oxyphil cells
+medullary μ
carcinomaa
midollare - 1mm
(CT neg)
TG > 1000 ng/ml
131I-SPECT/CT
18F-FDG PET/CT
18F-FDG PET/CT changes therapy management
in high-risk DTC after first radioiodine therapy
90 pts: T≥3 or T1-2 N1 or M1
Patient
management
All patients
FDG negative
Changed
Not changed
Patients FDGpositive lesions
FDG positive
FDG-positive
FDG- or iodine
Same lesions
lesions only
Positive lesions
FDG and
iodine-positive
0
19
15
4
0
64
7
0
0
7
Rosenbaum-Krumme SJ et al, Eur J Nucl Med Mol Imaging, in press,
(DOI 10.1007/s00259-012-2065-4)
18F-FDG PET/CT changes therapy management
in high-risk DTC after first radioiodine therapy
P<.01
Rosenbaum-Krumme SJ et al, Eur J Nucl Med Mol Imaging, in press,
(DOI 10.1007/s00259-012-2065-4)
PET e Tiroide
La specificità della tomografia ad emissione di
positroni nell’imaging delle malattie
neoplastiche della tiroide:
1. maggiore risoluzione (teoricamente
inferiore a 3 mm) enfatizzato
dall’ibridazzione con CT
2. impiego di traccianti con diverso destino
metabolico:



18F-FDG
124I
68Ga-Dotanoc
Clinical applications of 124I-PET/CT in patients
with differentiated thyroid cancer
24 h, 25 MBq 124I
D7, 10 GBq 131I
Freudenberg LS et al. Eur J Nucl Med Mol Imaging (2011) 38 (Suppl 1):S48–S56
124 I PET vs. 131I Planar Imaging in the
identification od residual thyroid tissue and/or
metastasis in Pts who have well DTC
Van Nostrand D et al. Thyroid 2010.20:879-883
rhTSH vs thyroid hormone withdrawal in the
identification of metastasis in DTC with 131I planar
whole-body imaging and 124I PET.
Prospective study:
Pts with strong evidence of metastatic DTC (TG, FNA,
enlarging mass, abnormal diagnostic study, no
demographic differences between groups).
patients with positive foci:
rhTSH 131I WBS
= 4% (1/24)
rhTSH 124I PET
= 29% (7/24)
THW 131I WBS = 63% (10/16), (P < 0.02).
THW 124I PET = 63% (10/16), (P < 0.03).
number of foci detected:
rhTSH 131I
=2
rhTSH 124I PET
= 17
THW 131I WBS = 58 (P < 0.05).
THW 124I PET = 117 (P < 0.03).
Van Nostrand D et al. J Nucl Med. 2012;53(3):359-62
The effectiveness of 124I PET/CT in patients with
differentiated thyroid cancer
PET/CT and WBS matched in
58/67 patients (86.6%)
In 12% PET/CT showed unknown
lymphnode metastases
In 4% PET/CTdetected unknown
distant metastases
Capoccetti F. et al. Q J Nucl Med Mol Imaging. 2009 Oct;53(5):536-45
Freudenberg LS e al.
Optimized 124I PET Dosimetry Protocol for
Radioiodine Therapy of Differentiated Thyroid
Cancer
Jentzen W Et al. J Nucl Med 2008; 49 : 1017-1023
Optimized 124I PET Dosimetry Protocol for
Radioiodine Therapy of Differentiated Thyroid
Cancer
lesion dose per administered activity of 131I (LDpA) in Gy GBq–1
24-h activity concentration (CpA) differed significantly among the LDpA
Jentzen W Et al. J Nucl Med 2008; 49 : 1017-1023
Jentzen W Et al. J Nucl Med 2008; 49 : 1017-1023
transferring information from PET to
SPECT
To avoid false negative results, 131-I WBS
should be performed
•
•
•
•
after high (therapeutic) activity
with adequate technology (thick crystal)
after adequate TSH stimulation
ioduria < 50 μg/dl
B.W.182123
131I - 5 mCi
131I- 200 mCi
Tg = 19,2 ng/mL
Ca Tiroideo differenziato – 131I SPECT/CT
TG
TG
Dose efficace con WBS con 7400 MBq di 131I
(calcoli dosimetrici con OlindaTM)
Radionuclide
Uptake tiroideo
Attività somministrata
I-131
Target Organ
Total DoseEDE
mGy
mSv
2,44E+02 1,22E+00
1,99E+02 9,94E-01
1,88E+02 9,40E+00
2,54E+02 0,00E+00
3,13E+02 3,76E+01
2,74E+02 1,37E+00
2,38E+02 2,86E+01
2,63E+02 1,32E+00
2,33E+02 0,00E+00
5,00E+02 2,50E+00
2,33E+02 1,16E+01
2,15E+02 2,58E+01
2,28E+02 1,14E+00
Adrenals
Brain
Breasts
Gallbladder Wall
LLI Wall
Small Intestine
Stomach Wall
ULI Wall
Heart Wall
Kidneys
Liver
Lungs
Muscle
Iodide
0%
7400 MBq
Ovaries
Pancreas
Red Marrow
Osteogenic Cells
Skin
Spleen
Testes
Thymus
Thyroid
Urinary Bladder Wall
Uterus
Total Body
3,13E+02
2,52E+02
1,99E+02
4,46E+02
1,86E+02
2,35E+02
2,58E+02
2,20E+02
2,20E+02
4,37E+03
4,02E+02
2,31E+02
6,25E+01
1,26E+00
2,39E+01
4,46E+00
1,86E+00
1,17E+00
0,00E+00
1,10E+00
1,10E+01
2,19E+02
2,01E+00
0,00E+00
Dose Efficace
4,50E+02 mSv
High Tg Level and Negative WBS
detection of mets with no 131I uptake :
•
•
•
•
•
ECHO of cervical region
High resolution CT scan of neck and Thorax
18FDG PET/CT
99mTc-MDP bone scan
PET (SPECT) with somatostatin receptors tracers
Temi della presentazione
Uptake tiroideo incidentale di F18-FDG in
soggetti studiati per altre patologie
F18-FDG PET nella stadiazione del DTC
F18-FDG PET nel F.U. del DTC
Ga68-Dota PET/CT in DTC & in
medullary Thyroid K
PET con 124I
Comparison of positron emission tomography with [18F]FDG and
[68Ga]DOTATOC in recurrent differentiated thyroid cancer: preliminary data
Middendorp M et al. Q J Nucl Med Mol Imaging. 2010 Feb;54(1):76-83
A patient with medullary thyroid carcinoma and right ventricular cardiac
metastasis treated by (90)Y-Dotatoc
Ct=2560;
CEA=8
111In-OCTREOSCAN
Bertagna F et al. Hell J Nucl Med. 2009 May-Aug;12(2):161-4.
A patient with medullary thyroid carcinoma and right ventricular cardiac
metastasis treated by (90)Y-Dotatoc
Bertagna F et al. Hell J Nucl Med. 2009 May-Aug;12(2):161-4.
A patient with medullary thyroid carcinoma and right ventricular cardiac
metastasis treated by (90)Y-Dotatoc
Bertagna F et al. Hell J Nucl Med. 2009 May-Aug;12(2):161-4.
68Ga-DOTATATE
and 18F-fluorodeoxyglucose PET/CT in the detection of recurrent medullary
thyroid carcinoma
Conry BG et al. Eur J Nucl Med Mol Imaging (2010) 37:49–57
68Ga-DOTATATE
and 18F-fluorodeoxyglucose PET/CT in the
detection of recurrent medullary thyroid carcinoma
Per patient (n.18) analysis: sensitivity
72.2% [95%CI: 46.4–89.3%] for 68Ga
DOTATATE
77.8% (95% CI: 51.9–92.6%) for 18F-FDG.
McNemar’s test, p value=0.056
Lesion detection:
55 lesions on 68Ga-DOTATATE
72 on 18F-FDG PET/CT.
per-region analysis
28 regions positive on 18F-FDG PET
23 on 68Ga-DOTATATE
Conry BG et al. Eur J Nucl Med Mol Imaging (2010) 37:49–57
Prospective evaluation of 68Ga-DOTA-NOC PET-CT in
patients with recurrent medullary thyroid carcinoma:
comparison with 18F-FDG PET-CT
51 Pt, with a history of appropriately treated MTC and elevation of the tumour
marker calcitonin (>30 pg/ml). 41 also underwent 18 F-FDG PET-CT imaging
within an interval of 4 weeks (median interval of 1 week)
Naswa N et al. Nuclear Medicine Communications 2012, 33:766–774
Final Results of a Phase 2A Study for theTreatment of Metastatic
NeuroendocrineTumors With a Fixed Activity of 90Y-DOTA-D-Phe1-Tyr3
Octreotide
17 pts partial responses (43.6%),
10 pts (stable disease 25.6%),
11 pts progressive disease (28.2%).
Savelli G, Bertagna F, Giubbini R et al, Cancer. 2012 Jun 1;118(11):2915-24
Conclusioni
18F-FDG PET/CT utile nella stadiazione del
DTC localmente avanzato o con sospetto
di metastasi
124I PET/CT evidenzia una sostanziale
inadeguatezza dei criteri diagnostici
tradizionali per una corretto staging post
chirurgico
68GA Dotanoc promettente nella
caratterizzazione del tumore midollare
della tiroide
Conclusioni
Da conigli………………a……………………predatori !!
FDG PET
SPECT
US
high dose
MRI
rTSH
AB_TG
THYROGLOBULIN
scinti
ECHO
stabe I urinary
131I-WBS
LOW-DOSE
124I
Ga68-DOTA
L-T4