A new method for radioguided occult lesion localization using a
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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