Best Practice & Research Clinical Endocrinology & Metabolism
11The value of positron emission tomography (PET) in the management of patients with thyroid cancer
Section snippets
History of FDG-PET and thyroid cancer
The first studies to clearly demonstrate increased glucose consumption by neoplastic tumors were those of Warburg et al.1 Subsequent investigations discovered this phenomenon to be due to both elevated membrane glucose transport2 and to increased intracellular glycolytic pathway activity.3 Sokoloff et al4 were the first to quantify this biological activity using deoxyglucose and autoradiography. These initial studies were followed by the development of 18F-fluoro-deoxyglucose (FDG) which could
Use of FDG-PET to detect occult metastases
Eight years after the initial observations by Joensuu and Ahonen, Feine et al*7, 8 and Grunwald et al9 confirmed that there was a reciprocal or ‘flip-flop’ relationship between FDG avidity and radio-iodine avidity in metastatic lesions. Well-differentiated thyroid cancers tended to concentrate RAI (but not FDG), while poorly differentiated or anaplastic tumors were highly FDG-avid, but frequently did not concentrate RAI. Some disagreement has arisen regarding the value of FDG scanning for
FDG-PET evaluation of thyroid nodules and incidentalomas
Adler and Bloom were the first to study thyroid nodules with PET scanning.27 They evaluated nine individuals and found increased FDG uptake in seven. Pathology showed that in only three of the seven were the lesions malignant. The malignant lesions all had higher SUVs than the benign ones. Importantly, they were unable to distinguish the malignant nodules based on the visual pattern of uptake. A somewhat larger series of 19 patients who all had surgical resection was reported by Bloom and Adler.
Comparison of PET/CT to PET OR CT in detecting metastatic lesions
The advent of PET/CT fusion technology has markedly increased the ability of radiologists to verify and validate PET findings. Zoller et al35 have compared the diagnostic accuracy of combined PET/CT with that of PET alone or CT alone. They found that PET/CT not only improved the diagnostic accuracy in patients with elevated serum thyroglobulin and negative diagnostic 131I scans, but it also had a dramatic effect on treatment decisions options. Freudenberg et al36 did a similar retrospective
Does the TSH level affect FDG-PET outcome?
Sisson at al39 was the first to observe that the uptake of FDG was apparently higher in thyroid cancer metastases when the level of thyroid-stimulating hormone (TSH) was elevated. The authors attributed this to the known induction of GLUT expression in thyroid cells by TSH.40
Wang et al18 subsequently confirmed that an elevated TSH often led to finding more metastatic lesions in the same patient compared with a suppressed TSH. However, in their series the new sites detected in the high TSH state
Does FDG-PET provide information about the biology of the tumor?
It is well established that metastases from thyroid carcinoma which do not concentrate radio-iodine are more clinically aggressive45, 46, and this has been confirmed histologically by the studies of Ghossein and colleagues.47 If FDG scans can detect thyroid cancer metastases which do not concentrate radio-iodine, one would hypothesize that the patients who harbored such lesions would have a less favorable prognosis. Wang et al48 directly tested this proposal by retrospectively evaluating
Resistance of FDG-AVID lesions to radioactive iodine therapy
The evidence to date clearly suggests a positive correlation between the FDG avidity of a metastatic lesion and the level of de-differentiation. There is ample evidence from the ‘flip-flop’ pattern that the less-differentiated lesions do not concentrate radio-iodine very effectively. How then are clinicians to approach the therapy of RAI-negative, FDG-positive lesions? A recent report from our unit examined the value of using very-high-dose 131I therapy for such lesions.50 We compared the
124I-iodine PET scanning comparison of FDG-PET to FDG-PET scanning
At present, many centers that treat patients with metastatic disease are using high-dose radio-iodine therapy, with minimal therapeutic effect but with all of the potential side-effects. There is currently no convenient means to accurately predict the radiation dose to an individual metastatic lesion. For the past 50 years we have based our treatments on not exceeding the maximum safe dose to blood or lung, rather than on the amount of radiation necessary to destroy the lesion. Based on studies
Summary
Despite the relatively good overall prognosis, approximately 1500 patients are expected to die of thyroid cancer in the US alone in 2008. More than 70% of the deaths occur in individuals whose initial histology was well-differentiated thyroid carcinoma. The current prognostic scoring systems (e.g. MACIS, TNM, AGES), which utilize clinical and pathological information obtained at the time of initial diagnosis, have served us well and have stood the test of time. Their major limitation is their
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Cited by (30)
Updated Review of Nuclear Molecular Imaging of Thyroid Cancers
2021, Endocrine PracticeCitation Excerpt :According to the latest guidelines issued by the American Thyroid Association, 18F-FDG PET/CT is recommended for use in high-risk DTC patients with elevated serum thyroglobulin and negative radioiodine imaging.39 Besides its role in initial staging in invasive Hürthle cell cancer,40 our quantitative study demonstrated that the SUVmax derived from 18F-FDG PET/CT could also predict the 131I avidity of metastases from DTC prior to initial radioiodine therapy.41 Because thyroid cancer is polymorphic and the differentiation status may change over time, use of 18F-FDG PET/CT is considered in patients with negative 131I scans and inexplicably increased thyroglobulin levels who were initially diagnosed with DTC.39
Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up
2019, Annals of OncologyCitation Excerpt :FDG–PET is more sensitive than therapeutic WBS for detecting persistent disease in patients with negative cross-sectional imaging studies, serum Tg levels >10 ng/dl, and/or aggressive histotypes (e.g. aggressive PTC, poorly differentiated TC, widely invasive follicular carcinoma) [67]. FDG uptake is associated with a worse prognosis and refractoriness to RAI treatment [68, 69], but it is not a reliable predictor of tumour growth [70]. FDG–PET is the first-line isotopic imaging technique for patients with RAI-refractory disease.
PET imaging for thyroid cancers: Current status and future directions
2017, Annales d'EndocrinologieCitation Excerpt :In 10% of patients, metastases may occur at initial stage or during patient follow-up. An intense 18F-FDG tumors uptake phenotype is associated with resistance to 131I and in consequences worsens patient survival, as first demonstrated by Robbins [25,26]. Indeed, Lazar et al. demonstrated a decrease in iodine/sodium symporter expression whilst an increase in glucose transporter Glut1 in dedifferentiated thyroid tumor cells, also called on functional imaging a “Flip-flop” phenomena (Fig. 1) [27].
<sup>131</sup>I imaging in the therapy of differentiated thyroid cancer
2012, Medecine Nucleaire[18F]Fluorodeoxyglucose positron emission tomography in advanced thyroid cancer
2011, Medecine Nucleaire