Technetium-99m Tetrofosmin Single Photon Emission Computed Tomography to Detect Metastatic Papillary Thyroid Carcinoma in Patients with Elevated Human Serum Thyroglobulin Levels but Negative I-131 Whole Body Scan

18F-fluorodeoxyglucose and 131I radioguided surgical management of thyroid cancer

OBJECTIVE

To describe a technique that assists in the surgical management of recurrent local regional well-differentiated thyroid cancer (WDTC).

STUDY DESIGN

Case series with chart review.

SETTING

Two academic health centers from 2001 to 2009.

SUBJECTS AND METHODS

Patients operated upon by the senior surgeon (BCS) for recurrent WDTC.

RESULTS

Thirteen patients with recurrent WDTC were operated upon with radioguided surgical (RGS) technique to indentify recurrence for excision. Eight patients had iodine avid disease and were candidates for RGS with (131)I. The remaining 5 patients had cancer with a proven loss of iodine avidity and were, therefore, operated upon with a fluorodeoxygluocose (FDG) RGS technique.

CONCLUSION

RGS is a feasible approach to identify recurrent disease in an operated field and ensure its successful excision. Although focal disease may be identified with this technique, this is not a tool for limited excisions ("berry picking").

Relation between (99m)Tc-tetrofosmin thyroid scintigraphy and mitogen-activated protein kinase in papillary thyroid cancer patients

PURPOSE

The aim of this study was to investigate the relation between (99m)Tc-tetrofosmin uptake and extracellular signal-regulated kinase mitogen-activated protein kinase (ERK MAPK) expression in papillary thyroid cancer patients.

MATERIALS AND METHODS

Our study population consisted of 14 patients. The histopathological findings for all patients were confirmed by surgery. Patients were administ 740 MBq of (99m)Tc-tetrofosmin. The tumor/background (T/B) ratios in regions of interest (ROIs) were measured at 10 min, 1 h, and 3 h to determine the uptake by papillary cancer. Immunohistopathological staining was performed, and the expression of phospho-ERK MAPK in papillary cancer was investigated. The relation between the expression of phospho-ERK MAPK and the T/B ratio was examined using the Mann-Whitney U-test.

RESULTS

(99m)Tc-tetrofosmin uptake was positive in all patients. There was a statistically significant relation between the T/B ratio (at 3 h) and the expression of phospho-ERK MAPK but not with the T/B ratio at 10 min or 1 h: T/B ratio at 10 min (P = 0.32), at 1 h (P = 0.62), and at 3 h (P = 0.0072).

CONCLUSION

Our results suggest that the relation between (99m)Tc-tetrofosmin uptake (3 h T/B ratio) may lead us to assume cell proliferation of papillary cancer.

99mTc-sestamibi radio-guided surgery of loco-regional 131Iodine-negative recurrent thyroid cancer

AIM

We report here our experience in a larger series of differentiated thyroid cancer (DTC) patients who had been treated by (99m)Tc-sestamibi radio-guided surgery (RGS) for (131)Iodine ((131)I)-negative loco-regional recurrent disease.

METHODS

Fifty-eight patients with loco-regional (131)I-negative recurrent disease from DTC were studied with (99m)Tc-sestamibi directed RGS using a hand-held 11-mm gamma probe as an intra-operative detector. Patients were selected for RGS on the basis of (a) progressive increase of serum thyroglobulin (Tg) levels after first treatment during follow-up, (b) negative high dose (100 mCi, 3.7 GBq) (131)I whole-body scan, and (c) positive pre-operative (99m)Tc-sestamibi scintigraphy for the presence of loco-regional recurrent disease. There were 41 papillary (1 "tall" cell variant), 13 follicular and 4 Hürthle cells tumours. In 14 patients thyroid cancer recurred in the thyroid bed while cervical lymph node metastases were found in 37 patients, and 7 patients had recurrent disease both in the thyroid bed and in cervical lymph nodes.

RESULTS

At bilateral neck exploration, 147 metastatic foci ranging from 4 mm to 51 mm in largest diameter (mean tumour diameter=17.3+/-9.5mm) were removed. Eighty-five of them (58%) had been pre-operatively identified at (99m)Tc-sestamibi scintigraphy. After RGS, serum Tg levels normalised in 43 of 58 patients (serum Tg<2 ng/ml--they were considered disease-free), serum Tg remained slightly increased in 12 patients without evidence of metastatic disease at scintigraphic and radiologic imaging (serum Tg<10 ng/mg--they were considered living with microscopic disease), while serum Tg significantly increased up to values>900 ng/ml in 3 patients who developed lung metastases. The mean lesion to background (99m)Tc-sestamibi uptake ratios decreased in all 58 patients (p<0.0001). Post-surgical follow-up ranged 6-72 months (mean+/-SD=29.6+/-13.5 months). The operating surgeon assessed RGS as very useful in 14 patients in whom metastatic foci were embedded in fibrotic tissues or located behind blood vessels, useful in 22 patients, moderately useful 17 patients and not useful in 5 patients.

CONCLUSION

Our data suggest that a (99m)Tc-sestamibi intra-operative gamma probe can be used to identify and guide resection of recurrent loco-regional tumour in DTC patients with (131)I-negative loco-regional metastatic foci.

Radio-guided surgery for non-131I-avid thyroid cancer

OBJECTIVE

In this paper we report in a larger series the use of radio-probe-guided surgery (RGS) in nonradioiodine avid, well-differentiated thyroid cancer (DTC).

DESIGN

Thirty-seven patients with locoregional recurrent, nonradioiodine avid DTC were studied with (99m)Tc-sestamibi directed RGS using a handheld gamma probe as an intraoperative detector.

OUTCOME

Twenty-three women and 14 men were followed after RGS for 35.4 +/- 12.5 months (range 9-57). There were 33 papillary (one "tall" cell variant), 2 follicular, and 2 Hürthle cell cancers. In 7 patients, thyroid cancer recurred in the neck while cervical lymph node metastases were found in 31 patients (one patient had papillary cancer in both the thyroid bed and cervical lymph nodes). Sixty-six discrete nodules ranging from 6 to 45mm (mean tumor diameter, 18.4 +/- 8.5mm) were identified by both high-resolution ultrasound and (99m)Tc-sestamibi probe-guided RGS. After RGS, Tg (thyroglobulin) fell in 33 of 37 patients and mean target=nontarget sestamibi uptake ratios decreased in all 37 patients ( p < 0.0001).

CONCLUSION

These data confirm our earlier observations that a (99m)Tc-sestamibi intraoperative gamma probe can be used to identify and guide resection of recurrent tumor and involved lymph nodes in locoregional metastases of nonradioiodine-avid thyroid cancer.