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Wadsley J, Balasubramanian SP, Madani G, Munday J, Roques T, Rowe CW, Touska P, Boelaert K. Consensus statement on the management of incidentally discovered FDG avid thyroid nodules in patients being investigated for other cancers. Clin Endocrinol (Oxf) 2023. [PMID: 36878888 DOI: 10.1111/cen.14905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023]
Abstract
With the widespread use of 18F-fluorodeoxyglucose positron emission tomography (FDG PET/CT) in the investigation and staging of cancers, incidental discovery of FDG-avid thyroid nodules is becoming increasingly common, with a reported incidence in the range 1%-4% of FDG PET/CT scans. The risk of malignancy in an incidentally discovered FDG avid thyroid nodule is not clear due to selection bias in reported retrospective series but is likely to be less than 15%. Even in cases where the nodule is found to be malignant, the majority will be differentiated thyroid cancers with an excellent prognosis even without treatment. If, due to index cancer diagnosis, age and co-morbidities, it is unlikely that the patient will survive 5 years, further investigation of an incidental FDG avid thyroid nodule is unlikely to be warranted. We provide a consensus statement on the circumstances in which further investigation of FDG avid thyroid nodules with ultrasound and fine needle aspiration might be appropriate.
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Affiliation(s)
| | | | - Gitta Madani
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Tom Roques
- Norfolk and Norwich Hospital, Norwich, UK
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Familiar C, Merino S, Valhondo R, López C, Pérez X, De Los Monteros PE, Hernández F, Pazos M, Pallarés R, Pascual AC. Prevalence and clinical significance in our setting of incidental uptake in the thyroid gland found on 18F-fluordeoxyglucose positron emission tomography-computed tomography (PET-CT). ENDOCRINOL DIAB NUTR 2023; 70:171-178. [PMID: 37030900 DOI: 10.1016/j.endien.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/25/2022] [Indexed: 04/10/2023]
Abstract
INTRODUCTION The expanding use of 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) has resulted in an increased frequency of incidentally discovered areas of FDG uptake within the thyroid gland. In these incidentalomas, high malignancy rates are reported. The study aimed, on the one hand, to determine the prevalence in our setting of thyroid incidentalomas in patients with no previous history of thyroid cancer undergoing an FDG PET-CT as well as the risk of malignancy and, on the other hand, to evaluate the usefulness of the maximum standard uptake value (SUVmax) for detecting thyroid cancer. MATERIAL AND METHODS The FDG PET-CT scans performed at our hospital between June 2013 and December 2020 were retrospectively reviewed. In those incidentalomas with sufficient additional investigation, a diagnosis of benign or malignant was established based on the complementary tests. RESULTS From the 21,594 PET-CT scans performed, 398 (1.8%) patients had an incidental FDG uptake, either focal (n=324) or diffuse (n=74). Among incidentalomas with further investigation, the rate of malignancy was higher in patients with focal FDG uptake than in those with diffuse uptake (26.5% versus 4%, respectively, p<0.05). The SUVmax value was significantly lower in benign focal lesions (5.7 [range: 2.3-66] than in malignant ones 10.6 [range: 3.1-51.2]; p<0.05). Nearly a quarter of malignant diagnoses (23.3%) were related to potentially aggressive tumours. CONCLUSION The high rate of malignant tumours found among PET-CT incidentalomas and the high proportion of aggressive tumours demonstrate the need for a standardised approach in the investigation of incidental focal FDG uptake in the thyroid gland.
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Affiliation(s)
- Cristina Familiar
- Servicio de Endocrinología, Hospital Clínico San Carlos Clínico, Madrid, Spain.
| | - Salomé Merino
- Servicio de Radiodiagnóstico, Hospital Clínico San Carlos Clínico, Madrid, Spain
| | - Raquel Valhondo
- Servicio de Medicina Nuclear, Hospital Del Mar, Barcelona, Spain
| | - Celia López
- Servicio de Endocrinología, Hospital Clínico San Carlos Clínico, Madrid, Spain
| | - Xavier Pérez
- Servicio de Endocrinología, Hospital Clínico San Carlos Clínico, Madrid, Spain
| | | | - Fernando Hernández
- Servicio de Endocrinología, Hospital Clínico San Carlos Clínico, Madrid, Spain
| | - Mario Pazos
- Servicio de Endocrinología, Hospital Clínico San Carlos Clínico, Madrid, Spain
| | - Raquel Pallarés
- Servicio de Endocrinología, Hospital Clínico San Carlos Clínico, Madrid, Spain
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Lee H, Hwang KH. Significance of incidental focal fluorine-18 fluorodeoxyglucose uptake in colon/rectum, thyroid, and prostate: With a brief literature review. World J Clin Cases 2022; 10:12532-12542. [PMID: 36579086 PMCID: PMC9791515 DOI: 10.12998/wjcc.v10.i34.12532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/10/2022] [Accepted: 11/08/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT), a functional imaging method, is usually performed on the entire torso, and regions of unexpected suspicious focal hypermetabolism are not infrequently observed. Among the regions, colon, thyroid, and prostate were found to be the common organs in a recent umbrella review. Some studies reported that a high rate of malignancy was shown in incidentally identified focal hypermetabolic regions and suggested that further examinations should not be ignored.
AIM To investigate the malignancy rate of incidental focal FDG uptake, useful PET parameters and their cutoffs in discrimination between malignant and benign lesions.
METHODS Retrospectively, the final reports of 16510 F-18 FDG PET/CT scans performed at our hospital between January 2016 and March 2022 were reviewed to identify incidentally observed FDG uptake in the colon/rectum, thyroid, and prostate. The scans of patients with current or prior malignancies at each corresponding location, without the final reports of histopathology or colonoscopy (for colon and rectum) for the corresponding hypermetabolic regions, or with diffuse (not focal) hypermetabolism were excluded. Finally, 88 regions of focal colorectal hypermetabolism in 85 patients (48 men and 37 women with mean age 67.0 ± 13.4 years and 63.4 ± 15.8 years, respectively), 48 focal thyroid uptakes in 48 patients (12 men and 36 women with mean age 62.2 ± 13.1 years and 60.8 ± 12.4 years, respectively), and 39 focal prostate uptakes in 39 patients (mean age 71.8 ± 7.5 years) were eligible for this study. For those unexpected focal hypermetabolic regions, rates of malignancy were calculated, PET parameters, such as standardized uptake value (SUV), capable of distinguishing between malignant and benign lesions were investigated, and the cutoffs of those PET parameters were determined by plotting receiver operating characteristic curves.
RESULTS In the colon and rectum, 29.5% (26/88) were malignant and 33.0% (29/88) were premalignant lesions. Both SUVmax and SUVpeak differentiated malignant/premalignant from benign lesions, however, no parameters could distinguish malignant from premalignant lesions. Higher area under the curve was shown with SUVmax (0.752, 95%CI: 0.649-0.856, P < 0.001) and the cutoff was 7.6. In the thyroid, 60.4% (29/48) were malignant. The majority were well-differentiated thyroid cancers (89.7%, 26/29). The results of BRAF mutation tests were available for 20 of the 26 well-differentiated thyroid cancers and all 20 had the mutation. Solely SUVmax differentiated malignant from benign lesions and the cutoff was 6.9. In the prostate, 56.4% (22/39) were malignant. Only SUVmax differentiated malignant from benign lesions and the cutoff was 3.8. Overall, among the 175 focal hypermetabolic regions, 60.6% (106/175) were proven to be malignant and premalignant (in colon and rectum) lesions.
CONCLUSION Approximately 60% of the incidentally observed focal F-18 FDG uptake in the colon/rectum, thyroid, and prostate were found to be malignant. Of the several PET parameters, SUVmax was superior to others in distinguishing between malignant/premalignant and benign lesions. Based on these findings, incidental focal hypermetabolism should not be ignored and lead physicians to conduct further investigations with greater confidence.
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Affiliation(s)
- Haejun Lee
- Department of Nuclear Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon 21565, South Korea
| | - Kyung-Hoon Hwang
- Department of Nuclear Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon 21565, South Korea
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Familiar C, Merino S, Valhondo R, López C, Pérez X, De Los Monteros PE, Hernández F, Pazos M, Pallarés R, Pascual AC. Prevalence and clinical significance in our setting of incidental uptake in the thyroid gland found on 18F-fluordeoxyglucose positron emission tomography-computed tomography (PET-CT). ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Gherghe M, Lazar AM, Mutuleanu MD, Stanciu AE, Martin S. Radiomics Analysis of [18F]FDG PET/CT Thyroid Incidentalomas: How Can It Improve Patients’ Clinical Management? A Systematic Review from the Literature. Diagnostics (Basel) 2022; 12:diagnostics12020471. [PMID: 35204561 PMCID: PMC8870948 DOI: 10.3390/diagnostics12020471] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 01/01/2023] Open
Abstract
Background: We performed a systematic review of the literature to provide an overview of the application of PET-based radiomics of [18F]FDG-avid thyroid incidentalomas and to discuss the additional value of PET volumetric parameters and radiomic features over clinical data. Methods: The most relevant databases were explored using an algorithm constructed based on a combination of terms related to our subject and English-language articles published until October 2021 were considered. Among the 247 identified articles, 19 studies were screened for eligibility and 11 met the criteria, with 4 studies including radiomics analyses. Results: We summarized the available literature based on a study of PET volumetric parameters and radiomics. Ten articles provided accurate details about volumetric parameters and their prospective value in tumour assessment. We included the data provided by these articles in a sub-analysis, but could not obtain statistically relevant results. Four publications analyzed the diagnostic potential of radiomics and the possibility of creating precise predictive models, their corresponding quality score being assessed. Conclusions: The use of PET volumetric parameters and radiomics analysis in patients with [18F]FDG-avid thyroid incidentalomas outlines a great prospect in diagnosis and stratification of patients with malignant nodules and may represent a way of limiting the need for unnecessary invasive procedures; however, further studies need to be performed for a standardization of the method.
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Affiliation(s)
- Mirela Gherghe
- Nuclear Medicine Department, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (M.G.); (M.-D.M.)
- Nuclear Medicine Department, Institute of Oncology “Profesor Doctor Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Alexandra Maria Lazar
- Nuclear Medicine Department, Institute of Oncology “Profesor Doctor Alexandru Trestioreanu”, 022328 Bucharest, Romania
- Correspondence:
| | - Mario-Demian Mutuleanu
- Nuclear Medicine Department, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (M.G.); (M.-D.M.)
- Nuclear Medicine Department, Institute of Oncology “Profesor Doctor Alexandru Trestioreanu”, 022328 Bucharest, Romania
| | - Adina Elena Stanciu
- Carcinogenesis and Molecular Biology Department, Institute of Oncology “Profesor Doctor Alexandru Trestioreanu”, 022328 Bucharest, Romania;
| | - Sorina Martin
- Endocrinology Department, Elias Emergency University Clinic Hospital, 011461 Bucharest, Romania;
- Endocrinology Department, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania
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Lee H, Chung YS, Lee JH, Lee KY, Hwang KH. Characterization of focal hypermetabolic thyroid incidentaloma: An analysis with F-18 fluorodeoxyglucose positron emission tomography/computed tomography parameters. World J Clin Cases 2022; 10:155-165. [PMID: 35071515 PMCID: PMC8727242 DOI: 10.12998/wjcc.v10.i1.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/09/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Incidentally found thyroid tumor (thyroid incidentaloma, TI) on F-18 fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) is reported in 2.5%-5% of patients being investigated for non-thyroid purposes. Up to 50% of these cases have been diagnosed to be malignant by cytological/histological results. Ultrasonography (US) and fine-needle aspiration cytology are recommended for thyroid nodules with high FDG uptake (hypermetabolism) that are 1 cm or greater in size. It is important to accurately determine whether a suspicious hypermetabolic TI is malignant or benign.
AIM To distinguish malignant hypermetabolic TIs from benign disease by analyzing F-18 FDG PET-CT parameters and to identify a cut-off value.
METHODS Totally, 12761 images of patients who underwent F-18 FDG PET-CT for non-thyroid purposes at our hospital between January 2016 and December 2020 were retrospectively reviewed, and 339 patients [185 men (mean age: 68 ± 11.2) and 154 women (mean age: 63 ± 15.0)] were found to have abnormal, either focal or diffuse, thyroid FDG uptake. After a thorough review of their medical records, US, and cytological/histological reports, 46 eligible patients with focal hypermetabolic TI were included in this study. The TIs were categorized as malignant and benign according to the cytological/histological reports, and four PET parameters [standardized uptake value (SUV)max, SUVpeak, SUVmean, and metabolic tumor volume (MTV)] were measured on FDG PET-CT. Total lesion glycolysis (TLG) was calculated by multiplying the SUVmean by MTV. Both parametric and non-parametric methods were used to compare the five parameters between malignant and benign lesions. Receiver operating characteristic (ROC) curve analysis was performed to identify a cut-off value.
RESULTS Each of the 46 patients [12 men (26.1%; mean age: 62 ± 13.1 years) and 34 women (73.9%; mean age: 60 ± 12.0 years)] with focal hypermetabolic TIs had one focal hypermetabolic TI. Among them, 26 (56.5%) were malignant and 20 (43.5%) were benign. SUVmax, SUVpeak, SUVmean, and TLG were all higher in malignant lesions than benign ones, but the difference was statistically significant (P = 0.012) only for SUVmax. There was a positive linear correlation (r = 0.339) between SUVmax and the diagnosis of malignancy. ROC curve analysis for SUVmax revealed an area under the curve of 0.702 (P < 0.05, 95% confidence interval: 0.550-0.855) and SUVmax cut-off of 8.5 with a sensitivity of 0.615 and a specificity of 0.789.
CONCLUSION More than half of focal hypermetabolic TIs on F-18 FDG PET-CT were revealed as malignant lesions, and SUVmax was the best parameter for discriminating between malignant and benign disease. Unexpected focal hypermetabolic TIs with the SUVmax above the cut-off value of 8.5 may have a greater than 70% chance of malignancy; therefore, further active assessment is required.
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Affiliation(s)
- Haejun Lee
- Department of Nuclear Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon 21565, South Korea
| | - Yoo Seung Chung
- Department of Endocrine Surgery, Gachon University College of Medicine, Gil Medical Center, Incheon 21565, South Korea
| | - Joon-Hyop Lee
- Department of Endocrine Surgery, Gachon University College of Medicine, Gil Medical Center, Incheon 21565, South Korea
| | - Ki-Young Lee
- Department of Endocrinology and Metabolism, Gachon University College of Medicine, Gil Medical Center, Incheon 21565, South Korea
| | - Kyung-Hoon Hwang
- Department of Nuclear Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon 21565, South Korea
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Korsholm K, Reichkendler M, Alslev L, Rasmussen ÅK, Oturai P. Long-Term Follow-Up of Thyroid Incidentalomas Visualized with 18F-Fluorodeoxyglucose Positron Emission Tomography-Impact of Thyroid Scintigraphy in the Diagnostic Work-Up. Diagnostics (Basel) 2021; 11:diagnostics11030557. [PMID: 33808919 PMCID: PMC8003788 DOI: 10.3390/diagnostics11030557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 11/16/2022] Open
Abstract
Our objective was to evaluate the frequency of malignancy in incidental thyroidal uptake on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in a cohort of Danish patients, and furthermore to evaluate the impact of thyroid scinti-graphy in the diagnostic work-up. All whole-body PET/CT reports from 1 January 2010 to 31 December 2013 were retrospectively reviewed and further analyzed if visually increased thyroidal FDG uptake was reported. Patient electronic files were searched for further thyroid evaluation. Of 13,195 18F-FDG-PET/CT scans in 9114 patients, 312 PET/CT reports mentioned incidental thyroid FDG-uptake, and 279 patients were included in the study (3.1%). The thyroid was further investigated in 137 patients (49%), and 75 patients underwent thyroid scintigraphy. A total of 57 patients had a thyroid biopsy and 21 proceeded to surgery. Surgical specimens displayed malignancy in 10 cases, and one thyroid malignancy was found by autopsy. Hence, 11 patients were diagnosed with thyroid malignancies among 279 patients with incidental thyroid 18F-FDG uptake (3.9%). In 34 patients, a biopsy was avoided due to the results of the thyroid scintigraphy. We conclude that patients with thyroid incidentalomas can benefit from further diagnostic work-up including a thyroid scintigraphy.
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Affiliation(s)
- Kirsten Korsholm
- Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark; (M.R.); (L.A.); (P.O.)
- Correspondence:
| | - Michala Reichkendler
- Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark; (M.R.); (L.A.); (P.O.)
| | - Louise Alslev
- Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark; (M.R.); (L.A.); (P.O.)
| | - Åse Krogh Rasmussen
- Department of Endocrinology, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark;
| | - Peter Oturai
- Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark; (M.R.); (L.A.); (P.O.)
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Ceriani L, Milan L, Virili C, Cascione L, Paone G, Trimboli P, Giovanella L. Radiomics Analysis of [ 18F]-Fluorodeoxyglucose-Avid Thyroid Incidentalomas Improves Risk Stratification and Selection for Clinical Assessment. Thyroid 2021; 31:88-95. [PMID: 32517585 DOI: 10.1089/thy.2020.0224] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background: [18F]-Fluorodeoxyglucose (FDG)-avid thyroid lesions incidentally detected on positron emission tomography/computed tomography (PET/CT) scans represent a tumor lesion in about 30% of cases. The present study evaluated the ability of PET metrics and radiomics features to predict final diagnosis of [18F]FDG thyroid incidentalomas (TIs). Methods: A total of 104 patients with 107 TIs were retrospectively studied; 30 nodules (28%) were diagnosed as malignant. After volumetric segmentation of each thyroid lesion, metabolic tumor volume (MTV), total lesion glycolysis (TLG), standardized uptake values (SUVs), and metabolic heterogeneity were estimated, and 107 radiomics features were extracted following a standard protocol. Results: MTV, TLG, SUVmax, SUVmean, and SUVpeak among functional PET parameters, and gray-level co-occurrence matrix (GLCM)_InverseDifferenceMoment, shape_Sphericity, GLCM_SumSquares, firstorder_Maximum2DDiameterSlice, firstorder_Energy, and GLCM_Contrast among nonredundant radiomics features, showed significantly different values between malignant and benign TIs (Mann-Whitney U-test, p < 0.01 for all). Univariate logistic regression revealed that these parameters demonstrated good ability to predict final diagnosis of TIs (p < 0.02 for all). Shape_Sphericity was the best predictor classifying 82% of TIs correctly (p < 0.0001). Only TLG, SUVmax, and shape_Sphericity retained significance (p < 0.0001) by multivariate analysis. Malignant lesion prevalence increased from 7% to 100% in accordance with the number (score, 0-3) of the three positive parameters present (χ2 trend, p < 0.0001). A score of 0 excludes malignant TIs with a negative predictive value of 93%, while a score of 3 predicted malignancy with a positive predictive value of 100%. Conclusions: PET metrics and radiomics analysis can improve identification of [18F]FDG-avid TIs at high risk of malignancy. A model based on TLG, SUVmax, and shape_Sphericity may allow prediction of a final diagnosis, providing useful information for the management of TIs.
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Affiliation(s)
- Luca Ceriani
- Clinic for Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Lugano, Switzerland
- Institute of Oncology Research, Faculty of Biomedical Sciences, Università della Svizzera italiana, Bellinzona, Switzerland
| | - Lisa Milan
- Clinic for Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Lugano, Switzerland
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Luciano Cascione
- Institute of Oncology Research, Faculty of Biomedical Sciences, Università della Svizzera italiana, Bellinzona, Switzerland
- SIB Swiss Institute of Bioinformatics, Quartier Sorge-Batiment Amphipole, Lausanne, Switzerland
| | - Gaetano Paone
- Clinic for Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Lugano, Switzerland
| | - Pierpaolo Trimboli
- Clinic for Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Lugano, Switzerland
- Competence Centre for Thyroid Diseases, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Luca Giovanella
- Clinic for Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Lugano, Switzerland
- Competence Centre for Thyroid Diseases, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Clinic for Nuclear Medicine, University Hospital and University of Zurich, Zurich, Switzerland
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