Thallium-201 scan in evaluating thyroid nodules following equivocal fine-needle aspiration cytology

Summary:

The aim of this prospective study was to evaluate the usefulness of the thallium-201 (²⁰¹Tl) thyroid scan in the detection of malignancy in cold thyroid nodules whose status was equivocal following palpation fine-needle aspiration cytology (FNAC). Patients, methods: Fifty-one patients with clinically palpable solitary cold thyroid nodules classified as non-diagnostic or suspicious following biopsy underwent ²⁰¹Tl thyroid scans. Each scan was performed 15 min (early scan) and 3 h (delayed scan) after an intravenous administration of 74 MBq ²⁰¹Tl. Thallium uptake in the nodules was visually assessed and scored on a three point scale, with a grade of three defining malignancy. All patients underwent surgery and the histopathology of nodule tissues were compared with results of the scans. Results: Fifty-one nodules were examined. Forty were benign and 11 were malignant. For early scans, the diagnostically relevant parameters were: sensitivity (100%), specificity (75%), and accuracy (80%). Corresponding findings for the delayed scan were: 91%, 98%, and 96%. Conclusion: The ²⁰¹Tl scan is useful for detecting malignancy in cold thyroid nodules classified as nondiagnostic or suspicious lesions by FNAC.

Zusammenfassung:

In dieser prospektiven Studie sollte der Nutzen einer Thallium- 201-(²⁰¹Tl)-Schilddrüsenszintigraphie zum Nachweis der Malignität von kalten Schilddrüsenknoten, deren Status nach Palpation und Feinnadelaspirationszytologie (FNAC) unklar war, untersucht werden. Patienten, Methodik: Bei 51 Patienten mit klinisch tastbaren, solitären kalten Schilddrüsenknoten, die einen unklaren oder malignitätsverdächtigen feinnadelzytologischen Befund aufwiesen, erfolgte eine ²⁰¹Tl-Schilddrüsenszintigraphie. Es erfolgten jeweils 15 Minuten (Frühaufnahme) und drei Stunden (Spätaufnahme) nach intravenöser Verabreichung von 74 MBq ²⁰¹Tl planare Szintigraphien. Die Thalliumaufnahme in die Knoten wurde visuell beurteilt und auf einer Dreipunkteskala bewertet; Grad 3 definierte dabei Malignität. Alle Patienten unterzogen sich einer Operation, der histopathologische Befund des Knotengewebes wurde mit den Ergebnissen der Szintigraphie verglichen. Ergebnisse: 51 Knoten wurden untersucht. 40 waren gutartig, 11 waren bösartig. Bei den Frühszintigraphien waren die diagnostisch relevanten Parameter: Sensitivität (100%), Spezifität (75%) und Genauigkeit (80%). Die entsprechenden Ergebnisse für das Spätszintigramm lagen bei 91%, 98% und 96%. Schlussfolgerung: Die ²⁰¹Tl-Szintigraphie eignet sich zum Nachweis der Malignität von kalten Schilddrüsenknoten, die anhand der FNAC als nicht diagnostizierbare oder als verdächtige Läsionen klassifiziert werden.

Key words:

Thallium-201 scan - fine-needle aspiration cytology - cold thyroid nodule - malignancy

Schlüsselwörter:

Thallium-201-Szintigraphie - Feinnadelaspirationszytologie - kalter Schilddrüsenknoten - Malignität

• References

• 1 Alexander EK, Heering JP, Benson CB. et al. Assessment of nondiagnostic ultrasound-guided fine needle aspirations of thyroid nodules. J Clin Endocrinol Metab 2002; 87: 4924-7.
• 2 Ando A, Ando I, Katayama M. et al. Biodistributions of ²⁰¹Tl in tumor bearing animals and inflammatory lesion induced animals. Eur J Nucl Med 1987; 12: 567-72.
• 3 Bae KT, Piwnica-Worms D. Pharmacokinetic modeling of multidrug resistance P-glycoprotein transporter of gamma-emitting substances. Q J Nucl Med 1997; 41: 101-10.
• 4 Bakhos R, Selvaggi SM, DeJong S. et al. Fineneedle aspiration of the thyroid: rate and causes of cytohistopathologic discordance. Diagn Cytopathol 2000; 23: 233-7.
• 5 Ballinger JR, Sheldon KM, Boxen I. et al. Differences between accumulation of ^99mTc-MIBI and ²⁰¹Tl-thallous chloride in tumor cells: role of P-glycoprotein. Q J Nucl Med 1995; 39: 122-8.
• 6 Baloch ZW, Fleisher S, LiVolsi VA. et al. Diagnosis of „follicular neoplasm“: a gray zone in thyroid fine-needle aspiration cytology. Diagn Cytopathol 2002; 26: 41-4.
• 7 Bleichrodt RP, Vermey A, Piers DA. et al. Early and delayed thallium 201 imaging. Diagnosis of patients with cold thyroid nodules. Cancer 1987; 60: 2621-3.
• 8 Brooks AD, Shaha AR, DuMornay W. et al. Role of fine needle aspiration biopsy and frozen section analysis in the surgical management of thyroid tumors. Ann Surg Oncol 2001; 8: 92-100.
• 9 Chow LS, Gharib H, Goellner JR. et al. Nondiagnostic thyroid fine-needle aspiration cytology: management dilemmas. Thyroid 2001; 11: 1147-51.
• 10 Cooper DS, Doherty GM, Haugen B. et al. Management guidelines for patients with thyroid nodulies and differentiated thyroid cancer. Thyroid 2006; 16: 1-33.
• 11 Demirel K, Kapucu Ö, Yücel C. et al. A comparison of radionuclide thyroid angiography, ^99mTc- MIBI scintigraphy and power Doppler ultrasonography in the differentiatial diagnosis pf solitary cold thyroid nodules. Eur J Nucl Med Mol Imaging 2003; 30: 642-50.
• 12 Derebek E, Biberoglu S, Kut O. et al. Early and delayed thallium-201 scintigraphy in thyroid nodules: the relationship between early thallium-201 uptake and perfusion. Eur J Nucl Med 1996; 23: 504-10.
• 13 El-Desouki M. ²⁰¹Tl thyroid imaging in differentiating benign from malignant thyroid nodules. Clin Nucl Med 1991; 16: 425-30.
• 14 Erdil TY, Ozker K, Kabasakal L. et al. Correlation of technetium-99m MIBI and thallium-201 retention in solitary cold thyroid nodules with postoperative histopathology. Eur J Nucl Med 2000; 27: 713-20.
• 15 Feld S. AACE Clinical Practice Guidelines for the diagnosis and management of thyroid nodule. Endocr Pract 1996; 2: 80-4.
• 16 Frable WJ. Aspiration cytology. In: Keebler CM, Somrak TM. (eds). The Manual of Cytotechnology. Hong Kong: ASCP Press; 1993: 240-5.
• 17 Gharib H, Goellner JR, Johnson DA. Fine-needle aspiration cytology of the thyroid. A 12-year experience with 11,000 biopsies. Clin Lab Med 1993; 13: 699-709.
• 18 Gharib H, Goellner JR. Fine-needle aspiration biopsy of the thyroid: an appraisal. Ann Intern Med 1993; 118: 282-9.
• 19 Gharib H. Fine-needle aspiration biopsy of thyroid nodules: advantages, limitations, and effect. Mayo Clin Proc 1994; 69: 44-9.
• 20 Greaves TS, Olvera M, Florentine BD. et al. Follicular lesions of thyroid: a 5-year fine-needle aspiration experience. Cancer 2000; 90: 335-41.
• 21 Hardoff R, Baron E, Sheinfeld M. Early and late lesion-to-non-lesion ratio of thallium-201 chloride uptake in the evaluation of „cold“ thyroid nodules. J Nucl Med 1991; 32: 1873-6.
• 22 Hegedus L. The thyroid nodule. N Engl J Med 2004; 351: 1764-71.
• 23 Hegedus L. Thyroid ultrasound. Endocrinol Metab Clin North Am 2001; 30: 339-60.
• 24 Henze E, Roth J, Boerer H. et al. Diagnostic value of early and delayed ²⁰¹Tl thyroid scintigraphy in the evaluation of cold nodules for malignancy. Eur J Nucl Med 1986; 11: 413-6.
• 25 Huang SM, Lee CH. et al. Characteristics of thyroidectomy in Taiwan. J Formos Med Assoc 2005; 104: 6-11.
• 26 Hurtado-López LM, Arellano-Montaño S, Migdalia E. et al. Combined use of fine-needle aspiration biopsy, MIBI scans and frozen section biopsy offers the best diagnostic accuracy in the assessment of the hypofunctioning solitary thyroid nodule. Eur J Nucl Med Imaging 2004; 31: 1273-9.
• 27 Kim ES, Kim TY, Koh JM. et al. Completion thyroidectomy in patients with thyroid cancer who initially underwent unilateral operation. Clin Endocrinol (Oxf) 2004; 61: 145-8.
• 28 Klain M, Maurea S, Cuocolo A. et al. Technetium- 99m tetrofosmin imaging in thyroid diseases: comparison with ^99mTc-pertechnetate, thallium- 201, and ^99mTc-methoxyisonitrile scans. Eur J Nucl Med Mol Imaging 1996; 23: 1568-74.
• 29 Klemenz B, Wiehler H, Kaiser KP. Value of color coded Doppler sonography in the differential diagnosis of nodular thyroid gland changes. Nuklearmedizin 1997; 36: 245-9.
• 30 Kume N, Suga K, Nishigauchi K. et al. Relationship between thallium-201 uptake and tumour proliferative ability in thyroid nodules. Eur J Nucl Med 1996; 23: 376-82.
• 31 Lind P, Gallowitsch HJ, Langsteger W. et al. Technetium- 99m-tetrofosmin whole body scintigraphy in the follow-up of differentiated thyroid cancer. J Nucl Med 1997; 38: 348-52.
• 32 Mazzaferri EL. Management of a solitary thyroid nodule. N Engl J Med 1993; 328: 553-9.
• 33 Nakahara H, Noguchi S, Murakami N. et al. Technetium- 99m-sestamibi scintigraphy compared with thallium-201 in evaluation of thyroid tumors. J Nucl Med 1996; 37: 901-4.
• 34 Nakamura K, Nishiguchi I, Takagi Y. et al. Accumulation mechanism of ²⁰¹Tl-K-contents and Na, K-ATPase activities of tissue. Radioisotopes 1983; 32: 626-8.
• 35 Ochi H, Sawa H, Fukuda T. et al. Thallium- 201-chloride thyroid scintigraphy to evaluate benign and/or malignant nodules: usefulness of the delayed scan. Cancer 1982; 50: 236-40.
• 36 Okumura Y, Takeda Y, Sato S. et al. Comparison of differential diagnostic capabilities of ²⁰¹Tl scintigraphy and fine-needle aspiration of thyroid nodules. J Nucl Med 1999; 40: 1971-7.
• 37 Ravetto C, Colombo L, Dottorini ME. Usefulness of fine-needle aspiration in the diagnosis of thyroid carcinoma: a retrospective study in 37,895 patients. Cancer 2000; 90: 357-63.
• 38 Sathekge MM, Mageza RB, Muthuphei MN. et al. Evaluation of thyroid nodules with technetium- 99m MIBI and technetium-99m pertechnetate. Head Neck 2001; 23: 305-10.
• 39 Sessler MJ, Geck P, Maul FD. et al. New aspects of cellular thallium uptake: Tl+-Na+-2Cl (-)-cotransport is the central mechanism of ion uptake. Nuklearmedizin 1986; 25: 24-7.
• 40 Silver RJ, Parangi S. Management of thyroid incidentalomas. Surg Clin North Am 2004; 84: 907-19.
• 41 Siperstein AE, Clark OH. Surgical therapy. In: The Thyroid: a Fundamental and Clinical Text. Braverman LE, Utiger RD. (eds). 8th ed. New York: Lippincott; 2000: 898-903.
• 42 Tennvall J, Palmer J, Biorklund A. et al. Kinetics of ²⁰¹Tl uptake in adenomas and well-differentiated carcinomas of the thyroid. A double isotope investigation with ^99mTc and ²⁰¹Tl. Acta Radiol Oncol 1984; 23: 55-9.
• 43 The National Health Insurance Statistics. Bureau of National Health Insurance, Taiwan. 2001 No. 82001-11.
• 44 Tyler DS, Shaha AR, Udelsman RA. et al. Thyroid cancer: 1999 update. Ann Surg Oncol 2000; 7: 376-98.
• 45 Waxman AD. Thallium-201 and technetium-99m methoxyisobutyl isonitrile (MIBI) in nuclear oncoloby. In: Sandler MP, Coleman RE, Patton JA. et al. (eds). Diagnostic nuclear medicine. 4th ed. New York: Lippincott; 2003: 931-50.