MIBI-Szintigrafie bei hypofunktionellen Schilddrüsenknoten

Zusammenfassung

Tc-99m-MIBI ist ein nicht spezifisches Radiopharmakon zur Tumordiagnostik und wurde historisch zum Nachweis radioiodnegativer Metastasen differenzierter Schilddrüsenkarzinome eingesetzt, eine Indikation, die heutzutage durch FDG-PET ersetzt ist. Tc-99m-MIBI hat einen klinischen Nutzen zur Abklärung hypofunktioneller Schilddrüsenknoten, wenngleich bisher kein kommerziell verfügbarer Kit hierfür eine offizielle Zulassung hat. Seit der letzten Übersichtsarbeit zum klinischen Nutzen von Tc-99m-MIBI zur Abklärung hypofunktioneller Schilddrüsenknoten in dieser Zeitschrift im Jahr 2010 sind weitere Arbeiten publiziert worden, die den positiven und negativen Vorhersagewert der Methode präzisierten und auch die Kosteneffizienz der Methode belegten. Nach Injektion von Tc-99m-MIBI wird die Retention des Radiopharmakons im abzuklärenden Knoten und dessen Anreicherung im Vergleich zum paranodulären Schilddrüsengewebe und im Vergleich zum Schilddrüsen-Szintigramm mit Pertechnetat beurteilt. Ein Match-Befund im Sinne einer konkordant verminderten Anreicherung hat einen hohen negativen prädiktiven Wert von≥97% zum Ausschluss eines differenzierten Schilddrüsenkarzinoms. Ein Mismatch mit vermehrter Anreicherung des Tc-99m-MIBI in einem hypofunktionellen Schilddrüsenknoten erhöht die Malignitätswahrscheinlichkeit auf ca. 15–20% in Deutschland. Eine isointense Anreicherung des Tc-99m-MIBI in dem hypofunktionellen Schilddrüsenknoten geht nach eigener Datenlage mit einer niedrigen Malignitätswahrscheinlichkeit einher, allerdings findet man in dieser Befundkategorie kleine papilläre Karzinome, die sich bei geringer Größe noch nicht eindeutig Tc-99m-MIBI-mehranreichernd demarkieren müssen. SPECT hat hier in 17–34% einen diagnostischen Zugewinn. Bei guter Indikationsstellung ist die Tc-99m-MIBI-Szintigrafie eine wertvolle ergänzende Methode zur Feinnadelaspirationsbiopsie (FNAB) und dient einem optimierten Patientenmanagement, um im Falle eines Match-Befunds ein konservatives Vorgehen zu vertreten oder im Falle eines Mismatch-Befunds ein operatives Vorgehen unter Berücksichtigung von Alter, Begleiterkrankungen und in Kenntnis des vollständigen Schilddrüsenbefunds zu rechtfertigen. Die offizielle Zulassung dieser Indikation ist überfällig.

Abstract

Tc-99m-MIBI is a non-specific radiopharmaceutical for tumor imaging. Historically, it was used for detection of radioiodine-negative metastases of differentiated thyroid carcinomas, an indication which has been replaced by FDG-PET nowadays. Tc-99m-MIBI is clinically useful for evaluation of hypofunctionning thyroid nodules, although no commercially available kit has an official registration for this indication. Since the last publication about the clinical usefulness of Tc-99m-MIBI for evaluation of hypofunctionning thyroid nodules in this journal in the year 2010 further data about this topic emerged characterizing the positive and negative predictive value of this method in more detail and reporting about its cost-effectiveness. After injection of Tc-99m-MIBI retention of this radiopharmaceutical in the thyroid nodule in comparison to the paranodular thyroid tissue and in comparison to pertechnetate scintigraphy has to be described. A match finding with concordant low uptake has a high negative predictive value ≥97% to exclude malignancy for differentiated thyroid carcinoma. A mismatch with increased Tc-99m-MIBI uptake in the hypofunctionning thyroid nodule has a likelihood of malignancy of about 15–20% in Germany. An isointense Tc-99m-MIBI uptake in the hypofunctionning thyroid nodule has a low likelihood for malignancy according to our data. However, in this category some small papillary thyroid carcinomas have been described which did not show clearly increased uptake with their small size. SPECT has added value in 17–34% of cases. With a good indication Tc-99m-MIBI scintigraphy is a very valuable method in addition to fine needle aspiration cytology for improved patient management. In case of a match finding a conservative approach can be justified and in case of a mismatch selective surgery can be justified taking into account patient age, comorbidities and the findings of a full thyroid evaluation. The official approval of this indication is overdue.

Schlüsselwörter

hypofunktioneller Schilddrüsenknoten - Tc-99m-MIBI - Sestamibi - Schilddrüsenkarzinom

Key words

hypofunctionning thyroid nodule - Tc-99m-MIBI - sestamibi - thyroid carcinoma

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