99Tc(m)-MIBI scanning of the thyroid gland in patients with markedly decreased pertechnetate uptake

Diagnostic accuracy of [99mTc]Tc-Sestamibi in the assessment of thyroid nodules

[^99mTc]Tc-Sestamibi (MIBI) is an increasingly used tool for evaluation of thyroid nodules. However, there is a lack of evidence about the accuracy of this method in the European population. The aim of this study was to assess the utility of MIBI for the differentiation of thyroid nodules in a large cohort. 161 patients underwent MIBI, followed by a thyroidectomy. We used a dual phase MIBI protocol. Interpretation of the images included a scoring system from 0 (absent) to 3 (increased); this was to provide a scale for the uptake of the thyroid nodule in comparison to the paranodular tissue. Additionally, we evaluated the tracer uptake trend in late images compared to early images. We used the final histopathology as the reference standard. Scores 0-1 in early images, scores 0-2 in late images, and an absence of increasing uptake in the thyroid nodule in late images, showed the best predictive values to exclude malignancy, respectively (negative predictive value (NPV) 89%). Highest sensitivity (91%) for malignant nodules was evident in early images with a score 1-3. Highest specificity (91%) was obtained when the negative was defined as an absence of uptake-increase, in the late images. This study confirms that the most valuable feature of MIBI is the high NPV. Thus, with the appropriate interpretation method, high sensitivity and specificity, and moderate PPV can be obtained.

Molecular Analysis by Gene Expression of Mitochondrial ATPase Subunits in Papillary Thyroid Cancer: Is ATP5E Transcript a Possible Early Tumor Marker?

BACKGROUND

Cancer development involves an "injury" to the respiratory machinery (Warburg effect) due to decreased or impaired mitochondrial function. This circumstance results in a down regulation of some of the ATPase subunits of the malignant tissue. The objective of this work was to assess and compare the relative expression of mRNA of mitochondrial ATPase subunits between samples of thyroid cancer and benign nodules.

MATERIAL AND METHODS

Samples from 31 patients who had an operation for PTC at the General Hospital of Mexico were snap-frozen and stored at -70°C. Thirty-five patients who had an operation for benign tumors were also included in the study. mRNA expression levels of alpha, beta, gamma, and epsilon subunits of F1 and "c12" of subunit Fo were determined by real-time RT-PCR (by duplicate), in order to determine if abnormal expression of these genes could partially explain the Warburg effect in papillary thyroid cancer (PTC).

RESULTS

ATP5E transcript alteration (down-expression) was highly associated to PTC diagnosis OR=11.76 (95% confidence interval, 1.245-237.98; p=0.04).

CONCLUSIONS

Relative down-expression of ATP5E transcript was highly associated with PTC diagnosis. This transcript alteration may be used as a tumoral marker in papillary thyroid cancer.

Evaluation of thyroid nodules--combined use of (99m)Tc-methylisobutylnitrile scintigraphy and aspiration cytology to assess risk of malignancy and stratify patients for surgical or nonsurgical therapy--a retrospective cohort study

OBJECTIVE

Thyroid nodules are a common clinical problem, and differentiation between benign and malignant nodules is essential. The aim of this study was to evaluate an approach for cold thyroid nodules including (99m)Tc-methylisobutylnitrile (MIBI) scintigraphy to assess risk of malignancy and stratify patients for therapy.

DESIGN

Retrospective cohort study; 391 patients with at least one cold thyroid nodule were consecutively admitted (between 1 January 2004 and 31 December 2006) and recommended for surgical or nonsurgical therapy.

MEASUREMENTS

Thyroid ultrasonography, (99m)Tc-pertechnetate scintigraphy, laboratory tests, fine needle aspiration cytology (FNAC) and MIBI scintigraphy.

RESULTS

57·3% (224/391) had one cold nodule, 17·9% (70/391) had several cold nodules, and 24·8% (97/391) had both cold and hot nodules. MIBI scintigraphy was classified into 'positive' (16·1%, 63/391), 'weakly positive' (19·2%, 75/391) or 'negative' (64·7%, 253/391). FNAC was classified into benign (87·9%, 247/281), nondiagnostic (6·8%, 19/281) or suspicious/malignant (5·3%, 15/281). 127 patients received surgery, revealing malignancy in 13·3% (17/127), predominantly papillary (64·7%, 11/17) and follicular carcinoma (23·5%, 4/17). MIBI scintigraphy was 'positive' (64·7%, 11/17) or 'weakly positive' (23·5%, 4/17) in most patients with malignant findings. FNAC was unavailable in 23·5% (4/17) with malignancy, positive in 38·5% (5/13) and negative in 61·5% (8/13). Among patients undergoing surgery, sensitivity, specificity, negative and positive predictive values for MIBI scintigraphy were 88·2%, 35·5%, 95·1% and 17·4%, for FNAC 38·5%, 90·6%, 90·6% and 38·5%, respectively, and for the combination (MIBI scan + FNAC) 92·3%, 30·6%, 96·3% and 16·9%. Benign MIBI-positive nodules were predominantly follicular adenomas (68%, 33/48).

CONCLUSION

Evaluation of cold thyroid nodules by MIBI scintigraphy aids therapeutic decisions: MIBI-negative findings support nonsurgical management in about two-thirds of patients, while MIBI-positive findings have an increased risk of malignancy, supporting surgical therapy. However, the positive predictive value was low, which requires further research.

(99m)Tc-sestamibi scanning in thyroid nodules with nondiagnostic cytology

BACKGROUND

Our aim in this study was to assess the relevance of (99m)Tc-sestaMIBI (MIBI) scan in the diagnostic evaluation of thyroid nodules with nondiagnostic cytology.

METHODS

In all, 74 patients with a single nodule and repeatedly nondiagnostic ultrasound-guided fine-needle aspiration cytology (US-FNAC) were enrolled. In all cases thyroid nodules were cold in (99m)Tc-pertechnetate (Tc) scans. Thyroid scans were also acquired 30 and 120 minutes after intravenous administration of MIBI. Nodules that concentrate MIBI were considered as positive (ie, suspicious for malignancy). Histologic findings were obtained after surgery in all patients.

RESULTS

No differences occurred in early and late MIBI images. None of 63 patients with a negative MIBI scan had a final histologic diagnosis of malignancy (ie, no false-negative results). Two patients with a final histologic diagnosis of papillary thyroid carcinoma (PTC) and 1 with follicular thyroid carcinoma (FTC) had a positive MIBI scan. Eight patients with a final histologic diagnosis of benign lesions (3 with follicular adenomas) also had MIBI-positive scans. The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were, respectively, 100%, 88%, 89%, 27%, and 100%.

CONCLUSIONS

A negative MIBI scan in a cold nodule accurately excludes malignancy when US-FNAC is reported as nondiagnostic. This avoids the need for more invasive diagnostic procedures (ie, surgery) and positively influences the cost-effectiveness profile. A MIBI scan may be performed by acquiring images 30 minutes after tracer administration alone. Histology is still necessary to distinguish benign from malignant disease in a MIBI-positive nodule but unnecessary surgery could have been reduced from 71 to 8 cases in our series.

Tc-99m-tetrofosmin thyroid scan in patients with low I-131 thyroid uptake

Low 24-hour thyroid uptake of I-131 (I-131 uptake) is a common finding that influences evaluation of the thyroid gland.

METHODS

We studied 20 female patients aged 16-82 years with low I-131 uptake. The following causes of reduced I-131 uptake were defined as (A) six cases with subacute thyroiditis, (B) seven cases with T4 suppression therapy, and (C) seven cases with iodinated pharmaceuticals use. Thirty-minute Tc-99m tetrofosmin thyroid scan was performed within 24 hours of the I-131 thyroid study.

RESULTS

The results were correlated with neck ultrasound, serum TSH and biopsy histopathological findings. Tc-99m tetrofosmin thyroid scans revealed 10 normal thyroids, five diffuse goiters, four multinodular goitres, and one solitary thyroid nodule.

CONCLUSIONS

Our results suggest that Tc-99m tetrofosmin thyroid scans may provide additional information to diagnose thyroid pathology in patients with low 24-hour I-131 uptake.

The effect of protein or energy restriction on the biodistribution of Na99TcmO4 in Wistar rats

The effect of malnutrition on the biodistribution of radiopharmaceuticals is not known. We studied the biodistribution of 99Tcm-labelled sodium pertechnetate (Na99TcmO4) in two rat models of malnutrition. Three groups of 2-month-old rats were separated according to their diets: (1) control diet, 23% protein (C); (2) protein-restricted, receiving 8% protein (PR), both ad libitum; and (3) energy-restricted, receiving 60% of control diet (ER). After 21 days of the diet, 99Tcm was injected and the animals were killed after 30 min. The organs were isolated, their weight determined and the absolute per cent (%ID) and the per cent per gram injected dose (%ID x g(-1)) calculated. The %ID and %ID x g(-1) had a similar pattern, increasing in stomach and brain and decreasing in the thyroid, but did not change significantly in kidney, lung, liver, bone or testis in PR rats, except in the heart where the increase was only observed in the %ID x g(-1). In the ER group the %ID x g(-1) was decreased in the bone only, and did not change in the other organs. It is suggested that when using Na99TcmO4 scintigraphy in malnourished patients, the different patterns of distribution must be kept in mind.