The Supreme Court Holds That the Trademark Trial and Appeal

05/03/2013
SPECT/CT in Thyroid cancer
To do / not to?
Thyroi
d
Cance
rSPECT
/CT
“To
Do /
Not
to”
HK Mohan
Department of Nuclear Medicine
Guys & St Thomas’ Hospitals, London
48 year old – PT3 N1bMO
• TSH = 88
• Tg = 129
• Pre therapy 185MBq I131 study
1
05/03/2013
48 year old – PT3 N1bMO
• Post Surgery – 5.5 Gbq I131
6 months later
• TSH = 113
• Tg = 1.1
Aided surgery
Liver uptake - Gall bladder. No MRI required
2
05/03/2013
26 year old male – PT2 N0Mx
•
•
•
•
TSH = 48
Tg = 12.9
3.7 Gbq I131
Post Therapy imaging
3
05/03/2013
26 year old male – PT2 N0Mx
6 months later
• TSH = 53
• Tg = <0.2
No need for further MRI / US post first
ablation
4
05/03/2013
58 year old male – PT3 N1bM1
• TSH = 62
• Tg = 152
• 3.7GBq I131 – Post Therapy imaging
5
05/03/2013
58 year old male – PT3 N1bM1
6 months later pre second ablation
• TSH = 77
• Tg = 22
• 5.5 GBq I131
Revealed destructive nature prompting
further investigation and EBRT
32 year old female – PT2 N0MO
• TSH = 52
• Tg = 24
• 5.5 Gbq I131- Post therapy study
6
05/03/2013
7
05/03/2013
32 year old female – PT2 N0MO
Prior to 4th ablation
• TSH = 44
• Tg = 1.8
• 5.5 Gbq I131
Aided decision re surgery and monitoring
response to therapy
41 year old female– PT3 N0Mx
• TSH = 88
• Tg = 152
• 3.7 GBq I131 study
8
05/03/2013
41 year old female– PT3 N0Mx
Revealed I131 negative disease and directed
further management
9
05/03/2013
Guys’ Experience
•
•
•
•
67 patients
5 year follow-up
57 – I131 avid disease
10 – Non I131 avid disease
Reporter confidence
Probable
Definite
Thyroid
remnant
5
23
Lymph nodes
12
5
Probable
Definite
Thyroid remnant
0
34
Lymph nodes
1
10
10
05/03/2013
Staging change -14/57 (25%)
Downstaging – 10 patients
Neck
8 definite LN
Thyroid remnant
Upstaging - 4 patients
Neck
3 thyroid remnant
3 LN
Thorax
1 lung
Physiologic breast uptake
1Node
Oesophageal
Thorax
1 oesophageal
I node
Literature review
N = 520
Management Impact due to change in staging
163 / 520 (31%)
Avram et al, 2010
48
28 / 48 (58%)
Spanu et al, 2009
117
33 / 117 (35.6%)
Schmidt et al. 2009
57
20 / 57 (35%)
Grewal et al 2010
148
29 / 148 (20%)
Chen L et al 2009
23
8 / 23 (35%)
S. Kohlfuerst et al 2009
41
17 / 41 (24.4%)
K Tharp et al 2004
61
22 / 61 (27%)
J Ruf et al 2004
25
6 / 25 (24%)
11
05/03/2013
Clinical Impact
Down staging
• Patient reassurance
Upstaging
• Targetted surgery / EBRT
• Efficient use of facilities
Avoiding US / CT / MRI
• Tailoring I131 dose
• Reduced therapies
Reduced side effects
• Reduced cost
• Reduced recurrence rates
Improved survival
Significant incidental findings
Does is impact survival?
•
•
•
•
>90% 10 yr survival
43 % of all relapses in 1st year
23 % years 2-5
9 % > 10 years
12
05/03/2013
Prognosis
CR 10YS %
• Lung only 131 I +ve 46% 62
• Lung only 131 I -ve
11
• Lung + other (bone)
10
Impact on Survival
• Early days
• 3-5 year followup currently available
• Lymphnode metastases - Still has >90% 10 year
survival rate
• Distant metastases 50 - 60% 10 year survival
rate
• Non I131 avid disease - Limited treatment
options
26
26
13
05/03/2013
Current indications for SPECT/CT
• High risk patients.
• Iodine uptake in neck which is disproportionate
to initial disease and staging.
• Any abnormal uptake outside neck for accurate
localisation and characterisation.
• Patients with raised thyroglobulin with negative
iodine whole body scintigraphy.
Imaging protocol
• Imaged 3-5 days post I131 administration
• WBS
Anterior and Posterior whole body images
Scanning speed - 3-8mm/sec
• SPECT
HEHR collimator
Matrix size - 64 x 64. 64 projections
Processing – FBP and OSEM
• CT
Voltage - 120 KV,
Tube current - 100mAs/slice
Slice thickness -1.5mm
CT dose exposure – 3 mSv
14
05/03/2013
Thanks for listening!!!
BTA / RCP - Guidelines for management of thyroid cancer, 2nd ed, 2007
EANM - Guidelines for radioiodine therapy of differentiated thyroid
cancer 2008
15
`