Nuclear Imaging in Endocrinology: Pitfalls and Artifacts

Nuclear Imaging in Endocrinology: Pitfalls and Artifacts

David Taïeb, Elif Hindié

FDG-PET in DTC

Small FDG-avid lung nodules in DTC

3 thyroid cancer patients with apparently solitary FDG-avid lung nodule

A-D: 5mm primary lung adenocarcinoma (TTF1+, anti-Tg-), E-H: Giant cell granulomatous lesions , I-L: Multiple

metastases from a PTC (anti-Tg+) and additional carcinoids (synapto+)

Retro-thyroid Mass

Goiter developed from the Zuckerkandl’s tubercle

(A) Enhanced CT scan (axial)

(B) Enhanced CT scan (frontal)

(C) Volume rendering image arteria lusoria

(D) 123I scintigraphy: mass of thyroid origin

P3-derived Adenoma

Subtraction protocol

(A) 99mTc-sestaMIBI

(B) B: 123I

(C) subtraction images

(D) SPECT images of parathyroid adenomas. Typical P3 adenoma which is located at the tip of the left inferior lobe on planar images and remains anterior on SPECT images

Subtraction protocol

(A) 99mTc-sestamibi pinhole planar image

(B) 123I scan

(C) subtraction image (99mTc-sestamibi-123I) parathyroid lesion in the right lower pole of the thyroid.

(D) The posterior extension of the adenoma on SPECT images is highly suggestive of P4 origin, despite its apparent right inferior origin on planar images

P4-derived Adenoma

P4-derived Adenoma

Ectopic Parathyroid Adenoma

99mTc-sestaMIBI scintigraphy. A.

Planar images find a left inferior

parathyroid adenoma. B-D. Fusion

SPECT/CT images (sagittal, axial

and coronal imaging planes) help in

the diagnosis of paraeophageal

ectopic adenoma.

Echographie + SP

Localisation Pas de localisation

Postérieure Antérieure

Abord latéral vidéo

assisté

Abord central (vidéo)

assisté Cervicotomie

conventionnelle

(A) 99mTc-sestamibi SPECT images

(B) 99mTc-sestamibi SPECT images:

(C) FDG-PET (CT, PET, fusion)

M, 74 y

Cal: 2.82 mmol/l

PTH: 12.4 pmol/l (1.6-

6.9)

FDG PET/CT in Adrenal masses: a non specific tracer

ACC

Metastasis (except renal)

PHEO

Lymphoma

Macronodular Adrenal hyperplasia (Cushing)

Early post-operative period (March 2006)

ACC

February 2007

August 2007

False negative 123I-MIBG scintigraphy

A. CT

B. FDG

C. FDOPA

123I-MIBG (post. view)

123I-MIBG

PHEOs/Abdo PGLs: Se: 83-100% (52-75% in hereditary), Sp>95%

HNPGLs: 18-50%

Ilias I et al, Journal of Nuclear Medicine 2008; Timmers HJ 2009; Timmers HJ et al, Journal of Clinical Endocrinology and Metabolism 2009;

Fiebrich HB et al, J Clin Endocrinol Metab 2009.

SRS

HNPGLs: Se: 89-100%, Sp: 90%

Muros MA et al, Nucl Med Commun 1998; Telischi FF et al, Otolaryngol Head Neck Surg 2000 ; Schmidt M et al, Eur J Nucl Med Mol Imaging 2002; Bustillo A

et al, Laryngoscope 2004; Duet M et al, J Nucl Med 2003; Koopmans KP et al, Journal of Nuclear Medicine 2008, Gimenez-Roqueplo AP, Journal of Clinical

Endocrinology and Metabolism 2013

HTA avec lésion

surrénalienne G au

scanner en contexte

de M.de

Recklinghausen

Pas de fixation décelable en région surrénalienne

Fixation ponctuelle en région cervicale

M. Guyot, Bordeaux

• Pas de fixation du nodule

surrénalienne gauche

• Plage de fixation loge

thyroïdienne gauche

- Widely distributed: HNPGLs, PHEO and Abdo. PGLs

- 30-35% hereditary (>10 susceptibility genes)

PGLs and PHEOs

SDHx-related PGLs/PHEOs

Multiple SDHD-related PGLs

Genotype/metabolic phenotype (SDHD)

Genotype/metabolic phenotype (SDHB)

Timmers HJ et al, Journal of Clinical Oncology 2007; Taieb D et al, Journal of Nuclear Medicine 2009; Timmers HJ et al, Journal of the National

Cancer Institute 2012, Fonte et al, Endocrine-related cancer 2012.

Early and prolonged pancreatic FDOPA uptake (exo and endocrine): major drawback in adults

Need to revise the protocol

Carbidopa (AADC-I)?: may mask tumor uptake (Kauhanen et

al, JCO 2008)

Timing of acquisition ?

Insulinoma

FDOPA

SRS

Sporadic

F, 70 y

Hyperinsulinic hypoglycemia

Contrast-enhanced US (1 tumor)>MRI (0)=CT (0)=SRS (0)

Carbidopa premedication, E/D Acq.

Insulinoma: protocol revisited

1 insulinoma pathologically-proven (Ki-67<1%)

Sporadic

M, 70 y

Hyperinsulinic hypoglycemia

MRI (1 tumors)=CT (1)=SRS (1)

Carbidopa premedication

1 insulinoma pathologically-proven (Ki-67=2-5%)

Insulinoma: protocol revisited

Non-secreting NET: protocol revisited

FDOPA 5 min

30 min

FDOPA 5 min

Non-secreting NET: protocol revisited

MEN-1

F, 44 y

Lung carcinoid

pHPT

Current status: non-secreting pancreatic NET and reccurent pHPT

MRI (3 tumors)>CT (2)>SRS (0)

Carbidopa premedication

Pancreatic NET

FDG FDOPA

MTC: Persistent/recurrent LN

Early vs delayed images

MTC: Intial staging

FDOPA

Multiple SRS+ lesions

CT MRI

US

SRS FDG FDOPA

FDOPA thyroid incidentaloma

Kindly provided by Alessio Imperiale

FDOPA+ pancreatic tumor

Harlequin syndrome: Excessive paroxysmal sweating and flushing on the left side of her face after physical exercise or emotional stress since 3 years

PHEOs and BAT activation

MIBG SRS FDOPA

WT KIT GIST FDG

CT-related GIST