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Erschienen in: Annals of Surgical Oncology 13/2018

Open Access 10.10.2018 | Endocrine Tumors

Medullary Thyroid Carcinoma: Do Ultrasonography and F-DOPA-PET-CT Influence the Initial Surgical Strategy?

verfasst von: Lindsay Brammen, MD, Martin B. Niederle, MD, Philipp Riss, MD, Christian Scheuba, MD, Andreas Selberherr, MD, Georgios Karanikas, MD, Gerd Bodner, MD, Oskar Koperek, MD, Bruno Niederle, MD

Erschienen in: Annals of Surgical Oncology | Ausgabe 13/2018

Abstract

Background

At the time of diagnosis, one-third of medullary thyroid carcinoma (MTC) patients show lymph node (LN) or distant metastasis. A metastasized MTC requires different surgical strategies.

Objective

This study aimed to determine the value of ultrasound and [18F]fluoro-dihydroxyphenylalanine positron emission tomography with computed tomography (F-DOPA-PET-CT) in localizing MTC, as well as LN and distant metastasis.

Methods

The study included 50 patients (24 males/26 females) with preoperative ultrasound, F-DOPA-PET-CT, and histologically proven MTC. Imaging results were correlated with both preoperative basal calcitonin (bCt) levels and final histology.

Results

Tumors were classified as pT1a:17 (diameter, mean ± standard deviation: 5.8 ± 3.0 mm), pT1b:15 (15.0 ± 3.2 mm), pT2:9 (27.3 ± 7.0 mm), and pT3:9 (38.3 ± 24.2 mm). The median bCt level was 202 pg/mL (lower/upper quartile: 82/1074 pg/mL). Ultrasound was positive for tumor in 45/50 (92%) patients (20.0 ± 16.0 mm) and negative in 5 patients (3.2 ± 2.2 mm). Overall, 43/50 (86%) patients had positive F-DOPA local scans (20.0 ± 16.4 mm), while 7 (14%) patients were negative (7.7 ± 8.1 mm). Lastly, 21/50 (42%) patients had LN metastasis; 8/21 (38%) patients had positive LNs suspected with ultrasound, and 12/21 (57%) patients had positive LNs suspected with F-DOPA. Tumor and LN sensitivity of ultrasound was 92% and 43%, respectively, and 86% and 57% of F-DOPA-PET-CT, respectively. In 3/50 (6%) patients and 3/50 (6%) patients, mediastinal LN metastasis and distant metastasis, respectively, were diagnosed only by F-DOPA-PET-CT.

Conclusion

Ultrasound and F-DOPA-PET-CT are sensitive for the localization of MTC but not for the presence and location of LN metastasis (limitations: size/number). Only F-DOPA ensures the diagnosis of distant metastasis and influences the extent of LN surgery. Surgical strategy cannot be predicted based on neither ultrasound nor F-DOPA-PET-CT.
In medullary thyroid carcinoma (MTC), the number of positive lymph nodes (LNs) and involved anatomical compartments are cancer-specific prognostic factors.1 Exact preoperative staging may help to select a stage-adapted surgical strategy.
Neck ultrasound is the first imaging modality used in MTC to assess the local extent and regional lymphatic spread. MTC as a neuroendocrine tumor is able to absorb, store, and decarboxylate dopamine. Therefore [18F]fluoro-dihydroxyphenylalanine positron emission tomography with computed tomography (F-DOPA-PET-CT), combining anatomic and ‘functional’ imaging, may further improve initial local and distal staging of biochemically suspected MTC.
F-DOPA-PET-CT is one of the recommended imaging modalities in patients with persistent MTC and basal calcitonin (bCt) levels ≥ 150 pg/mL before reoperations;25 however, no studies with a larger patient population evaluating ultrasound in addition to F-DOPA-PET-CT in locating the primary tumor, LN and distant metastasis, and possible consequences to the surgical strategy, have been performed.
This prospective observation study aims to determine the value of ultrasound and F-DOPA-PET-CT in radiomorphological detection of primary tumors, identification of possible LN metastasis, and detection of possible distant metastasis before initial surgery, and how a combination of these techniques may help to improve the standardized diagnostic and therapeutic protocol correlating preoperative biochemical and postoperative morphological results.

Materials and Methods

Patients

Overall, 50 patients (24 males/26 females) with biochemical criteria of MTC6 who underwent initial surgery were included in the study. Inclusion criteria consisted of preoperative neck ultrasound and F-DOPA-PET-CT, biochemical parameters, surgery, final histology, and follow-up in all patients.
The present study was approved by the local Institutional Review Board (EK reference number: 1083/2016). All patients signed written informed consent for all diagnostic and therapeutic procedures.

Laboratory Measurements

Since 1994, in our institution, the consequent determination of calcitonin (‘calcitonin screening’) has been performed during the diagnostic work-up of all thyroid nodules regardless of thyroid function, sonomorphology, and size of the thyroid lesion before surgery.
Following the local diagnostic standard operating procedure (SOP), bCt > 8 pg/mL for males or > 6 pg/mL for females, and calcium-stimulated Ct > 100 pg/mL, were considered highly suspicious of MTC and were therefore an indication for surgery.
The Ct levels were assessed using a two-site chemiluminescent immunometric assay from Diagnostic Products Corporation (Los Angeles, CA, USA), running as a fully automated test on a Siemens Immulite 2000 Immunoassay System (Siemens Diagnostics) with a lower detection limit of 0.5 pg/mL and an intra-assay coefficient variation of ≤ 2%.

Diagnostic Procedures

Neck Ultrasound

A standardized neck ultrasound of the cervical and supraclavicular regions (General Electric [GE] LOGIQ E9 device; 9 MHz probe) was performed and analyzed preoperatively by one radiologist (GB), who was aware of the biochemically supposed diagnosis. A suspicious local lesion was characterized as a solid hypoechoic, microcalcification, echogenic foci, intranodular vessel and, if advanced disease, extension beyond the thyroid margin.7 Positive metastatic LNs were described as round in shape, necrotic, calcified, loss of the nodal hilum, and peripheral vascularity.8

F-DOPA-PET-CT

As previously described,9 PET/CT in a two-dimensional mode with subsequent reconstruction from the top of the skull to the thigh using an integrated camera was performed. One experienced nuclear medicine physician (GK) and one experienced radiologist (GB) interpreted all imaging examinations independently. A lesion was considered ‘PET positive’ if focal was greater than physiologic tracer uptake and greater than background blood-pool activity. LNs were considered highly suspect for malignancy when the diameter was > 10 mm, and showed round configuration, contrast enhancement, and F-DOPA enhancement without fatty hilus.3
True-positive patients had at least one pathologically verified malignant lesion, whereas false-negative patients had positive histopathological results but negative F-DOPA-PET-CT findings.

Surgical Procedure

In accordance with our surgical SOP (6), all patients underwent (total) thyroidectomy with bilateral central neck dissection (level VI) and bilateral lateral lymphadenectomy (level II–V) independent of the bCt levels, sparing all vessels, muscles and nerves (functional lateral neck dissection). The surgeon knew all the results of preoperative ultrasound and F-DOPA-PET-CT imaging. Only the knowledge of F-DOPA-PET-CT-positive LNs in the mediastinum and distant metastasis influenced the extent of surgery. In patients with positive F-DOPA-PET-CT imaging in the mediastinum, but negative imaging for distant metastasis, a mediastinal LN dissection was conducted. In patients with distant metastasis, a radical central, but a less radical lateral, cervical LN dissection was conducted to avoid complications by positive residual LNs in the central neck.
Surgical outcome was based on the assessment of bCt (and calcium-stimulated Ct) levels determined during the follow-up program. A biochemical cure was achieved if the postoperative b and stimulated Ct levels were undetectable.

Pathological Examinations

The pathologist was aware of the elevated bCt levels, and therefore of the suspected MTC. Macroscopically suspected lesions (primary tumor; LNs) were stained with hematoxylin and eosin (H&E), and immunohistochemistry was performed by one pathologist (OK) to confirm primary or metastatic MTC.

TNM Classification

TNM classification based on the 7th Edition of the American Joint Committee on Cancer Staging Manual was used for all histopathological results.10

Statistical Analysis

Descriptive statistics analyzed age, sex, tumor characteristics (diameter), number of LNs detected and surgically removed, and bCt levels. Data are given as median (25th–75th percentile) or mean (± standard deviation). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated applying Statistical Package for Social Sciences (SPSS) version 23 for Windows (IBM Corporation, Armonk, NY, USA).
Sensitivity for ultrasound and F-DOPA-PET-CT was calculated for different tumor sizes (pT) and different bCt cut-offs. Patients were grouped into those with tumors ≤ 10 mm (‘microcarcinoma’; pT1a) and those with tumors > 11 mm (‘macrocarcinoma’; pT1b–T4).
Patients with a bCt cut-off level > 43 pg/mL have MTC independent of the patient’s sex.11 The American Thyroid Association (ATA) guidelines recommended functional imaging techniques in patients with bCt > 150 pg/mL, to localize persistent disease.12
The optimal cut-off for bCt in diagnosing lateral compartment LN metastasis was calculated using a receiver operating characteristic (ROC) curve (not shown in detail). Positive lateral LNs were only found in patients with bCt levels ≥ 85 pg/mL (sensitivity 100%). Sensitivity, specificity, positive predictive and NPVs to diagnose and locate positive lateral LNs were calculated based on this bCt cut-off.

Results

Patient characteristics, correlation of tumor classification, and imaging results are summarized in Table 1. Tables 2 and 3 provide the overall results, localizing the primary tumor and affected LNs by ultrasound and F-DOPA-PET-CT.
Table 1
Patient characteristics
No. of patients
50
 Males:females
24:26
Mean age, years (range)
56.9 (8.8–78.9)
Basal CTa (range)
202 pg/mL (82–1074)
CEA (range)
12.8 µg/mL (3.85–52.3)
T-stage classificationb [n (%)]
 pT1a
17/50 (34)
 pT1b
15/50 (30)
 pT2
9/50 (18)
 pT3
9/50 (18)
Multifocal [n (%)]
8/50 (16)
 Unilateral versus bilateral
2 versus 6
Hereditary MTC [n (%)]
8/50 (16)
Mean tumor size [mm (± SD)]
18.3 (± 16.0)
N1c [n (%)]
21/50 (42)
 N1a [n (%)]
Central
18/21 (85.7)
 N1b [n (%)]
Lateral
16/21 (76.2)
Mediastinal
3/21 (14)
Mean number of LNs removed (± SD)
74 (± 7)
Mean number of positive LNs (± SD)
6.7 (± 2)
M1d (%)
3/50 (6)
CEA Carcinoembryonic antigen, MTC medullary thyroid carcinoma, SD standard deviation, LNs lymph nodes, UICC Union for International Cancer Control, LNs lymph nodes
aCalcitonin (Siemens Diagnostic Products Corporation). Normal range: bCt: ≤ 8 pg/mL males, ≤ 5 pg/mL females; CEA: 0–3.8 μg/L (0–6.5 μg/L in smokers)
bUICC 201010 (p: pathological classification). pT1a: ≤ 10 mm; pT1b: 11–20 mm; pT2: 21–40 mm; pT3: > 40 mm or any size with minimal extrathyroidal extension; pT4: moderately advanced or very advanced disease
cN1: regional LN metastasis; N1a: metastasis to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian LNs N1b. Metastasis to unilateral, bilateral, or contralateral cervical (levels I, II, III, IV, or V), retropharyngeal or superior mediastinal LNs (level VII)
dM1: distant metastasis
Table 2
Diagnosis of primary tumor: ultrasound and F-DOPA-PET-CT
 
Ultrasound
F-DOPA-PET-CT
Yes (n)
No (n)
Sensitivity (%)
Yes (n)
No (n)
Sensitivity (%)
All (pT1a–pT3)
45
5
90
43
7
86
pT1a
12
5
71
11
6
65
pT1b
15
0
100
15
0
100
pT2
9
0
100
8
1
89
pT3
9
0
100
9
0
100
pT1a (maxDM ≤ 10 mm)
12
5
71
11
6
67
pT1b–4 (maxDM > 10 mm)
32
0
100
31
1
97
Calcitonin levela
      
bCt ≤ 43 pg/mL
8
1
89
4
5
44
bCt > 43 pg/mLb
41
0
100
39
2
95
bCt ≤ 150 pg/mLc
22
1
96
16
7
70
bCt > 150 pg/mL
27
0
100
27
0
100
F-DOPA-PET-CT [18F]fluoro-dihydroxyphenylalanine positron emission tomography with computed tomography, pT pathological tumor classification (11), maxDM maximal tumor diameter, bCt basal calcitonin level, MTC medullary thyroid carcinoma
aTwo-site chemiluminescent immunometric assay: Diagnostic Products Corporation (Los Angeles, CA, USA)
bAll patients with bCt > 43 pg/mL were shown to have MTC, independent of the patient’s sex
cbCT of 150 pg/mL is the lowest value recommended in the American Thyroid Association guidelines for performing functional imaging techniques in (persisting) MTC
Table 3
Value of ultrasound and F-DOPA-PET-CT: analysis of patients with central and lateral neck LN metastasis
Lymph node metastasis
Ultrasound
F-DOPA-PET-CT
Central
Lateral
Overalla
Central
Lateral
Overalla
True positive (n)
1
9
9
5b
12
12
True negative (n)
32
33
28
32
34
29
False positive (n)
0
1
1
0
0
0
False negative (n)
17
7
12
13
4
9
Sensitivity (%)
6
56
43
28
75
57
Specificity (%)
100
97
97
100
100
100
PPV (%)
100
90
90
100
100
100
NPV (%)
65
83
70
71
89
76
Accuracy (%)
66
84
74
74
92
82
F-DOPA-PET-CT [18F]fluoro-dihydroxyphenylalanine positron emission tomography with computed tomography, LN lymph node, PPV positive predictive value, NPV negative predictive value
aEvaluation of ALL neck compartments together
bPatients had both positive central and lateral LNs

Primary Tumor

Neck ultrasound was true positive in 45/50 (90%) patients (mean diameter: 20.0 ± 16.0 mm). In 5 (10%) patients (3.2 ± 2.2 mm; 4/5 with bilateral thyroid nodules), the specific malignant nodule was not preoperatively identified in the correct lobe (Table 3).
F-DOPA-PET-CT was true positive in 43/50 (86%) patients (20.0 ± 16.4 mm). When studying the F-DOPA scans for diagnosis of the primary tumors, the preoperative diagnostic scans were false negative in 7 (14%) patients (7.7 ± 8.1 mm; 3/7 with bilateral thyroid nodules) (Table 2).

Lymph Node Metastasis

LN metastasis was pathologically reported in 21/50 (42%) patients. Ultrasound and F-DOPA-PET-CT predicted true-positive LN metastasis in 9/21 (42.9%) patients and 12/21 (57.1%) patients, respectively. The overall sensitivities of ultrasound and F-DOPA-PET-CT were 43% and 57%, respectively (Table 3).

Compartment Correlation

Central Neck (N1a; Localized Disease)

In terms of diagnosing central LN metastasis, neck ultrasound was true positive in one patient (diameter: 20 mm), while 17/18 (94.4%) patients were false negative (6.2 ± 4.87 mm; sensitivity: 6%; specificity: 100%; overall accuracy: 66%) (Table 3).
F-DOPA-PET–CT was true positive in 5/18 (27.7%) patients (15.0 ± 5.77 mm), and false negative in 13/18 (72.2%) patients (4.41 ± 2.65 mm; sensitivity: 28%; specificity: 100%; overall accuracy: 74%).

Lateral Neck and Mediastinum (N1b; Regional Disease)

LN metastasis in the lateral neck was found in 16/21 (76.2%) patients; neck ultrasound was true positive in 9/16 (56%) patients (11.88 ± 13.31 mm). With one false-positive and seven false-negative patients (6.93 ± 6.56 mm), a sensitivity of 56% and specificity of 97% was calculated (overall accuracy: 84%).
In F-DOPA-PET-CT, 12/16 (75%) scans were true positive (11.08 ± 12.08 mm); four (25%) were false negative (5.62 ± 5.09 mm). No patients were false positive (sensitivity: 75%; specificity: 100%; overall accuracy: 92%).

Upper Mediastinum

Additionally, F-DOPA-PET-CT was true positive in three patients with mediastinal LN metastasis. These patients had bCt levels of 12,411, 14,360, and 14,686 pg/mL, respectively, and none of these patients had distant metastases.

Comparing the Diagnostic Value of bCt and Imaging Techniques

All 16 patients with LN metastasis in the lateral neck had bCt levels of > 85 pg/mL (sensitivity: 100%); however, given that 21 LN-negative patients had bCt levels > 85 pg/mL, the specificity was 38% (Table 4).
Table 4
Biochemical calculation (optimal bCT cut-off for lateral LN metastasis: > 85 pg/mL) and radiological methods (ultrasound or F-DOPA-PET-CT) to predict lateral neck LN metastasis
Lymph node metastasis in the lateral necka
bCt cut-off > 85 pg/mLb
Ultrasound
F-DOPA-PET-CT
True positive (n)
16
9
12
True negative (n)
13
33
34
False positive (n)
21
1
0
False negative (n)
0
7a
4b
Sensitivity (%)
100
56
75
Specificity (%)
38
97
100
PPV (%)
43
90
100
NPV (%)
100
83
89
Accuracy (%)
58
84
92
F-DOPA-PET-CT [18F]fluoro-dihydroxyphenylalanine positron emission tomography with computed tomography, bCt basal calcitonin level, LN lymph node, PPV positive predictive value, NPV negative predictive value
aPatients had 1–17 positive lateral LNs
bLateral lymph node metastasis was only found in patients with bCt levels ≥ 85 pg/mL

Number of Metastasis, Sensitivity of Ultrasound and F-DOPA-PET-CT

The sensitivity for each imaging technique was analyzed for patients with less than (n = 11) or more than 10 (n = 8) LN metastasis. The sensitivity of ultrasound or F-DOPA-PET-CT in patients with ≤ 10 positive LNs was 9% and 27%, respectively, and 80% and 90%, respectively, for patients with > 10 positive LNs. Analyzing the individual patients with true-positive F-DOPA-PET-CT and more than 10 positive LNs, the positive LNs were arranged as LN bulks.

Distant Disease

Three patients (two males, one female; mean age 63.1 years) had distant metastasis diagnosed in F-DOPA-PET-CT preoperatively (liver metastasis: n = 2; bCt values: 1942 pg/mL and 22,953 pg/mL; lung, liver and bone metastasis: n = 1; bCt 8397 pg/mL). All three patients underwent a palliative surgical approach with thyroidectomy, central neck, and a less extended lateral LN dissection. F-DOPA-PET-CT positively identified all distant metastasis.

Morbidity

No permanent complications (hypoparathyroidism, paralysis of the recurrent nerve) were documented in the study patients. Temporary hypoparathyroidism was documented in 7/50 (14%) patients, and temporary paralysis was documented in 4/100 (4%) nerves at risk. Two patients suffered from unilateral temporary weakness of the accessory nerve and shoulder dysfunction.

Follow-Up

Table 5 summarizes the biochemical follow-up of the study population. By definition, 34/50 (68%) patients were cured. In one (4.8%) patient and in 15 (30%) patients, recurrent and persisting disease, respectively, were documented. Five (4.8%) patients died of progressive MTC.
Table 5
Staging and follow-up of the study population (mean follow-up: 60 ± 31 months)
Stage
T
N
M
Number of patients
Cureda
Persisting diseaseb
Recurrent diseasec
Total
I
1a
0
0
14
  
14
1b
7
  
7
II
2
0
0
4
 
1
5
3
3
  
3
III
1a
1a
0
2
  
2
1b
1
  
1
2
1
  
1
3
    
IVA
4a
0/1a
     
1a
1b
0
1
  
1
1b
 
1
6
 
7
2
  
1
 
1
3
  
5 (died: 2d)
 
5
IVB
4b
Any N
1
    
IVC
Any T
Any N
 
3 (died: 2d)
  
 
n
34 (68%)
15 (30%; died: 4.8%d)
1
50
TNM, see Edge and Compton10 and Wells et al.12
bCt Basal calcitonin level
aCured: At the time of follow-up, normal/undetectable bCt levels
bPersisting disease: bCt levels never decreased to normal/undetectable values
cRecurrent disease: Normalization of bCt levels for at least 1 year, than a recurrent increase
dn patients died of MTC

Discussion

This study analyses the value of ultrasound and F-DOPA-PET-CT in localizing MTC, and LN and distant metastasis, before initial surgery to select stage-adapted surgery.
Neck ultrasound and F-DOPA-PET-CT achieved an overall sensitivity of 90% and 86%, respectively, in locating MTC in the correct thyroid lobe. As expected, the sensitivity depends on the size of the tumor and whether it is found as a solitary nodule or in multiple nodules. When localizing microcarcinoma (tumor size ≤ 10 mm), the sensitivity for ultrasound and F-DOPA-PET-CT was 71% and 67%, respectively, and 100% and 97%, respectively, for macrocarcinoma (tumor size > 10 mm). In four patients with multinodular goiter, ultrasound failed to diagnose the malignant micronodules in all patients, while F-DOPA-PET-CT failed in three of the four patients. In the literature, the sensitivity for ultrasound to localize the primary tumor ranges between 27 and 97%, and the sensitivity of F-DOPA-PET-CT ranges between 65 and 100%.2226 This current study exhibited high sensitivity in lesion-based ultrasound and F-DOPA-PET-CT. Ni Mhuircheartaigh et al.13 reported an average nodule size of at least 15.6 mm diagnosed in PET-CT. Therefore, size seems an unreliable criterion when it comes to localizing a malignant thyroid tumor.1416 False negatives could also be due to the fact that F-DOPA is not retained for a long period of time in small-sized MTCs.2,17
Several studies document that tumor burden positively correlates with bCt levels.13,14 In patients with bCt > 43 pg/mL and > 150 pg/mL, a sensitivity of 100% was achieved for diagnosing the primary tumor with ultrasound. However, one must take into account that the radiologist may have been biased in the preoperative neck ultrasound examinations, considering that all patients sent for ultrasound met the biochemical criteria for MTC. In addition, the experience of the radiologist also plays a role in the correct diagnosis. F-DOPA-PET-CT for primary tumor showed a sensitivity of 95% in patients with bCt > 43 pg/mL, and 100% in patients with bCt > 150 pg/mL, compared with 44% and 70%, respectively, in patients with lower bCt levels. Therefore, bCt levels influence the sensitivity of F-DOPA-PET-CT in primary tumor localization.
There is a broad overlap in the aspect of benign and malignant LNs. In this study, a low sensitivity was achieved in diagnosing LN metastasis by ultrasound. While the overall sensitivity of 43% lies within the reported range (29–100%1831), it is still much lower than the pooled sensitivity in the reviewed literature (72%). In terms of diagnosing central LN metastasis, neck ultrasound demonstrated only a 6% sensitivity. In particular, micrometastasis may be hidden by the thyroid gland and may therefore be missed on ultrasound. However, this study demonstrated a high PPV (100%), higher than previous studies (77–83%24,3234).
Ultrasound demonstrated a sensitivity of 56% and specificity of 97% in diagnosing lateral LN metastasis. This study demonstrated a high PPV (90%), similar to previous studies (85–88%24,32,35). Overall accuracy in the central compartment (66%) was lower than in the lateral compartment (84%), in accordance with other studies.29,36,37
When analyzing the individual LN compartments, F-DOPA-PET-CT exhibited only 28% sensitivity and 100% specificity for the central compartment. A higher sensitivity (75%) and specificity (100%) were seen in the lateral compartment. When applying F-DOPA-PET-CT in diagnosing and localizing LN metastasis, an overall sensitivity of 57% was demonstrated. In patients with bCt > 43 pg/mL and > 150 pg/mL, a sensitivity of 60% and 73%, respectively, was achieved. As previously mentioned, the small size of LN metastasis and the short retention time of F-DOPA may affect LN imaging and therefore the low overall sensitivity.
As shown by Machens and Dralle1, surgical cure is possible in patients with ≤ 10 LN metastases. A subanalysis demonstrated a very low sensitivity of 27% in localizing positive nodes by F-DOPA-PET-CT when applying the cut-off of ≤ 10 LN metastases. This sensitivity increased to 90% in patients with ≥ 10 LN metastases. Therefore, in patients where only a few, or micro, LN metastases are expected, F-DOPA-PET-CT is not beneficial for diagnostic purposes. Therefore, these findings justify a radical surgical procedure, even in the lateral neck, taking into account possible skip lesions.1
A limitation of ultrasound is that LN metastasis in the mediastinum or distant metastasis cannot be diagnosed; however, F-DOPA-PET-CT demonstrated 100% sensitivity and specificity in diagnosing positive mediastinal LNs and distant metastasis. According to the current ATA guidelines,12 patients with Ct levels > 500 pg/mL before the initial operation, or patients with Ct levels > 150 pg/mL in follow-up should undergo CT imaging with/without PET.12,38 All patients with positive LNs in the mediastinum and/or with distant metastasis had bCt values ≥ 500 pg/mL. Given the high sensitivity of F-DOPA-PET-CT with mediastinal LNs and distant metastases, all patients with bCt values > 500 pg/mL should primarily undergo F-DOPA-PET-CT to diagnose mediastinal LNs or distant metastasis preoperatively.
Patients with positive LNs in the upper mediastinum, but without distant metastasis, may benefit from mediastinal dissection. Furthermore, in patients with distant metastasis, a less extended neck surgery should be considered to avoid local complications and to circumvent complications arising from an extended surgery in the lateral neck.
Generally, the primary workup by ultrasound documents a nodule that is possibly malignant with a clear indication for surgery. F-DOPA-PET-CT improves the results in the central neck from a sensitivity of 6% to 28% in respect of diagnosing positive central nodes. However, neither ultrasound nor F-DOPA-PET are helpful in limiting surgery in the central neck because of the overall imprecise radiological localization of the primary tumor and LN metastasis.
Independent of a positive or negative preoperative imaging study, the primary operation has to meet oncological standards ([total] thyroidectomy; bilateral central [level VI] dissection) in patients who fulfill the biochemical criteria for MTC. One has to keep in mind that the study was performed within a ‘calcitonin screening program’ documenting pT1a in 17/50 (34%) patients (diameter ≤ 5 mm in 6 [25%] patients), 3 (17.6%) of whom presented with only one or two central LN micrometastases.
Micrometastatic changes in LNs may also influence the low sensitivity in correctly diagnosing and localizing lateral LN metastasis. While the PPV was only 38%, retrospectively, it may be recommended to apply ‘functional lateral neck dissection’ in at least all patients with bCt > 85 pg/mL. However, in 21/50 (42%) patients, the lateral neck dissection revealed negative LNs.
When determining which preoperative examinations to conduct, the advantages and disadvantages for each test must be evaluated. Neck ultrasound is non-invasive, widely available, less expensive than other imaging techniques, and is very safe as no ionizing radiation is used; however, the results are dependent on the radiologist and his/her training and experience. F-DOPA-PET-CT is a functional technique able to provide important anatomical information, especially when it comes to diagnosing distant metastasis. However, its disadvantages include limited availability, high radiation dose (approximately 25 mSv39,40 depending on body weight), possible allergic reactions to the contrast medium, and it is expensive.

Conclusions

This large, single-center study evaluated how neck ultrasound and whole-body F-DOPA-PET-CT may influence the initial surgical strategy in a center with routine measurement of calcitonin in all patients with thyroid nodules. While the sensitivity of ultrasound in diagnosing the primary tumor was very high (92%), it was unfortunately quite low (43%) in detecting the presence and location of LN metastasis. F-DOPA PET-CT also exhibited a good sensitivity of 86% in detecting the primary tumor, but also a low sensitivity (57%) when diagnosing the presence and location of LN metastasis. Therefore, the extent of lateral LN surgery cannot be determined, based on neither ultrasound nor F-DOPA-PET-CT. However, the detection of distant metastasis by functioning imaging may help limit the extent of lateral neck and/or mediastinal dissection. Patients who fulfill the biochemical criteria for MTC should undergo a tailored surgical approach.

Acknowledgments

Open access funding provided by Medical University of Vienna.

Disclosure

Lindsay Brammen, Martin B. Niederle, Philipp Riss, Christian Scheuba, Andreas Selberherr, Georgios Karanikas, Gerd Bodner, Oskar Koperek, and Bruno Niederle have no conflicts of interest to declare.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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Literatur
1.
Zurück zum Zitat Machens A, Dralle H. Surgical treatment of medullary thyroid cancer. Recent results. Cancer Res. 2015;204:187–205. Machens A, Dralle H. Surgical treatment of medullary thyroid cancer. Recent results. Cancer Res. 2015;204:187–205.
2.
Zurück zum Zitat Archier A, Heimburger C, Guerin C, et al. (18)F-DOPA PET/CT in the diagnosis and localization of persistent medullary thyroid carcinoma. Eur J Nucl Med Mol Imaging. 2016;43:1027–1033.CrossRef Archier A, Heimburger C, Guerin C, et al. (18)F-DOPA PET/CT in the diagnosis and localization of persistent medullary thyroid carcinoma. Eur J Nucl Med Mol Imaging. 2016;43:1027–1033.CrossRef
3.
Zurück zum Zitat Beheshti M, Pocher S, Vali R, et al. The value of 18F-DOPA PET-CT in patients with medullary thyroid carcinoma: comparison with 18F-FDG PET-CT. Eur Radiol. 2009;19:1425–1434.CrossRef Beheshti M, Pocher S, Vali R, et al. The value of 18F-DOPA PET-CT in patients with medullary thyroid carcinoma: comparison with 18F-FDG PET-CT. Eur Radiol. 2009;19:1425–1434.CrossRef
4.
Zurück zum Zitat Koopmans KP, de Groot JW, Plukker JT, et al. 18F-dihydroxyphenylalanine PET in patients with biochemical evidence of medullary thyroid cancer: relation to tumor differentiation. J Nucl Med. 2008;49:524–531.CrossRef Koopmans KP, de Groot JW, Plukker JT, et al. 18F-dihydroxyphenylalanine PET in patients with biochemical evidence of medullary thyroid cancer: relation to tumor differentiation. J Nucl Med. 2008;49:524–531.CrossRef
5.
Zurück zum Zitat Luster M, Karges W, Zeich K, et al. Clinical value of 18-fluorine-fluorodihydroxyphenylalanine positron emission tomography/computed tomography in the follow-up of medullary thyroid carcinoma. Thyroid. 2010;20:527–533.CrossRef Luster M, Karges W, Zeich K, et al. Clinical value of 18-fluorine-fluorodihydroxyphenylalanine positron emission tomography/computed tomography in the follow-up of medullary thyroid carcinoma. Thyroid. 2010;20:527–533.CrossRef
6.
Zurück zum Zitat Scheuba C, Kaserer K, Bieglmayer C, et al. Medullary thyroid microcarcinoma recommendations for treatment—a single-center experience. Surgery. 2007;142:1003–1010; discussion 1010.e1–3.CrossRef Scheuba C, Kaserer K, Bieglmayer C, et al. Medullary thyroid microcarcinoma recommendations for treatment—a single-center experience. Surgery. 2007;142:1003–1010; discussion 1010.e1–3.CrossRef
7.
Zurück zum Zitat Wong KT, Ahuja AT. Ultrasound of thyroid cancer. Cancer Imaging. 2005;5:157–166.CrossRef Wong KT, Ahuja AT. Ultrasound of thyroid cancer. Cancer Imaging. 2005;5:157–166.CrossRef
8.
Zurück zum Zitat Ahuja AT, Ying M, Ho SY, et al. Ultrasound of malignant cervical lymph nodes. Cancer Imaging. 2008;8:48–56.CrossRef Ahuja AT, Ying M, Ho SY, et al. Ultrasound of malignant cervical lymph nodes. Cancer Imaging. 2008;8:48–56.CrossRef
10.
Zurück zum Zitat Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol. 2010;17:1471–1474.CrossRef Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol. 2010;17:1471–1474.CrossRef
11.
Zurück zum Zitat Niederle MB, Scheuba C, Gessl A, et al. Calcium-stimulated calcitonin: the “new standard” in the diagnosis of thyroid C-cell disease—clinically relevant gender-specific cut-off levels for an “old test”. Biochem Med (Zagreb). 2018;28:473–484.CrossRef Niederle MB, Scheuba C, Gessl A, et al. Calcium-stimulated calcitonin: the “new standard” in the diagnosis of thyroid C-cell disease—clinically relevant gender-specific cut-off levels for an “old test”. Biochem Med (Zagreb). 2018;28:473–484.CrossRef
12.
Zurück zum Zitat Wells SA Jr, Asa SL, Dralle H, et al. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid. 2015;25:567–610.CrossRef Wells SA Jr, Asa SL, Dralle H, et al. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid. 2015;25:567–610.CrossRef
13.
Zurück zum Zitat Ni Mhuircheartaigh JM, Siewert B, Sun MR. Correlation between the size of incidental thyroid nodules detected on CT, MRI or PET-CT and subsequent ultrasound. Clin Imaging. 2016;40:1162–1166.CrossRef Ni Mhuircheartaigh JM, Siewert B, Sun MR. Correlation between the size of incidental thyroid nodules detected on CT, MRI or PET-CT and subsequent ultrasound. Clin Imaging. 2016;40:1162–1166.CrossRef
14.
Zurück zum Zitat Bollen EC, Goei R, van’t Hof-Grootenboer BE, Versteege CW, Engelshove HA, Lamers RJ. Interobserver variability and accuracy of computed tomographic assessment of nodal status in lung cancer. Ann Thorac Surg. 1994;58:158–162.CrossRef Bollen EC, Goei R, van’t Hof-Grootenboer BE, Versteege CW, Engelshove HA, Lamers RJ. Interobserver variability and accuracy of computed tomographic assessment of nodal status in lung cancer. Ann Thorac Surg. 1994;58:158–162.CrossRef
15.
Zurück zum Zitat Gdeedo A, Van Schil P, Corthouts B, Van Mieghem F, Van Meerbeeck J, Van Marck E. Comparison of imaging TNM [(i)TNM] and pathological TNM [pTNM] in staging of bronchogenic carcinoma. Eur J Cardiothorac Surg. 1997;12:224–227.CrossRef Gdeedo A, Van Schil P, Corthouts B, Van Mieghem F, Van Meerbeeck J, Van Marck E. Comparison of imaging TNM [(i)TNM] and pathological TNM [pTNM] in staging of bronchogenic carcinoma. Eur J Cardiothorac Surg. 1997;12:224–227.CrossRef
16.
Zurück zum Zitat Stomper P. Cancer imaging manual. Philadelphia, PA: Lippincott; 1993. pp. 51–60. Stomper P. Cancer imaging manual. Philadelphia, PA: Lippincott; 1993. pp. 51–60.
17.
Zurück zum Zitat Soussan M, Nataf V, Kerrou K, et al. Added value of early 18F-FDOPA PET/CT acquisition time in medullary thyroid cancer. Nucl Med Commun. 2012;33:775–779.CrossRef Soussan M, Nataf V, Kerrou K, et al. Added value of early 18F-FDOPA PET/CT acquisition time in medullary thyroid cancer. Nucl Med Commun. 2012;33:775–779.CrossRef
18.
Zurück zum Zitat Baatenburg de Jong RJ, Rongen RJ, Lameris JS, Harthoorn M, Verwoerd CD, Knegt P. Metastatic neck disease. Palpation versus ultrasound examination. Arch Otolaryngol Head Neck Surg. 1989;115:689–690. Baatenburg de Jong RJ, Rongen RJ, Lameris JS, Harthoorn M, Verwoerd CD, Knegt P. Metastatic neck disease. Palpation versus ultrasound examination. Arch Otolaryngol Head Neck Surg. 1989;115:689–690.
19.
Zurück zum Zitat Bruneton JN, Roux P, Caramella E, Demard F, Vallicioni J, Chauvel P. Ear, nose, and throat cancer: ultrasound diagnosis of metastasis to cervical lymph nodes. Radiology. 1984;152:771–773.CrossRef Bruneton JN, Roux P, Caramella E, Demard F, Vallicioni J, Chauvel P. Ear, nose, and throat cancer: ultrasound diagnosis of metastasis to cervical lymph nodes. Radiology. 1984;152:771–773.CrossRef
20.
Zurück zum Zitat Gorges R, Eising EG, Fotescu D, et al. Diagnostic value of high-resolution B-mode and power-mode sonography in the follow-up of thyroid cancer. Eur J Ultrasound. 2003;16:191–206.CrossRef Gorges R, Eising EG, Fotescu D, et al. Diagnostic value of high-resolution B-mode and power-mode sonography in the follow-up of thyroid cancer. Eur J Ultrasound. 2003;16:191–206.CrossRef
21.
Zurück zum Zitat Sugitani I, Fujimoto Y, Yamada K, Yamamoto N. Prospective outcomes of selective lymph node dissection for papillary thyroid carcinoma based on preoperative ultrasonography. World J Surg. 2008;32:2494–2502.CrossRef Sugitani I, Fujimoto Y, Yamada K, Yamamoto N. Prospective outcomes of selective lymph node dissection for papillary thyroid carcinoma based on preoperative ultrasonography. World J Surg. 2008;32:2494–2502.CrossRef
22.
Zurück zum Zitat Shimamoto K, Satake H, Sawaki A, Ishigaki T, Funahashi H, Imai T. Preoperative staging of thyroid papillary carcinoma with ultrasonography. Eur J Radiol. 1998;29:4–10.CrossRef Shimamoto K, Satake H, Sawaki A, Ishigaki T, Funahashi H, Imai T. Preoperative staging of thyroid papillary carcinoma with ultrasonography. Eur J Radiol. 1998;29:4–10.CrossRef
23.
Zurück zum Zitat Jeong HS, Baek CH, Son YI, et al. Integrated 18F-FDG PET/CT for the initial evaluation of cervical node level of patients with papillary thyroid carcinoma: comparison with ultrasound and contrast-enhanced CT. Clin Endocrinol (Oxf). 2006;65:402–407.CrossRef Jeong HS, Baek CH, Son YI, et al. Integrated 18F-FDG PET/CT for the initial evaluation of cervical node level of patients with papillary thyroid carcinoma: comparison with ultrasound and contrast-enhanced CT. Clin Endocrinol (Oxf). 2006;65:402–407.CrossRef
24.
Zurück zum Zitat Ahn JE, Lee JH, Yi JS, et al. Diagnostic accuracy of CT and ultrasonography for evaluating metastatic cervical lymph nodes in patients with thyroid cancer. World J Surg. 2008;32:1552–1558.CrossRef Ahn JE, Lee JH, Yi JS, et al. Diagnostic accuracy of CT and ultrasonography for evaluating metastatic cervical lymph nodes in patients with thyroid cancer. World J Surg. 2008;32:1552–1558.CrossRef
25.
Zurück zum Zitat Roh JL, Park JY, Kim JM, Song CJ. Use of preoperative ultrasonography as guidance for neck dissection in patients with papillary thyroid carcinoma. J Surg Oncol. 2009;99:28–31.CrossRef Roh JL, Park JY, Kim JM, Song CJ. Use of preoperative ultrasonography as guidance for neck dissection in patients with papillary thyroid carcinoma. J Surg Oncol. 2009;99:28–31.CrossRef
26.
Zurück zum Zitat Hwang HS, Perez DA, Orloff LA. Comparison of positron emission tomography/computed tomography imaging and ultrasound in staging and surveillance of head and neck and thyroid cancer. Laryngoscope. 2009;119:1958–1965.CrossRef Hwang HS, Perez DA, Orloff LA. Comparison of positron emission tomography/computed tomography imaging and ultrasound in staging and surveillance of head and neck and thyroid cancer. Laryngoscope. 2009;119:1958–1965.CrossRef
27.
Zurück zum Zitat Lee K, Kawata R, Nishikawa S, Yoshimura K, Takenaka H. Diagnostic criteria of ultrasonographic examination for lateral node metastasis of papillary thyroid carcinoma. Acta Otolaryngol. 2010;130:161–166.CrossRef Lee K, Kawata R, Nishikawa S, Yoshimura K, Takenaka H. Diagnostic criteria of ultrasonographic examination for lateral node metastasis of papillary thyroid carcinoma. Acta Otolaryngol. 2010;130:161–166.CrossRef
28.
Zurück zum Zitat Park JS, Son KR, Na DG, Kim E, Kim S. Performance of preoperative sonographic staging of papillary thyroid carcinoma based on the sixth edition of the AJCC/UICC TNM classification system. AJR Am J Roentgenol. 2009;192:66–72.CrossRef Park JS, Son KR, Na DG, Kim E, Kim S. Performance of preoperative sonographic staging of papillary thyroid carcinoma based on the sixth edition of the AJCC/UICC TNM classification system. AJR Am J Roentgenol. 2009;192:66–72.CrossRef
29.
Zurück zum Zitat Choi JS, Kim J, Kwak JY, Kim MJ, Chang HS, Kim EK. Preoperative staging of papillary thyroid carcinoma: comparison of ultrasound imaging and CT. AJR Am J Roentgenol. 2009;193:871–878.CrossRef Choi JS, Kim J, Kwak JY, Kim MJ, Chang HS, Kim EK. Preoperative staging of papillary thyroid carcinoma: comparison of ultrasound imaging and CT. AJR Am J Roentgenol. 2009;193:871–878.CrossRef
30.
Zurück zum Zitat Kessler A, Rappaport Y, Blank A, Marmor S, Weiss J, Graif M. Cystic appearance of cervical lymph nodes is characteristic of metastatic papillary thyroid carcinoma. J Clin Ultrasound. 2003;31:21–25.CrossRef Kessler A, Rappaport Y, Blank A, Marmor S, Weiss J, Graif M. Cystic appearance of cervical lymph nodes is characteristic of metastatic papillary thyroid carcinoma. J Clin Ultrasound. 2003;31:21–25.CrossRef
31.
Zurück zum Zitat Gonzalez HE, Cruz F, O’Brien A, et al. Impact of preoperative ultrasonographic staging of the neck in papillary thyroid carcinoma. Arch Otolaryngol Head Neck Surg. 2007;133:1258–1262.CrossRef Gonzalez HE, Cruz F, O’Brien A, et al. Impact of preoperative ultrasonographic staging of the neck in papillary thyroid carcinoma. Arch Otolaryngol Head Neck Surg. 2007;133:1258–1262.CrossRef
32.
Zurück zum Zitat Kocharyan D, Schwenter F, Belair M, Nassif E. The relevance of preoperative ultrasound cervical mapping in patients with thyroid cancer. Can J Surg. 2016;59:113–117.CrossRef Kocharyan D, Schwenter F, Belair M, Nassif E. The relevance of preoperative ultrasound cervical mapping in patients with thyroid cancer. Can J Surg. 2016;59:113–117.CrossRef
33.
Zurück zum Zitat Mizrachi A, Feinmesser R, Bachar G, Hilly O, Cohen M. Value of ultrasound in detecting central compartment lymph node metastases in differentiated thyroid carcinoma. Eur Arch Otorhinolaryngol. 2014;271:1215–1218.CrossRef Mizrachi A, Feinmesser R, Bachar G, Hilly O, Cohen M. Value of ultrasound in detecting central compartment lymph node metastases in differentiated thyroid carcinoma. Eur Arch Otorhinolaryngol. 2014;271:1215–1218.CrossRef
34.
Zurück zum Zitat Kim E, Park JS, Son KR, Kim JH, Jeon SJ, Na DG. Preoperative diagnosis of cervical metastatic lymph nodes in papillary thyroid carcinoma: comparison of ultrasound, computed tomography, and combined ultrasound with computed tomography. Thyroid. 2008;18:411–418.CrossRef Kim E, Park JS, Son KR, Kim JH, Jeon SJ, Na DG. Preoperative diagnosis of cervical metastatic lymph nodes in papillary thyroid carcinoma: comparison of ultrasound, computed tomography, and combined ultrasound with computed tomography. Thyroid. 2008;18:411–418.CrossRef
35.
Zurück zum Zitat Al-Hilli Z, Strajina V, McKenzie TJ, Thompson GB, Farley DR, Richards ML. The role of lateral neck ultrasound in detecting single or multiple lymph nodes in papillary thyroid cancer. Am J Surg. 2016;212:1147–1153.CrossRef Al-Hilli Z, Strajina V, McKenzie TJ, Thompson GB, Farley DR, Richards ML. The role of lateral neck ultrasound in detecting single or multiple lymph nodes in papillary thyroid cancer. Am J Surg. 2016;212:1147–1153.CrossRef
36.
Zurück zum Zitat Lee YJ, Kim DW, Park HK, et al. Pre-operative ultrasound diagnosis of nodal metastasis in papillary thyroid carcinoma patients according to nodal compartment. Ultrasound Med Biol. 2015;41:1294–1300.CrossRef Lee YJ, Kim DW, Park HK, et al. Pre-operative ultrasound diagnosis of nodal metastasis in papillary thyroid carcinoma patients according to nodal compartment. Ultrasound Med Biol. 2015;41:1294–1300.CrossRef
37.
Zurück zum Zitat Lee DW, Ji YB, Sung ES, et al. Roles of ultrasonography and computed tomography in the surgical management of cervical lymph node metastases in papillary thyroid carcinoma. Eur J Surg Oncol. 2013;39:191–196.CrossRef Lee DW, Ji YB, Sung ES, et al. Roles of ultrasonography and computed tomography in the surgical management of cervical lymph node metastases in papillary thyroid carcinoma. Eur J Surg Oncol. 2013;39:191–196.CrossRef
38.
Zurück zum Zitat Pacini F, Castagna MG, Brilli L, Pentheroudakis G; ESMO Guidelines Working Group. Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2012;23 Suppl 7:vii110–119. Pacini F, Castagna MG, Brilli L, Pentheroudakis G; ESMO Guidelines Working Group. Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2012;23 Suppl 7:vii110–119.
39.
Zurück zum Zitat Brix G, Lechel U, Glatting G, et al. Radiation exposure of patients undergoing whole-body dual-modality 18F-FDG PET/CT examinations. J Nucl Med. 2005;46:608–613.PubMed Brix G, Lechel U, Glatting G, et al. Radiation exposure of patients undergoing whole-body dual-modality 18F-FDG PET/CT examinations. J Nucl Med. 2005;46:608–613.PubMed
40.
Zurück zum Zitat Huang B, Law MW, Khong PL. Whole-body PET/CT scanning: estimation of radiation dose and cancer risk. Radiology. 2009;251:166–174.CrossRef Huang B, Law MW, Khong PL. Whole-body PET/CT scanning: estimation of radiation dose and cancer risk. Radiology. 2009;251:166–174.CrossRef
Metadaten
Titel
Medullary Thyroid Carcinoma: Do Ultrasonography and F-DOPA-PET-CT Influence the Initial Surgical Strategy?
verfasst von
Lindsay Brammen, MD
Martin B. Niederle, MD
Philipp Riss, MD
Christian Scheuba, MD
Andreas Selberherr, MD
Georgios Karanikas, MD
Gerd Bodner, MD
Oskar Koperek, MD
Bruno Niederle, MD
Publikationsdatum
10.10.2018
Verlag
Springer International Publishing
Erschienen in
Annals of Surgical Oncology / Ausgabe 13/2018
Print ISSN: 1068-9265
Elektronische ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-018-6829-3

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