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About 65% of metastases are detectable by RAI scanning, but only after optimal preparation: Patients should ideally have a total or near-total thyroidectomy, since any residual normal thyroid competes for RAI with metastases, which are less avid for iodine To avoid nonradioactive iodine competitive inhibition of RAI uptake, intravenous iodinated contrast must be avoided for at least 2 months before scanning; patients must follow a low-iodine diet for at least 2 weeks before scanning and continue to limit iodine consumption until the scan is complete or until after 131I therapy In addition, patients must have high levels of TSH to stimulate metastases to take up more RAI, making them visible on scanning This can be accomplished by allowing the patient to become hypothyroid or by administering synthetic rhTSH The use of rhTSH has become more widespread for surveillance scanning and stimulated thyroglobulin determinations following thyroidectomy for differentiated thyroid carcinoma, due to its convenience for the patient However, rhTSH-stimulated scanning is slightly less sensitive than hypothyroid-stimulated scanning For stage I II patients, it is reasonable to perform a thyroid-withdrawal scan once; if it is negative and the serum thyroglobulin is < 2 ng/mL, an rhTSH scan can be performed 1 and 3 years thereafter a Thyrotropin-stimulated serum Tg and radioiodine scanning The use of recombinant human thyrotropin- (Thyrogen; rhTSH) injections can replace thyroid withdrawal with much less discomfort for most patients Thyrotropin stimulates uptake of RAI and production of thyroglobulin by differentiated thyroid cancer or residual thyroid The use of rhTSH is particularly suited to low-risk patients: those with a small papillary thyroid carcinoma who have had a total or near-total thyroidectomy and have no known local or distal metastases and a serum thyroglobulin < 1 mcg/L during thyroxine suppression of serum TSH In about 21% of such low-risk patients, rhTSH stimulates serum thyroglobulin to above 2 mcg/L; such patients have a 23% risk of local neck metastases and a 13% risk of distant metastases Stimulated radioiodine neck and whole-body scanning can detect only about half of these metastases because they are small or not avid for iodine Thyrotropin must be kept refrigerated and may be administered according to the following protocol: Thyroxine replacement is held for 2 days before rhTSH and for 3 days afterward On Monday and Tuesday, thyrotropin 09 mg is administered intragluteally (not intravenously) On Wednesday, serum is drawn for TSH and thyroglobulin determinations Immediately thereafter, RAI is administered in a scanning dose (see above) On Friday, serum is drawn for thyroglobulin and the whole-body scan is performed Side effects of thyrotropin injections include nausea (11%) and headache (7%) Hyperthyroidism can occur in patients with significant metastases or residual normal thyroid Thyrotropin has caused neurologic deterioration in 7% of patients with central nervous system metastases The combination of thyrotropin-stimulated scanning and thyroglobulin levels detects a thyroid remnant or cancer with a sensitivity of 84% However, the presence of anti-thyroglobulin antibodies renders the serum thyroglobulin determination uninterpretable Thyrotropin stimulation does not
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patients with a detectable serum thyroglobulin (especially serum thyroglobulin levels > 10 ng/mL and rising) who have a normal whole-body RAI scan and an unrevealing neck ultrasound PET scanning can be combined with a CT scan; the resultant PET/CT fusion scan is 60% sensitive for detecting metastases that are not visible by other methods This scan is less sensitive for small brain metastases 18FDG-PET scanning detects the metabolic activity of tumor tissue; for differentiated thyroid carcinoma, this scan is more sensitive when the patient is hypothyroid or pretreated with thyrotropin as described above One problem with 18FDG-PET scanning is its lack of specificity For example, false-positives can occur with benign hepatic tumors, sarcoidosis, radiation therapy, suture granulomas, reactive lymph nodes, or inflammation at surgical sites that can persist for months False-positive uptake can also occur in muscles and brown fat in the neck and shoulders, axillae, mediastinum, perinephric regions, intercostal paravertebral spaces, and paravertebral muscles A fusion 18FDG-PET/CT (no contrast) scan improves specificity but cannot distinguish thyroid carcinoma from other unrelated malignancies that may be present concurrently Smaller metastases are often present on PET scanning before becoming visible on CT or even MRI scanning 18 FDG-PET scanning is particularly sensitive for detecting medullary thyroid carcinoma metastases, and prescan thyrotropin does not improve the PET scan sensitivity for medullary thyroid carcinoma 5 Other scanning Thallium-201 (201Tl) scans may be useful for detecting metastatic differentiated thyroid carcinoma when the 131I scan is normal but serum thyroglobulin is elevated MRI scanning is particularly useful for imaging metastases in the brain, mediastinum, or bones CT scanning is useful for imaging and monitoring pulmonary metastases
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prepare patients for 131I treatment; they must be prepared for treatment by becoming hypothyroid as described below b Thyroid withdrawal-stimulated serum Tg and radioiodine scanning Recombinant human TSH (rhTSH, Thyrogen) has largely replaced thyroid withdrawal, as noted above But thyroid hormone withdrawal is still used, allowing the patient to become hypothyroid; high levels of endogenous TSH stimulate the uptake of RAI and production of thyroglobulin by thyroid cancer or residual thyroid Serum thyroxine is held for 14 days Prior to scanning, serum TSH is assayed to confirm that it is > 30 mcU/mL; serum hCG is assayed to screen for pregnancy; serum thyroglobulin titers are also determined Following radioisotope scanning, or 4 days after 131I therapy (see above), thyroxine therapy may be resumed at full replacement dose Patients with papillary carcinoma should have at least two annual consecutively negative stimulated serum thyroglobulin determinations < 1 mcg/L and normal RAI scans (if done) before they are considered to be in remission Patients with persistent RAI uptake restricted to the thyroid bed need not have repeated 131I therapies if neck ultrasound appears benign and serum thyroglobulin is < 5 ng/mL Further radioiodine or other scans may be required for patients with more aggressive papillary-follicular, follicular, or medullary thyroid carcinomas, prior metastases, rising serum thyroglobulin levels, or other evidence of metastases Patients often have a negative whole-body radioiodine scan but have serum thyroglobulin levels that are > 2 ng/mL In such cases, another thyroglobulin assay should be sent to a different reference laboratory to confirm the accuracy of the thyroglobulin determination Patients with serum Tg levels > 2 ng/mL require close continued monitoring Those with progressively rising Tg levels are at high risk for occult thyroid cancer metastases Other scanning methods may be used in an effort to detect such metastases 4 Positron emission tomography scanning PET wholebody scanning using 18FDG-PET is a relatively sensitive method for detecting thyroid cancer metastases particularly those that are not revealed on RAI scanning PET scanning is particularly useful for detecting thyroid cancer metastases in
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