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Preoperative PET-CT in papillary thyroid cancer
Chung-Ang University, KoreaDepartment of Surgery
Byung Seup Kim, Ju Won Seok, Han suk Ryu, Kyung Ho Kang, Sung Jun Park, Bo Youn Cho
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Introduction
PET – CT 2-[fluorine-18]fluoro-2-deoxy- glucose
FDG
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Introduction
Meaning of FDG -uptake
Rate of uptake of FDG is proportional to
metabolic activity
An introduction to PET-CT imaging. Radigraphics 2004; 523-543
Uptake of FDG
Metabolic activity
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Flip – flop phenomenon
PTC
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Introduction
About Primary le-sion
We evaluated the FDG uptake of papillary thy-roid cancer in preoperative PET CT.
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Method
FNAB :Papillary thy-roid cancer
Preoperative PET-CT
Operation
Period : 2011.3.1 ~ 2012. 2. 29PTC was preoperatively confirmed by FANBCND was routinely performed.Preoperative PET CT was performed when patient argeed it Enrolled patients : 194
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Divided into PET negative(-) and positive(+) group
Negative ;Absence of FDG up-tatke
Postive ;Presence of FDG up-take
VS.
Method
Backgroud : surrounding thyroid tis-sue
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Method
1. Analyze the cliniopathologic factors related to PET (+)2. .Analyze quantity of SUVmax value according to clinicopathologic factors
SUVmax : maximal standardized uptake value SUVmax of PET negative patient = SUV of surrounding thy-roid tissue
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ResultsPET sensitivity
① Primary tumor : 71.7% (138/194 pa-tients)
② Central lymph node metz. : 4.3% (3/70 patients)
③ Lateral lymph node metz. : 62.5% (15/24 pa-tients) False positive : 1.1%
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ResultsTable 1-1. PET-CT and clinicopathologic parameters
Variables PET (-) PET (+) P value(n=56, 28.9%) (n=138, 71.7%)
Sex Male 19 (33.9 %) 21 (15.2%) 0.004
Female 37 (66.1%) 117 (84.8%) Age < 45 years 22 (39.3%) 61 (44.2%) 0.530
≥ 45 years 34 (60.7%) 77 (55.8%) Size ≤ 1cm 49 (87.5%) 77 (55.8%) <0.001
> 1cm 7 (12.5%) 61 (44.2%) Multicenticity Absence 31 (55.4%) 71 (51.4%) 0.621
Presence 25 (44.6%) 67 (48.6%) Extrathyroidal extension Absence 43 (76.8%) 87 (63.0%) 0.065
Presence 13 (23.2%) 51 (37.0%) Lymph node metastasis Absence 33 (58.9%) 67 (48.6%) 0.190
Presence 23 (41.1%) 71 (51.4%)
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Table 1-2. PET-CT and clinicopathologic parameters
Variables PET (-) PET (+) P value(n=56, 28.9%) (n=138, 71.7%)
Coexisting pathology 0.001 None 31 (55.4%) 41 (29.7%) Nodular hyperplasia (NH) 18 (32.1%) 40 (29.0%) Hashimoto thyroiditis (HT) 5 (8.9%) 36 (26.1%) NHa+ HTb 2 (3.6%) 21 (15.2%)Subtype of PTC 0.001 Classic 38 (67.9%) 110 (79.7%) Follicular variant 17 (30.4%) 12 (8.7%) Oncocytic variant 1 (1.8%) 14 (10.1%) Solid 0 (0%) 1 (0.7%) Tall cell variant 0 (0%) 1 (0.7%)
Coexisting pathology 0.001 Abscence 31 (43.1%) 41 (56.9%) Presence 25 (20.5%) 97 (79.5%)Subtype of PTC <0.001 Non-follicular variant 39 (23.6%) 126 (76.4%) Follicular variant 17 (58.6%) 12 (41.4%)
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ResultsTable 2. PET positivity and cliniocopathologic parameters by logistic regression
Variable Hazard ratio (95% CIb) P value
Sex Male 1 (reference) 0.021
Female 2.843 ( 1.171 - 6.905)
Size ≤ 1cm 1 (reference) < 0.001
> 1cm 8.090 (3.000 - 21.813)
Coexisting pathology Absence 1 (reference) 0.005
Presence 2.983 (1.393 - 6.386)
Subtype of PTCa Follicular variant 1 (reference) 0.003
Non-follicular variant 4.032 (1.619 - 10.038) PTCa Papillary thyroid cancer
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2. Analysis for quantity of FDG uptake
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SUVmax
Kolmogorov-Smirnove goodness
P < 0.001
Non normally distributed data
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Table 3. SUVmax by clinicopathologic parameters
Variables N Median Q25 - Q75 P valueSex Male 40 1.850 1.000 - 4.175 0.042 Female 154 2.700 1.575 - 4.400 Age < 45 years 83 2.700 1.000 - 4.200 0.658 ≥ 45 years 111 2.500 1.000 - 4.400 Tumor size ≤ 1cm 126 2.100 1.000 - 3.000 0.001 > 1cm 68 4.900 2.900 -10.200 Multicenticity Absence 102 2.600 1.000 - 4.525 0.888 Presence 92 2.600 1.000 - 4.300 Extrathyroidal extension Absence 130 2.300 1.000 - 3.300 < 0.001 Presence 64 4.00 1.900 - 9.400 Lymph node metastasis Absence 100 2.400 1.000 - 3.400 0.017 Presence 94 3.000 1.125 - 5.000 Coexisting pathology 0.253 None 72 2.150 1.875 - 4.225 Nodular hyperplasia (NH) 58 2.300 1.000 – 4.150 Hashimoti thyroiditis (HT) 35 2.800 2.400 – 4.100 NH + HT 22 3.450 2.475 – 4.475Subtype of PTC (Papillary thyroid cancer) 0.001 Classic 148 2.750 1.000 – 4.875 Follicular variant 29 1.000 1.000 – 2.450 Oncocytic variant 15 2.900 2.300 – 3.200 Solid 1 2.100 Not availabled
Tall cell variant 1 8.300 Not availabled
d The number of case was only one so that quartile was not available
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P value < 0.001
SUVmax 2.6 sensitivity 70.3% specificity 60.0%
Analysis for quantity of FDG uptake
Relationship between extrathyroidal extension and SUVmax
ROC curve
1-specificity
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Results
ETE (-) (n=130, 67.0%)
ETE (+)(n=64, 33.0%) P value
Lymph node metz.
(+) 52 (40.0%) 42 (65.6%) 0.001
Size > 1cm 31 (23.8%) 64 (33.0%) < 0.001
Age ≥ 45 years 74 (56.9%) 37 (57.8%) 0.906
Female 107 (82.3%) 47 (73.4%) 0.151
Multicenticity 59 (45.7%) 33 (51.6%) 0.446
SUVmax ≥ 2.6 55 (42.3%) 45 (70.3%) <0.001
Subtype (follicular) 24 (18.5%) 4 (6.3%) 0.029
Coexisting pathology 82 (63.1%) 40 (62.5%) 0.938
Cliniopathologic factors and Extrathyroidal exnte-sion by univariate analysis
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Extrathyroidal extension and clinicopathologic factors by mulivariate analysis
Variable Hazard ratio (95% CI) P-value
Lymph node metz. Absence 1 (reference) 0.046
Presence 2.063 ( 1.014 – 4.199)
Size ≤ 1cm 1 (reference) 0.016
> 1cm 2.552( 1.193 – 5.460)
SUVmax < 2.6 1 (reference) 0.316
≥ 2.6 1.488 (0.684 – 3.238)
Subtype Follicular variant 1 (reference) 0.114
Non follicular variant 4.469 (1.757 – 11.371)
→ SUVmax was not related to extrathyroidal ex-tension
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Results
LN metz. (-) (n=100, 51.5%)
LN metz. (+)(n=94, 48.5%) P-value
Extrathyroidal ext.
(+)22 (22.0%) 42 (44.7%) 0.001
Size > 1cm 25 (25.0%) 43 (45.7%) 0.002
Age ≥ 45 years 72 (72.0%) 39 (41.5%) <0.001
Female 81(81.0%) 73 (77.7%) 0.565
Multicenticity 45 (45.5%) 47 (50.0%) 0.527
SUVmax ≥ 2.9 38 (38.0%) 49 (52.1%) 0.048
Subtype(follicular) 20 (20.0%) 8 (8.5%) 0.023
Coexisting pathology 65 (65.0%) 57 (60.6%) 0.530
Cliniopathologic factors and lymph node metastasis by univariate analysis
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Variable Hazard ratio (95% CI) P value
ETE Absence 1 (reference) 0.011
Presence 2.503 ( 1.231 – 5.090)
Size ≤ 1cm 1 (reference) 0.081
> 1cm 1.972( 0.919 – 4.234)
Age < 45 years 0.245 (0.129 – 0.466) <0.001
≥ 45 years 1 (reference)
SUVmax < 2.9 1 (reference) 0.884
≥ 2.9 0.947 (0.455 – 1.971)
Subtype Follicular variant 1 (reference) 0.103
Non-follicular variant 2.255 (0.848 – 5.993)
Lymph node metastasis and clinicopathologic factors by mulivariate analysis
→ SUVmax was not related to lymph node metastasis
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Subtype
P value < 0.001
FDG 2.0 sensitivity 70.9% specificity 69.0 %
Relationship between Non-follicular subtype and SUVmax
ROC curve
1-specificity
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Results
Non follicular (n=165, 85.1%)
follicular(n=29, 14.9%) P-value
Extrathyroidal ex-tension 60 (36.1%) 4 (14.3%) 0.018
Lymph node metz. 86 (51.8) 9 (28.6%) 0.042
Size > 1cm 62 (37.3%) 6 (21.4%) 0.079
Age ≥ 45 years 94 (56.6%) 17 (60.7) 0.686
Female 133 (80.7%) 21 (71.4%) 0.261
Multicenticity 81 (49.1%) 12 (39.3%) 0.337
SUVmax ≥ 2.0 117 (70.9%) 9 (28.6%) <0.001
Coexisting pathology 107 (64.5%) 15 (53.6%) 0.270
Cliniopathologic factors and subtype of PTC by univariate analysis
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Non-follicular variant and clinicopathologic fac-tors
by mulivariate analysis
Variable Hazard ratio (95%
CI)P value
Extrathyroidal
extensionAbsence 1 (reference) 0.092
Presence2.690 (0.851 -
8.502)
Lymph node
metastasisAbsence 1 (reference) 0.141
Presence1.964 (0.800 –
4.820)
SUVmax of primary
lesion< 2.0 1 (reference) <0.001
≥ 2.05.044 (2.111 –
12.056)
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Conclusion
The usefulness of preoperative PET-CT for PTC was not yet certain.
PET positive results and SUVmax had no relation to signifi-cant clinical factors such as extrathyroidal extension and lymph node metastasis.
PET negative results or low SUVmax indicate the possibility of follicular variant subtype in papillar thyroid cancer.
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Thank you for your at-tention