Review article PET in the follow-up of differentiated thyroid cancer

Fluorine-18-fluorodeoxyglucose (FDG) PET has become an increasingly important functional imaging modality in clinical oncology. This article will focus primarily on the role of FDG PET during treatment and follow-up of thyroid cancer. The major role of FDG PET is in patients with elevated thyroglobulin (Tg) levels where thyroid cancer tissue does not concentrate radioiodine rendering false-negative results on I-131 scanning. FDG PET imaging takes advantage of the increased uptake of FDG in cancer cells and is sensitive (60-94%) to the detection of recurrent or metastatic cancer in patients who have negative radioiodine scans. The specificity (25-90%) of PET imaging is relatively less than its sensitivity because some inflammatory processes avidly accumulate FDG. PET can fail to localize the tumour sites in some patients with well-differentiated thyroid cancer that retain good iodine ability. This can result the well recognized phenomenon of ''flip-flop'' depending on the differentiation of the thyroid cancer. Several studies have documented the higher accuracy of PET, compared with other imaging modalities in the evaluation of patients with recurrent or metastatic differentiated thyroid cancer. The value of thyroid stimulating hormone stimulation for FDG PET has recently been reported. Therefore, if available, this method should be considered in all patients of differentiated thyroid cancer with suspected recurrence and/or metastasis. The four broad categories of primary thyroid cancer include (i) papillary carcinoma, (ii) follicular carcinoma, (iii) medullary carcinoma, and (iv) anaplastic thyroid carcinoma (1). Each of these morphologic patterns has its own distinctive biology and clinical significance. The dif- ferentiated thyroid carcinoma (DTC) consists of papillary and follicular carcinomas deriving from follicular cells of the thyroid. These tumours, representing the most com- mon type of thyroid cancers, can be cured with initial adequate surgical treatment and subsequent adjunctive therapy. However, tumour recurrence either involving the thyroid bed or the regional lymph nodes or both, can be associated with significant morbidity and even mortality (2). The prognosis of patients with recurrent or metastatic disease depends on the size and extent of tumour when detected (3). After primary treatment, patients are rou- tinely followed-up using serum thyroglobulin (Tg) mea- surement and conventional I-131/123 scintigraphy (4). An elevated serum Tg concentration is usually associated with abnormal I-131 scan findings in case of recurrent or