thyriod gland part 5 molecular nuclear imaging spect imaging dr ahmed esawy include different cases for oral radiodiagnosis examination all over the world CT /MRI Plain X ray ultrasound images INDICATIONS FOR PERFORMING ULTRASOUND-GUIDED FNA BIOPSY OF A THYROID NODULE GOITRE FOCAL/NODULAR MULTINODULAR UNINODULAR TOXIC NODULE INACTIVE COLD TOXIC NODULE TOXIC MULTINODULAR GIOTRE INACTIVE COLD DIFFUSE GIOTRE Hshimoto s thyroiditis Graves disease Subacute thyroiditis Suppurative thyroiditis Drug-induced thyroiditis Riedel s thyroiditis Iodine deficiency Organification defect Radiotion exposure pregnant ,menopause thyroiditis Silent thyrioditis/post partum thyroiditis Cold Thyroid Nodule  BENIGN TUMOR  Nonfunctioning adenoma  Cyst (11–20%)  Involutional nodule  Parathyroid tumor  INFLAMMATORY MASS  Focal thyroiditis  Granuloma  Abscess  MALIGNANT TUMOR  Carcinoma  Lymphoma  Metastasis  BENIGN NODULAR GIOTRE  NEOPLASM  Benign thyroid cysts (degenerated nodules)  Simple cyst  Haemorrhagic Cystic nodule in solid tumour  COLLIOD  Dominent colliod nodule in MNG  uninodular  Adenoma  macrofollicular (simple colliod)  microfollicular (fetal)  embryonal (trabecular)  hurthe cell adenoma  atypical adenoma  adenoma with papillae  signet ring adenoma  Inflammatory disorder  subacute thyrioditis  lymphocystic thyrioditis  granulomatous disease  (sarciodosis/TB)  abscess  developmental  dermiod  unilateral lobe agenesis  MALIGNANT NODULAR GIOTRE  MALIGNANT  Papillary carcinoma  Follicular carcinoma  Hurthle cell tumor  Medullary Thyroid Carcinoma  Anaplastic Carcinoma  Lymphoma of thyroid  HYPOTHYRIODISM  CONGENITAL  Hypoplasia & mal-descent  Agenesis ,hemiagenesis  Ectopia thyriod (sublingual thyriod)  Familial enzyme defects  Iodine deficiency (endemic cretinism)  Intake of goitrogens during pregnancy  Pituitary defects  Idiopathic  ACQUIRED  Iodine deficiency(diffuse giotre)  Hashimoto´s thyroiditis (autoimmune thyroiditis)  Subacute (De Quervein’s) thyroiditis  Thyroidectomy or RAI therapy  TSH or TRH deficiency  Medications (iodide & Cobalt,amiodarone))  Idiopathic  Post partum  amyliodosis  COMMON CAUSES OF HYPERTHYROIDISM  autoimmune diseases Graves disease (the most common cause of hyperthyroidism Lymphocytic thyroiditis With hyperthyroidism (silent thyroiditis) Postpartum thyrotoxicosis (PPT)  functioning thyroid adenomas (Hyperfunctioning thyroid nodules (toxic adenoma, toxic multinodular goiter, Plummer's disease)  Toxic multinodular goiter

1. Imaging inThyroid disorders
Molecular imaging
Radionuclide imaging
Isotope scanning
SPECT/CT
Dr Ahmed Esawy

2. Dr. Ahmed Eisawy
MBBS M.Sc MD
Dr Ahmed Esawy

3. Thyroid Scintigraphy:
Indications and contraindications
.Thyroid uptake is useful for:
1. Differentiating hyperthyroidism from other forms of
thyrotoxicosis (e.g., thyroiditis and thyrotoxicosis factitia).
2. Calculating iodine-131 administered activity for patients to be
treated for hyperthyroidism or ablative therapy.
.Whole-body imaging for thyroid carcinoma is useful for:
1. Determining the presence and location of residual functioning
thyroid tissue after surgery for thyroid cancer or after ablative
therapy with radioactive iodine.
2. Determining the presence and location of metastases from
iodine-avid forms of thyroid cancer.
Dr Ahmed Esawy

4. Contraindications toThyroid Scintigraphy :
Administration of iodine-131 sodium iodide to pregnant
or lactating patients (whether currently nursing or not) is
contraindicated.
Dr Ahmed Esawy

5. Evaluation of the Thyroid Disease
(Radioisotope Scanning)
 Prior to FNA, was the initial diagnostic procedure of
choice
 Performed with: technetium 99m pertechnetate or
radioactive iodine
 Technetium 99m pertechnetate
 cost-effective
 readily available
 short half-life
 trapped but not organified by the thyroid - cannot determine
functionality of a nodule
Dr Ahmed Esawy

6. Imaging in Pediatric Thyroid
disorders: Outline
Imaging modalities
• ACR-SNM-SPR guidelines for thyroid scintigraphy
Imaging in:
1. Congenital hypothyroidism
2.Thyrotoxicosis
3.Thyroid nodules
4. Radioiodine whole body scan in differentiated
thyroid cancers .
Dr Ahmed Esawy

7. Normal scan of thyroid gland
Dr Ahmed Esawy

8. Dr Ahmed Esawy

9. GIOTRE
DIFFUSE FOCAL/NODULAR
MULTINODULAR UNINODULAR
NON-TOXIC TOXIC
Structural / Anatomy
Functional /biochemical
Dr Ahmed Esawy

10. Dr Ahmed Esawy

11. palpable cold nodule in a patient with Graves disease
has a high likelihood of malignancy (4%)
 mnemonic: CATCH LAMP
 Colloid cyst
 Adenoma (most common)
 Thyroiditis
 Carcinoma
 Hematoma
 Lymphoma, Lymph node
 Abscess
 Metastasis (kidney, breast)
 Parathyroid
 Probability of a cold nodule to represent thyroid cancer:
Dr Ahmed Esawy

12. Graves Disease
 24/M
 (+) thyrotoxic symptoms
 131I thyroid scan &
uptake
 Diffuse thyromegaly
 Elevated RAI uptake
values
Dr Ahmed Esawy

13. Diffuse Toxic Goiter
 30/F
 Palpitations, excessive
sweating, irritability,
anterior neck enlargement
 99mTcO4 thyroid scan
 Diffuse thyromegaly
 Scintigraphic evidence of
increased gland uptake
function
 38 sec acquisition time
 Reduced background tracer
activity
Dr Ahmed Esawy

14. Graves’ disease
Dr Ahmed Esawy

15. Graves – Basedow disease
Dr Ahmed Esawy

16. Dr Ahmed Esawy

17. Congenital hypothyroidism:
Scintigraphy
Dr Ahmed Esawy

18. Congenital hypothyroidism:
Dyshormonogenesis
Dr Ahmed Esawy

19. 10-day-old girl with
sublingual thyroid
gland..
Dr Ahmed Esawy

20.  Ultrasound: Less sensitive in detecting
ectopic thyroid (although has high specificity)
NM thyroid scintigraphy :Tc 99m
pertechnetate or I -123
Dr Ahmed Esawy

21.  Preclinical stage: Scintigraphy may show
increased uptake
• Difficult to distinguish Hashitoxicosis from
Graves disease by US or scintigraphy.
Dr Ahmed Esawy

22. 14-day-old girl with thyroid agenesis.
Dr Ahmed Esawy

23. 7-day-old boy with thyroid hemiagenesis.
Dr Ahmed Esawy

24. 20-day-old girl with hemiagenesis and sublingual thyroid.
Dr Ahmed Esawy

25. 9-day-old boy with thyroid gland in normal location.
Dr Ahmed Esawy

26. Hashitoxicosis
Dr Ahmed Esawy

27. Graves disease / Hashimotos
thyroiditis
Thyroid
inferno Graves disease: 4 hour uptake of 40%Dr Ahmed Esawy

28. Subacute Thyroiditis
 30/M
 Hyperthyroid
symptoms
 131I thyroid scan
 Thyroid not
visualized
 Only background
radioactivity
Dr Ahmed Esawy

29. Iodine-131 radionuclide scan shows virtually
no uptake of radioactive iodine by the thyroid
gland.
Dr Ahmed Esawy

30. NODULAR GIOTRE
UNINODULAR
MULTINODULAR
MNG
INACTIVE
COLD
TOXIC NODULE
TOXIC NODULE
TOXIC MULTINODULAR GIOTRE INACTIVE
COLD
MALIGNANT BENIGN
Dr Ahmed Esawy

31. NODULAR GIOTRE
BENIGN
ADENOMA
NEOPLASM
COLLIOD
Cyst
Complex cyst
Focal thyrioditis
MALIGNANT
As function: biochemical
- hot (toxic)
- cold (N :TSH)
cold nodule in a toxic thyroid (as may occur in
Grave’s disease)Dr Ahmed Esawy

32. Cold Thyroid Nodule
 BENIGNTUMOR
 Nonfunctioning adenoma
 Cyst (20%)
 Involutional nodule
 Parathyroid tumor
 INFLAMMATORY MASS
 Focal thyroiditis
 Granuloma
 Abscess
 MALIGNANTTUMOR
 Carcinoma
 Lymphoma
 Metastasis
Dr Ahmed Esawy

33. “Cold” nodule = focal defect
Dr Ahmed Esawy

34. Cold nodule, R lobe (99mTcO4)
Dr Ahmed Esawy

35. Dr Ahmed Esawy

36. Adenomatous nodule in a 66-year-old man with a low thyroid-stimulating hormone level of 0.1
mIU/mL. (a) Transverse US image shows a predominantly solid 2.4-cm nodule with well-
circumscribed margins and a surrounding halo (benign US features). (b) Scintigraphic image
obtained with 123I shows increased uptake in a hot nodule and relative photopenia of the
adjacent normal thyroid tissue.The outline of the neck is not well visualized.
Dr Ahmed Esawy

37. Autonomous functioning
thyroid adenoma
Dr Ahmed Esawy

38. Thyroid nodules. CT scan shows a mass
in the posterior mediastinum (P),
which displaces the air-filled
esophagus to the right (arrow)
Thyroid nodules. Iodine-123 thyroid scan shows that
a mass is a multinodular goiter (G).The posterior
mediastinal mass is a hiatus hernia (H); the stomach
(S) is shown. Further investigation revealed that
thyrotoxicosis was the cause of the patient's
symptoms
Dr Ahmed Esawy

39. Dr Ahmed Esawy

40. Autonomous adenoma
Initial scan - euthyreosis Repeat scan - hyperhyreosisDr Ahmed Esawy

41.  Cold nodule
Dr Ahmed Esawy

42. SPECT/CT
 Improved detection and localization of
disease (superior to SPECT alone)
 In radionuclide therapy, provides more
insight into the effectiveness of targeting and
may explain the observed response
Dr Ahmed Esawy

43. Thyroid SPECT Agents
 99mTcO4
 99mTc sestamibi
 99mTc tetrofosmi
 201TlCl
 123I
 131I
Dr Ahmed Esawy

44. 18FDG PET/CT
 Well-established usefulness inWDTC ifTg (+)
and WBS (–)
 Helpful in anaplastic/medullary thyroid
cancer
 May be complimented by PET studies using
68Ga-DOTATOC and 18F-DOPA when looking
for recurrent disease
Dr Ahmed Esawy

45. 131I SPECT/CT
 131I SPECT-CT is more accurate than 18FDG
PET-CT in well-differentiated thyroid cancer
 regional and distant metastasis
 residual/recurrent disease
 The most important advantage of fusion 18FDG
PET-CT and 131I SPECT-CT is detection of
metastasis in normal sized lymph nodes.
Dr Ahmed Esawy

46. Indications of PET/CT
 residual or recurrent thyroid cancerWHEN
elevatedTg + RAI scan (–)
 When localized, may require surgery or
radiotherapy
 Extent of poorly differentiatedTCAs &
invasive Hurthle cell Cas
 Treatment response following systemic or
local therapy
Dr Ahmed Esawy

47. BNMS Guidelines on TCA
 Assessment of patients with elevated
thyroglobulin levels and negative iodine
scintigraphy with suspected recurrent disease.
 To evaluate disease in treated medullary thyroid
carcinoma associated with elevated calcitonin
levels with equivocal or normal cross-sectional
imaging, bone and octreotide scintigraphy - for
alternative PET imaging with 68Ga- DOTA-
octreotate (DOTATATE), DOTA-1-NaI3-
octreotide (DOTANOC) or DOTA- octreotide
(DOTATOC).
Dr Ahmed Esawy

48. 131I SPECT/CT
Dr Ahmed Esawy

49. Thyroid cancer TCA with mets
Dr Ahmed Esawy

50. Dr Ahmed Esawy

51. 99mTc sestamibi-Parathyroid
Dr Ahmed Esawy

52. Medullary Thyroid Carcinoma
Dr Ahmed Esawy

53. Dr Ahmed Esawy

54. Whole body 131I Scintigraphy
78/M, (+) 13-year FU, (+) risingTg up to 1447 µg/L
Dr Ahmed Esawy

55. PET in TCA with increasing
TG, negative TBS
Dr Ahmed Esawy

56. Dr Ahmed Esawy

57. Metastatic PTCA
Dr Ahmed Esawy

58. Metastatic PTCA
Dr Ahmed Esawy

59. 131IWBS (–)
18FDG PET (–)
↑↑Tg (56000 µg/L)
Dr Ahmed Esawy

60. 68Ga DOTA-TATE PET/CT SCAN
Dr Ahmed Esawy

61. 68Ga DOTA-TATE PET/CT SCAN
 Somatostatin receptor
expression in thyroid
CA
 Patients with positive
studies may be treated
with Peptide Receptor
RadionuclideTherapy
(PRRT)
 117Lu DOTA-TATE
 90Y DOTA-TATE
Dr Ahmed Esawy

62. 18FDG Scan in Medullary TCA
 Intense FDG uptake
in a hypodense
nodule, L thyroid
lobe
 Serum Calcitonin:
800
 Final Diagnosis:
MedullaryTCA
PET only CT Only
PET-CT Fusion
Dr Ahmed Esawy

63. Other findings in PET
 ↑FDG uptake in thyroid nodule as part of
whole body study for cancer imaging =
moderately high risk of malignancy
 Require further evaluation
 Differentials = Graves' disease & thyroiditis
 Otherwise, thyroid gland should be normal in
PET
Dr Ahmed Esawy

64. Diffuse 18FDG uptake (benign)
Dr Ahmed Esawy

65. Advantages of PET/CT
 Can detect significantly more tumor sites
 Only imaging modality that can screen for
malignancy in multiple organs at once
 Can lead to more appropriate clinical
management
Dr Ahmed Esawy

66. Other uses of 18FDG PET
 Indeterminate thyroid nodules (3 cases)
 Calcitonin-positive medullaryTCA
 18F-DOPA is superior to 18FDG for this
 One case was negative on 18FDG
 Anaplastic thyroid cancer
 Insular thyroid carcinoma
Dr Ahmed Esawy

67. Summary of 18FDG PET Impact
on Thyroid Cancer Management
 Determination of definitive therapy for RAI
scan (–)WDTCA with elevatedTg
 Evaluation of aggressive and difficult-to-treat
TCA and poorly differentiatedTCA
 Discrimination of malignancy from thyroiditis
in questionable thyroid nodules
Dr Ahmed Esawy

68. Greatest impact of PET/CT
 ForWDTCA whose I-131 WBS is negative with
increasing thyroglobulin but positive in PET
as therapy is more definitive
 For aggressive and difficult to treatTCA and
undifferentiatedTCA
 For questionable thyroid nodules
differentiating malignancy and thyroiditis
Dr Ahmed Esawy

69. Interesting Case
CT (L) & fused PET/CT (R) in 56 y/o woman with lung cancer. Focal FDG uptake in R
thyroid lobe with low CT attenuation (76 HU). PTCA on histopath.
Dr Ahmed Esawy

70. Interesting Case
CT (L) & fused PET/CT (R) in 65 y/o man with esophageal cancer. Focal FDG uptake in L
thyroid lobe with very low CT attenuation (3.6 HU). Diffusely increased FDG uptake in
surrounding gland tissue. Follicular adenoma with lymphocytic thyroiditis on
histopath.
Dr Ahmed Esawy

71. Interesting Case
 63/M with PTCA, s/p thyroidectomy, RAI
therapy, thoracotomy, and radiotherapy
 Neck MRI = L anterior neck nodule suspicious
for recurrence
 (+) pulmonary nodules on CT
 Biopsy of thyroid & lung nodules = not
malignant
 (+) RAI-avid right cervical lesion with elevated
Tg
Dr Ahmed Esawy

72. Interesting Case
Calcified hypermetabolic R paratracheal node, multiple bilateral hypermetabolic non-
calcified pulmonary nodules, multiple cervical, hilar and substernal nodes, and
hypermetabolic lesions in a left rib and sternum, suspicious for metastases.
Dr Ahmed Esawy

73. Interesting Case
 65/F with PTCA, s/p thyroidectomy & multiple
RAI therapies (cumulative dose = 1150 mCi)
 elevatedTg at >800
 (+) nodules in both lungs and left adrenal
 (+) R lung base RAI-avid lesion on post-
therapy whole body scan
Dr Ahmed Esawy

74. Interesting Case
Hypermetabolic right lung base mass corresponding to RAI-avid R lung base lesion
seen on post-therapy scan, consistent with persistent metastatic thyroid cancer.
Dr Ahmed Esawy

75. Interesting Case
 67/F with PTCA, s/p thyroidectomy, L radical
neck dissection, multiple RAI therapies &
gamma knife treatment
 elevatedTg, (–) RAI whole body scan
 (+) nodules in both lungs and left adrenal
 (+) R lung base RAI-avid lesion on post-
therapy whole body scan
 CT showed possible recurrence in L thyroid
bed
Dr Ahmed Esawy

76. Interesting Case
FDG-avid right cavernous sinus mass involving the petrous part of
the temporal bone is most likely metastatic in nature.
Dr Ahmed Esawy

77. Interesting Case
Hypermetabolic lesions/masses in the left neck extending to the thoracic inlet
specifically to the left thyroid bed with hypermetabolic bilateral cervical
lymphadenopathies are consistent with recurrent metastatic disease.
Dr Ahmed Esawy

78. Interesting Case
Hypermetabolic osseous metastases in the cervico
thoracic spine.
Dr Ahmed Esawy

79. Interesting Case
 77/M with insularTCA, s/p thyroidectomy
 L thyroid nodule and lung nodules on pre-op
CT
 Post-op PET was requested for evaluation of
disease extent
Dr Ahmed Esawy

80. Interesting Case
Hypermetabolic lesion in the left thyroid bed may be inflammatory
but residual disease cannot be ruled out.
Dr Ahmed Esawy

81. Interesting Case
Hypermetabolic R hilar nodes. Differentials include inflammatory
reaction vs. metastases.
Dr Ahmed Esawy

82. TCA Staging
Dr Ahmed Esawy

83. TCA Follow-up & Monitoring
Dr Ahmed Esawy

84. Conclusions
 Ultrasound and thyroid scans are still the
mainstay in imaging the thyroid gland
 CT and MRI have limited values and can be
utilized in identifying lymph nodes, local
tumor extension, diff. thyroiditis and as FNA
guide
 PET/CT is best forWDTCA that have
dedifferentiated hence negative on I-131-
WBS but increasing thyroglobulin as well as
in aggressive and difficult cases ofTCA and
certain suspicious nodules by FNAB
Dr Ahmed Esawy

85. Thanks you so much!
Dr Ahmed Esawy