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1、核医学在甲状腺癌诊断中的临床应用,内容,甲状腺癌的诊断及鉴别诊断 甲状腺癌治疗后复发、转移的监测 甲状腺偶发瘤的检出,甲状腺癌的诊断及鉴别诊断,甲状腺结节发病率高 触诊：3%8% 高分辨率B超：20%30%，甚至可达50% 甲状腺癌发病率不断升高 1/100000-男性 2.6/100000女性 女性恶性肿瘤第七位 约80%为乳头状癌 早期发现、预后较好,手术治疗,可明确诊断 手术治疗的并发症 术后呼吸困难和窒息 喉返、喉上神经损伤 甲状旁腺功能减退 甲状腺危象 未经选择的手术治疗存在风险,甲状腺结节的鉴别诊断,触诊 B超 CT MRI FNA 单光子核素显像（SPECT） 正电子核素显像（P
2、ET）,触诊,灵敏度最差 操作者手法、经验,B超,无创价廉、性价比高 灵敏度高、适合初筛 任一恶性特征诊断（ 灵敏度83.3%，特异性74.0% ，准确率78.0%） 恶性特征（灵敏度、特异性），P0.05： 形状（40.0%，91.4%） 边缘毛刺（ 48.3%，91.4% ） 显著低回声（ 41.4%，92.2% ） 微小钙化（ 44.2%，90.8% ） 巨大钙化（ 9.7%，96.1% ） 良性特征（灵敏度、特异性），P0.01： 等回声（56.6%，88.1%） 海绵状（ 10.4%，99.7% ） 操作者手法,Moon WJ, Jung SL, Lee JH, et al. Ben
3、ign and malignant thyroid nodules: US differentiation-multicenter retrospective study. Radiology. 2008;247(3):762-770.,CT,价值有限 灵敏度78.6%（CT）vs 85.7%（B超） 进展期病例的诊断价值高于B超,Ishigaki S, Shimamoto K, Satake H, et al. Multi-slice CT of thyroid nodules: comparison with ultrasonography.Radiat Med. 2004 Sep-Oct
4、;22(5):346-353.,腺瘤,侵犯气管,MRI,报道较少 MR弥散加权 灵敏度：97.5% 特异性：91.7% 准确率：98.9%,Razek AA, Sadek AG, Kombar OR, et al. Role of apparent diffusion coefficient values in differentiation between malignant and benign solitary thyroid nodules. AJNR Am J Neuroradiol. 2008 Mar;29(3):563-8.,腺瘤,乳头状癌,囊肿,FNA,有创操作 并发症：出血、
5、血肿 继发感染；虚脱或晕厥等 灵敏度存在争议 不同学者研究差异大 Tee等综合统计后仅66% 漏诊恶性病变1/3 FNA阴性者需长期随访,Tee YY, Lowe AJ, Brand CA, et al. Fine-needle aspiration may miss a third of all malignancy in palpable thyroid nodules: a comprehensive literature review.Ann Surg. 2007;246(5):714-720.,FNA,Layfield LJ, Cibas ES, Gharib H, et al. T
6、hyroid aspiration cytology: current status. CA Cancer J Clin. 2009;59(2):99-110.,单光子核素显像,99mTc甲状腺结节功能、良恶性筛查 123I、131I分化型甲状腺癌转移灶寻找 201Tl未分化甲状腺癌转移灶寻找 99mTc（V）-DMSA髓样癌 111In-Octreotide髓样癌 99mTc-MIBI 99mTc-tetrofosmin,Sisson JC. Thyroid. Selection of the optimal scanning agent for thyroid cancer.1997;7(
7、2):295-302.,99mTcO4-显像,123I和131I显像,A 23-year-old patient with thyroid papillary carcinoma and multiple metastatic lesions to the lungs was examined with both 123I and 131I. More lesions are seen on the 123I scans (a) because of the superior spatial resolution of the images generated with this radiot
8、racer compared to that of the post-therapy 131I scans (b),Eur J Nucl Med Mol Imaging. 2007 Jul;34(7):1012-7.,201Tl显像,Nucl Med Commun. 2007 Sep;28(9):681-7.,99mTc-DMSA显像,Tc-99m DMSA (V) scan shows neck and superior mediastinal metastases in a patient with elevated postoperative serum calcitonin.,Sing
9、apore Med J. 2008 Jan;49(1):19-22.,111In-DTPA-Octreotide显像,111In-DTPA-octreotide anterior scintigraphy of the lung in a 58-y-old man with metastatic MTC; pre-treatment A and post-treatment B with 90Y-DOTATOC, reveals that the number of lesions and tracer accumulation in the metastatic lesion are mai
10、nly unchanged,J Cancer Res Clin Oncol. 2004 Nov;130(11):649-56.,2,Fig. 1 Anterior view of 99mTc-methoxyisobutyl isonitrile (MIBI) (a) and 131I (b) scans, both showing thyroid remnants (white and blue arrows). The patient had undergone near-total throidectomy for papillary thyroid cancer. Thyreoglobu
11、lin value was 19.7 ng/ml. MIBI scan showed mild uptake in the thyroid bed. 131I scan confirmed the presence of thyroid remnants.,99mTc-MIBI显像,Nucl Med Commun. 2010 Apr;31(4):274-9.,2,Fig. 2 Anterior view of 99mTc-methoxyisobutyl isonitrile (MIBI) (a) and 131I (b) scans in a patient who had previousl
12、y undergone near-total thyroidectomy for follicular thyroid cancer (thyreoglobulin: 2334 ng/ml). MIBI images showed abnormal uptake in the upper mediastinum (red arrows). 131I scan (b) was positive, and confirmed the presence of metastatic foci (red arrows). In this case, MIBI scan (a) revealed no a
13、rea of focal tracer uptake in the thyroid bed, whereas 131I scan (b) showed residual thyroid uptake (blue arrow).,99mTc-MIBI显像,2,99mTc-tetrofosmin显像,(a) 99mTc-Tetrofosmin scan in a patient with a solitary cold nodule in the right lobe of the thyroid, showing avid tracer concentration at 30 min (left
14、-hand image). Delayed images at 120 min show persistence of radiotracer in the region of the thyroid nodule (right-hand image). The 120/30 min radio uptake ratio was 1.24. After surgery, the histopathological report was consistent with a papillary carcinoma of the thyroid. (b) Transverse color Doppl
15、er image of the nodule illustrated in (a), showing an extensive increase in the internal central vascular flow.,Nucl Med Commun. 2007 Nov;28(11):847-51.,2,Fig. 2 (a) 99mTc-Tetrofosmin scan in a patient with a cold nodule in the left lobe of the thyroid, showing tracer concentration at 30 min (left-h
16、and image). Delayed images at 120 min show significant washout from the thyroid nodule (right-hand image). The 120/30 min radio uptake ratio was 0.34. The histopathology reported a colloid goiter. (b) Transverse color Doppler image of the nodule illustrated in (a), showing increased vascular flow along the periphery of the nodule.,99mTc-tetrofosmin显像,PET/CT分子影像诊断地位,PET/CT 灵敏度高、特异性强、定位精确 正电子标记药物 18F-脱氧葡萄糖（FDG）是目前PET/CT最常用的药物，它能显示有 氧酵解增强的肿瘤并用于疗效和预后分析。 早期研究表明其对甲状腺结节鉴别诊断价值有限 灵敏度 58% 特异性100% 准确率73% SUVmax: 正常腺体 1.00.2 腺瘤 2.1 0.4 乳头状癌 4.73.2 滤泡状癌 4.6 2.9 甲状腺癌术后随访,
