Complementary Roles of 18F-DOPA PET/CT and 18F-FDG PET/CT in Medullary Thyroid Cancer

Saila Kauhanen; Camilla Schalin-Jäntti; Marko Seppänen; Sami Kajander; Sami Virtanen; Jukka Schildt; Irina Lisinen; Aapo Ahonen; Ilkka Heiskanen; Mika Väisänen; Johanna Arola; Pirkko Korsoff; Tapani Ebeling; Timo Sane; Heikki Minn; Matti J. Välimäki; Pirjo Nuutila

doi:10.2967/jnumed.111.094771

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FIGURE 1.
Patient flow chart.
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FIGURE 2.
(A) Calcitonin and CEA correlation for number of lesions detected on ¹⁸F-DOPA PET/CT. (B) Calcitonin and CEA correlation for number of lesions detected on ¹⁸F-FDG PET/CT.
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FIGURE 3.
(A) CEA and calcitonin doubling time (mo) for number of lesions detected on ¹⁸F-FDG PET/CT. (B) CEA and calcitonin doubling time (mo) for number of lesions detected on ¹⁸F-DOPA PET/CT. Ct = calcitonin.
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FIGURE 4.
Total number of lesions detected using different imaging techniques in stable (0) and unstable (1) tumor marker groups. Ct = calcitonin.
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FIGURE 5.
61-y-old woman (patient 11) with occult MTC and calcitonin level of 44.8 pmol/L 9 y after primary therapy. Imaging with MDCT (A) and MRI (B) was negative. ¹⁸F-DOPA PET/CT (C) demonstrated increased uptake of ¹⁸F-DOPA in neck. ¹⁸F-FDG PET/CT (D) was negative. Lesion was surgically removed; histology was compatible with lymph node metastasis, and Ki-67 was 5% (E).
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FIGURE 6.
56-y-old man (patient 10) with aggressive MTC and high primary tumor Ki-67 of 30%. Two years after primary treatment, calcitonin level was 1,598 pmol/L and CEA 460 μg/L, with unstable calcitonin and CEA doubling time (10 mo). ¹⁸F-FDG PET/CT demonstrated disseminated disease (A, several lesions in liver, skeleton, neck, and paraaortal region), but ¹⁸F-DOPA PET/CT was negative (B). MDCT (C) and MRI (D) showed lesions in liver, skeleton, and neck. Patient died 3 mo after imaging.

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TABLE 1

Comparison of Different Imaging Methods, Calcitonin and CEA Doubling Time, and Ki-67 Expression

	Ki-67 (%) in primary operation (primary tumor/metastasis)	Number of lesions				Doubling time (mo)
Patient no.	Ki-67 (%) in primary operation (primary tumor/metastasis)	¹⁸F-DOPA PET/CT	¹⁸F-FDG PET/CT	MDCT	MRI	Calcitonin	CEA	Ki-67(%) in recurrence	Histologic verification or follow-up
1	1	0	0	0	0	8.3	61.7	5^*	F-U: 37 mo^{^†}
2	10	1	1	1	1	4.3	9.3	15	H: metastasis in neck (20 mm)
3	1	1	1	0	0	31.4	51.0	2	H: metastasis (6 mm)
4	5	4^‡	4^‡	2^‡	>10^‡	24.3	171.0	5	H: resection of rib, neck dissection, biopsy of liver
5	2	0	2 FP	2 FP	1 FP	76.0	122.0	—	H: benign neck lymph node
6	2	6	2 (+1 FP)	2	5	42.0	28.7	30	H: metastasis (10 mm)
7	2	1	1	1	1	28.3	67.0	5	H: metastasis (19 mm)
8	1	1	0	0	3 FP	28.3	NA	—	H: parathyroid adenoma and benign neck lymph node
9	2	>10	1	>10	>10	16.0	NA	—	F-U: exitus, no H
10	30/30	0	>10	>10	>10	10.8	13.7	—	F-U: exitus, no H
11	2	1	0	0	0	54.9	122.0	5	H: metastasis
12	5	0	0	0	0	239.5	190.0	—	F-U: 17 mo
13	5	0	0	0	1 FP	8.2	8.5	—	H: benign neck lymph node
14	20/5	10	8	8	8	14.7	84.0	—	F-U: no H, 11 mo
15	2/2	0	0	0	ND^§	27.4	98.5	—	F-U: 11 mo
16	2	0	0	0	ND^║	154.4	180.0	—	F-U: 9 mo
17	2	5^¶	10^¶	7	8	25.1	40.8	—	F-U: H only from pheochromocytoma
18	60/60	>10	10	7	>10	0.35	2.10	60	H: metastasis (30 mm)
19	5	3	0	0	7	19.5	NA	5	H: metastasis (7 mm)

↵* Metastatic lesion in neck detected after 37 mo of follow-up.
↵† Neck metastasis detected at end of follow-up (37 mo) and operated on.
↵‡ Lesions were detected in different regions.
↵§ Due to claustrophobia.
↵║ Due to metallic foreign body.
↵¶ Both ¹⁸F-DOPA and ¹⁸F-FDG PET/CT showed pheochromocytoma.
F-U = follow-up; H = histologic verification; FP = false-positive; NA = not applicable; ND = not determined.