Diagnostic Performance of [18F]TFB PET/CT Compared with Therapeutic Activity [131I]Iodine SPECT/CT and [18F]FDG PET/CT in Recurrent Differentiated Thyroid Carcinoma

David Ventura; Matthias Dittmann; Florian Büther; Michael Schäfers; Kambiz Rahbar; Daniel Hescheler; Michael Claesener; Philipp Schindler; Burkhard Riemann; Robert Seifert; Wolfgang Roll

doi:10.2967/jnumed.123.266513

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FIGURE 1.
Heterogeneous disease pattern. 71-y-old man with follicular thyroid carcinoma and various bone metastases. Rib metastases show heterogeneous disease pattern: intense [¹⁸F]TFB (A) and [¹³¹I]iodine (B) uptake but low [¹⁸F]FDG (C) uptake (green arrow); intense [¹⁸F]FDG (C) uptake but no relevant [¹⁸F]TFB (A) and [¹³¹I]iodine (B) uptake (red arrows).
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FIGURE 2.
False-positive thymus uptake in [¹³¹I]iodine SPECT/CT. 49-y-old woman with follicular thyroid cancer. Absent [¹⁸F]TFB uptake (A) in [¹³¹I]iodine-positive (B) mediastinal mass (red arrow). Subsequent contrast-enhanced MRI showed thymus rebound (green arrow) in T1-weighted (after gadolinium) (T1w post GD) and T2-weighted (T2w) (C and D) sequences. [¹³¹I]iodine uptake therefore was considered to be false-positive, a conclusion that was also confirmed by further follow-up.
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FIGURE 3.
False-positive low mediastinal mass in [¹³¹I]iodine SPECT/CT. 67-y-old woman with papillary thyroid cancer. Intense [¹³¹I]iodine uptake in low mediastinal mass (red arrow, A) with absent uptake of [¹⁸F]TFB (green arrow, B) and [¹⁸F]FDG (blue arrow, C). CT scan revealed probably benign hypodense lesion. Histologic confirmation was recommended due to intense [¹³¹I]iodine uptake. Samples were obtained by endobronchial ultrasound-guided transbronchial needle aspiration, which revealed benign soft-tissue cells, suggesting hemorrhagic cyst. Additionally, [¹⁸F]FDG-positive (black arrow) and [¹⁸F]TFB/[¹³¹I]iodine–negative mediastinal lymph node metastases were visualized by maximum-intensity-projection imaging.
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FIGURE 4.
Lesion [¹⁸F]TFB vs. [¹⁸F]FDG uptake. 70-y-old man with follicular thyroid carcinoma and singular bone metastasis in left ilium. Dedifferentiation was demonstrated with low [¹⁸F]TFB uptake (A) and intense [¹⁸F]FDG uptake (B). 75-y-old woman with follicular thyroid carcinoma and singular differentiated bone metastasis in left-side sacrum. High NIS expression was demonstrated with intense [¹⁸F]TFB uptake (C) and low [¹⁸F]FDG uptake (D). (E) Inverse Pearson correlation representing significant inverse relationship between NIS expression (differentiation) and glucose consumption ([¹⁸F]FDG) in lesion SUV_max of [¹⁸F]TFB and [¹⁸F]FDG.

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TABLE 1.

Patient Characteristics

Characteristic	n	%	Median	Range	95% CI
Patients^*	26
Sex
Women	12	46.2
Men	14	53.8
Histology
PTC	11	42.3
FTC	13	50
OTC	2	7.7
UICC TNM (33)
pT1	4	15.4
pT2	7	27
pT3	9	34.6
pT4	3	11.5
pTx	3	11.5
pN0	5	19.2
pN1	7	27
pNx	14	53.8
cM0	5	19.2
cM1	16	61.5
cMx	5	19.2
PUL	5	19.2
OSS	7	27
OTH	4	15.4
Laboratory analysis
TG^† (ng/mL)			10.1	0.15–10,807
Anti-TG^† (IU/mL)			17.2	<15–230
TSH (μU/mL)			0.1	0.02–2.36
TSH after stimulation (μU/mL)			122	51.8–424.1
TG after stimulation (ng/mL)			61.9	0.46–21,200
8 wk after RAI
TG^†			6.7	0.15–10,780
Anti-TG^†			15.6	<15–238
RAI and PET/CT
GBq of [¹³¹I]iodine			6,023		5,032–6,497
MBq of [¹⁸F]TFB			321		297–342
MBq of [¹⁸F]FDG			326		270–317

↵* Median age was 64.5 y, and range was 38–87.
↵† If measurable.
PTC = papillary thyroid carcinoma; FTC = follicular thyroid carcinoma; OTC = oncocytic carcinoma of thyroid; PUL = pulmonary metastases; OSS = bone metastases; OTH = other-side metastases; anti-TG = antibodies against thyroglobulin.

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TABLE 2.

Findings Per Patient

Patient identification	Finding	[¹⁸F]TFB	[¹³¹I]iodine TxWBS- SPECT/CT	[¹⁸F]FDG	Dominant tumor burden
1	Cervical and mediastinal lymph nodes	N	P	P	[¹⁸F]FDG
2	Lung nodules	N	N	N	N/A
3	Bone lesions and lung nodules	P	N	P	[¹⁸F]FDG
4	N/A	N	N	N	N/A
5	Lung nodules	N	N	P	[¹⁸F]FDG
6	Glottis and cervical lymph nodes	P	P	N	[¹⁸F]TFB/[¹³¹I]iodine
7	Local recurrence	P	N	P	[¹⁸F]TFB
8	High mediastinal lymph nodes and low mediastinal mass	N	fP^*	P	[¹⁸F]FDG
9	Lung nodules	N	N	N	N/A
10	Local recurrence on right	P	P	N	[¹⁸F]TFB/[¹³¹I]iodine
11	Lung nodules	P	P	N	[¹⁸F]TFB/[¹³¹I]iodine
12	Lung nodules and inflammation	N	fP^†	N	N/A
13	Lung nodules	P	P	P	[¹⁸F]FDG
14	Bone lesions	P	P	P	[¹⁸F]FDG
15	Local recurrence on right and bone lesions	P	P	N	[¹⁸F]TFB/[¹³¹I]iodine
16	N/A	N	N	N	N/A
17	Lung nodules and bone lesions	N	P	P	[¹⁸F]FDG
18	Bone lesions	P	P	N	[¹⁸F]TFB/[¹³¹I]iodine
19	Bone lesions	P	P	N	[¹⁸F]TFB
20	Lung lesions and soft-tissue lesion	N	P	P	[¹³¹I]iodine
21	N/A	N	N	N	N/A
22	N/A	N	N	N	N/A
23	N/A	N	N	N/A	N/A
24	Thymus and cervical lymph nodes	N	fP^‡	P	[¹⁸F]FDG
25	Bone lesions	P	P	P	[¹⁸F]TFB/[¹³¹I]iodine
26	N/A	N	N	N	N/A

↵* Histologic verification: no malignancy was found in [¹³¹I]iodine-positive low mediastinal mass.
↵† Primary pulmonary inflammation due to chronic obstructive pulmonary disease.
↵‡ Follow-up: [¹³¹I]iodine accumulation in projection onto thymus, verification by MRI.
N = negative; P = positive; N/A = not available; fP = false-positive.
[¹³¹I]iodine-positive mismatch detailed patient analysis: patient 1—predominantly [¹⁸F]FDG-positive (SUV_max, 8.3) tumor burden with low [¹³¹I]iodine uptake in solitary mediastinal lymph node metastases; patient 17—predominantly [¹⁸F]FDG-positive (SUV_max, 15.8) tumor burden with low [¹³¹I]iodine uptake in solitary lung and bone metastases; patient 20—predominantly [¹⁸F]FDG-positive (SUV_max, 5.2) tumor burden with intermediate [¹³¹I]iodine uptake in solitary soft-tissue metastasis.