The Role of 18F-FDOPA PET/CT in Recurrent Medullary Thyroid Cancer Patients with Elevated Serum Calcitonin Levels

Abstract

Objectives: To evaluate the diagnostic performance of ¹⁸F-dihydroxyphenylalanine (FDOPA) positron emission tomography/computed tomography (PET/CT) in the detection of medullary thyroid carcinoma (MTC) recurrence in patients with elevated calcitonin levels.

Methods: The patients who had undergone ¹⁸F-FDOPA PET/CT imaging for elevated calcitonin levels after primary surgery of MTC were included in the study. addition, if available ¹⁸F-fluorodeoxyglucose (FDG) PET/CT and Gallium-68 (⁶⁸Ga)- DOTATATE PET/CT images of the patients were evaluated retrospectively. The sensitivity and diagnostic performance of ¹⁸F-DOPA PET/CT were investigated.

Results: A total of 14 patients (9 F and 5 M; median age: 45) were included in the analysis. Three patients had MEN IIA syndrome and 1 patient had MEN IIB syndrome, 10 patients had a diagnosis of sporadic MTC. Median calcitonin levels of the patients were calculated as 757.5 (min-max: 28.5-7911) pg/mL. Nine patients and 5 patients had undergone ultrasound and contrast-enhanced computed tomography (ceCT) of the neck, respectively, before ¹⁸F-FDOPA PET/CT imaging. ¹⁸F-FDOPA PET/CT revealed pathological uptake in the thyroid bed, lymph nodes, and distant organs in three, five and two patients, respectively. Median maximum standardized uptake value for the recurrent or metastatic lesions were calculated as 6.4 (min-max: 1.9-18.4). The sensitivity of ¹⁸F-FDOPA PET/CT in the detection of recurrent disease was calculated as 64%. Eight patients had ⁶⁸Ga-DOTATATE PET/CT and 7 of them had ¹⁸F-FDG PET/CT within 3 months period before ¹⁸F-FDOPA PET/CT. ¹⁸F-FDOPA PET/CT revealed recurrent disease in 4 of 5 and 2 of the 5 patients who had negative ¹⁸F-FDG PET/CT and negative ⁶⁸Ga- DOTATATE PET/CT, respectively.

Conclusion: ¹⁸F-FDOPA PET/CT can detect recurrence in about two- thirds of patients with elevated calcitonin levels after primary surgery for MTC. Due to variable differentiation degree, different receptor status, and clinical behavior of MTC, all three radiopharmaceuticals can be beneficial and are complementary to each other in patient management.

Keywords: Medullary thyroid cancer; PET/CT; 18F-FDOPA; calcitonin.

Figure 1

⁶⁸Ga- DOTATATE and ¹⁸F-FDOPA PET/CT images of patient number 5. Forty-five years old female diagnosed with MEN IIA syndrome (medullary thyroid carcinoma and adrenal paraganglioma) was referred with elevated serum calcitonin levels (1372 pg/mL) following total thyroidectomy. On maximum intensity projection (A, B), axial CT, and fusion images of ⁶⁸Ga-DOTATATE (C, D) and ¹⁸F-FDOPA (E, F) PET/CT studies, focal pathological ¹⁸F-FDOPA uptake was detected on a nodular lesion located in the thyroid bed (SUV_max: 2.2), which was ⁶⁸Ga-DOTATATE negative (arrows). A biopsy revealed local recurrence in the thyroid bed ⁶⁸Ga: Gallium-68, FDOPA: ¹⁸F-dihydroxyphenylalanine, PET/CT: Positron emission tomography/computed tomography, SUV_max: Maximum standardized uptake value