Coverage Policy Manual
Policy #: 2004024
Category: Radiology
Initiated: January 2004
Last Review: January 2024
  PET or PET/CT for Thyroid Cancer
Description:
Note:  This policy is intended for those members with contracts that do not have requirements for prior approval for imaging procedures through an independent imaging review organization.
 
 
Positron emission tomography (PET) scans are based on the use of positron emitting radionuclide tracers coupled to organic molecules, such as glucose, ammonia, or water.  The radionuclide tracers simultaneously emit 2 high-energy photons in opposite directions that can be simultaneously detected (referred to as coincidence detection) by a PET scanner, consisting of multiple stationary detectors that encircle the area of interest.
 
The radiotracer most commonly used in oncology imaging is fluorine-18 coupled with fluorodeoxyglucose (FDG), which has a metabolism related to glucose metabolism.  FDG is considered useful in cancer imaging since tumor cells show increased metabolism of glucose.   Tracers have a short half-life and the majority are made locally which requires an on-site cyclotron.
 
PET has been proposed as a method for diagnosing, staging, monitoring nonsurgical treatment, and determining prognosis of the so-called differentiated, or follicular-derived, forms of thyroid cancer and for diagnosing and staging medullary thyroid cancer.
 
Definitions
 
Screening – testing in the absence of an established or clinically suspected diagnosis
 
Diagnosis - testing based on a reasonable clinical suspicion of a particular condition or disorder
 
Diagnostic Workup – initial staging of documented malignancy
 
Management – testing to direct therapy of an established condition, which may include preoperative or postoperative imaging, or imaging performed to evaluate the response to nonsurgical intervention. In oncologic imaging, management applies to patients with measurable disease and to imaging performed before or after planned treatment intervention, therapy response, restaging or clinically suspected recurrence.
 
Surveillance – periodic assessment following completion of therapy. In oncologic imaging, surveillance applies to asymptomatic patients in remission and/or without measurable disease
 
Cannot be performed or is nondiagnostic – applies when the test:
    • Is positive or indeterminate for clinically significant pathology when the information provided about the abnormality by the test is not sufficient to direct subsequent management
    • Is negative when the negative likelihood ratio of the test is both insufficient to confidently exclude the absence of suspected disease and unable to direct subsequent management. This typically applies in scenarios with moderate to high clinical pretest probability with negative testing or low pretest probability with clear evidence for net benefit
    • Has been previously nondiagnostic because of a persistent clinical factor (e.g., body habitus, immobility) that is very likely to make retesting nondiagnostic as well Cannot be performed due to a medical contraindication (e.g., contrast nephrotoxicity, allergy, or in highly radiation sensitive populations such as pediatrics and pregnancy) or reasonable unavailability related to lack of local expertise or service availability
Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending
on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
Policy/
Coverage:
Effective April 09, 2023
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT for patients with Thyroid Cancer meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for:
 
Fluorodeoxyglucose (FDG)-PET/CT
Diagnostic Workup:
Indicated for ANY of the following subtypes:
            • Poorly differentiated papillary
            • Anaplastic
            • Hurthle Cell
(note: especially useful for anaplastic thyroid cancer)
 
Management:
Indicated in ANY of the following scenarios:
            • Follow up of poorly differentiated papillary or anaplastic carcinoma
            • Suspected recurrence of well-differentiated papillary, follicular, or Hurthle cell thyroid cancer when I 131 scan is negative (or has been negative in the past) and stimulated thyroglobulin level is > 2 ng/dL in the absence of antibodies
            • Suspected recurrent medullary carcinoma when detectable basal calcitonin or elevated CEA, and standard imaging is negative
 
Somatostatin Receptor PET/CT
Diagnostic Workup:
Indicated for:
            • Medullary carcinoma
Management:
Indicated for suspected recurrent medullary carcinoma when detectable basal calcitonin or elevated CEA, and standard imaging is negative
 
For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for patients with for patients with Thyroid Cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for any indication or any circumstance other than those listed above including but not limited to:
    • Surveillance*
For contracts without primary coverage criteria, PET/CT for patients with for patients with Thyroid Cancer is considered investigational and is not covered for any indication or any circumstance other than those listed above including but not limited to:
    • Surveillance*
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
*For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Effective March 13, 2022 to April 08, 2023
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
FDG-PET/CT for patients with Thyroid Cancer meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for:
Diagnostic Workup:
Indicated for ANY of the following subtypes:
        • Poorly differentiated papillary
        • Anaplastic
        • Medullary
        • Hurthle Cell
(note: especially useful for anaplastic thyroid cancer)
Management:
Indicated in EITHER of the following:
        • Follow up of poorly differentiated papillary, anaplastic, medullary, or Hurthle cell carcinoma
        • Evaluation of suspected recurrence of well-differentiated papillary or follicular thyroid cancer when I 131 scan is negative (or has been negative in the past) and stimulated thyroglobulin level is > 2 ng/dL in the absence of antibodies
 
* For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
PET/CT for patients with for patients with Thyroid Cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for any indication or any circumstance other than those listed above including but not limited to:
    • Surveillance*
For contracts without primary coverage criteria, PET/CT for patients with for patients with Thyroid Cancer is considered investigational and is not covered for any indication or any circumstance other than those listed above including but not limited to:
    • Surveillance*
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
* For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Note: Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
 
Effective Prior to March 13, 2022
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
FDG-PET/CT for patients with thyroid cancer meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for:  
 
Diagnostic Workup
As clinically indicated for ANY of the following subtypes:
    • Poorly differentiated papillary
    • Anaplastic
    • Medullary
    • Hurthle Cell  
(note: especially useful for anaplastic thyroid cancer)   
Management
As clinically indicated in EITHER of the following:
    • Follow up of poorly differentiated papillary, anaplastic, medullary, or Hurthle cell carcinoma; or  
    • Evaluation of suspected recurrence of well-differentiated papillary or follicular thyroid cancer when I 131 scan is negative (or has been negative in the past) and stimulated thyroglobulin level is > 2 ng/dL in the absence of antibodies.
 
For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
PET/CT for patients with thyroid cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for improving health outcomes for:
    • Screening and surveillance;
    • Any other indication not specifically listed as covered above.
 
For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
For members with contracts without primary coverage criteria, PET/CT for patients with thyroid cancer is considered investigational for:
    • Screening and surveillance;
    • Any other indication not specifically listed as covered above.
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective Prior to May 2021
“PET scan” refers to FDG PET or PET/CT.
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
PET scanning meets primary coverage criteria for effectiveness and is covered for members with contracts without primary coverage criteria for restaging of recurrent or residual follicular thyroid cancer after thyroidectomy or radioiodine ablation when serum thyroglobulin is greater than 10 ng/ml and whole body I-131 scan is negative.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
PET for monitoring response to therapy of thyroid cancer does not meet member benefit certificate primary coverage criteria for effectiveness as there are no studies which indicate improvement in health outcomes.
 
For members with contracts without primary coverage criteria, PET for monitoring response to therapy of thyroid cancer is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
PET for surveillance of asymptomatic patients with no clinical, laboratory, or radiological evidence of recurrence does not meet member benefit certificate primary coverage criteria for effectiveness as there are no studies which indicate improvement in health outcomes.
 
For members with contracts without primary coverage criteria, PET for surveillance of asymptomatic patients with no clinical, laboratory, or radiological evidence of recurrence is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
 
Rationale:
Literature Review
No controlled studies with comparison groups have been published. No studies on the effect of PET on overall survival have been published; and no comparative studies on the effect of PET on   patient outcome (other than from Kaplan-Meier curves) have been published. .All published   reports as of the date of this coverage statement, are from small series of patients.
  
Expert Panel Review (Fletcher JW, 2008):
The March 2008 “Recommendations on the Use of FDG-PET in Oncology by a number of “experts” from the U.S. and England made recommendations only for the use of PET in detecting recurrence of thyroid cancer.  The panel concluded that PET should be routinely performed for patients previously treated for well-differentiated (papillary or follicular) thyroid cancer when I-131 whole body imaging is negative and serum Tg is > 10 ng/ml.  They found no evidence to support the use of PET when both the I-131 imaging AND the serum Tg marker were both negative.
   
Technology Assessment – Agency for Healthcare Research & Quality (McEwan AJ, 2008):
There is no review of, or recommendation for or against, PET for thyroid carcinoma.
   
 
NCCN Task Force Report (Podoloff DA, 2009):
The role of PET is limited for MCT but expanding in DTC.  Research data best support using PET in established intermediate- and high-risk patients with DTC and those with ATC.  PET is a powerful prognostic indicator in the metastatic setting.  One emerging use is in assessing patients with high Tg and negative I-131 imaging when a positive PET may be indicative of dedifferentiation associating with tumor aggressiveness, necessitating modification in treatment plans.
    • Diagnosis/staging: not for diagnosis;
    • Restaging/recurrence: MTC-restage when calcitonin > 1000 pg/ml;   DTC – detection of suspected recurrence when Tg is elevated and whole-body I-131 imaging is negative;
    • Prognosis: MTC-unclear;  DTC-negative correlation with survival.
    • Treatment planning/response monitoring: unclear.
 
National Oncologic PET Registry reports, 2008, 2009:
There is no statistical information for or against PET specifically for thyroid carcinoma
 
Eur J Endocrinol. 2010 Aug;163(2):177-83. Epub 2010 May 19.
The role of TSH for 18F-FDG-PET in the diagnosis of recurrence and metastases of differentiated thyroid carcinoma with elevated thyroglobulin and negative scan: a meta-analysis.
Ma C, Xie J, Lou Y, Gao Y, Zuo S, Wang X.
Source
Department of Nuclear Medicine, Affiliated Hospital of Medical College Qingdao University, Qingdao, Shandong Province, People's Republic of China. Mc_7419@hotmail.com
Abstract
PURPOSE:
To establish the effects of TSH stimulation on the uptake of fluorine-18-labeled 2-fluoro-2-deoxy-d-glucose for differentiated thyroid carcinoma (DTC) with thyroglobulin-positive and scan negative metastases.
MATERIALS AND METHODS:
We searched the MEDLINE, EMBASE and the Cochrane Library for prospective controlled trials using TSH stimulation as an intervention. The outcomes of positron emission tomography (PET)-positive lesions, tumor-to-background ratio, maximum standard uptake value of the detected lesions were extracted and synthesized, and patients with the altered clinical management were studied. A meta-analysis was carried out using the Review Manager software.
RESULTS:
Seven prospective controlled clinical trials with 168 patients were found. All studies had a low risk of bias. PET scans under TSH stimulation versus thyroid hormone suppression showed statistically significant differences in the number of patients with PET true-positive lesions (odds ratio (OR) 2.45, 95% confidence interval (CI) 1.23-4.90) and in the number of the PET-detected lesions (OR 4.92, 95% CI 2.70-8.95) and tumor-to-background ratios. PET scans taken under TSH stimulation altered clinical management in altogether 12/130 (9%) patients in five paired studies (OR 2.40, 95% CI 1.11-5.22).
CONCLUSION:
The data indicate that TSH stimulation should be recommended for DTC patients undergoing PET scanning in these circumstances. However, further well-designed studies emphasizing on the clinical significance of altered management by PET under TSH stimulation are needed.
PMID: 0484385   [PubMed - indexed for MEDLINE]
 
Nucl Med Commun. 2010 Jun;31(6):567-75.
Role of [(18)F]FDG-PET/CT in the detection of occult recurrent medullary thyroid cancer.
Skoura E, Rondogianni P, Alevizaki M, Tzanela M, Tsagarakis S, Piaditis G, Tolis G, Datseris IE.
Source
Department of Nuclear Medicine, Evangelismos Hospital, Athens, Greece. lskoura@yahoo.gr
Abstract
PURPOSE:
Many patients with medullary thyroid carcinoma (MTC) have persistently elevated calcitonin levels after initial treatment, indicating disease recurrence. Conventional imaging is often negative or shows equivocal findings. In this study we report our experience with 2-deoxy-2-[(18)F]fluoro-D-glucose positron emission tomography/computed tomography ([(18)F]FDG-PET/CT) in the evaluation of this specific group.
METHODS:
Between February 2007 and May 2009, 38 [(18)F]FDG-PET/CT scans were performed on 32 patients with MTC and elevated calcitonin levels for localization of recurrent disease. Six of these patients had a second [(18)F]FDG-PET/CT scan.
RESULTS:
Among the 38 [(18)F]FDG-PET/CT scans there were 18 positive and 20 negative scans. Out of the 18 positive scans, 17 were true positive and one false positive. These findings suggest that [(18)F]FDG-PET/CT provides additional information in almost half of all cases (overall per patient sensitivity of 47.4%) but using a serum calcitonin cut-off of 1000 pg/ml this rate is increased to 80%. An interesting finding of the study was that none of the six patients with multiple endocrine neoplasia type IIA syndrome had a positive [(18)F]FDG-PET/CT scan for MTC. When these patients were excluded, the overall per patient sensitivity rose to 60% and in patients with calcitonin levels >1000 pg/ml this rate increased to 100%. The mean SUV(max) of all lesions showing [(18)F]FDG uptake was 3.96 + or - 1.61 (range, 2-7).
CONCLUSION:
[(18)F]FDG-PET/CT seems to be valuable for the detection of recurrence in patients with highly elevated calcitonin levels and negative conventional imaging findings. In addition, it seems that the sensitivity of [(18)F]FDG-PET/CT may be higher in patients with sporadic or familial MTC than in patients with MTC as part of multiple endocrine neoplasia type IIA syndrome.
PMID: 20335822   [PubMed - indexed for MEDLINE]
 
Technology Assessment – Canadian Agency for Drugs and Technologies in Health (Mujoomdar M, 2010):  
The April 2010 Canadian Agency for Drugs and Technologies in Health assessment of PET in Oncology did address PET for thyroid carcinoma.  Their conclusions:
    • Diagnosis: no evidence to support PET use;
    • Staging/re-staging: no evidence to support PET use;
    • Metastases or recurrence: Useful for detecting recurrence in patients treated for well-differentiated thyroid cancer when findings of 131 scintigraphy negative and serum thyroglobulin marker elevated.
 
 
 
Clin Nucl Med. 2011 Dec;36(12):e180-5.  PET/CT imaging of thyroid cancer. Mosci C, Iagaru A.
Source:Division of Nuclear Medicine, Stanford University Medical Center, Stanford, CA, USA.
Abstract
Positron emission tomography (PET) is a highly sensitive, low invasive technology for cancer biology imaging. The role of F-18 FDG PET/CT in differentiated thyroid cancer (DTC) is well established, particularly in patients presenting with elevated Tg levels and negative radioactive iodine WBS. It has been demonstrated that F-18 FDG uptake represents less differentiated thyroid cancer cells or dedifferentiated cells and PET positive lesions are more likely to be resistant to I treatment. The uptake of F-18 FDG is related to tumor size, thyroid capsule invasion and histological variants with a poor prognosis. As in other cancers, early detection of recurrences improves outcomes and survival. I PET/CT can also be used to image the patients with DTC, similarly to I WBS. Compared with F-18 FDG PET/CT, its spatial resolution is only slightly degraded but increasing the imaging time reduces this difference. In addition, F-18 FDG PET/CT has been found helpful in the management of patients with anaplastic and medullary thyroid cancer. Other radiopharmaceuticals such as Ga-DOTATOC and F-18 DOPA may provide complimentary information to F-18 FDG PET/CT in the detection of recurrent thyroid cancer.  PMID: 22064103   [PubMed - in process]
 
Ann Nucl Med. 2011 Oct 19. [Epub ahead of print]
Can (18)F-FDG-PET/CT be generally recommended in patients with differentiated thyroid carcinoma and elevated thyroglobulin levels but negative I-131 whole body scan?  Bannas P, Derlin T, Groth M, Apostolova I, Adam G, Mester J, Klutmann S.
Source: Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany, p.bannas@uke.de.
Abstract
BACKGROUND:
Exact localization of recurrent iodine-negative thyroid cancer is mandatory, since surgery is the only curative therapy option in patients with iodine-negative tumor tissue. The aim of this study was to evaluate the impact of (18)F-FDG-PET/CT as a routine diagnostic tool on clinical management in patients with suspected thyroid cancer recurrence and elevated serum thyroglobulin (Tg) but negative radioiodine whole body scan.
METHODS AND MATERIALS:
After total thyroidectomy followed by radioiodine ablation, 30 consecutive patients with differentiated thyroid cancer, elevated serum thyroglobulin levels and negative whole body radioiodine scan underwent (18)F-FDG-PET/CT. Results were verified by histology, ultrasound, or clinical follow-up. Diagnostic accuracy was determined for the whole study population and for subgroups with serum thyroglobulin below and above 10 ng/ml, respectively. Impact of PET/CT on clinical management was assessed.
RESULTS:
PET/CT identified FDG accumulating lesions in 19 of 30 patients. 17 were true-positive and 2 false-positive. In the true-positive group, 11 of the 17 patients had loco-regional disease, 3 had distant metastases only and 3 patients had both loco-regional and distant metastatic involvement. (18)F-FDG-PET/CT was true-negative in 3 patients and false-negative in 8 patients. Overall sensitivity, specificity and accuracy were 68.0, 60.0, and 66.7%, respectively. In the subgroup of patients with serum thyroglobulin above 10 ng/ml (n = 21) the sensitivity, specificity and accuracy were substantially higher with 70.0, 100.0, and 71.4%, respectively. Clinical management was changed for 17 (57%) of 30 patients, guiding to a curative surgical intervention in 9 patients (30%).
CONCLUSIONS:
(18)F-FDG-PET/CT enables detection and precise localization of loco-regional recurrence and distant metastases of differentiated thyroid cancer in patients with elevated serum thyroglobulin but negative radioiodine with significant impact on patient management and can therefore be recommended as a routine diagnostic tool.
 
Ann Nucl Med. 2011 Oct 5. [Epub ahead of print]
Diagnostic accuracy of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in differentiated thyroid cancer patients with elevated thyroglobulin and negative (131)I whole body scan: evaluation by thyroglobulin level.  Na SJ, Yoo IR, O JH, Lin C, Lin Q, Kim SH, Chung SK.
Source: Department of Radiology, School of Medicine, The Catholic University of Korea, Seoul, South Korea.
Abstract
BACKGROUND:
To evaluate the diagnostic accuracy of (18)F-FDG PET/CT in detection of recurrent differentiated thyroid cancer (DTC) in patients with elevated stimulated thyroglobulin (Tg) or anti-Tg antibody (Ab) levels, and negative (131)I whole body scan according to the Tg level.
METHODS:
PET/CT images of well DTC patients who had total thyroidectomy and radioiodine ablation were included. Patients showing elevated Tg titer (≥2.0 ng/ml after TSH stimulation) or elevated anti-Tg titer (≥70.0 IU/ml) while diagnostic radioiodine scan was negative were enrolled. PET/CT was classified as positive or negative on the basis of visual interpretation. The maximum standard uptake values (SUV max) of the suspected lesions on PET/CT were also recorded. The PET/CT findings were compared with histological or clinical follow-up results based on other imaging modalities and serum Tg/anti-Tg Ab titers. The diagnostic performance of PET/CT was compared among 4 subgroups according to the Tg level [2 ng/ml ≤ stimulated Tg (sTg) < 5 ng/ml, 5 ng/ml ≤ sTg < 10 ng/ml, 10 ng/ml ≤ sTg < 20 ng/ml, and ≥20 ng/ml].
RESULTS:
A total of 68 PET/CT images from 60 patients were included, and histological confirmations were available in 32 images. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of PET/CT were 69.4, 66.7, 69.1, 95.6, and 17.4%, respectively. There were 3 PET/CT cases with high anti-Tg Ab level, and low (<2 ng/ml) Tg level, and all 3 were positive of recurrence. The mean SUV max of the suspected lesions on PET/CT was 2.9 ± 4.5 (range 1.3-29.7). The sensitivity of PET/CT according to Tg levels was 28.6% when Tg was between 2 and 5, 57.1% between 5 and 10, 60.0% between 10 and 20, and 85.7% when Tg was equal to or greater than 20 ng/ml sub-groups, respectively.
CONCLUSION:
Diagnostic accuracy of FDG PET in radioiodine negative thyroid cancer may vary depending on serum Tg levels at imaging. (18)F-FDG PET/CT is useful in detection and localization of recurrent thyroid cancer in patients with negative diagnostic radioiodine scan despite elevated Tg greater than 20 ng/ml or high anti-Tg Ab titers. In contrast, PET/CT provides little additional information when the Tg is less than 5 ng/ml.
PMID: 21971605   [PubMed - as supplied by publisher]
 
Nucl Med Commun. 2011 Dec;32(12):1162-8.
Impact of ¹⁸F-FDG PET/CT for detecting recurrence of medullary thyroid carcinoma. Ozkan E, Soydal C, Kucuk ON, Ibis E, Erbay G.
Source: Department of Nuclear Medicine, Faculty of Medicine, Ankara University, Ankara, Turkey.
Abstract
OBJECTIVE:
The aim of this study was to evaluate the value of fluorine-18 (¹⁸F) fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in the detection of recurrent medullary thyroid carcinoma (MTC) in patients with elevated calcitonin levels.
METHODS:
Thirty-three patients (nine men, 24 women; mean age: 50.3 ± 12 years) who were referred to undergo ¹⁸F-FDG PET/CT for restaging of MTC in patients with high calcitonin levels were included in this study. Five patients also had suspected lymph nodes detected by neck ultrasonography. The results of ¹⁸F-FDG PET/CT and clinical follow-up data were reviewed retrospectively. Histological analysis has been accepted as the gold standard in the confirmation of ¹⁸F-FDG PET/CT results. Patients were followed up for 45.6 ± 4.2 months.
RESULTS:
There were 14 negative and 19 positive scans for possible recurrence of MTC. In the positive scans, the possible recurrence sites were neck lymph nodes, thyroid bed, mediastinal lymph nodes, and the lung in 14, two, two, and one patient, respectively. Disease recurrence in 13 patients was confirmed histologically by surgical excision or fine-needle aspiration biopsy. In the remaining six patients, recurrence was excluded as it was reactive as a result of pathological examination. However, one patient had a negative scan, underwent neck lymph node excision after ¹⁸F-FDG PET/CT examination, and lymph node recurrence was detected histologically. According to these results, the sensitivity and specificity of PET/CT were calculated as 93 and 68%, respectively. According to the recommended calcitonin level by the American Thyroid Association (calcitonin levels higher than 150 pg/ml), sensitivity was calculated as 90%. Although the mean maximum standardized uptake values of the true-positive and false-positive groups were calculated as 4.72 ± 2.17 and 4.22 ± 1.02, respectively, the difference between the two groups was not statistically significant (P>0.05).
CONCLUSION:
PET/CT is a sensitive imaging tool in the detection of MTC recurrence, especially in patients with high calcitonin levels, and it gives additional information in one third of all patients on an average by detecting an occult disease or confirming findings of other imaging tools.
PMID: 21946617 [PubMed - in process
 
Head Neck. 2011 Aug 17. doi: 10.1002/hed.21791. [Epub ahead of print]
Relationship between serum thyroglobulin and (18) FDG-PET/CT in (131) I-negative differentiated thyroid carcinomas.  Giovanella L, Ceriani L, De Palma D, Suriano S, Castellani M, Verburg FA.
Source: Department of Nuclear Medicine and Thyroid Diseases Centre, Oncology Institute of Southern Switzerland, Via Ospedale 12, CH-6500 Bellinzona, Switzerland. Luca.giovanella@eoc.ch.
Abstract
BACKGROUND:
The purpose of this study was to assess the relationship between [(18) F]-fluorodeoxyglucose ((18) FDG)-positron emission tomography/CT ((18) FDG-PET/CT) and serum thyroglobulin (Tg) in patients with recurrent differentiated thyroid carcinoma (DTC).
METHODS:
Forty-two patients with recurrent DTC and negative Tg antibodies were included in the study. All patients underwent (131) I therapy due to an increasing serum Tg with a corresponding negative (131) I post treatment whole body scan. The (18) FDG-PET/CT scans were then performed on all patients, serum Tg was measured concurrently, and respective results were compared.
RESULTS:
Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of the (18) FDG-PET/CT examination were 93%, 84%, 93%, 84%, and 90%, respectively. The sensitivity of (18) FDG-PET/CT significantly increased in patients with serum Tg levels ≥4.6 ng/mL (96%) in comparison with patients having lower levels (25%; p < .001). Nonetheless, 3 of 27 patients (11%) with a true-positive (18) FDG-PET/CT still had a Tg <4.6 ng/mL.
CONCLUSION:
Although (18) FDG-PET/CT scans are more likely to be positive with pretest Tg levels ≥4.6 ng/mL, 11% of patients with DTC with a lower serum Tg level will still have a positive scan. Our findings are in contrast with the American Thyroid Association (ATA) guidelines, which only recommend to perform (18) FDG-PET/CT in patients with Tg levels >10 ng/mL. © 2011 Wiley Periodicals, Inc. Head Neck, 2011.
Copyright © 2011 Wiley Periodicals, Inc.
PMID: 21850699   [PubMed - as supplied by publisher]
 
 
Semin Nucl Med. 2011 Mar;41(2):121-38.
Thyroid cancer--indications and opportunities for positron emission tomography/computed tomography imaging.
Abraham T, Schöder H.
Source
Department of Nuclear Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, New York, NY, USA.
Abstract
Although thyroid cancer is a comparatively rare malignancy, it represents the vast majority of endocrine cancers and its incidence is increasing. Most differentiated thyroid cancers have an excellent prognosis if diagnosed early and treated appropriately. Aggressive histologic subtypes and variants carry a worse prognosis. During the last 2 decades positron emission tomography (PET) and PET/computed tomography (CT), mostly with fluorodeoxyglucose (FDG), has been used increasingly in patients with thyroid cancers. Currently, the most valuable role FDG-PET/CT exists in the work-up of patients with differentiated thyroid cancer status post thyroidectomy who present with increasing thyroglobulin levels and a negative (131)I whole-body scan. FDG-PET/CT is also useful in the initial (post thyroidectomy) staging of high-risk patients with less differentiated (and thus less iodine-avid and clinically more aggressive) subtypes, such as tall cell variant and Hürthle cell carcinoma, but in particular poorly differentiated and anaplastic carcinoma. FDG-PET/CT may help in defining the extent of disease in some patients with medullary thyroid carcinoma and rising postoperative calcitonin levels. However, FDOPA has emerged as an alternate and more promising radiotracer in this setting. In aggressive cancers that are less amenable to treatment with (131)iodine, FDG-PET/CT may help in radiotherapy planning, and in assessing the response to radiotherapy, embolization, or experimental systemic treatments. (124)Iodine PET/CT may serve a role in obtaining lesion dosimetry for better and more rationale planning of treatment with (131)iodine. Thyroid cancer is not a monolithic disease, and different stages and histologic entities require different approaches in imaging and individualized therapy.
Copyright © 2011 Elsevier Inc. All rights reserved.
PMID: 21272686   [PubMed - indexed for MEDLINE]
 
 
 
American College of Radiology Appropriateness Criteria, 2011:
There are no appropriateness criteria for PET for thyroid carcinoma.   
 
2012 Update
Literature was reviewed.  No articles were identified that would change the coverage statement.
 
2013 Update:
A review of literature on PubMed through December 2012 was performed. There were no published
articles identified that would prompt a change in the coverage statement.  
 
 
Riemann and colleagues (2012):
The clinical significance of 18 F-FDG-PET/CT in the follow-up of patients with differentiated thyroid carcinoma was evaluated and the results were compared with those of 18 F-FDG-PET, 131 I-whole-body scintigraphy (WBS) including SPECT/CT and ultrasound.  The impact of 18 F-FDG-PET/CT on the therapeutic management was also investigated. The study included 327 patients with differentiated thyroid cancer (242 papillary, 75 follicular, 6 mixed, 1 Hürthle cell and 3 poorly differentiated tumors) were analyzed retrospectively at four tertiary referral centers.  Imaging included: 289 18 F-FDG-PET/CT and 118 18 F-FDG-PET studies were performed in these patients between 2007 and 2010. Additional clinical evaluation was performed that included cytology, histology, thyroglobulin level, ultrasound, WBS, and subsequent clinical course in order to compare the molecular imaging results. Finally, the change in therapeutic management due to findings of 18 F-FDG-PET/CT was investigated. Results: The sensitivity of 18 F-FDG-PET/CT was 92%, the specificity was 95%. Sensitivity and specificity of 18 F-FDG-PET alone were 67% and 93%, respectively. WBS showed a sensitivity of 65% and a specificity of 94%. The corresponding values of ultrasound were 37% and 94%, respectively. The sensitivity of 18 F-FDG-PET/CT in the group of patients with a negative WBS (n=194) amounted to 96%. When 18 F-FDG-PET/CT and WBS were considered in combination, tumor tissue was missed in only 2 out of 133 patients; when 18 F-FDG-PET and WBS were combined, tumor tissue was missed in 1 out of 24 patients. 18 F-FDG-PET/CT resulted in management change in 43% (n=57/133) with a decision on surgical approach in 20% (n=27/133).  The authors concluded that 18 F-FDG-PET/CT is superior to 18 F-FDG-PET alone in patients with differentiated thyroid cancer and has a direct impact on the therapeutic management of patients with suspected local recurrence or metastases, particularly in those with negative WBS.
 
Creach and colleagues (2013):
A retrospective review was conducted to determine if FDG-PET results can predict for outcome in thyroid cancer patients with elevated Tg and negative I-131 imaging.  The study included  76 patients who had elevated serum Tg and negative (131)I scintigraphy and who underwent FDG-PET. After FDG-PET, patients underwent neck dissection or radiation.
Results:  The 51 patients with positive FDG-PET had a 5-year survival of 63% compared to 100% (p<0.049) for the 25 patients with negative PET. Patients with FDG-avid disease isolated to the lymph nodes had 5-year CSS of 91% compared to 32% (p=0.0033) for those with disease outside the regional lymph nodes. Twenty-nine patients with disease isolated to the regional lymph nodes underwent salvage neck dissection and 22 remain NED after 28months.
The authors concluded that negative FDG-PET with elevated Tg predicts an excellent outcome. FDG-avid disease isolated to the regional lymph nodes had a low likelihood of death due to thyroid cancer.
 
NCCN Guidelines, Version 1.2013:
Guidelines list PET/CT along with ultrasound of the neck, CT of the neck and CT of the chest as nonradioiodine imaging studies that could be considered for surveillance of patients with negative I131 imaging and a stimulated thyroglobulin level >2.5 ng/ml.
 
2014 Update
A literature search using the MEDLINE database through September 2014 did not reveal any new information that would prompt a change in the coverage statement.
 
2015 Update
A literature search conducted through September 2015 did not reveal any new information that would prompt a change in the coverage statement.
 
2017 Update
A literature search conducted through September 2017 did not reveal any new information that would prompt a change in the coverage statement.  The key identified literature is summarized below.
 
THYROID CANCER/18F-FDG-PET
Differentiated
In 2016, Haslerud and colleagues conducted a meta-analysis on studies using 18F-FDG-PET to detect recurrent differentiated thyroid cancer in patients who had undergone ablative therapy (Haslerud, 2016). The literature search, conducted through December 2014, identified 34 studies (total N=2639 patients) for inclusion: 17 18F-FDG-PET/CT, 11 18F-FDG-PET/CT, and 6 combined both methods. Study quality was assessed using QUADAS. Pooled sensitivity and specificity for 18F-FDG-PET/CT was 80% (95% CI, 74% to 86%) and 76% (95% CI, 63% to 85%). Pooled sensitivity and specificity for 18F-FDG-PET alone was 77% (95% CI, 63% to 86%) and 76% (95% CI, 60% to 87%). Combining all 34 studies in the meta-analysis resulted in sensitivity and specificity of 79% (95% CI, 74% to 84%) and 79% (95% CI, 71% to 85%).
 
Medullary  
A meta-analysis of studies on detecting recurrent or metastatic medullary thyroid carcinoma was conducted by Cheng and colleagues (Cheng, 2012).  The literature search, conducted through December 2010, identified 15 studies to be included in the meta-analysis: 8 used 18F-FDG-PET and 7 used 18F-FDG-PET/CT. The pooled sensitivity for 18F-FDGPET alone in detecting recurrent or metastatic medullary thyroid cancer was 68% (95% CI, 64% to 72%). The pooled sensitivity for 18F-FDG-PET/CT was 69% (95% CI, 64% to 74%).
 
Current NCCN guidelines for thyroid carcinoma do not include PET or PET/CT in the management of medullary thyroid cancer recommend contrast-enhanced CT with or without PET at 2-3 months postoperative surveillance (NCCN, 2017).
 
Summary: Thyroid Cancer
Evidence for the use of PET and PET/CT to diagnose recurrent differentiated and medullary thyroid cancer consists of systematic reviews and meta-analyses. Pooled sensitivity and specificity for 18F-FDG-PET/CT and 18F-FDG-PET/CT in detecting recurrent differentiated thyroid cancer were comparable, ranging from 76% to 80%. Pooled sensitivity for both PET and PET/CT in detecting recurrent medullary thyroid cancer were also comparable (68% to 69%).
 
For individuals with diagnosed thyroid cancer who receive 18F-FDG-PET or PET/CT, evidence includes systematic reviews and meta-analyses. Relevant outcomes are test accuracy and test validity. Pooled analyses showed that PET or PET/CT can be effective in detecting recurrent differentiated thyroid cancer.
Clinical guidelines include PET/CT to inform management decisions that may offer clinical benefit. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
 
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2018. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
THYROID CANCER AND 18F-FDG-PET AND 18F-FDG-PET/CT
Differentiated
The 2009 NCCN report on PET showed that PET can localize recurrent disease when other imaging tests are negative (Podoloff, 2009). Additionally, PET was found to be prognostic in this setting: More metabolically active lesions on PET were strongly correlated with reduced survival (Pace, 2015).
 
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2019. No new literature was identified that would prompt a change in the coverage statement.
 
2020 Update
A literature search was conducted through February 2020.  There was no new information identified that would prompt a change in the coverage statement.  
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through January 2021. No new literature was identified that would prompt a change in the coverage statement.
 
2022 Update
A literature review was performed through September 2021. Following is a summary of the key literature to date.
 
DIAGNOSTIC WORKUP
Thyroid cancer is staged using the American Joint Committee on Cancer TNM system. Thyroid cancer frequently involves cervical lymph nodes, and the addition of ultrasound can result in detection and alteration in management in up to 40% of patients. (1, 2) Compared to CT, high-resolution ultrasound is more accurate for evaluation of extrathyroidal tumor extension and at least equivalent for evaluation of lateral lymph nodes. (3) Sensitivity, specificity, and diagnostic accuracy of ultrasound were 77%, 70%, and 74%, respectively, while those for CT were 62%, 79%, and 68%.4 MRI and PET have relatively low sensitivities ranging from 30%-40%. (5, 6) For dedifferentiated thyroid cancer, PET is indicated. Although there is a lack of prospective evidence, PET has been shown to detect metastatic disease not identified by conventional imaging in 35% of patients.7 Change in management based on PET imaging findings can be as high as 25%-50%. (8)
 
MANAGEMENT
For follow up of well-differentiated thyroid cancer, CT or MRI is not indicated unless there is clinical evidence of recurrence. Patients with high-risk features generally undergo additional imaging and/or treatment with radioactive iodine. For suspected iodine non-avid papillary or follicular thyroid cancer, PET may be useful. The overall accuracy, sensitivity, and specificity for PET/CT in I-131 negative patients were 93%, 93%, and 81%, respectively. (9) For suspected recurrence of medullary thyroid cancer, a study comparing several imaging modalities found that ultrasound outperformed CT and PET for detection of locally recurrent disease (56% accuracy for ultrasound vs 42% and 32% for CT and PET, respectively). CT was superior to PET for evaluation of metastatic lung and mediastinal lymph node involvement, with a reported sensitivity and specificity for CT of 35% and 31%, respectively, versus 15% and 20% for PET. Detection of liver metastases with MRI, CT, ultrasound, and PET showed accuracy rates of 49%, 44%, 41%, and 27%, respectively, while bone metastases were better detected using bone scan or MRI (40%) as compared to PET (35%). (10) In a review of PET for evaluation of recurrent anaplastic thyroid cancer, higher sensitivity (66% to 100%) and specificity (79% to 90%) were seen when compared to conventional imaging modalities. (11)
 
These guidelines for thyroid cancer are in concordance with the National Comprehensive Cancer Network Guidelines for Thyroid Carcinoma as well as the American Thyroid Association Practice Guidelines. (12, 13)
 
SURVEILLANCE
Biochemical monitoring remains the most vital component for surveillance of differentiated thyroid cancer; although conventional imaging may also be considered when clinically indicated. Both the American Thyroid Association and National Comprehensive Cancer Network do give consideration to a single exam after completion of therapy in intermediate and high risk differentiated thyroid cancer patients. The value of continued monitoring if no evidence of disease is seen is controversial. (6, 12)
 
Current References
    1. Kouvaraki MA, Shapiro SE, Fornage BD, et al. Role of preoperative ultrasonography in the surgical management of patients with thyroid cancer. Surgery. 2003;134(6):946-54; discussion 54-5. PMID: 14668727
    2. Stulak JM, Grant CS, Farley DR, et al. Value of preoperative ultrasonography in the surgical management of initial and reoperative papillary thyroid cancer. Arch Surg. 2006;141(5):489-94; discussion 94-6. PMID: 16702521
    3. Choi JS, Kim J, Kwak JY, et al. Preoperative staging of papillary thyroid carcinoma: comparison of ultrasound imaging and CT. AJR Am J Roentgenol. 2009;193(3):871-8. PMID: 19696304
    4. Ahn JE, Lee JH, Yi JS, et al. Diagnostic accuracy of CT and ultrasonography for evaluating metastatic cervical lymph nodes in patients with thyroid cancer. World J Surg. 2008;32(7):1552-8. PMID: 18408961
    5. Chen Q, Raghavan P, Mukherjee S, et al. Accuracy of MRI for the diagnosis of metastatic cervical lymphadenopathy in patients with thyroid cancer. Radiol Med (Torino). 2015;120(10):959-66. PMID: 25725789
    6. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1-133. PMID: 26462967
    7. Poisson T, Deandreis D, Leboulleux S, et al. 18F-fluorodeoxyglucose positron emission tomography and computed tomography in anaplastic thyroid cancer. Eur J Nucl Med Mol Imaging. 2010;37(12):2277-85. PMID: 20694463
    8. Bogsrud TV, Karantanis D, Nathan MA, et al. 18F-FDG PET in the management of patients with anaplastic thyroid carcinoma. Thyroid. 2008;18(7):713-9. PMID: 18630999
    9. Caetano R, Bastos CR, de Oliveira IA, et al. Accuracy of positron emission tomography and positron emission tomography-CT in the detection of differentiated thyroid cancer recurrence with negative (131) I whole-body scan results: a meta-analysis. Head Neck. 2016;38(2):316-27. PMID: 25251544
    10. Giraudet AL, Vanel D, Leboulleux S, et al. Imaging medullary thyroid carcinoma with persistent elevated calcitonin levels. J Clin Endocrinol Metab. 2007;92(11):4185-90. PMID: 17726071
    11. Khan N, Oriuchi N, Higuchi T, et al. Review of fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) in the follow-up of medullary and anaplastic thyroid carcinomas. Cancer Control. 2005;12(4):254-60. PMID: 16258498
    12. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Thyroid Carcinoma (Version 3.2020). Available at http://www.nccn.org. ©National Comprehensive Cancer Network, 2020.
    13. Yeh MW, Bauer AJ, Bernet VA, et al. American Thyroid Association statement on preoperative imaging for thyroid cancer surgery. Thyroid. 2015;25(1):3-14. PMID: 25188202
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2022.
 
NCCN Guidelines for Thyroid Carcinoma (Version 2022) were reviewed with no change from Version 2021 with regard to PET applications.
 
For follow up of well-differentiated thyroid cancer, CT or MRI is not indicated unless there is clinical evidence of recurrence. Patients with high-risk features generally undergo additional imaging and/or treatment with radioactive iodine. For suspected iodine non-avid papillary, follicular, or Hürthle cell thyroid cancer, PET may be useful (Caetano et al, 2016).  
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2023.  
 
NCCN Guidelines for Thyroid Carcinoma (Version 2023) were reviewed with no change from Version 2022 with regard to PET applications.
 
An evidence-based guideline from the American Thyroid Association makes a strong recommendation for cross-sectional imaging in the initial tumor staging workup, including CT neck, chest, abdomen, and pelvis (or MRI). They also recommend the use of FDG-PET/CT, but state that bone scan can be obtained to evaluate for bony metastases in the absence of PET imaging (Bible et al, 2021).
CPT/HCPCS:
78811Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)
78812Positron emission tomography (PET) imaging; skull base to mid thigh
78813Positron emission tomography (PET) imaging; whole body
78814Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)
78815Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid thigh
78816Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body
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Bible KC, Kebebew E, Brierley J, et al.(2021) 2021 American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid. 2021;31(3):337-86.

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Coleman RE, Hillner BE, et al.(2010) PET and PET/CT Reports: Observations from the National Oncologic PET Registry. J Nucl Med, 2010; 51:158-163.

Creach KM, Nussenbaum B, Siegel BA, et al.(2013) Thyroid carcinoma uptake of (18)F-Fluorodeoxyglucose in patients with elevated serum thyroglobulin and negative (131)I scintigraphy. Am J Otolaryngol. 2013 Jan;34(1):51-6. doi: 10.1016/j.amjoto.2012.08.006.

Fletcher JW, Djulbegovic B, et al.(2008) Recommendations on the Use of 18F-FDG PET in Oncology. J Nucl Med, 2008; 49:480-508.

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Haslerud T, Brauckhoff K, Reisaeter L, et al.(2016) F18-FDG-PET for recurrent differentiated thyroid cancer: a systematic meta-analysis. Acta Radiol. Oct 2016;57(10):1193-1200. PMID 26163534

Ma C, Xie J, et al.(2010) The role of TSH for 18F-FDG-PET in the diagnosis of recurrence and metastases of differentiated thyroid cancer with elevated thyroglobulin and negative scan: a meta-analysis. Eur J Endocrinol, 2010; 163:177-83.

Mosci C, Iagaru A.(2011) PET/CT imaging of thyroid cancer. Clin Nucl Med, 2011; 36:e180-5.

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Na SJ, Yoo IR, et al.(2011) Diagnostic accuracy of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in differentiated thyroid cancer patients with elevated thyroglobulin and negative (131)I whole body scan: avaluation by thyroglobulin level. Ann Nucl Med, 2011 Oct 5 [Epub ahead of print].

National Comprehensive Cancer Network (NCCN).(2017) Clinical Practice Guidelines in Oncology. Thyroid Carcinoma V 1.2017. https://www.nccn.org/professionals/physician_gls/pdf/thyroid.pdf.

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Ozkan E, Soydal C, et al.(2011) Impact of 18F-FDG PET/CT for detecting recurrence of medullary thyroid carcinoma. Nucl Med Commun, 2011; 32:1162-8.

Pace L, Klain M, Salvatore B, et al.(2015) Prognostic role of 18F-FDG PET/CT in the postoperative evaluation of differentiated thyroid cancer patients. Clin Nucl Med. Feb 2015;40(2):111-115. PMID 25546215

Podoloff DA, Ball DW, et al.(2009) NCCN Task Force Report: Clinical Utility of PET in a Variety of Tumor Types. J Natl Comprehensive Cancer Network, 2009; 7

Postitron emission tomography (PET) for thyroid cancer. Hayes Technology Assessment 2003.

Pryma DA, Schoder H, et al.(2006) Diagnostic accuracy and prognostic value of 18F-FDG PET in Hurthle cell thyroid cancer patients. J Nucl Med, 2006; 47:1260-66.

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