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© Borgis - Postępy Nauk Medycznych 12/2015, s. 862-868
*Magdalena Kochman
Diagnostyka obrazowa raka rdzeniastego tarczycy
Diagnostic imaging of medullary thyroid cancer
Department of Endocrinology, Centre of Postgraduate Medical Education, Bielański Hospital, Warszawa
Head of Department: prof. Wojciech Zgliczyński, MD, PhD
Rak rdzeniasty (MTC) jest rzadko występującym nowotworem tarczycy o dużej skłonności do tworzenia przerzutów zarówno do węzłów chłonnych, jak i odległych. W przypadku wznowy raka rdzeniastego tarczycy najistotniejsze znaczenie dla rokowania mają: wczesne rozpoznanie, lokalizacja ognisk nowotworu i właściwa kwalifikacja chorych do dalszego leczenia. W monitorowaniu chorych z tym nowotworem powszechnie uznaną rolę odgrywa okresowa ocena stężenia kalcytoniny, pozwalająca na wczesne wykrycie wznowy. Nie ma jednak jednej uniwersalnej metody diagnostycznej pozwalającej wykryć wszystkie ogniska nawrotu tego nowotworu, choć obserwowany w ostatnich latach rozwój pozytonowej tomografii emisyjnej (PET) przyniósł istotny postęp w tej dziedzinie. Podstawową rolę w diagnostyce raka rdzeniastego tarczycy odgrywają obecnie metody diagnostyki konwencjonalnej (ultrasonografia, tomografia komputerowa, rezonans magnetyczny). W artykule omówiono również wykorzystywane w diagnostyce tego nowotworu metody medycyny nuklearnej, zarówno oparte na klasycznej scyntygrafii, jak i wykorzystujące technikę pozytonowej tomografii emisyjnej. Szczególną uwagę zwrócono na zastosowanie poszczególnych metod w zależności od sytuacji klinicznej i przewidywanej lokalizacji ognisk nowotworu.
Medullary thyroid cancer (MTC) is an uncommon malignancy with a high tendency to metastasize both to lymph nodes and distant localizations. In recurrent disease the most important prognostic factors are the early diagnosis, localization of the recurrent lesions and adequate patient selection for further treatment. An important role in monitoring of patients with medullary thyroid cancer plays periodical measurement of calcitonin concentration, which allows to detect the recurrence early. There is no single universal diagnostic method to localize all medullary thyroid cancer recurrence lesions, however, the development of positron emission tomography (PET) methods observed in recent years led to an important progress in this field. Conventional diagnostic methods (ultasonography, computed tomography, magnetic resonance) currently play the basic role in the diagnosis of the medullary thyroid carcinoma. In this article we also described nuclear medicine imaging, both convencional scintigraphy and positron emission tomography methods, used in diagnosing of this neoplasm. Particular attention was paid to the use of each method depending on the clinical situation and the suspected location of tumor foci.

Medullary thyroid cancer (MTC) is a malignancy that originates from the neuroendocrine calcitonin-secreting parafolicullar C cells. According to the latest data it represents only about 1-2% of the thyroid cancers (1). Due to another origin than differentiated thyroid cancers groving from thyrocytes it has different biology and worse prognosis, accounting for 13.4% of deaths caused by thyroid cancers (2). Approximately 25% of the MTC are the forms of hereditary syndromes associated with type 2 multiple endocrine neoplasia (MEN 2) (1). MTC has a high tendency to metastasize both by lymphatic system (to the cervical lymph nodes, mediastinum and pulmonary hila) and by blood (most often to the liver, lungs, bones, rarely to the brain, breast and skin). In 81% of palpable tumours lymph node matastasis is found on the side of the tumour, and in 44% – at the opposite side (3). Even if at the time of diagnosis the distant metastases are not found, the recurrence rate after total thyroidectomy with lymphadenectomy is 50% (4).
The main markers of MTC are calcitonin and carcinoembryonic antigen (CEA). Serum calcitonin concentration correlates well with the tumour mass – for example, when the tumour diameter is approximately 3 mm serum calcitonin is below 100 pg/ml, and when the diameter is 25 mm – it exceeds 1000 pg/ml (5). Usually, when calcitonin is above 200 pg/ml, there are already metastases to the cervical lymph nodes on the side opposite to the tumour (6). The American Thyroid Association recommends preoperative diagnostic imaging oriented on searching for distant metastases in patients with calcitonin levels greater than 500 pg/ml or with lymph node metastasis (1). Increased calcitonin concentration in the patient after total thyroidectomy indicates incomplete tumour excision or recurrence. If serum calcitonin concentration after the surgery normalizes, pentagastrin-stimulation test (not available in Poland currently) or calcium gluconate-stimulation test may be considered. A 10-year survival rate for patients with biochemical remission (calcitonin undetectable under baseline conditions or after stimulation) is 97.7% (7). Evaluation of CEA level is important especially in patients with poorly differentiated MTC, in whom the neoplastic cells in the process of dedifferentiation lose their ability to synthesize and secrete calcitonin (1). The time that is needed to double the calcitonin and CEA concentrations plays an important prognostic role in patients with MTC (1).
Primary tumour diagnosis
Ultrasonography of the neck plays a fundamental role in the diagnosis of the primary tumour. Computed tomography (CT) and magnetic resonance imaging (MRI) are used mainly to assess tumour infiltration of the surrounding muscles, trachea, larynx, oesophagus, retro-oesophageal space and mediastinum.
Medullary cancer observed in ultrasonographic imaging is not significantly different from other thyroid cancers. As the tumour originates from parafollicular C cells, which are mainly located in the upper and central parts of the lobes, it is often found there. In heritable forms, the lesions are frequently multifocal, and may be present in both lobes (1). Ultrasound features indicating the malignancy of the thyroid tumour is a solid structure, hypoechogenicity, enhanced central flow, irregular margin, anterior-posterior dimension greater than the transverse one and internal calcifications (especially microcalcifications) (fig. 1A) (8, 9). Compared to the papillary cancer, however, MTC more often exhibitis the characteristics of benign lesions such as oval shape, homogeneous structure, cystic degenerative lesions or smooth well-defined margins (fig. 1B) (10). According to some authors, the morphology of up to 1/3 of the medullary cancers is not suspected in ultrasound imaging (9, 10). In the elastographic examination, MTC often does not have a typical for cancer “hard” character also (11). Hence, many experts call for the introduction of routine calcitonin determination in the diagnosis of thyroid focal lesions.
Fig. 1. A – thyroid tumor with characteristics suggestive of malignancy (solid structure, markedly reduced heterogeneous echogenicity, microcalcifications, irregular margins, infiltration of surrounding tissues); B – medullary thyroid cancer showing no typical ultrasound features of malignancy (solid with cystic areas, isoechogenic, homogenous, oval, smooth well-defined margins).
Ultrasound imaging is the basis for the classification of thyroid tumours for fine needle aspiration biopsy (FNAB), which is the golden standard in the diagnosis of thyroid cancer. FNAB sensitivity in the diagnosis of MTC is about 44-63% (12, 13). Medullary thyroid cancer may be misdiagnosed as follicular tumour, parathyroid tumour, poorly differentiated cancer of unknown aetiology or (rarely) anaplastic cancer. Immunocytochemical detection of calcitonin, calcitonin gene-related peptide (CGRP), chromogranin A, CEA or neuron-specific enolase (NSE), as well as calcitonin measurement in fine-needle aspiration biopsy wash-out fluid, significantly increase the diagnostic value of FNAB (1).
The size and morphology of the primary lesion significantly correlate both with lymph node and distant metastases. Metastases to cervical lymph nodes are found in 20-30% of tumours less than 1 cm in diameter and in more than 90% of lesions over 4 cm (14). In MTC it was also shown, that the presence of ultrasonographic features of tumour malignancy (solid, hypoechoic nodule with irregular margins) is associated with greater local advancement, higher incidence of lymph node and distant metastases and significantly poorer prognosis compared to benign ultrasound morphology (10).
Monitoring of patients
In the recurrence of MTC, the most important prognostic factors are early diagnosis, location of the tumour foci and proper qualification of patients for further treatment. In monitoring a patient after the surgery, it is essential to determine the concentrations of calcitonin and CEA periodically. The first test is recommended after 3 months (1). It shall not be performed earlier than 2-3 months after the surgery, due to the possibility of increased levels of calcitonin during wound healing and long half-life of calcitonin and CEA. Further measurements should be made depending on the results: if the concentrations are undetectable – every 6 months in the first year and then every 12 months; if they are detectable – at least every 6 months (1). In the case of undetectable or normal basal concentrations of calcitonin, the ultrasound of the neck should be performed and the stimulation test with pentagastrin or calcium (15) shall be considered.
In the case of local recurrence, reoperation is the only treatment that gives a chance for long-term remission or even curing the patient (16).
Imagining of both local recurrence as well as distant metastases of MTC is often a big challenge for the clinician. None of the currently available methods is sufficiently sensitive in the detection of local recurrence or metastatic lesions to be used alone. Even the combination of various diagnostic procedures allows for location of the recurrent tumour in approximately 40% of patients only (17).
Diagnosis of local recurrence and lymph node metastases
The lymph nodes are the most common site of MTC metastasis. At the time of diagnosis lymph node metastases are found in 75-81% of patients and the distant ones – in up to 13% (3, 18, 19).
In patients with calcitonin concentration of up to 150 pg/ml, the first-line examination is the ultrasound of the neck, since in these cases local recurrence or metastasis to the neck lymph nodes are most common (1). The lymph nodes with metastatic lesions are usually oval or round in shape (the ratio of the long to short axis of node is < 1.5), with blurred hilum, increased heterogeneous echogenicity, contain cystic degenerative lesions or calcifications and have chaotic blood flow in Doppler imaging. The sensitivity of ultrasound is 46-88%, similar to CT (42-86%) and MRI of the neck (38-91%), which are, however, complementary, as they allow to visualize the nodes inaccessible by ultrasound, located in the retro-tracheal as well as in the para- and retro-oesophageal space (20-25). An important role in the diagnosis of nodal metastases, especially when small nodes with no obvious morphological changes are found, plays the FNAB with the assessment of calcitonin concentration in the biopsy needle wash-out fluid (26).

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otrzymano: 2015-10-30
zaakceptowano do druku: 2015-11-23

Adres do korespondencji:
*Magdalena Kochman
Department of Endocrinology Centre of Postgraduate Medical Education Bielański Hospital
ul. Cegłowska 80, 01-809 Warszawa
tel. +48 (22) 834-31-31

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