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Images In Medicine
2017:30:1;48-48
PMID: 28731009

Interlesional 'flip-flop' between 68Ga-DOTATATE and FDG-PET/CT in thyroglobulin-elevated negative iodine scintigraphy (TENIS) syndrome

Sandip Basu, Ashwini Kalshetty, Preeti Fargose
 Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Jerbai Wadia Road, Parel, Mumbai, Maharashtra, India

Corresponding Author:
Sandip Basu
Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Jerbai Wadia Road, Parel, Mumbai, Maharashtra
India
drsanb@yahoo.com
How to cite this article:
Basu S, Kalshetty A, Fargose P. Interlesional 'flip-flop' between 68Ga-DOTATATE and FDG-PET/CT in thyroglobulin-elevated negative iodine scintigraphy (TENIS) syndrome. Natl Med J India 2017;30:48
Copyright: (C)2017 The National Medical Journal of India

Patients with elevated thyroglobulin and negative iodine scintigraphy (TENIS) are a challenging group among patients of thyroid carcinoma. Currently, multiple therapeutic options and approaches (such as tyrosine kinase inhibitors, PRRT) are being explored. We illustrate the case of an 81-year-old man with a diagnosis of TENIS with both pulmonary and skeletal metastases (serum thyroglobulin level >300 μg/dl), where an interesting ‘flip-flop’ phenomenon was observed between individual metastatic lesions: the skeletal lesions were mostly 68Ga-DOTATATE-positive (SUVmax 15.27 and 8.52) but FDG-negative (SUVmax 1.5 and 2.8) whereas the pulmonary lesions were FDG-positive (SUVmax 10.44) with minimal or absent uptake on 68Ga-DOTATATE-PET/CT (SUVmax 3.7; [Figure - 1]). A solitary left pulmonary lesion was negative on both tracers ([Figure - 1] coronal slices). Interestingly, the patient had a recent history of associated middle ear infection, which was manifested by uptake on FDG-PET/CT in the petrous bone ([Figure - 1] MIP). Biopsy of the prominent right lung nodule showed a focus of poorly differentiated thyroid carcinoma arising in a conventional papillary thyroid carcinoma. The patient had relatively stable disease compared to his previous FDG-PET/CT (68Ga-DOTATATE was not done previously). In view of his skeletal symptoms and the vertebral lesions showing intense uptake on 68Ga-DOTATATE PET/CT, he was considered for PRRT with 177Lu-DOTATATE.

Figure 1: 1. MIP and fused coronal and transaxial slices of PET-CT with 68Ga-DOTATATE (left columns) and FDG (right columns) showing interlesional 'flip-flop' between the two PET tracers

Molecular imaging with multitracer PET can depict tumour biology and aid in devising management strategy.


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