Update 2019 zur MIBI-Szintigrafie bei hypofunktionellen Schilddrüsenknoten

Zusammenfassung

^99 m Tc-MIBI ist ein nicht-spezifisches Radiopharmakon zur Tumordiagnostik und wurde historisch zum Nachweis radioiodnegativer Metastasen differenzierter Schilddrüsenkarzinome eingesetzt. ^99 mTc-MIBI hat einen klinischen Nutzen zur Abklärung hypofunktioneller („kalter“) Schilddrüsenknoten, wenngleich bisher kein kommerziell verfügbares Kit hierfür eine offizielle Zulassung hat. Seit der letzten Übersichtsarbeit zum klinischen Nutzen von ^99 mTc-MIBI zur Abklärung hypofunktioneller Schilddrüsenknoten in dieser Zeitschrift sind weitere Arbeiten publiziert worden, die den positiven und negativen Vorhersagewert der Methode präzisierten und auch die Kosteneffizienz der Methode belegten. Nach Injektion von ^99 mTc-MIBI wird die Retention des Radiopharmakons im abzuklärenden Knoten und dessen Anreicherung im Vergleich zum paranodulären Schilddrüsengewebe und im Vergleich zum Schilddrüsen-Szintigramm mit Pertechnetat beurteilt. Ein Match-Befund im Sinne einer konkordant verminderten Anreicherung hat einen hohen negativen prädiktiven Wert von ca. 94 % zum Ausschluss eines differenzierten Schilddrüsenkarzinoms. Ein Mismatch mit vermehrter Anreicherung des ^99 mTc-MIBI in einem hypofunktionellen Schilddrüsenknoten erhöht die Malignitätswahrscheinlichkeit auf ca. 15 – 20 % in Deutschland. Eine isointense Anreicherung des ^99 mTc-MIBI in dem hypofunktionellen Schilddrüsenknoten geht nach eigener Datenlage mit einer niedrigen Malignitätswahrscheinlichkeit einher, allerdings findet man in dieser Befundkategorie kleine papilläre Karzinome, die sich bei geringer Größe noch nicht eindeutig ^99 mTc-MIBI-mehranreichernd demarkieren müssen. SPECT hat hier in 17 – 34 % einen diagnostischen Zugewinn. Bei guter Indikationsstellung ist die ^99 mTc-MIBI-Szintigrafie eine wertvolle ergänzende Methode zur Feinnadelaspirationsbiopsie und dient einem optimierten Patientenmanagement, um im Falle eines Match-Befundes ein konservatives Vorgehen zu vertreten oder im Falle eines Mismatch-Befundes ein operatives Vorgehen unter Berücksichtigung von Alter, Begleiterkrankungen und in Kenntnis des vollständigen Schilddrüsenbefundes zu rechtfertigen. Die offizielle Zulassung dieser Indikation ist überfällig.

Abstract

^99 mTc-MIBI is a non-specific radiopharmaceutical for tumor imaging. Historically, it was used for detection of radioiodine-negative metastases of differentiated thyroid carcinomas, an indication which has been replaced by FDG-PET nowadays. ^99 mTc-MIBI is clinically useful for evaluation of cold thyroid nodules, although no commercially available kit has an official registration for this indication. Since the last publication about the clinical usefulness of ^99 mTc-MIBI for evaluation of cold thyroid nodules in this journal further data about this topic emerged characterizing the positive and negative predictive value of this method in more detail and reporting about its cost-effectiveness. After injection of ^99 mTc-MIBI retention of this radiopharmaceutical in the thyroid nodule in comparison to the paranodular thyroid tissue and in comparison to pertechnetate scintigraphy has to be described. A match finding with concordant low uptake has a high negative predictive value of about 94 % to exclude malignancy for differentiated thyroid carcinoma. A mismatch with increased ^99 mTc-MIBI uptake in the cold thyroid nodule has a likelihood of malignancy of about 15 – 20 % in Germany. An isointense ^99 mTc-MIBI uptake in the cold thyroid nodule has a low likelihood for malignancy according to our data. However, in this category some small papillary thyroid carcinomas have been described which did not show clearly increased uptake most likely due to their small size. SPECT has added value in 17 – 34 % of cases. ^99 mTc-MIBI scintigraphy is a very valuable method in addition to fine needle aspiration cytology for improved patient management. In case of a match finding a conservative approach can be justified and in case of a mismatch selective surgery can be indicated taking into account patient age, comorbidities and the findings of a full thyroid evaluation. The official approval of this indication is overdue.

Schlüsselwörter

hypofunktioneller Schilddrüsenknoten - ^99 mTc-MIBI - Sestamibi - Schilddrüsenkarzinom

Keywords

hypofunctioning/cold thyroid nodule - ^99 mTc-MIBI - sestamibi - thyroid carcinoma

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