Value of 201Tl imaging in predicting therapeutic 131I uptake in patients with thyroglobulin-positive but 131I scan-negative differentiated thyroid carcinoma

Background: Serum thyroglobulin assay and 131Iodine (1311) whole body scan are considered complementary in detecting malignant thyroid tissue or metastases. A large number of patients, however, are encountered presenting with scan-negative, thyroglobulin-positive differentiated thyroid carcinoma posing a dilemma in therapeutic management. One of the first alternative scanning agents to be employed is 201Thallium (201Tl). Recent studies have demonstrated its usefulness in identifying lesions that are not visualized with traditional 131I whole body scan. It is not clear, however, whether 201Tl scan helps in the decision-making for subsequent 131I therapy. This study was conducted to determine if 201Tl scan can predict therapeutic 131I uptake and to define the clinical role of 201Tl scanning in these patients. Methods and results: A total of 12 patients (20-63 y/o), 5 males and 7 females, underwent surgery for differentiated thyroid cancer and all had serum thyroglobulin values above 10 ng/ml and normal TPO autoantibodies. Pre-therapy 131I scan using 111 MBq (3mCi) of 131I were obtained. As required for inclusion, all patients had negative pre-therapy scan and negative TPO autoantibody results and underwent 20lTl scanning within 3 weeks. All patients were given 131I therapy (3.7-5.5 GBq or 100-150 mCi) between one to two months after 201Tl scanning. Within a week after therapy, all patients underwent whole body 1311 scanning. 201Tl imaging demonstrated thyroid remnants in 9 out of 12 patients having positive 201Tl scan but negative pre-therapy 1311 scan. However, only 2 of the positive 201Tl scans showed 131I uptake post-therapy (positive predictive value of 20%). None of the subjects presented with a negative 201Tl scan and a positive post-therapy 131I scan. Conclusion: Our study suggests that evidence of remnants or metastases on 201Tl scanning may be an inappropriate basis for the decision to proceed with 131I therapy. The role of 20lTl imaging in this subset of patients may be limited to localization of metastases for surgical excision or localized radiation therapy. (authors)