核医学分子影像在放射性碘难治性分化型甲状腺癌评估中的独特价值与争议

doi:10.19401/j.cnki.1007-3639.2025.01.006

摘要/Abstract

摘要：

核医学分子影像具有无创、高灵敏度、时空动态可视化、可定性及定量分析等特点，借助融合影像技术的优势，兼备了反映功能代谢和解剖结构的特点。核医学分子影像评估贯穿于放射性碘难治性分化型甲状腺癌（radioactive iodine-refractory differentiated thyroid cancer，RAIR-DTC）诊治管理的全流程，包括界定、探查病灶、指导治疗决策、评价疗效及评估预后等。¹³¹I全身显像（¹³¹I-whole body scan，¹³¹I-WBS）是判断RAIR-DTC的重要依据。其中诊断性¹³¹I-WBS可在¹³¹I治疗前探查术后残留甲状腺及可疑摄碘性转移灶，有助于后续¹³¹I治疗决策。治疗后¹³¹I-WBS可进一步明确病灶摄碘特征，以及探查诊断性WBS未能显示的病灶，为明确患者临床分期、制订随访管理方案提供参考依据。治疗后¹³¹I-WBS显示的病灶摄碘能力还可预判¹³¹I治疗效果。¹³¹I-WBS结合血清学及其他影像学检查还可用于评价¹³¹I治疗效果。¹⁸F-FDG正电子发射计算机体层成像（positron emission tomography and computed tomography，PET/CT）主要用于血清甲状腺球蛋白（thyroglobulin，Tg）或Tg抗体（Tg antibody，TgAb）水平持续增高而¹³¹I-WBS阴性的高危DTC患者，可辅助寻找和定位病灶。¹⁸F-FDG PET/CT与¹³¹I-WBS结合有助于全面评估全身肿瘤负荷。DTC转移灶摄取¹⁸F-FDG预示着¹³¹I治疗效果不佳，患者生存预后较差，是疾病快速进展及肿瘤特异性死亡风险增高的预测因素。RAIR-DTC病灶接受局部或系统治疗后，可通过治疗前后的早期代谢反应预测患者的临床获益，以便及时调整治疗方案。此外，靶向反映新生血管生成的RGD肽及前列腺特异性膜抗原、靶向成纤维细胞激活蛋白、靶向生长抑素受体等的多种新型核素显像可作为¹⁸F-FDG PET/CT阴性时的补充手段，探查RAIR-DTC病灶，还可根据对显像剂的摄取能力筛选适合行靶向性核素治疗的患者，为多线治疗后疾病仍进展的RAIR-DTC患者提供有效的核素诊疗一体化新选择。

关键词: 分子影像, 分化型甲状腺癌, 放射性碘难治, 诊断, 治疗前评估, 疗效评价

Abstract:

Nuclear medicine molecular imaging has the characteristics of non-invasiveness, high sensitivity, spatiotemporal dynamic visualization, qualitative and quantitative analysis, and by virtue of the advantages of fusion imaging technology, it combines the features of functional metabolism and anatomical structure. Nuclear medicine molecular imaging evaluation is integrated throughout the management of radioactive iodine-refractory differentiated thyroid cancer (RAIR-DTC), including defining RAIR, exploring the lesions, guiding treatment decisions, evaluating efficacy, and assessing prognosis. ¹³¹I-whole body scan (¹³¹I-WBS) is critical for determining RAIR-DTC. Diagnostic ¹³¹I-WBS can be used to explore postoperative residual thyroid and suspected iodine-avid metastases before ¹³¹I treatment, which is helpful for subsequent ¹³¹I treatment decisions. Post-treatment ¹³¹I-WBS can further clarify the iodine uptake characteristics of lesions and explore lesions not shown by diagnostic WBS, providing a reference for clarifying the clinical stage of patients and formulating follow-up management plans. The iodine uptake ability of lesions shown by post-treatment ¹³¹I-WBS can also predict the therapeutic efficacy of ¹³¹I treatment. ¹³¹I-WBS combined with biochemical changes and other imaging examinations can also be used to evaluate the therapeutic efficacy of ¹³¹I treatment. ¹⁸F-FDG positron emission tomography and computed tomography (PET/CT) is mainly used for high-risk DTC patients with persistently elevated serum thyroglobulin (Tg) or Tg antibody (TgAb) levels and negative 131I-WBS, and can explore and locate lesions. Combining ¹⁸F-FDG PET/CT with ¹³¹I-WBS provides a thorough evaluation of the overall tumor burden. The uptake of ¹⁸F-FDG by DTC metastases indicates poor ¹³¹I treatment response and poor prognosis for patients, and is a predictor of rapid disease progression and an increased risk of tumor-specific death. After local or systemic treatment of RAIR-DTC lesions, the early metabolic response to treatment can predict the clinical benefit of patients, allowing for timely adjustment of treatment strategies. In addition, various new radionuclide imaging techniques targeting angiogenesis (such as RGD peptides and prostate specific membrane antigen), fibroblast activation protein and somatostatin receptor can be used as supplementary means when ¹⁸F-FDG PET/CT is negative to detect RAIR-DTC lesions. They can also screen patients who qualify for targeted radionuclide therapy based on the uptake ability of imaging agents. These novel theranostics provide new options for progressive RAIR-DTC patients after multiline treatment.

Key words: Molecular imaging, Differentiated thyroid cancer, Radioactive iodine-refractory, Diagnosis, Pre-treatment evaluation, Efficacy assessment

中图分类号:

R736.1

王任飞, 卢改霞. 核医学分子影像在放射性碘难治性分化型甲状腺癌评估中的独特价值与争议[J]. 中国癌症杂志, 2025, 35(1): 49-57.

WANG Renfei, LU Gaixia. The unique value and controversy of nuclear medicine molecular imaging in the evaluation of radioiodine-refractory differentiated thyroid cancer[J]. China Oncology, 2025, 35(1): 49-57.

图/表 4

参考文献 35

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