Background: Publication of the 2015 American Thyroid Association (ATA) management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer was met with disagreement by the extended nuclear medicine community with regard to some of the recommendations related to the diagnostic and therapeutic use of radioiodine (131 I). Because of these concerns, the European Association of Nuclear Medicine and the Society of Nuclear Medicine and Molecular Imaging declined to endorse the ATA guidelines. As a result of these differences in opinion, patients and clinicians risk receiving conflicting advice with regard to several key thyroid cancer management issues. Summary: To address some of the differences in opinion and controversies associated with the therapeutic uses of 131 I in differentiated thyroid cancer constructively, the ATA, the European Association of Nuclear Medicine, the Society of Nuclear Medicine and Molecular Imaging, and the European Thyroid Association each sent senior leadership and subject-matter experts to a two-day interactive meeting. The goals of this first meeting were to (i) formalize the dialogue and activities between the four societies; (ii) discuss indications for 131 I adjuvant treatment; (iii) define the optimal prescribed activity of 131 I for adjuvant treatment; and (iv) clarify the definition and classification of 131 I-refractory thyroid cancer. Conclusion: By fostering an open, productive, and evidence-based discussion, the Martinique meeting restored trust, confidence, and a sense of collegiality between individuals and organizations that are committed to optimal thyroid disease management. The result of this first meeting is a set of nine principles (The Martinique

† Breast cancer, colon cancer, lung cancer, lymphoma, melanoma, sarcoma, and head and neck cancer.‡ Patient management includes diagnostic management and treatment management. § Patient clinical outcomes include overall survival, event-free survival, progression-free survival, disease-specific survival, disease-free survival, skeletal-related events, or change in outcome.

Background: The American Thyroid Association (ATA), the European Association of Nuclear Medicine, the European Thyroid Association, and the Society of Nuclear Medicine and Molecular Imaging have established an intersocietal working group to address the current controversies and evolving concepts in thyroid cancer management and therapy. The working group annually identifies topics that may significantly impact clinical practice and publishes expert opinion articles reflecting intersocietal collaboration, consensus, and suggestions for further research to address these important management issues. Summary: In 2019, the intersocietal working group identified the following topics for review and interdisciplinary discussion: (i) perioperative risk stratification, (ii) the role of diagnostic radioactive iodine (RAI) imaging in initial staging, and (iii) indicators of response to RAI therapy. Conclusions: The intersocietal working group agreed that (i) initial patient management decisions should be guided by perioperative risk stratification that should include the eighth edition American Joint Committee on Cancer staging system to predict disease specific mortality, the modified 2009 ATA risk stratification system to

On the basis of 8 patients of our own and a survey of the literature, the present state of chemotherapy of thyroid carcinoma is discussed. Chemotherapy is only indicated in cases of progressing disease after exhaustion of all conventional therapies. Only in cases of undifferentiated giant- or spindle-cell thyroid carcinomas can chemotherapy following conventional treatment be approved right from the beginning. The three most widely applied cytostatics are adriamycin, bleomycin and cis-platinum, and it seems that adriamycin monotherapy, is superior to all other therapies, even combinations, except probably for the undifferentiated thyroid carcinoma. In addition to the patient's general condition, a sufficiently high single dose of adriamycin, which should be increased in case of nonresponse, appears to be essential for the therapeutical effect. Due to its low toxicity, especially cardiotoxicity, 4'-epi-adriamycin, which, while being almost as effective, can be applied at higher doses and over longer periods, seems to be promising. Approximately 1/3 of thyroid carcinomas respond to adriamycin monotherapy, the response rate probably being highest for medullary types and lowest for undifferentiated thyroid carcinomas. The highest response is observed in the case of pulmonary metastases, followed by bone metastases and local tumor growth. If thyroid carcinomas respond to chemotherapy--even by no-change behavior only--a prolongation of median survival rates from 3-5 months (nonresponders) to 15-20 months (responders) can be achieved.

In the last decade, myocardial perfusion imaging (MPI) with PET has emerged to play a pivotal role in the clinical routine process for the detection of hemodynamically significant obstructive coronary artery disease (CAD) and cardiovascular risk stratification (1-5). The high spatial and contrast resolution in concert with photon attenuation-free images of PET have led to high image quality associated with the highest sensitivity and specificity of PET/CT perfusion imaging in the detection and characterization of CAD (1,2,6,7). In addition, the noninvasive evaluation and quantification of global and regional myocardial blood flow (MBF) in milliliters per gram per minute during hyperemic stress and at rest, as well as the calculation of the resulting myocardial flow reserve (MFR), extends the scope of standard MPI from the detection of advanced and flow-limiting epicardial CAD to a comprehensive assessment of ischemic burden. This improved scope results not only from the traditionally sought significant left main or multivessel disease, but also from the more recently appreciated cardiac effects of nonobstructive CAD and coronary microvascular disease (CMD), which conveys important diagnostic and incremental prognostic information (1,2,4-11). The increased availability and high sensitivity of PET MPI in concert with concerns about missed diagnoses, however, may at times lead to an inappropriate application of this technology. Thus, to avoid unnecessary financial burden on the health-care system and, in some cases, unnecessary exposure of patients to ionizing radiation, we have established a consensus document that outlines the most appropriate and cost-effective use of PET MPI. It is hoped that this expert guidance will help to render the use of PET MPI more consistent and will improve health-care outcomes for the targeted patient population while minimizing unnecessary imaging costs. The goal of this document is to describe the appropriate use of PET MPI in patients with suspected or known CAD and in patients with suspected microvascular angina. Through these recommendations, it is expected that PET MPI will be applied to benefit these patients in the most cost-effective manner. Representatives from the Society of Nuclear Medicine and Molecular Imaging (SNMMI), the American College of Cardiology (ACC), the American Society of Nuclear Cardiology (ASNC), the Canadian Cardiovascular Society (CCS), the Canadian Society of Cardiovascular Nuclear and CT Imaging (CSCNCTI), the Society of Cardiovascular CT (SCCT), the American Heart Association (AHA), the American College of Physicians (ACP), and the European Association of Nuclear Medicine (EANM) assembled as an autonomous workgroup to develop the following appropriate use criteria (AUC). This process was performed in accordance with the Protecting Access to Medicare Act of 2014. This legislation requires that all referring physicians consult AUC by using a clinical decision support mechanism before ordering any advanced diagnostic imaging services. Such services are de...

Fifty-seven (35.6%) of 160 patients with papillary thyroid carcinoma had lymph node metastases at the primary treatment. Children and adolescents were most frequently affected (69.2%), followed by the age group of 21-40-year olds (38.8%). Those older than 40 had the lowest incidence of lymph node metastases (29.6%; p less than 0.05). One fifth of all patients had lymph node metastases as first indication of papillary thyroid carcinoma. Two thirds of these patients were 40 years old or younger. Lymph node involvement affected the jugular vein in nearly all cases (78.8%) and the upper mediastinum as well in just under 15%. Women predominated (67.5 vs. 35.3%; p less than 0.05) if there was intrathyroidal tumor growth with lymph node metastases which occurred most frequently in the age group of 21-40-year olds. On the other hand, men had the highest incidence (67.7 vs. 32.5%; p less than 0.05) of lymph node metastases in connection with tumor growth outside the organ. Fixed lymph node metastases occurred more often in men, particularly in those older than 40 years of age. A pT4 stage (tumor growth outside the organ, 66.7%) was often present at the same time. Especially young patients had a high incidence of lymph node metastases in connection with multifocal intrathyroidal tumor growth, the lymph node metastases often being substantially larger than the mostly occult foci of thyroid carcinomas. Cystic degenerations were occasionally mistaken for cervical cysts.

Twenty-two of 251 patients with differentiated thyroid carcinoma suffered from or had a history of hyperthyroidism. They were hyperthyroid with a diffuse goitre (N=4), a diffuse goitre with a cold nodule (N= 10), a multinodular goitre (N=6), and an autonomous adenoma (N=2). Among the 22 patients, more than one fourth had an occult thyroid carcinoma with a diameter of 1 cm or less, those with the papillary tumour types, less frequently had lymph node metastases than the total group of patients with papillary carcinomas (13.3 vs 35.6%). The clinical courses of the 22 patients resembled those of the other thyroid carcinoma patients whose age and initial findings were comparable. In 643 patients who underwent surgery for hyperthyroidism the incidence of thyroid carcinoma was 2.3%. The increase in coincidence of hyperthyroidism and thyroid carcinoma repeatedly reported in recent years is probably ascribable primarily to extensive and improved diagnostics and not to a direct connection between hyperthyroidism and development of thyroid carcinoma. On the other hand, our findings do confirm that, even in the presence of hyperthyroidism, all thyroid nodules require careful diagnostics for exclusion of malignancy.Opinions differ as to whether a connection exists between hyperthyroidism and thyroid carcinoma. In 1937, Means (1) still considered hyperthyroid¬ ism to be an "insurance against cancer of the thy¬ roid". This assumption was questioned in the early fifties (2,3), and, by the mid-sixties, a connection was even seen between hyperthyroidism and thy¬ roid carcinoma (4). The carcinoma incidence was between 0.2 and 0.5% in the large investigation series of Beahrs et al. (2;3029 patients with Graves' disease), Sokal (3; 13621 patients with hyperthy¬ roidism) and the prospective study of Dobyns et al.

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