ORIGINAL ARTICLE Journal of Breast Cancer J Breast Cancer 2009 December; 12(4): DOI: /jbc 유방암환자의 F-18 FDG PET/CT 영상에서우연히관찰

Size: px

Start display at page:

Download "ORIGINAL ARTICLE Journal of Breast Cancer J Breast Cancer 2009 December; 12(4): DOI: /jbc 유방암환자의 F-18 FDG PET/CT 영상에서우연히관찰"

승겨 봉
5 years ago
Views:

1 ORIGINAL ARTICLE Journal of Breast Cancer J Breast Cancer 2009 December; 12(4): DOI: /jbc 유방암환자의 F-18 FDG PET/CT 영상에서우연히관찰되는갑상샘의미만성섭취증가의임상적의의 정영진 1,4 ㆍ임석태 1,3,4 ㆍ김동욱 1,3,4 ㆍ정환정 1,3,4 ㆍ윤현조 2,3 ㆍ정성후 2,3 ㆍ손명희 1,3,4 전북대학교의학전문대학원 1 핵의학교실 2 외과학교실 3 임상의학연구소 4 사이클로트론연구소 The Clinical Significance of Diffuse Thyroid Uptake That is Incidentally Identified by F-18 FDG PET/CT Imaging in Patients with Breast Cancer Young Jin Jeong 1,4, Seok Tae Lim 1,3,4, Dong Wook Kim 1,3,4, Hwan-Jeong Jeong 1,3,4, Hyun Jo Youn 2,3, Sung Hoo Jung 2,3, Myung-Hee Sohn 1,3,4 Departments of 1 Nuclear Medicine, 2 Surgery, 3 Research Institute of Clinical Medicine, and 4 Cyclotron Research Center, Chonbuk National University Medical School and Hospital, Jeonju, Korea Purpose: This study was to investigate the clinical significance of diffusely increased F-18 FDG uptake in the thyroid gland as an incidental finding on F-18 FDG PET/CT imaging in patients with breast carcinoma. Methods: One hundred four patients with breast carcinoma who had no prior history of thyroid disease were enrolled. All patients underwent F- 18 FDG PET/CT, ultrasound and thyroid function test (TFT- TSH, FT4, and T3), anti-tpo antibody test within 2 weeks. Also we checked estrogen (ER) and progesterone receptors (PR). We classified all patients into subgroups according to the existence and degree of F-18 FDG uptake in the thyroid gland, and evaluated the difference between subgroups. Results: Of the 104 patients, 42 (40.4%) subjects showed diffusely increased thyroid uptakes. There was no significant difference in rate of abnormality in TFT and thyroid US, and existence of anti-tpo antibody and ER/PR between two groups. Of 42 patient who showed diffuse uptake, 12 (28.5%), 13 (31.0%), and 17 (40.5%) subjects demonstrated hypointense, isointense, and hyperintense thyroid uptake compared with activity of mediastinal blood pool. Thirteen (76.4%) of 17 subjects in the hyperintense thyroid uptake group revealed abnormality in various tests (US, TFT, and anti-tpo antibody). The rate of abnormality in this group was significantly different with the other two groups (p=0.002). Conclusion: Our data suggested that the rate of diffuse thyroid uptakes on F-18 FDG PET/CT imaging of patients with breast carcinoma was higher than healthy subjects. In case of someone who had no prior thyroid disease showed diffuse thyroid uptakes more than activity of mediastinal blood pool on F-18 FDG PET/CT imaging, it should be considered further evaluation about the thyroid gland. Key Words: Breast, Carcinoma, Diffuse, F-18 FDG PET/CT, Thyroid 중심단어 : 유방, 암, 미만성, F-18 FDG 양전자방출단층촬영, 갑상샘 책임저자 : 임석태 전북전주시덕진구금암동산 2-20, 전북대학교의학전문대학원핵의학과 Tel: , Fax: stlim@chonbuk.ac.kr 접수일 : 2009년 5월 13일게재승인일 : 2009년 7월 6일 This study was supported by Nuclear Research & Development Program of the Korea Science and Engineering Foundation (KOSEF) grant founded by the Korean governmnet (MEST) (Grant code: ). 서론 Fluorine-18 Fluoro-2-Deoxy-D-Glucose Positron Emission Tomography/Computed Tomography (F-18 FDG PET/ CT) 는포도당과유사한물질인 FDG 에방사성동위원소인 F-18 을표지한후체내에주입하여당대사가높은병변을평가하는비 309

310 Young Jin Jeong, et al. 침습적영상진단장비로써, 대부분의암이포도당대사가높은점에착안하여현재많은암의진단과추적검사에사용되고있다. 유방암은현재빈도가증가하고있는관심의대상이되는질환으로진단과추적관찰에대해많은검사법들이연구되고있다.

갑상샘은일반적으로지방산대사가당대사보다원활한장기로알려져있기때문에,(4,5) 보통의경우에는갑상샘은 F-18 FDG PET/CT를이용한최대강도투사 (maximum intensity projection, MIP) 영상에서는관찰되지않는것으로일반적으로알려져있다.

(7-12) 갑상샘질환의기왕력이없는유방암환자의수술후 F-18 FDG PET/CT 영상에서갑상샘의미만성섭취증가소견은정상인에비해흔히관찰되는소견으로생각되며, 유방암과갑상샘질환사이에연관성이있음에관한기존의연구들을고려해볼때,(13,14) 유방암환자에서우연히보이는갑상샘의미만성 F-18 FDG 섭취증가는갑상샘의이상과관련이있을것으로생각된다.

방법대상환자 2000년 1월에서 2008년 10 월사이에유방암으로수술을시행받고 F-18 FDG PET/CT 검사를받은환자중에서유방암진단전에갑상샘관련질환이없었던 104명의환자 (51.9±8.3세) 를대상으로하였다.

F-18 FDG PET/CT 검사방법모든환자는영상촬영전최소한 6시간이상의금식과충분한수분섭취 (1 L 정도 ) 를하고적정혈당 (180 mg/dl 이하 ) 이확인된후에검사를시행하였다. PET/CT (Biograph16 Hi-Res; Siemens, Erlangen, Germany) 를이용해두개골기저부에서 B D A C E Figure 1.

2 310 Young Jin Jeong, et al. 침습적영상진단장비로써, 대부분의암이포도당대사가높은점에착안하여현재많은암의진단과추적검사에사용되고있다. 유방암은현재빈도가증가하고있는관심의대상이되는질환으로진단과추적관찰에대해많은검사법들이연구되고있다. F- 18 FDG PET/CT도최근에유방암의진단과치료효과판정및재발평가를포함하는추적관찰에있어유용한검사로인정받고있으며,(1-3) 유방암에서 F-18 FDG PET/CT를이용한검사건수도증가하고있다. 이러한유방암환자의경과관찰을위한 F- 18 FDG PET/CT 영상에서갑상샘질환의기왕력이없는환자에서도갑상샘에미만성의당대사증가소견을종종발견할수있다. 갑상샘은일반적으로지방산대사가당대사보다원활한장기로알려져있기때문에,(4,5) 보통의경우에는갑상샘은 F-18 FDG PET/CT를이용한최대강도투사 (maximum intensity projection, MIP) 영상에서는관찰되지않는것으로일반적으로알려져있다.(6) 정상인을대상으로시행한기존의몇몇연구에서우연히발견된갑상샘의미만성섭취증가의의미에대해서연구했으며, 이러한소견이보이는경우정상에서보이는비특이적인소견이거나갑상샘염과연관되어있음을보고하였다.(7-12) 갑상샘질환의기왕력이없는유방암환자의수술후 F-18 FDG PET/CT 영상에서갑상샘의미만성섭취증가소견은정상인에비해흔히관찰되는소견으로생각되며, 유방암과갑상샘질환사이에연관성이있음에관한기존의연구들을고려해볼때,(13,14) 유방암환자에서우연히보이는갑상샘의미만성 F-18 FDG 섭취증가는갑상샘의이상과관련이있을것으로생각된다. 지금까 지유방암에서이러한소견이갖는의미에관한연구는없었기때문에, 저자들은갑상샘질환의기왕력이없는유방암환자에서수술후에시행한 F-18 FDG PET/CT 영상에서우연히발견된미만성의갑상샘섭취증가의임상적의미에대하여알아보고자하였다. 방법대상환자 2000년 1월에서 2008년 10 월사이에유방암으로수술을시행받고 F-18 FDG PET/CT 검사를받은환자중에서유방암진단전에갑상샘관련질환이없었던 104명의환자 (51.9±8.3세) 를대상으로하였다. 모든환자들은 2주이내에 F-18 FDG PET/CT, 갑상샘초음파, 갑상샘기능검사 (triiodothyronine [T3], free thyroxine [FT4], thyroid-stimulating hormone [TSH]) 와갑상샘자가항체검사중항TPO 항체를시행받았다. 또한수술결과를토대로모든환자에서프로게스테론수용체와에스트로겐수용체의양성여부를조사하였다. F-18 FDG PET/CT 검사방법모든환자는영상촬영전최소한 6시간이상의금식과충분한수분섭취 (1 L 정도 ) 를하고적정혈당 (180 mg/dl 이하 ) 이확인된후에검사를시행하였다. PET/CT (Biograph16 Hi-Res; Siemens, Erlangen, Germany) 를이용해두개골기저부에서 B D A C E Figure 1. A case of diffusely increased F-18 FDG uptake, but less than activity of mediastinal blood pool, in the thyroid gland of 55-yrold patient. On ultrasound examination, echogenecity of thyroid gland was homogeneous and blood flow was normal. Serum TSH was 2.61 miu/l (reference range, miu/l), free T4 was 10.9 ng/dl (reference range, ng/dl) and T3 was 2.03 ng/dl (reference range, ng/dl), suggestive of normal state of thyroid function. Shown are 3D MIP image (A), transaxial PET image (B), transaxial fused PET/CT image (C), ultrasound image (D), and doppler ultrasound image (E).

Diffuse F-18 FDG Thyroid Uptake 311 근위대퇴부까지전신영상을얻었다.

25 MBq) 를정맥내로주입하고 50-60분간안정을취하도록하였다. 안정후먼저 CT 로투과영상을얻었다.

iterations, 8 subsets) 을이용하여재구성하였고, CT 영상을이용하여감쇠보정하였다.

종격동의혈액풀의섭취정도와비교하여갑상샘의섭취정도가혈액풀과비교하여낮은군, 비슷한군, 높은군의세그룹으로분류하였고

A case of diffusely increased F-18 FDG uptake, similar intensity

flow was mildly increased. Serum TSH was 2.09 miu/l, free T4 was 11.

22 ng/dl, suggestive of normal state of thyroid function.

A case of intensely and diffusely increased F-18 FDG uptake, more

3 Diffuse F-18 FDG Thyroid Uptake 311 근위대퇴부까지전신영상을얻었다. 소변배설을원활히하기위해라식스 20 mg 을경구섭취하고 F-18 FDG (kg당 9.25 MBq) 를정맥내로주입하고 50-60분간안정을취하도록하였다. 안정후먼저 CT 로투과영상을얻었다. 바로이어서 10-15분간에걸쳐 PET 으로방출영상을획득하였으며, PET 영상은 OSEM 알고리즘 (4 iterations, 8 subsets) 을이용하여재구성하였고, CT 영상을이용하여감쇠보정하였다. F-18 FDG PET/CT 영상분석촬영된 F-18 FDG PET/CT 영상은 2명의숙련된핵의학과의사가고해상도모니터를이용해육안분석하였다. MIP 영상과평면영상을이용해갑상샘의 F-18 FDG 섭취정도를평가하였으며, 미만성의갑상샘섭취증가를보인경우, 종격동의혈액풀의섭취정도와비교하여갑상샘의섭취정도가혈액풀과비교하여낮은군, 비슷한군, 높은군의세그룹으로분류하였고 (Figures 1-3), B D A C E Figure 2. A case of diffusely increased F-18 FDG uptake, similar intensity with mediastinal blood pool, in the thyroid gland of 46-yr-old patient. On ultrasound examination, thyroid gland was homogeneous and blood flow was mildly increased. Serum TSH was 2.09 miu/l, free T4 was 11.3 ng/dl and T3 was 1.22 ng/dl, suggestive of normal state of thyroid function. B D A C E Figure 3. A case of intensely and diffusely increased F-18 FDG uptake, more than activity of mediastinal blood pool, in the thyroid gland of 58-yr-old patient. On ultrasound examination, thyroid gland was prominent and heterogeneous. Blood flow of thyroid gland was slightly increased. Serum TSH was 2.09 miu/l, free T4 was 11.3 ng/dl, T3 was 1.22 ng/dl and TPO antibodies were elevated at 100 IU/mL (reference range, IU/mL), suggestive of diagnosis of Hashimoto s thyroiditis.

4 312 Young Jin Jeong, et al. 각그룹들에서여러가지검사결과들을비교하였다. 통계분석 F-18 FDG PET/CT 영상에서관찰된갑상샘의섭취증가여부와정도를보고분류한그룹들사이에서여러가지검사상비정상의결과를보인빈도의차이를비교하기위해 Pearson chi-square test 혹은 Fisher s exact test를시행하였다. 통계분석은 SPSS 14 (SPSS Inc., Chicago, USA) 프로그램을이용하였으며, p 값이 0.05 이하일때통계적유의성이있는것으로정하였다. 미만성갑상샘섭취증가 결 전체 104명의유방암환자중에서 42명 (40.4%) 의환자의갑상샘이미만성의 F-18 FDG의섭취증가를보였으며, 나머지 62 명 (59.6%) 의환자들은갑상샘의섭취증가가관찰되지않았다. 섭 Table 1. Number of patients with abnormal laboratory data, surgical data, and US finding in two groups, classified by diffuse thyroid uptake Parameter No. of total patients 과 With diffuse thyroid uptake Without diffuse thyroid uptake p- value No. of patients with * abnormal TFT No. of patients with anti-tpo Ab No. of patients with abnormal US finding No. of patients with * positive ER/PR TFT=thyroid function test; anti-tpo Ab=anti-thyroid peroxidase antibody; US=ultrasound; ER/PR=estrogen receptor/progesterone receptor. *Pearson chi-square test; Fisher s exact test. 취증가를보였던 42 명의환자를종격동의혈액풀의섭취정도와비교하였을때, 12 명 (28.5%) 은갑상샘의섭취정도가종격동의혈액풀보다낮았으며, 13 명 (31.0%) 은유사한정도의섭취증가를보였고, 17명 (40.5%) 은갑상샘의섭취정도가더높았다 (Tables 1, 2). 미만성갑상샘섭취증가를보인그룹과보이지않은그룹간비교갑상샘기능검사상총 104 명중 17 명에서이상소견을보였고, 미만성의섭취증가를보인환자 42 명중 8명 (19.0%, 기능항진 : 2명, 무증상기능저하 : 5명, 무증상기능항진 : 1명 ), 섭취증가가없었던 62명중 9명 (14.5%, 기능저하 : 2명, 기능항진 : 3명, 무증상기능저하 : 4명 ) 이었다 (Table 1). 갑상샘에관한자가항체중항TPO 검사에양성을보인환자는전체대상환자 104명중 6명 (5.8%) 이었고, 미만성의섭취증가를보인환자 42명중 5명 (11.9%), 섭취증가가없었던 62 명중 1명 (1.6%) 이었다. 갑상샘초음파검사상이상소견을보인환자는총 12 명이었고, 모두갑상샘염에합당한초음파소견을보였다. 12 명의환자중에서 10 명은미만성갑상샘섭취증가를보였으며, 나머지 2명은섭취증가를보이지않았다. 수술결과를토대로조사한프로게스테론수용체와에스트로겐수용체의양성여부를조사하였을때, 총 104 명의환자중양성은 60명 (57.7%), 음성은 44 명 (42.3%) 이었다. 미만성갑상샘섭취증가를보인 42명에서양성은 23명 (54.8%), 음성은 19명 (45.2%) 이었고, 섭취증가를보이지않았던 62명중, 37명 (59.7%) 에서양성, 25명 (40.3%) 에서음성소견을보였다. F-18 FDG PET/CT 영상에서갑상샘의미만성섭취증가여부에따라분류한두그룹에서갑상샘기능검사, 초음파, 항TPO 항체, 수용체검사상통계적으로유의한차이는보이지않았다. Table 2. Number of patients with abnormal laboratory data, surgical data, and US finding in three groups, classified by degree of thyroid uptake Total (n=42) Group 1 (n=12) Group 2 (n=13) Group 3 (n=17) p-value No. of patients with abnormal TFT 1 (hyperthyroidism), 1 (hyperthyroidism) 3 (subclinical hypothyroidism), 0.453* 2 (subclinical hypothyroidism) 1 (subclinical hyperthyroidism) No. of patients with anti-tpo Ab * No. of patients with abnormal US finding 0 1 (thyroiditis) 9 (thyroiditis) 0.001* No. of patients with positive ER/PR * TFT=thyroid function test; anti-tpo Ab=anti-thyroid peroxidase antibody; US=ultrasound; ER/PR=estrogen receptor/progesterone receptor; Group 1=less than blood pool activity of mediastinum; Group 2=equal to blood pool activity of mediastinum; Group 3=higher than blood pool activity of mediastinum. *Fisher s exact test.

5 Diffuse F-18 FDG Thyroid Uptake 313 미만성갑상샘섭취증가를보인그룹에서섭취정도에따른그룹간의비교갑상샘의미만성섭취증가를보인 42 명의환자에서갑상샘기능검사를시행하였을때, 기능검사상 34 명 (81.0%) 은정상이었고, 나머지 8명 (19.0%) 은이상소견을보였다 (Table 2). 그중 2명 (4.7%) 은갑상샘기능항진, 5명 (11.9%) 은무증상갑상샘기능저하, 1명 (2.4%) 은무증상갑상샘기능항진소견을보였다. 특히갑상샘의 F-18 FDG 섭취정도가혈액풀보다높았던 17 명중 4명 (23.5 %) 에서갑상샘기능이상소견을보였다. 갑상샘항체검사상양성을보였던환자 6명중에서 5명은미만성갑상샘섭취증가를보였고, 나머지 1명은섭취증가소견을보이지않았다. 항체양성이면서미만성섭취증가소견을보였던 5명중 4명은갑상샘의섭취정도가혈액풀보다높은소견을보였으며, 나머지 1명은혈액풀보다낮은소견을보였다. 갑상샘초음파에서는미만성갑상샘섭취증가를보였던 42 명의환자들중 10 명에서갑상샘염소견을보였고, 이들중 3명에서갑상샘기능검사상이상소견을보이거나항TPO 항체가양성이었다. 초음파상이상소견을보였던 10 명중 9명은혈액풀보다높은섭취증가를보였으며, 나머지 1명은혈액풀과유사한정도의섭취증가를보였다. 수술결과를참조하여조사한유방암조직검사상프로게스테론수용체와에스트로겐수용체는총 42 명의환자중 23 명 (54.8%) 에서양성소견을보였다. 갑상샘의미만성섭취증가의정도로나눈 3그룹사이에서수용체양성정도에는유의한차이를보이지않았다 (p=0.377). 고찰여러가지종양의평가에사용되고있는 F-18 FDG PET/CT 영상에서갑상샘은지방산대사가높으므로 (4,5) 정상적인경우관찰되지않는것이일반적으로알려져있다.(6) 하지만우연한갑상샘의 F-18 FDG 섭취증가를종종관찰할수있는데, 섭취증가를보이는형태에따라갑상샘의일부에만국한하여섭취증가를보이는국소적인형태, 갑상샘전반에증가된섭취를보이는미만성의형태, 그리고미만성섭취증가에국소적섭취증가를동시에보이는혼합형의 3가지형태로나눌수있다. 이중에서국소형의경우 26-66% 에서갑상샘종양이확인되었으며, 혼합형의경우에도국소적섭취증가를보이는부위에종양이확인되었던예들이보고되어있어갑상샘의섭취증가가국소적인형태를보이는경우추가적인검사를시행할것을권고하고있다.(8-10) 하지만미만성의갑상샘섭취증가는보고된연구들에따르면정상인에서 % 에서보이는소견으로경우종양의가능성은 매우낮은것으로알려져있으며정상적인상황에서보이는비특이적인현상이거나갑상샘염, 갑상선기능항진또는저하등에서나타날수있다.(7-12) 유방암환자에서하시모토갑상샘염과같은갑상샘의자가면역질환의빈도가높음이알려져있었는데,(13,14) Giustarini 등 (14) 은유방암에서갑상샘의이상소견은유방암치료전부터관찰되어치료와관계없이나타나는현상임을보고하였다. 따라서유방암환자의 F-18 FDG PET/CT 영상에서갑상샘의미만성섭취증가는일반인에비해빈도가높을것으로예상할수있으며실제 Tateishi 등 (15) 의연구에따르면대상유방암환자의 20% 정도에서 F-18 FDG PET/CT 검사상갑상샘에미만성섭취증가가관찰되었다고보고하여기존의정상인을대상으로한연구들에서보고한 % 의빈도보다높은수치를보였다. 이러한결과는이번연구에서도확인할수있었는데총 104 명의중 42 명인 40.4% 에서갑상샘의미만성섭취증가를보여정상인의비율보다훨씬높은수치를보였다. 기존연구결과인 20% 와는수치적으로차이를보이는데이러한차이는대상환자의차이에서기인하는것으로생각된다. Tateishi 등 (15) 은종격동혈액풀보다높은정도의갑상샘섭취증가를보인환자만을대상으로한반면에이번저자들의연구에서는 MIP 영상에서갑상샘의섭취가보인환자를모두대상으로하였기때문에이러한차이를보인것으로생각되며저자들의연구에서종격동혈액풀보다높은섭취증가를보였던환자만을대상으로하였을때는 104 명중 17명인 16.3% 로기존의연구결과와비슷한값을보였다. 이번연구에포함된총 104 명의환자들을갑상샘의미만성섭취증가여부를기준으로두그룹으로나누어보았을때. 섭취증가를보였던환자는 42명 (40.4%), 보이지않았던환자는 62명 (59.6%) 이었다. 양그룹에서유의한차이를보인것은항TPO 항체의양성률 (p=0.038) 과초음파소견 (p=0.003) 으로항체양성을보였던 6명중 5명에서미만성의섭취증가 (4 명 : 종격동혈액풀보다높음, 1명 : 혈액풀과유사함 ) 를보였는데항체양성인환자의수가적긴하였지만기존의보고대로항체양성인환자들에서미만성섭취증가를보였다는결과를확인할수있었다. 갑상샘초음파에서총 12 명의환자에서이상소견을보였는데모두동일하게갑상샘염의소견을보였다. 이중 10 명은섭취증가를보였던그룹에속했고나머지 2명은섭취증가를보이지않았던그룹에속했다. 그외에갑상샘기능검사는두그룹에서큰차이를보이지않았는데, TSH 의수치가갑상샘세포의포도당대사와연관되어있다는기존의연구 (16) 와는다른결과를보였다. 이에대한명확한이유를알수는없었지만갑상샘호르몬변화의기간등에대한고려가있어야할것으로생각된다. 또한프로게스테론수용체와에스트로겐수용체의양성여부를조사하였을때, 미만

6 314 Young Jin Jeong, et al. 성갑상샘섭취증가를보인 42명에서 23명 (54.8%), 섭취증가를보이지않았던 62명중, 37명 (59.7%) 에서양성소견을보였다. 두그룹에서수용체의양성여부는통계적으로유의한차이를보이지않아수용체의발현여부와 F-18 FDG의섭취여부사이에는상관관계가없는것으로생각되며이전연구결과 (13) 와동일한결과를얻었다. 갑상샘의미만성섭취증가를보인 42 명의환자들을섭취정도에따라세그룹으로나누었는데, 12 명 (28.5%) 은종격동의혈액풀보다낮았으며, 13 명 (31.0%) 은유사한정도였으며, 17 명 (40.5 %) 은갑상샘의섭취정도가더높았다. 세그룹에서통계적으로유의한차이를보인것은항TPO 항체 (p=0.043) 와갑상샘초음파에서이상소견여부 (p=0.001) 이었다. 종격동혈액풀보다높은갑상샘섭취증가를보였던 17명중 4명 (23.5%) 에서항TPO 항체의증가가관찰되었으며, 9명 (52.9%) 에서초음파소견상갑상샘염의소견을보였다. 따라서항TPO 항체양성과초음파상이상소견의대부분은종격동혈액풀보다높은갑상샘섭취증가를보였던그룹에서나타난소견임을알수있다. 갑상샘기능이상소견은세그룹에서통계적으로유의한차이를보이지않았지만, 객관적인갑상샘이상소견이라고할수있는갑상샘기능검사와항TPO 항체검사중한가지라도이상소견을보인환자의수를세그룹에서구하여보았다. 혈액풀보다낮은그룹 12 명중 4명 (33.3%), 혈액풀과유사한그룹 13 명중 1명 (8.3%), 혈액풀보다높은그룹 17 명중 7명 (41.1%) 에서갑상샘의이상소견을보였다. 비록세그룹사이에의미있는차이는보이지않았지만 (p= 0.125) 혈액풀보다높은섭취증가를보인그룹에서약절반정도이상소견을보이고있었다. 여기에초음파이상소견여부를보인환자까지함께고려하면각각 4명 (33.3%), 2명 (15.4%), 13명 (76.5%) 에서이상소견을보여갑상샘의섭취증가정도가종격동혈액풀보다높은그룹의경우다른그룹과비교하여통계적으로유의한차이를보임을알수있었다 (p=0.002). F-18 FDG PET/ CT 영상에서갑상샘의섭취증가는정상적으로관찰되지않는다고알려졌지만기존의연구들에서도다른검사상정상소견을보였던비특이적섭취증가가있음이보고되었고,(7-12) 이번연구에서도미만성의섭취증가를보였던 42 명중 23 명 (54.8%) 에서모든검사상정상소견을보여비특이적섭취라고생각할수있었다. 비록지방산대사가갑상샘에서주역할을할지라도포도당대사도함께작용하고있다는사실이밝혀지기시작하면서갑상샘에도정상적으로약한섭취증가를보일수있다는것이다.(17) 하지만어느정도의섭취증가를이상소견으로볼것인가하는질문에관한답을제시한연구는아직까지없었다. 지금까지보고된대부분의연구 (6-12) 에서 F-18 FDG의미만성갑상샘섭취증가환자의선택은특별한기준이없이육안으로보이느냐아니냐에따 라결정이되었기때문에비특이적섭취증가도포함되었으리라생각할수있다. 저자들의지식으로는갑상샘의섭취정도를등급별로나누어유방암에서분석한것은이번연구가처음이다. 종격동의혈액풀을기준으로하였을때, 갑상샘이혈액풀보다높은섭취증가를보이는경우 76.5% 에서갑상샘의이상소견이발견되었으므로 (Table 3) 혈액풀보다높은정도의갑상샘섭취를의미있는섭취정도로보는기준으로사용할수있을것으로생각된다. 비록이러한기준은여전히주관적인요소를완전히배제할수없기는하지만임상판독현장에서복잡한조작없이쉽게사용할수있는방법이라여겨진다. 비록이번연구에서갑상샘의섭취정도를표준섭취계수 (standardized uptake value, SUV) 와같은정량적방법으로측정하지않았지만섭취정도를평가하는데는종격동의혈액풀과단순비교하는육안판독의방법만으로충분할것으로생각된다. 결론적으로유방암환자에서우연히관찰되는 F-18 FDG의미만성갑상샘섭취증가빈도는기존에보고된정상인의빈도보다훨씬높은수치를보였고이런환자들의상당수가갑상샘에이상소견을보였다. 따라서유방암환자에서 F-18 FDG PET/CT 영상에서우연히관찰되는갑상샘의 F-18 FDG의미만성섭취증가정도가종격동혈액풀보다높을때는반드시갑상샘에대한 Table 3. Laboratory, surgical data, and US findings in 17 patients who showed diffuse thyroid uptake more than blood pool activity of mediastinum Patient No. Anti- TPO Ab T3* FT4* TSH* US* ER/PR NS N thyroiditis N thyroiditis P NS P NS P NS N thyroiditis P thyroiditis P thyroiditis P NS N NS P NS N thyroiditis P NS N thyroiditis N thyroiditis P thyroiditis N US=ultrasound; Anti-TPO Ab=anti-thyroid peroxidase antibody; T3= triiodothyronine; FT4=free thyroxine; TSH=thyroid-stimulating hormone; ER/PR=estrogen receptor/progesterone receptor; NS=not significant; P=positive; N=negative. *Reference values=tsh, miu/l; T3, ng/dl; FT4, ng/dl; TPO antibody, IU/mL.

7 Diffuse F-18 FDG Thyroid Uptake 315 추가검사가필요할것으로생각된다. 참고문헌 1. KIM TS, Moon WK, Lee DS. FDG-PET for the detection of recurrent or metastatic breast cancer. J Korean Breast Cancer Soc 2000; 3: Noh DY, Yun IJ, Kang HS, Kim JS, Lee DS, Chung JK, et al. The diagnostic value of positron emission tomography in detecting the breast cancer. J Korean Breast Cancer Soc 1998;1: Fletcher JW, Djulbegovic B, Soares HP, Siegel BA, Lowe VJ, Lyman GH, et al. Recommendations on the use of 18F-FDG PET in oncology. J Nucl Med 2008;49: Field J. Intermediary metabolism of the thyroid. In: Astwood EB, Greep RO, editors. American Physiological Society Handbook of Physiology: Endocrinology-Section 7, Volume III, Thyroid. Washington, DC: American Physiological Society; p Hosaka Y, Tawata M, Kurihara A, Ohtaka M, Endo T, Onaya T. The regulation of two distinct glucose transporter (GLUT1 and GLUT4) gene expressions in cultured rat thyroid cells by thyrotropin. Endocrinology 1992;131: Nakamoto Y, Tatsumi M, Hammoud D, Cohade C, Osman MM, Wahl RL. Normal FDG distribution patterns in the head and neck: PET/CT evaluation. Radiology 2005;234: Karantanis D, Bogsrud TV, Wiseman GA, Mullan BP, Subramaniam RM, Nathan MA, et al. Clinical significance of diffusely increased F-18 FDG uptake in the thyroid gland. J Nucl Med 2007;48: Kurata S, Ishibashi M, Hiromatsu Y, Kaida H, Miyake I, Uchida M, et al. Diffuse and diffuse-plus-focal uptake in the thyroid gland identified by using FDG-PET: prevalence of thyroid cancer and Hashimoto s thyroiditis. Ann Nucl Med 2007;21: Salvatori M, Melis L, Castaldi P, Maussier ML, Rufini V, Perotti G, et al. Clinical significance of focal and diffuse thyroid diseases identified by 18 F-fluorodeoxyglucose positron emission tomography. Biomed Pharmacother 2007;61: Liu Y. Clinical significance of thyroid uptake on F-18 fluorodeoxyglucose positron emission tomography. Ann Nucl Med 2009;23: Yasuda S, Shohtsu A, Ide M, Takagi S, Takahashi W, Suzuki Y, et al. Chronic thyroiditis: diffuse uptake of FDG at PET. Radiology 1998; 207: Chen YK, Chen YL, Cheng RH, Yeh CL, Lee CC, Hsu CH. The significance of FDG uptake in bilateral thyroid glands. Nucl Med Commun 2007;28: Giani C, Fierabracci P, Bonacci R, Gigliotti A, Campani D, De Negri F, et al. Relationship between breast cancer and thyroid disease: relevance of autoimmune thyroid disorders in breast malignancy. J Clin Endocrinol Metab 1996;81: Giustarini E, Pinchera A, Fierabracci P, Roncella M, Fustaino L, Mammoli C, et al. Thyroid autoimmunity in patients with malignant and benign breast diseases before surgery. Eur J Endocrinol 2006; 154: Tateishi U, Gamez C, Dawood S, Yeung HW, Cristofanilli M, Inoue T, et al. Chronic thyroiditis in patients with advanced breast carcinoma: metabolic and morphologic changes on PET-CT. Eur J Nucl Med Mol Imaging 2009;36: Kim TY, Kim WB, Ryu JS, Gong G, Hong SJ, Shong YK. 18F-fluorodeoxyglucose uptake in thyroid from positron emission tomogram (PET) for evaluation in cancer patients: high prevalence of malignancy in thyroid PET incidentaloma. Laryngoscope 2005;115: Wolf G, Aigner RM, Schaffler G, Schwarz T, Krippl P. Pathology results in [18F]fluorodeoxyglucose positron emission tomography of the thyroid gland. Nucl Med Commun 2003;24:

<303820BFF8C0FA B1E8C8F1B0E62DB0ADC8A3C3B62E687770>

<303820BFF8C0FA B1E8C8F1B0E62DB0ADC8A3C3B62E687770> 대한내과학회지 : 제 81 권제 5 호 2011 18 F-FDG PET 상관찰되는미만성갑상선섭취의임상적의의 전남대학교의과대학내과학교실 김희경 윤지희 김수정 강호철 Clinical Meaning of Diffuse 18 F-FDG PET Thyroid Uptake Hee Kyung Kim, Jee Hee Yoon, Soo Jeong Kim, and Ho-Cheol