Characterization of focal hypermetabolic thyroid incidentaloma: An analysis with F-18 fluorodeoxyglucose positron emission tomography/computed tomography parameters

BACKGROUND: Incidentally found thyroid tumor (thyroid incidentaloma, TI) on F-18 fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) is reported in 2.5%-5% of patients being investigated for non-thyroid purposes. Up to 50% of these cases have been diagnosed to be malignant by cytological/histological results. Ultrasonography (US) and fine-needle aspiration cytology are recommended for thyroid nodules with high FDG uptake (hypermetabolism) that are 1 cm or greater in size. It is important to accurately determine whether a suspicious hypermetabolic TI is malignant or benign. AIM: To distinguish malignant hypermetabolic TIs from benign disease by analyzing F-18 FDG PET-CT parameters and to identify a cut-off value. METHODS: Totally, 12761 images of patients who underwent F-18 FDG PET-CT for non-thyroid purposes at our hospital between January 2016 and December 2020 were retrospectively reviewed, and 339 patients [185 men (mean age: 68 ± 11.2) and 154 women (mean age: 63 ± 15.0)] were found to have abnormal, either focal or diffuse, thyroid FDG uptake. After a thorough review of their medical records, US, and cytological/histological reports, 46 eligible patients with focal hypermetabolic TI were included in this study. The TIs were categorized as malignant and benign according to the cytological/histological reports, and four PET parameters [standardized uptake value (SUV)(max), SUV(peak), SUV(mean), and metabolic tumor volume (MTV)] were measured on FDG PET-CT. Total lesion glycolysis (TLG) was calculated by multiplying the SUV(mean )by MTV. Both parametric and non-parametric methods were used to compare the five parameters between malignant and benign lesions. Receiver operating characteristic (ROC) curve analysis was performed to identify a cut-off value. RESULTS: Each of the 46 patients [12 men (26.1%; mean age: 62 ± 13.1 years) and 34 women (73.9%; mean age: 60 ± 12.0 years)] with focal hypermetabolic TIs had one focal hypermetabolic TI. Among them, 26 (56.5%) were malignant and 20 (43.5%) were benign. SUV(max), SUV(peak), SUV(mean), and TLG were all higher in malignant lesions than benign ones, but the difference was statistically significant (P = 0.012) only for SUV(max). There was a positive linear correlation (r = 0.339) between SUV(max) and the diagnosis of malignancy. ROC curve analysis for SUV(max) revealed an area under the curve of 0.702 (P < 0.05, 95% confidence interval: 0.550-0.855) and SUV(max) cut-off of 8.5 with a sensitivity of 0.615 and a specificity of 0.789. CONCLUSION: More than half of focal hypermetabolic TIs on F-18 FDG PET-CT were revealed as malignant lesions, and SUV(max) was the best parameter for discriminating between malignant and benign disease. Unexpected focal hypermetabolic TIs with the SUV(max) above the cut-off value of 8.5 may have a greater than 70% chance of malignancy; therefore, further active assessment is required.