Metastatic Medullary Thyroid Cancer: The Role of (68)Gallium-DOTA-Somatostatin Analogue PET/CT and Peptide Receptor Radionuclide Therapy

Context: Metastatic medullary thyroid cancer (MTC) is a rare malignancy with minimal treatment options. Many, but not all, MTCs express somatostatin receptors. Objective: Our aim was to explore the role of Ga-68-DOTA-somatostatin analogue (SSA) positron emission tomography (PET)/computed tomography (CT) in patients with metastatic MTC and to determine their eligibility for peptide receptor radionuclide therapy (PRRT). Methods: We retrospectively identified patients with metastatic MTC who had Ga-68-DOTA-SSA PET/CT at 5 centers. We collected characteristics on contrast-enhanced CT, Ga-68-DOTA-SSA and F-18-FDG PET/CT. The efficacy of PRRT was explored in a subgroup of patients. Kaplan-Meier analysis was used to estimate time to treatment failure (TTF) and overall survival (OS). Results: Seventy-one patients were included (10 local recurrence, 61 distant disease). Of the patients with distant disease, 16 (26%) had >= 50% of disease sites with tracer avidity greater than background liver, including 10 (10/61, 16%) with >90%. In 19 patients with contemporaneous contrast-enhanced CT, no disease regions were independently identified on Ga-68-DOTA-SSA PET/CT. Thirty-five patients had an F-18-FDG PET/CT, with 18F-FDG positive/Ga-68-DOTA-SSA negative metastases identified in 15 (43%). Twenty-one patients had PRRT with a median TTF of 14 months (95% CI 8-25) and a median OS of 63 months (95% CI 21-not reached). Of the entire cohort, the median OS was 323 months (95% CI 152-not reached). Predictors of poorer OS included a short calcitonin doubling-time (<= 24 months), strong F-18-FDG avidity, and age >= 60 years. Conclusions: The prevalence of high tumor avidity on Ga-68-DOTA-SSA PET/CT is low in the setting of metastatic MTC; nevertheless, PRRT may still be a viable treatment option in select patients.