Many isotopes are available for imaging patients with suspected thyroid cancer recurrence and metastases. TSH-stimulated low-dose 131I whole-body scanning with serum thyroglobulin either by standard LT4 withdrawal or rhTSH stimulation is the preferred test for monitoring patients without palpable disease or elevated serum thyroglobulin on LT4 therapy (Fig. 5). This approach has the advantage of finding disease that may be amenable to 131I therapy, although low-dose 131I scans are less sensitive than are scans with other imaging agents. 123I has better imaging characteristics than 131I and has been shown to be equivalent or superior to low-dose 131I in recent studies. As the availability of 123I increases and the cost decreases, this agent may replace 131I in imaging for recurrent or metastatic thyroid cancer. Patients who have an elevated serum thyroglobulin on LT4 therapy or after TSH stimulation but have a negative low-dose 131I scan require other imaging procedures to find the suspected disease. The authors currently perform a sensitive neck ultrasound to look for surgically remediable disease and consider a noncontrast CT scan of the chest to look for small pulmonary metastases that poorly concentrate low doses of 131I (Fig. 5). Fluoro-18-deoxyglucose PET, 99mTc MIBI, 201Tl, and 99mTc tetrofosmin are primarily useful in the setting of a negative whole-body 131I scan and elevated serum thyroglobulin. 18FDG-PET seems to have the highest sensitivity in this setting and would be the preferred imaging agent, but availability and cost are major issues (Fig. 5). Although some researchers have advocated these radiopharmaceuticals as first-line agents replacing 131I, there is little support for this position. This approach to imaging is not cost-effective because positive scans in these patients would most likely require 131I scintigraphy to determine whether the lesions are amenable to radioiodine therapy. 99mTc pertechnetate, 99mTc furifosmin, and somatostatin receptor scintigraphy have a limited role in imaging for recurrent or metastatic differentiated thyroid carcinoma. In choosing among 99mTc MIBI, 201Tl, and 99mTc tetrofosmin, the technetium label of sestamibi and tetrofosmin results in better image quality and faster imaging than 201Tl. Although 99mTc sestamibi and 99mTc tetrofosmin have not been compared in a large series, the higher tumor-to-background ratio and consistently high sensitivities of 99mTc tetrofosmin suggest that it could potentially have additional value over 99mTc sestamibi, but there is still limited experience with 99mTc tetrofosmin.