FUNGAL INFECTIONS MIMICKING METASTATIC DIFFERENTIATED THYROID CANCER (DTC)
AACE ePoster Library. Velasco M. 05/13/15; 97811; 1083
Dr. Maria Velasco
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Abstract
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Objectives: DTC accounts for 95% of all thyroid malignancies. Distant metastases (DM) most commonly occur in lung. Whole body I-131 scans (WBS) and PET/CT are modalities used for detecting DM. However, false positive cases have been reported in patients with aspergillus (ASP). We report 2 cases of young women with fungal infections mimicking metastatic papillary thyroid cancer (PTC).
Methods: Cases at MD Anderson (MDA) were reviewed
Case1: A 39 y/o woman presented 1 yr prior with abdominal pain/vomiting to a local ER. CT scan showed left lung nodules. PET/CT showed thyroid and left (L) 2.2 cm lung nodule with satellite lesions. She underwent total thyroidectomy (TT) which showed a 1.2 cm PTC with no lymphovascular invasion (LVI). She then received 2 doses of I-131 (cumulative=255mCi), with post-tx scans showing uptake in thyroid bed and L lung. Stimulated Tg was not available, however, 2 mos s/p I131, Tg was undetectable (TSH=2.3). Biopsy of the lung showed inflammatory cells. WBS repeated 4 mos later showed uptake in L lung with undetectable stimulated Tg. CT 4 mos later showed increase in size of the lung mass. Pt was referred to MDA. She then underwent wedge resection of the lesion, which grew ASP and was treated with voriconazole.
Case 2: A 29 y/o woman was diagnosed with PTC 3 yrs prior. She underwent TT and bilateral neck dissection. Pathology showed a 5 cm PTC with LVI and multiple + nodes (T34aN1b). 100 mCi of I131 was given with no uptake on post-tx scan. Stimulated Tg not available but the patient had + Tg antibodies (=942) on subsequent testing. PET/CT was negative. Antibodies declined but were persistent for 3 years after surgery. She was referred to MDA. Neck u/s showed a small pretracheal node. PET/CT showed a new lung nodule measuring 1.4 cm with low SUV, and her antibodies continued to decline to 156. CT 6 months later showed increase in size of the nodule with cavitation. Tg antibody=134, which was not consistent with worsening of her DTC. Core biopsy of the lung showed necrotizing granuloma and fungal stains were consistent with coccidiomycosis. She was treated for 9 mos with fluconazole.
Discussion: Fungal infections as well as inflammatory lung disease can capture I131 and FDG, mimicking DM. This abnormal uptake seen in fungal infections and bronchiolitis is enhanced possibly by the oxidant-antioxidant environment found in sites of inflammation. In the case of ASP it has been attributed to the endotoxins and enzymes released by the fungus.
Conclusion: Caution should be used when discordant results between the tumor marker and WBS or PET/CT in young patients with DTC. Biopsy of suspicious lung lesions should be considered.
Figure 1 (FOR POSTER ONLY):
Patient 1:
Examination: Chest CT with Contrast, 10/25/2013
Clinical History: Thyroid carcinoma.
Indication: Thyroid carcinoma.
Comparison: 02/26/2013 CT of the abdomen and 09/11/2002 CT of the chest.
Technique: Chest CT with contrast, 2.5 mm collimation, coronal sagittal reformations.
Findings: In the left lower lobe, there are clustered nodules, the largest one, measures 2.3 cm on image 69. This lesion is surrounded by satellite nodules. When compared to 09/11/2012 (series 3, image 55) the dominant nodule has increased in size by 1-2 mm. Th surrounding opacities have slightly progressed. There is associated air trapping. There is no evidence of additional nodules. There is no evidence of mediastinal, hilar, or axillary adenopathy.
The adrenal glands are unremarkable. No focal lesions in the liver or in the spleen. No upper abdominal adenopathy.
There is no evidence of any bony destructive process.
No supraclavicular adenopathy.
IMPRESSION:
There are clustered nodular and elongated opacities in the left upper lobe associated with air trapping. These opacities have slightly progressed when compared to 02/26/2013 and 09/11/2012, but there is no additional nodule seen in the rest of the lungs parenchyma. The findings might represent slowly growing endobronchial metastasis, but there is also possible that this process might represent an area of bronchial atresia with mucous plugging and associated inflammatory infectious process. Histologic correlation is recommended.
Patient 2:
Examination: PET/CT Scan, 12/18/2008
Clinical History: A 29-year-old female with metastatic papillary thyroid cancer. Patient had thyroidectomy in January 2006 with lymph node positive disease. After undergoing radioiodine ablation, she has had multiple neck nodes biopsied, none of which have shown evidence of malignancy. Patient comes to M.D. Anderson for consultation. No prior PET/CT studies for comparison. Correlation is made with ultrasound of the neck from 12/16/2008.
Comparison is made with limited images from outside PET/CT study from 01/18/2007 and with outside CT scan of the chest from 08/18/2008
Technique: F18-FDG 11.3 mCi was administered intravenously in right antecubital fossa and imaging was performed approximately 70 minutes later on a GE multislice camera. PET and non-contrast CT images were acquired from vertex of skull to mid thighs. The non-contrast CT scan was used for attenuation correction and diagnostic purposes. PET and CT datasets were fused and reviewed on workstation with multiplanar and projection capability. Body weight SUV max is reported unless otherwise specified. The patient's blood glucose level prior to 18F-FDG administration was 93 mg/dL.
Findings:
Head and Neck: No cervical nodal hypermetabolism. Multiple surgical clips in the thyroid bed, extending into the anterior mediastinum, just behind the manubrium. No abnormal metabolic activity in postsurgical bed to suggest local recurrence.
No significant cervical nodal lymphadenopathy or nodal hypermetabolism.
Chest: No significant mediastinal or axillary lymphadenopathy or nodal hypermetabolism. Small thymus with minimal metabolic activity, is normal age appropriate variant.
A 4 mm nodule in right lower lobe on image 58; this has mild metabolic activity with SUV 1.4 that may be an underestimate due to partial volume effects with respiratory motion and size of lesion. This nodule is new compared with outside CT scan of 08/2008 and outside PET/CT study of 01/2007.
Abdomen and Pelvis: Homogeneous metabolic activity throughout the liver without focal hypermetabolism. No significant abdominal or pelvic lymphadenopathy or nodal hypermetabolism.
Musculoskeletal: No hypermetabolic osseous lesions.
IMPRESSION:
1. No evidence for local recurrence of thyroid cancer.
2. New subcentimeter nodule in right lower lobe. Given the relatively rapid appearance, an inflammatory etiology must be considered, although neoplasm is not excluded. Followup with dedicated CT scan of the chest in three to four months is suggested.
Examination: CT Chest with Contrast
Clinical History: Papillary thyroid carcinoma. Evaluate for progression of right lung nodule.
Comparison: CT chest from outside institution dated 08/18/2008. PET/CT dated 12/18/2008.
Findings: Since the prior study (PET/CT), the right lower lobe nodule has increased in size, now approximately 8.5 mm in greatest diameter, compared to about 6mm in the previous study. This nodule now demonstrates early central cavitation. Minimal biapical scarring is unchanged since August 2008. Otherwise, the lungs remain clear. No additional nodules have developed in the interval. No signs of pleural disease.
Changes of total thyroidectomy are identified. No evidence of new mediastinal, hilar or axillary adenopathy. The heart and great vessels appear normal. The esophagus is unremarkable. There is a very tiny (1-2 mm) hypodensity in the right hepatic lobe (image 137 series 2), non-specific, which in the study from outside institution was not identified, perhaps due to differences in technique. No other focal liver lesions are seen. Both adrenal glands are normal in appearance. The remainder of the visualized solid organs are also unremarkable. No intraabdominal or retroperitoneal adenopathy is seen. The bowel appears normal. The gallbladder is well distended. No bony lesions or soft tissue abnormalities are identified.
IMPRESSION:
1. Interval enlargement and development of central early cavitation in the right lower lobe nodule, highly suspicious for metastasis. Primary malignancy is less likely.
2. No evidence of acute cardiopulmonary disease.
3. No signs of intraabdominal metastatic disease.
Methods: Cases at MD Anderson (MDA) were reviewed
Case1: A 39 y/o woman presented 1 yr prior with abdominal pain/vomiting to a local ER. CT scan showed left lung nodules. PET/CT showed thyroid and left (L) 2.2 cm lung nodule with satellite lesions. She underwent total thyroidectomy (TT) which showed a 1.2 cm PTC with no lymphovascular invasion (LVI). She then received 2 doses of I-131 (cumulative=255mCi), with post-tx scans showing uptake in thyroid bed and L lung. Stimulated Tg was not available, however, 2 mos s/p I131, Tg was undetectable (TSH=2.3). Biopsy of the lung showed inflammatory cells. WBS repeated 4 mos later showed uptake in L lung with undetectable stimulated Tg. CT 4 mos later showed increase in size of the lung mass. Pt was referred to MDA. She then underwent wedge resection of the lesion, which grew ASP and was treated with voriconazole.
Case 2: A 29 y/o woman was diagnosed with PTC 3 yrs prior. She underwent TT and bilateral neck dissection. Pathology showed a 5 cm PTC with LVI and multiple + nodes (T34aN1b). 100 mCi of I131 was given with no uptake on post-tx scan. Stimulated Tg not available but the patient had + Tg antibodies (=942) on subsequent testing. PET/CT was negative. Antibodies declined but were persistent for 3 years after surgery. She was referred to MDA. Neck u/s showed a small pretracheal node. PET/CT showed a new lung nodule measuring 1.4 cm with low SUV, and her antibodies continued to decline to 156. CT 6 months later showed increase in size of the nodule with cavitation. Tg antibody=134, which was not consistent with worsening of her DTC. Core biopsy of the lung showed necrotizing granuloma and fungal stains were consistent with coccidiomycosis. She was treated for 9 mos with fluconazole.
Discussion: Fungal infections as well as inflammatory lung disease can capture I131 and FDG, mimicking DM. This abnormal uptake seen in fungal infections and bronchiolitis is enhanced possibly by the oxidant-antioxidant environment found in sites of inflammation. In the case of ASP it has been attributed to the endotoxins and enzymes released by the fungus.
Conclusion: Caution should be used when discordant results between the tumor marker and WBS or PET/CT in young patients with DTC. Biopsy of suspicious lung lesions should be considered.
Figure 1 (FOR POSTER ONLY):
Patient 1:
Examination: Chest CT with Contrast, 10/25/2013
Clinical History: Thyroid carcinoma.
Indication: Thyroid carcinoma.
Comparison: 02/26/2013 CT of the abdomen and 09/11/2002 CT of the chest.
Technique: Chest CT with contrast, 2.5 mm collimation, coronal sagittal reformations.
Findings: In the left lower lobe, there are clustered nodules, the largest one, measures 2.3 cm on image 69. This lesion is surrounded by satellite nodules. When compared to 09/11/2012 (series 3, image 55) the dominant nodule has increased in size by 1-2 mm. Th surrounding opacities have slightly progressed. There is associated air trapping. There is no evidence of additional nodules. There is no evidence of mediastinal, hilar, or axillary adenopathy.
The adrenal glands are unremarkable. No focal lesions in the liver or in the spleen. No upper abdominal adenopathy.
There is no evidence of any bony destructive process.
No supraclavicular adenopathy.
IMPRESSION:
There are clustered nodular and elongated opacities in the left upper lobe associated with air trapping. These opacities have slightly progressed when compared to 02/26/2013 and 09/11/2012, but there is no additional nodule seen in the rest of the lungs parenchyma. The findings might represent slowly growing endobronchial metastasis, but there is also possible that this process might represent an area of bronchial atresia with mucous plugging and associated inflammatory infectious process. Histologic correlation is recommended.
Patient 2:
Examination: PET/CT Scan, 12/18/2008
Clinical History: A 29-year-old female with metastatic papillary thyroid cancer. Patient had thyroidectomy in January 2006 with lymph node positive disease. After undergoing radioiodine ablation, she has had multiple neck nodes biopsied, none of which have shown evidence of malignancy. Patient comes to M.D. Anderson for consultation. No prior PET/CT studies for comparison. Correlation is made with ultrasound of the neck from 12/16/2008.
Comparison is made with limited images from outside PET/CT study from 01/18/2007 and with outside CT scan of the chest from 08/18/2008
Technique: F18-FDG 11.3 mCi was administered intravenously in right antecubital fossa and imaging was performed approximately 70 minutes later on a GE multislice camera. PET and non-contrast CT images were acquired from vertex of skull to mid thighs. The non-contrast CT scan was used for attenuation correction and diagnostic purposes. PET and CT datasets were fused and reviewed on workstation with multiplanar and projection capability. Body weight SUV max is reported unless otherwise specified. The patient's blood glucose level prior to 18F-FDG administration was 93 mg/dL.
Findings:
Head and Neck: No cervical nodal hypermetabolism. Multiple surgical clips in the thyroid bed, extending into the anterior mediastinum, just behind the manubrium. No abnormal metabolic activity in postsurgical bed to suggest local recurrence.
No significant cervical nodal lymphadenopathy or nodal hypermetabolism.
Chest: No significant mediastinal or axillary lymphadenopathy or nodal hypermetabolism. Small thymus with minimal metabolic activity, is normal age appropriate variant.
A 4 mm nodule in right lower lobe on image 58; this has mild metabolic activity with SUV 1.4 that may be an underestimate due to partial volume effects with respiratory motion and size of lesion. This nodule is new compared with outside CT scan of 08/2008 and outside PET/CT study of 01/2007.
Abdomen and Pelvis: Homogeneous metabolic activity throughout the liver without focal hypermetabolism. No significant abdominal or pelvic lymphadenopathy or nodal hypermetabolism.
Musculoskeletal: No hypermetabolic osseous lesions.
IMPRESSION:
1. No evidence for local recurrence of thyroid cancer.
2. New subcentimeter nodule in right lower lobe. Given the relatively rapid appearance, an inflammatory etiology must be considered, although neoplasm is not excluded. Followup with dedicated CT scan of the chest in three to four months is suggested.
Examination: CT Chest with Contrast
Clinical History: Papillary thyroid carcinoma. Evaluate for progression of right lung nodule.
Comparison: CT chest from outside institution dated 08/18/2008. PET/CT dated 12/18/2008.
Findings: Since the prior study (PET/CT), the right lower lobe nodule has increased in size, now approximately 8.5 mm in greatest diameter, compared to about 6mm in the previous study. This nodule now demonstrates early central cavitation. Minimal biapical scarring is unchanged since August 2008. Otherwise, the lungs remain clear. No additional nodules have developed in the interval. No signs of pleural disease.
Changes of total thyroidectomy are identified. No evidence of new mediastinal, hilar or axillary adenopathy. The heart and great vessels appear normal. The esophagus is unremarkable. There is a very tiny (1-2 mm) hypodensity in the right hepatic lobe (image 137 series 2), non-specific, which in the study from outside institution was not identified, perhaps due to differences in technique. No other focal liver lesions are seen. Both adrenal glands are normal in appearance. The remainder of the visualized solid organs are also unremarkable. No intraabdominal or retroperitoneal adenopathy is seen. The bowel appears normal. The gallbladder is well distended. No bony lesions or soft tissue abnormalities are identified.
IMPRESSION:
1. Interval enlargement and development of central early cavitation in the right lower lobe nodule, highly suspicious for metastasis. Primary malignancy is less likely.
2. No evidence of acute cardiopulmonary disease.
3. No signs of intraabdominal metastatic disease.
Objectives: DTC accounts for 95% of all thyroid malignancies. Distant metastases (DM) most commonly occur in lung. Whole body I-131 scans (WBS) and PET/CT are modalities used for detecting DM. However, false positive cases have been reported in patients with aspergillus (ASP). We report 2 cases of young women with fungal infections mimicking metastatic papillary thyroid cancer (PTC).
Methods: Cases at MD Anderson (MDA) were reviewed
Case1: A 39 y/o woman presented 1 yr prior with abdominal pain/vomiting to a local ER. CT scan showed left lung nodules. PET/CT showed thyroid and left (L) 2.2 cm lung nodule with satellite lesions. She underwent total thyroidectomy (TT) which showed a 1.2 cm PTC with no lymphovascular invasion (LVI). She then received 2 doses of I-131 (cumulative=255mCi), with post-tx scans showing uptake in thyroid bed and L lung. Stimulated Tg was not available, however, 2 mos s/p I131, Tg was undetectable (TSH=2.3). Biopsy of the lung showed inflammatory cells. WBS repeated 4 mos later showed uptake in L lung with undetectable stimulated Tg. CT 4 mos later showed increase in size of the lung mass. Pt was referred to MDA. She then underwent wedge resection of the lesion, which grew ASP and was treated with voriconazole.
Case 2: A 29 y/o woman was diagnosed with PTC 3 yrs prior. She underwent TT and bilateral neck dissection. Pathology showed a 5 cm PTC with LVI and multiple + nodes (T34aN1b). 100 mCi of I131 was given with no uptake on post-tx scan. Stimulated Tg not available but the patient had + Tg antibodies (=942) on subsequent testing. PET/CT was negative. Antibodies declined but were persistent for 3 years after surgery. She was referred to MDA. Neck u/s showed a small pretracheal node. PET/CT showed a new lung nodule measuring 1.4 cm with low SUV, and her antibodies continued to decline to 156. CT 6 months later showed increase in size of the nodule with cavitation. Tg antibody=134, which was not consistent with worsening of her DTC. Core biopsy of the lung showed necrotizing granuloma and fungal stains were consistent with coccidiomycosis. She was treated for 9 mos with fluconazole.
Discussion: Fungal infections as well as inflammatory lung disease can capture I131 and FDG, mimicking DM. This abnormal uptake seen in fungal infections and bronchiolitis is enhanced possibly by the oxidant-antioxidant environment found in sites of inflammation. In the case of ASP it has been attributed to the endotoxins and enzymes released by the fungus.
Conclusion: Caution should be used when discordant results between the tumor marker and WBS or PET/CT in young patients with DTC. Biopsy of suspicious lung lesions should be considered.
Figure 1 (FOR POSTER ONLY):
Patient 1:
Examination: Chest CT with Contrast, 10/25/2013
Clinical History: Thyroid carcinoma.
Indication: Thyroid carcinoma.
Comparison: 02/26/2013 CT of the abdomen and 09/11/2002 CT of the chest.
Technique: Chest CT with contrast, 2.5 mm collimation, coronal sagittal reformations.
Findings: In the left lower lobe, there are clustered nodules, the largest one, measures 2.3 cm on image 69. This lesion is surrounded by satellite nodules. When compared to 09/11/2012 (series 3, image 55) the dominant nodule has increased in size by 1-2 mm. Th surrounding opacities have slightly progressed. There is associated air trapping. There is no evidence of additional nodules. There is no evidence of mediastinal, hilar, or axillary adenopathy.
The adrenal glands are unremarkable. No focal lesions in the liver or in the spleen. No upper abdominal adenopathy.
There is no evidence of any bony destructive process.
No supraclavicular adenopathy.
IMPRESSION:
There are clustered nodular and elongated opacities in the left upper lobe associated with air trapping. These opacities have slightly progressed when compared to 02/26/2013 and 09/11/2012, but there is no additional nodule seen in the rest of the lungs parenchyma. The findings might represent slowly growing endobronchial metastasis, but there is also possible that this process might represent an area of bronchial atresia with mucous plugging and associated inflammatory infectious process. Histologic correlation is recommended.
Patient 2:
Examination: PET/CT Scan, 12/18/2008
Clinical History: A 29-year-old female with metastatic papillary thyroid cancer. Patient had thyroidectomy in January 2006 with lymph node positive disease. After undergoing radioiodine ablation, she has had multiple neck nodes biopsied, none of which have shown evidence of malignancy. Patient comes to M.D. Anderson for consultation. No prior PET/CT studies for comparison. Correlation is made with ultrasound of the neck from 12/16/2008.
Comparison is made with limited images from outside PET/CT study from 01/18/2007 and with outside CT scan of the chest from 08/18/2008
Technique: F18-FDG 11.3 mCi was administered intravenously in right antecubital fossa and imaging was performed approximately 70 minutes later on a GE multislice camera. PET and non-contrast CT images were acquired from vertex of skull to mid thighs. The non-contrast CT scan was used for attenuation correction and diagnostic purposes. PET and CT datasets were fused and reviewed on workstation with multiplanar and projection capability. Body weight SUV max is reported unless otherwise specified. The patient's blood glucose level prior to 18F-FDG administration was 93 mg/dL.
Findings:
Head and Neck: No cervical nodal hypermetabolism. Multiple surgical clips in the thyroid bed, extending into the anterior mediastinum, just behind the manubrium. No abnormal metabolic activity in postsurgical bed to suggest local recurrence.
No significant cervical nodal lymphadenopathy or nodal hypermetabolism.
Chest: No significant mediastinal or axillary lymphadenopathy or nodal hypermetabolism. Small thymus with minimal metabolic activity, is normal age appropriate variant.
A 4 mm nodule in right lower lobe on image 58; this has mild metabolic activity with SUV 1.4 that may be an underestimate due to partial volume effects with respiratory motion and size of lesion. This nodule is new compared with outside CT scan of 08/2008 and outside PET/CT study of 01/2007.
Abdomen and Pelvis: Homogeneous metabolic activity throughout the liver without focal hypermetabolism. No significant abdominal or pelvic lymphadenopathy or nodal hypermetabolism.
Musculoskeletal: No hypermetabolic osseous lesions.
IMPRESSION:
1. No evidence for local recurrence of thyroid cancer.
2. New subcentimeter nodule in right lower lobe. Given the relatively rapid appearance, an inflammatory etiology must be considered, although neoplasm is not excluded. Followup with dedicated CT scan of the chest in three to four months is suggested.
Examination: CT Chest with Contrast
Clinical History: Papillary thyroid carcinoma. Evaluate for progression of right lung nodule.
Comparison: CT chest from outside institution dated 08/18/2008. PET/CT dated 12/18/2008.
Findings: Since the prior study (PET/CT), the right lower lobe nodule has increased in size, now approximately 8.5 mm in greatest diameter, compared to about 6mm in the previous study. This nodule now demonstrates early central cavitation. Minimal biapical scarring is unchanged since August 2008. Otherwise, the lungs remain clear. No additional nodules have developed in the interval. No signs of pleural disease.
Changes of total thyroidectomy are identified. No evidence of new mediastinal, hilar or axillary adenopathy. The heart and great vessels appear normal. The esophagus is unremarkable. There is a very tiny (1-2 mm) hypodensity in the right hepatic lobe (image 137 series 2), non-specific, which in the study from outside institution was not identified, perhaps due to differences in technique. No other focal liver lesions are seen. Both adrenal glands are normal in appearance. The remainder of the visualized solid organs are also unremarkable. No intraabdominal or retroperitoneal adenopathy is seen. The bowel appears normal. The gallbladder is well distended. No bony lesions or soft tissue abnormalities are identified.
IMPRESSION:
1. Interval enlargement and development of central early cavitation in the right lower lobe nodule, highly suspicious for metastasis. Primary malignancy is less likely.
2. No evidence of acute cardiopulmonary disease.
3. No signs of intraabdominal metastatic disease.
Methods: Cases at MD Anderson (MDA) were reviewed
Case1: A 39 y/o woman presented 1 yr prior with abdominal pain/vomiting to a local ER. CT scan showed left lung nodules. PET/CT showed thyroid and left (L) 2.2 cm lung nodule with satellite lesions. She underwent total thyroidectomy (TT) which showed a 1.2 cm PTC with no lymphovascular invasion (LVI). She then received 2 doses of I-131 (cumulative=255mCi), with post-tx scans showing uptake in thyroid bed and L lung. Stimulated Tg was not available, however, 2 mos s/p I131, Tg was undetectable (TSH=2.3). Biopsy of the lung showed inflammatory cells. WBS repeated 4 mos later showed uptake in L lung with undetectable stimulated Tg. CT 4 mos later showed increase in size of the lung mass. Pt was referred to MDA. She then underwent wedge resection of the lesion, which grew ASP and was treated with voriconazole.
Case 2: A 29 y/o woman was diagnosed with PTC 3 yrs prior. She underwent TT and bilateral neck dissection. Pathology showed a 5 cm PTC with LVI and multiple + nodes (T34aN1b). 100 mCi of I131 was given with no uptake on post-tx scan. Stimulated Tg not available but the patient had + Tg antibodies (=942) on subsequent testing. PET/CT was negative. Antibodies declined but were persistent for 3 years after surgery. She was referred to MDA. Neck u/s showed a small pretracheal node. PET/CT showed a new lung nodule measuring 1.4 cm with low SUV, and her antibodies continued to decline to 156. CT 6 months later showed increase in size of the nodule with cavitation. Tg antibody=134, which was not consistent with worsening of her DTC. Core biopsy of the lung showed necrotizing granuloma and fungal stains were consistent with coccidiomycosis. She was treated for 9 mos with fluconazole.
Discussion: Fungal infections as well as inflammatory lung disease can capture I131 and FDG, mimicking DM. This abnormal uptake seen in fungal infections and bronchiolitis is enhanced possibly by the oxidant-antioxidant environment found in sites of inflammation. In the case of ASP it has been attributed to the endotoxins and enzymes released by the fungus.
Conclusion: Caution should be used when discordant results between the tumor marker and WBS or PET/CT in young patients with DTC. Biopsy of suspicious lung lesions should be considered.
Figure 1 (FOR POSTER ONLY):
Patient 1:
Examination: Chest CT with Contrast, 10/25/2013
Clinical History: Thyroid carcinoma.
Indication: Thyroid carcinoma.
Comparison: 02/26/2013 CT of the abdomen and 09/11/2002 CT of the chest.
Technique: Chest CT with contrast, 2.5 mm collimation, coronal sagittal reformations.
Findings: In the left lower lobe, there are clustered nodules, the largest one, measures 2.3 cm on image 69. This lesion is surrounded by satellite nodules. When compared to 09/11/2012 (series 3, image 55) the dominant nodule has increased in size by 1-2 mm. Th surrounding opacities have slightly progressed. There is associated air trapping. There is no evidence of additional nodules. There is no evidence of mediastinal, hilar, or axillary adenopathy.
The adrenal glands are unremarkable. No focal lesions in the liver or in the spleen. No upper abdominal adenopathy.
There is no evidence of any bony destructive process.
No supraclavicular adenopathy.
IMPRESSION:
There are clustered nodular and elongated opacities in the left upper lobe associated with air trapping. These opacities have slightly progressed when compared to 02/26/2013 and 09/11/2012, but there is no additional nodule seen in the rest of the lungs parenchyma. The findings might represent slowly growing endobronchial metastasis, but there is also possible that this process might represent an area of bronchial atresia with mucous plugging and associated inflammatory infectious process. Histologic correlation is recommended.
Patient 2:
Examination: PET/CT Scan, 12/18/2008
Clinical History: A 29-year-old female with metastatic papillary thyroid cancer. Patient had thyroidectomy in January 2006 with lymph node positive disease. After undergoing radioiodine ablation, she has had multiple neck nodes biopsied, none of which have shown evidence of malignancy. Patient comes to M.D. Anderson for consultation. No prior PET/CT studies for comparison. Correlation is made with ultrasound of the neck from 12/16/2008.
Comparison is made with limited images from outside PET/CT study from 01/18/2007 and with outside CT scan of the chest from 08/18/2008
Technique: F18-FDG 11.3 mCi was administered intravenously in right antecubital fossa and imaging was performed approximately 70 minutes later on a GE multislice camera. PET and non-contrast CT images were acquired from vertex of skull to mid thighs. The non-contrast CT scan was used for attenuation correction and diagnostic purposes. PET and CT datasets were fused and reviewed on workstation with multiplanar and projection capability. Body weight SUV max is reported unless otherwise specified. The patient's blood glucose level prior to 18F-FDG administration was 93 mg/dL.
Findings:
Head and Neck: No cervical nodal hypermetabolism. Multiple surgical clips in the thyroid bed, extending into the anterior mediastinum, just behind the manubrium. No abnormal metabolic activity in postsurgical bed to suggest local recurrence.
No significant cervical nodal lymphadenopathy or nodal hypermetabolism.
Chest: No significant mediastinal or axillary lymphadenopathy or nodal hypermetabolism. Small thymus with minimal metabolic activity, is normal age appropriate variant.
A 4 mm nodule in right lower lobe on image 58; this has mild metabolic activity with SUV 1.4 that may be an underestimate due to partial volume effects with respiratory motion and size of lesion. This nodule is new compared with outside CT scan of 08/2008 and outside PET/CT study of 01/2007.
Abdomen and Pelvis: Homogeneous metabolic activity throughout the liver without focal hypermetabolism. No significant abdominal or pelvic lymphadenopathy or nodal hypermetabolism.
Musculoskeletal: No hypermetabolic osseous lesions.
IMPRESSION:
1. No evidence for local recurrence of thyroid cancer.
2. New subcentimeter nodule in right lower lobe. Given the relatively rapid appearance, an inflammatory etiology must be considered, although neoplasm is not excluded. Followup with dedicated CT scan of the chest in three to four months is suggested.
Examination: CT Chest with Contrast
Clinical History: Papillary thyroid carcinoma. Evaluate for progression of right lung nodule.
Comparison: CT chest from outside institution dated 08/18/2008. PET/CT dated 12/18/2008.
Findings: Since the prior study (PET/CT), the right lower lobe nodule has increased in size, now approximately 8.5 mm in greatest diameter, compared to about 6mm in the previous study. This nodule now demonstrates early central cavitation. Minimal biapical scarring is unchanged since August 2008. Otherwise, the lungs remain clear. No additional nodules have developed in the interval. No signs of pleural disease.
Changes of total thyroidectomy are identified. No evidence of new mediastinal, hilar or axillary adenopathy. The heart and great vessels appear normal. The esophagus is unremarkable. There is a very tiny (1-2 mm) hypodensity in the right hepatic lobe (image 137 series 2), non-specific, which in the study from outside institution was not identified, perhaps due to differences in technique. No other focal liver lesions are seen. Both adrenal glands are normal in appearance. The remainder of the visualized solid organs are also unremarkable. No intraabdominal or retroperitoneal adenopathy is seen. The bowel appears normal. The gallbladder is well distended. No bony lesions or soft tissue abnormalities are identified.
IMPRESSION:
1. Interval enlargement and development of central early cavitation in the right lower lobe nodule, highly suspicious for metastasis. Primary malignancy is less likely.
2. No evidence of acute cardiopulmonary disease.
3. No signs of intraabdominal metastatic disease.
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