The lung is one of the common metastatic sitesfor well-differentiated thyroid carcinoma. Pulmonarymetastases can present in several forms: mediastinallymphadenopathy, parenchymal nodules, miliary lesions, or lymphangitic spread. In nearly all instancesthe lesions are apparent on the chest roentgenogram.This case report records an instance where pulmonary metastases of well-differentiated thyroid carcinoma were not detectable by roentgenogram butwere quite obvious on 1311scintiscan of the chest.

CASE REPORT

Patient WB, a 20-year-old male, was referredfor followup care of thyroid carcinoma in May,1964. A neck mass was first noted at age I 0. Therewas no history of irradiation to the neck or headand no history of symptoms suggestive of thyroiddisease. There was no family history of goiter orother thyroid disease. The neck mass created nosymptoms and underwent no changes until January,I963. While serving with the Air Force in Turkeythe patient noted progressive enlargement of themass and concomitantly began to notice weight loss.

Routine physical examination in July 1963 revealed a I 5-lb weight loss, a 3 X 4-cm firm, nonfixed mass in the left neck and several smaller lymphnodes palpable in the left anterior cervical chain.There were no symptoms or signs of hyper- or hypothyroidism except for the weight loss. The patientwas transferred to the U.S. Air Force Hospital,Wiesbaden, Germany. Radioactive iodine uptake,performed at that facility, was 26% at 24 hr. Thyroid scintiscan demonstrated several “cold―areasin the left lobe of the thyroid, coincident with thepalpable mass. Chest roentgenogram revealed 5everal masses consistent with metastatic disease. Atumor mass inifitrating locally became evident during surgical exploration of the neck. There wereobvious local lymph node metastases. A biopsy wastaken but no definitive surgery was attempted. The

biopsy report was mixed follicular and papillaryadenocarcinoma of the thyroid.

Patient WB was transferred to U.S. Air ForceHospital, Wilford Hall, San Antonio, Texas. On September 25, 1963, a total thyroidectomy with bilateralnode dissection was performed. The left recurrentlaryngeal nerve was invaded by tumor and was sacrificed. The postoperative course was complicatedby continued bleeding which necessitated reoperation and ligation of numerous small vessels, by pneumonia which responded to antibiotics and bronchialhygiene, and by hypocalcemia and hyperphosphate

Received Mar. 7, 1972; revision accepted June 28, 1972.For reprints contact : G. John Weir, Radioisotope Labo

ratory, Naval Hospital, Great Lakes, Ill. 60088.

FIG. 1. Normalchestroentgenogram,October1965.

I852 JOURNAL OF NUCLEAR MEDICINE

lUll/CASE REPORT

PULMONARY METASTASES FROM THYROID CARCINOMA

DETECTABLEONLY BY 1311SCAN. TREATMENTAND RESPONSE

J. E. Turner and G. J. Weir, Jr.

Naval Hospital, Philadelphia, Pennsylvania

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neck and chest, after thyrotropin stimulation, revealed no evidence of metastases.

Vitamin D and calcium supplementation wasregulated by daily monitoring of urinary calcium(Sulkowitch test) performed by the patient. Serumcalcium was determined at intervals of 3—6months.There was no recurrence of hypercalcemia on thisregimen. Dyspnea on exertion recurred in October1967 with no cough and no chest pain. Roentgenogram of the chest was normal (Fig. 3) . A scintiscanagain revealed extensive metastatic uptake of isotope within the chest (Fig. 4) . A third dose of 200mCi 1311was given on October 12, 1967. Again, the

OCT 67

FIG. 3. Normalchestroentgenogram,October1967.

FIG.4. 3811scintiscanof chest,October1967.Scanagainshows extensive uptake of isotope in lung fields.

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a...

FIG.2. ‘@‘iscintiscanof chest,October1965.Scanshowscxtensive uptake of isotope throughout both lung fields.

mia. Vitamin D and calcium supplementation became necessary because of persistent hypoparathyroidism. When the patient had recovered from theoperation, thyrotropin, 10 units daily for 5 days,

was given intramuscularly and scintiscanning of theneck and chest was performed with 850 j@Ciof 1311.Multiple areas of isotope concentration were presentin the neck, mediastinum, and lungs. A therapeuticdose of 200 mCi 1311was administered. The patientwas discharged from the hospital in good healthin January 1964. Medications taken at the time ofdischarge were calcium lactate tablets, 1,800 mg fourtimes daily; vitamin D, 60,000 units three timesdaily; and dessicated thyroid, 6 grains daily.

The patient noted mild dyspnea on exertion beginning May 1964 but continued in good healthuntil October 1965 when he presented with headache, constipation, weakness, nausea, and vomitingof 3 days' duration. Serum calcium was 16.5 mg%.He was hospitalized, vitamin D and calcium supplementation was discontinued, and intravenous fluidswere used to promote diuresis. Over a 3-day periodthe serum calcium returned to normal (vitamin Dand calcium supplementation again became necessary) and the symptoms abated.

During this hospitalization a chest roentgenogramwas normal (see Fig. I ) . Chest scintiscan was performed with 1 mCi 1311after administration of thyrotropin, 10 units daily for 3 days. There was ex

tensive uptake of isotope throughout both lungfields (see Fig. 2) . Again, a therapeutic dose of200 mCi 1311 was given. The patient experiencedno chest pain, cough, or increase in dyspnea following the therapy. Serial white blood counts revealedno decrease in lymphocytes or leukocytes followingthe treatment. In February 1966 the chest roentgenogram continued normal and a 1311scintiscan of

I

Volume 13, Number 11 853

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. .

..@ .. ;“

@1

.. .

Date

Normal 10—27—65 2—9-66 10—10—67 4—30—68

TURNER AND WEIR

TABLE 1. PULMONARY FUNCTION STUDIES

Vital capacity

Timed vital capacity

100% predicted

1 sec,83°f.3 sec, 97°f.

140°f.

80.6°f.96.0°f.

107 L

301 L

106°f.

79°f.95,',

96 1

278 1

3.0

0.220

77°f.97°f.

118 1

273 1

1.6

0.14

83°f.97°f,

115 1

115 1

2.0

0.08

Maximum breathing capacity

Maximum expiratory flow rate

Pulmonary resistance

Pulmonary compliance

158 1

2001/mmCM/HsO/L/sec

L/cmH.O0.2

patient experienced no exacerbation of dyspnea, nocough or chest pain, and blood counts revealed noevidence of bone marrow damage. Subsequent to thislast treatment the exertional dyspnea has cleared andthe patient became asymptomatic.

In May 1969 scintiscanningwith 1 mCi of 131!after a 3-day course of thyrotropin, 10 units daily,was repeated (see Fig. 5) . No evidence of metastaseswas found. At the most recent followup examination in July 1970 the patient was still free of symptoms with no cough or chest pain. He worked as asurveyor and frequently played 18 holes of golf without experiencing dyspnea. Chest roentogenogramand scintiscan with 131! and 99mTc revealed no evidence of metastases. These studies were performedwithout withdrawal of thyroid replacement or administration of thyrotropin. The findings were similarto Fig. 5. The possibility of stimulating tumorgrowth by thyrotropin was felt to outweigh the advantages to be gained by its administration. Pulmonary function studies were performed at intervals

*@,/@

@_;...

throughout the treatment period and are presentedin Table 1. The vital capacity and timed vital capacity have been normal or nearly normal throughoutthe treatment period. Maximum expiratory flow ratewas diminished prior to treatment in October 1967but returned to normal after treatment. Dynamiccompliance has shown no definite change. The maximum breathing capacity has fallen significantly andpulmonary resistance has risen but has remainedwithin normal limits.

DISCUSSION

Well-differentiated carcinomas of the thyroid areusually slow-growing tumors exhibiting a low gradeof malignancy. Life expectancy, even with knownmetastatic spread, is appreciable. Many patients willdie of other causes before they succumb to theirmalignancy (1 ) . Current evidence strongly indicatesthat this indolent course may be further slowed bythyrotrophic hormone suppression by full replacement of thyroid hormone and by the avoidance of

@ .xogenous thyrotropin (2,3).Pulmonary metastases can present in any of the

fashions common to other malignancies. Mediastinallymphadenopathy due to metastatic deposits, nodules,miliary deposits, and lymphangitic invasion are allseen. Whatever form pulmonary metastases take,they are ordinarily apparent on chest roentgenogram.The present case is the fourth published instance ofmetastases which were demonstrated by 131! scmtiscan in the presence of a normal roentgenogram(4—6). These cases demonstrate the advantages ofextensive scanning in thyroid malignancies. Thyrotropin will enhance isotope concentration in tumorswhich retain responsiveness. The advantages of increasing detectability of metastases must be weighedagainst the possibility of stimulating growth of the

t@ tumor.Frazell, et al (7) and Rall, et al (8) have re

corded deaths due to radiation pneumonitis following 1311 therapy of pulmonary metastases. This patient exhibited no symptoms of acute radiation injury

.4.

FIG.5. Normalscintiscanof chestandneck,May1969.Activity In lower right side of scan is normal uptake in gastric mucosa.

854 JOURNAL OF NUCLEAR MEDICINE

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PULMONARY METASTASES FROM THYROID CARCINOMA DETECTED BY 131! SCAN

at the times of treatment and so far has not notedsymptoms of chronic injury. The decrease in maximum breathing capacity is of some concern; however, the pulmonary resistance and complianceremain normal.

SUMMARY

A case of thyroid carcinoma with pulmonary metastases evident on 1311scintiscan but with a normalchest roentgenogram is presented. Only three similar cases have been reported in world literature.

Treatment with three doses of 200 mCi of 1311was given over a 3-year period. Complications ofthis therapy could include radiation pneumonitis andbone marrow suppression. Neither were seen in thiscase.

ACKNOWLEDGMENT

The opinions and conclusions expressed herein are thoseof the authors and do not necessarily reflect the views ofthe Department of the Navy, the Bureau of Medicine andSurgery, or the naval service at large.

REFERENCES

1. MEANS JH, DEGROOT U, STANBURY JB: The Thy

roid and its Diseases, 3rd ed, New York, McGraw-Hill,1966

2. THOMAS CG : Progression in thyroid cancer. In Clinical Endocrinology, vol 2, Astwood EB, Cassidy CE, eds,New York, Grune and Stratton, 1968, p 262—278

3. CRILE G : Survival of patients with papillary carcinoma of the thyroid after conservative operations. AmerJSurg 108: 862—866, 1964

4. B@iuErr 0, STENBERGES: Pulmonary metastasesfrom thyroid carcinoma : an unusual case. Ann Intern Med62:767—770,1965

5. BERTOLOTTI A : Metastasi pulmonari radiogicamantemute, da struma tiroideo, rilevate con l―impiegoradio jodio( 1315) dopo tiroidectomia. Arch Chir Torac Cardiovasc21:401—422,1964

6. CATZ B, STARR P: Cancer of the thyroid with metastases to the lungs : condition shown by scintigram in absence of definite x-ray findings. JAMA 160, 1046—1047,1956

7. FRAZELL EL, FOOTE FW: Papillary cancer of thethyroid. A review of 25 years of experience. Cancer 11:895—922,1958

8. RALL JE, ALPERS JB, LEWALLEN CG, et al : Radiation pneumonitis and fibrosis: A complication of radioiodinetreatment of pulmonary metastases from cancer of thethyroid.I ClinEndocr 17: 1263—1276,1957

Volume 13, Number 11 855

THE SOCIETY OF NUCLEAR MEDICINE20th ANNUAL MEETING

June 12—15, 1973 Americana Hotel Miami Beach, Florida

SECOND CALL FOR SCIENTIFIC EXHIBITS

The Scientific Exhibits Committee announces that abstracts of exhibits are now being reviewed for the20thAnnualMeeting.Abstractsof exhibits,large or small,are welcomedfrom members,nonmembers,and organizations. Exhibits supporting scientific papers are encouraged. View boxes for transilluminatedmaterial will be available.

Abstract Format: Abstracts must be submitted on a special abstract form for scientific exhibits which

is available from the Society of Nuclear Medicine, 211 E. 43rd Street, New York, New York 10017.Scientific Exhibit Awards: The Society is pleased to announce the presentation of Gold Medal, Silver

Medal, and Bronze Medal awards for outstanding exhibits in each of the following categories: Clinical Nuclear Medicine; Instructional; and Biophysics and Instrumentation. Judging is based on scientific merit, originality, display format, and appearance.Judging will occuron the first full meetingday.

Abstract Deadline: Abstracts should be submitted on or before March 1, 1973 to:

James J. Conway, M.D.Department of RadiologyThe Children's Memorial Hospital2300Children'sPlazaChicago, Illinois 60614

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1972;13:852-855.J Nucl Med.   J. E. Turner and G. J. Weir, Jr.  Treatment and Response

I Scan.131Pulmonary Metastases from Thyroid Carcinoma Detectable Only by

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