Background
The term non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was recently proposed as a non-malignant thyroid lesion with indolent behavior that does not require post-operative radio-iodine treatment. We are reporting a case of NIFTP with bone metastasis that is the second case reported so far.
Case presentation
We describe a 38-year-old woman who presented with an indeterminate thyroid nodule and underwent total thyroidectomy with the finding of NIFTP on careful pathologic examination. However, her initial follow-up evaluation revealed a serum thyroglobulin level of > 300 ng/ml and a diagnostic whole body 131I scan demonstrated a focus of increased uptake in the left hemipelvis, confirmed on CT scan to be a lytic lesion in the left iliac bone. She was treated with 7.4GBq (200 mCi) of 131I and her follow-up 1 year later revealed an undetectable serum thyroglobulin and a negative whole body 131I scan with no visible uptake in the iliac bone indicating an excellent response.
Conclusion
This case presentation reminds us to be alert to the rare occurrence of distant metastasis in NIFTP and the need for a case by case analysis and continuing post-operative follow-up for detection of residual or recurrent disease.
A 59-year-old woman with follicular thyroid carcinoma underwent total thyroidectomy followed by radioiodine treatment. Following treatment, the whole-body scan did not show any abnormal radioiodine uptake. However, during the follow-up, the serum thyroglobulin (Tg) value increased without detectable thyroglobulin-antibodies. We performed a Ga-68 DOTA-TATE PET/CT showing a sternal lesion and several lung nodules with high somatostatin receptor density. Also, on the next day, FDG PET/CT was performed, which confirmed the findings. Considering the high levels of somatostatin receptor expression in such metastases, we planned lu177 DOTA-TATE therapy. After two cycles of lu177 DOTA-TATE injection, serum thyroglobulin significantly dropped, and she claimed that her sternal pain and dyspnea were much better. This was the case of a patient suffering from iodine-refractory follicular thyroid carcinoma, with somatostatin-receptor expression, treated with 177Lu-DOTA-TATE, showing a significant response.
A 33-year-old female with a history of total thyroidectomy for papillary thyroid carcinoma was referred to the nuclear medicine department for ablative radioiodine therapy. Post ablation scan showed an area of intense iodine uptake on the left side of the pelvic region, corresponding to the large well-defined heterogeneous mass in the left ovary in the SPECT/CT images. The radiologic features of this lesion were compatible with a dermoid cyst, previously unrecognized. Eventually, the lesion was laparoscopically removed, and a typical dermoid cyst was confirmed through histopathologic assessment.
A 55-year-old disabled man with glioblastoma multiforme was referred to us for fibroblast activation protein inhibitor (FAPI) PET/CT imaging. 68Ga-DOTA-FAPI-46 scan revealed uptake in the primary tumor and unexpected uptakes in soft tissue, especially in periarticular regions. These latter foci were compatible with calcifications on the CT. One in the breast was compatible with fibrotic tissue, but 2 other foci, in the rectus abdominis and gallbladder wall, could not be correlated with the CT findings. In Neurogenic heterotopic ossification, hypoxia-associated oxidative stress results in the metaplastic transformation of fibroblasts. Abnormal differentiation of fibroblasts in neurogenic heterotopic ossification before ossification could explain radiolabeled FAPI avidity in the mentioned areas.
A 2-month-old infant was referred for hepatobiliary scintigraphy due to ascites of unknown cause. The top differential diagnosis was spontaneous perforation of the biliary ducts. Delayed images up to 4 hours were against this diagnosis showing normal distribution of the radiotracer throughout the bowel. However, on delayed images, the scan showed mild tracer retention in the ascites confirmed by SPECT/CT images. Surprisingly, the exploratory abdominal surgery revealed an intact hepatobiliary system, pointing toward other possible etiologies. Second-review surgery was performed due to uncontrolled progressive ascites showing congestive hepatopathy and biliary leak from the hepatic surface suggestive of the "crying liver".
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