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Hyperthyroidism Caused by a Toxic Intrathoracic Goiter with a Normal-Sized Cervical Thyroid Gland

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Hyperthyroidism Caused by a Toxic Intrathoracic Goiter with a Normal-Sized Cervical Thyroid Gland CaseReports Hyperthyroidism Caused by a Toxic Intrathoracic Goiter with a Normal-Sized Cervical Thyroid Gland R. Prakash, N. Lakshmipathi, A. Jena, V. Behari, and M.K. Chopra Medical Division, Institute ofNuc!ear Medicine and Allied Sciences, Delhi, India The rare presentation of hyperthyroidism caused by an intrathoracic goiter with a normal sized cervical thyroid gland is described. The toxic intrathoracic goiter demonstrated avid uptake of [1311]and [@“Tc]pertechnetate,with comparatively faint isotopic accumulation seen in the cervical thyroid. A chest roentgenogram and radioisotope scan should be mandatory in casesof hyperthyroidismhavingno cervicalthyroidenlargementto explorethe possibilityof a toxic intrathoracicgoiter. J NucI Med 27:1423—1427,1986 ntrathoracic goiter most commonly presents as a CASE REPORT @ superior mediastinal mass and accounts for 10% of all mediastinal masses (1,2). Pathological studies have A 52-yr-old female presented with a 4-mo history of weak shown that intrathoracic goiters almost always occur as ness,weightlossin spiteofa normalappetite,and twoepisodes a result of inferior extension of thyroid tissue in the of hemoptysis. There were associated symptoms of increased neck (3). The connection between intrathoracically bowel frequency, nervousness, palpitations, insomnia, and placed goiters and the cervical gland is clearly demon tremulousness. Physical examination revealed a slightly overweight female strable in the majority ofcases (4,5), which are classified in no distress, blood pressure was 140/90 mmHg supine, pulse as secondary intrathoracic goiters. Completely sepa 96 and regular. Her skin was warm and moist, and she had rated, aberrant, or primary intrathoracic goiters arise fine finger tremors. A mild lid lag and lid retraction was from ectopic tissue which has separated from the gland evident on the right side. There was no palpable goiter. proper during embryonic life and descended into the Chest x-ray (Figs. 1 and 2) showed a 6 x 5 cm diameter mediastinum (6,7). mass in the right superior middle mediastinum with central Intrathoracic goiters may be asymptomatic and dis calcification. There was no significant tracheal compression covered incidentally, but may cause clinical symptoms or displacement. due to pressure on adjacent structures as the goiter Laboratoryinvestigationsconfirmedthe clinicaldiagnosis enlarges within the rigid thoracic inlet (8). These goiters of hyperthyroidism.Thyroid hormone estimation done by are usually nontoxic nodules; hyperthyroidism has been radioimmunoassay showed serum total tniodothyronine level of 390 ng/dl (normal range 70—220ng/dl) and serum reported to be an unusual accompaniment ranging from thyroxine of2l @zg/dl(normal 5—13.5). 0 to 15% in recent series (4,5). However, all these Thyroid radioactive iodine uptake (RAIU) was measured reported cases had enlarged thyroid glands in the neck. over the neck with a single channel analyzer and as per IAEA We report a case of intrathoracic goiter causing hy recommendations (9). The uptake after oral administration perthyroidism and feedback suppression of a normal of25 @@Ciiodine-131 (‘31I)was15% at 2 hr and 34% at 24 hr. sized cervical thyroid gland. Radioisotope scans showed A gamma camera thyroid scan was done at 24 hr (Fig. 3) faint continuity ofthe intrathoracic mass with the lower using an 8-mm aperture pinhole collimator positioned 7 cm pole of the right lobe of the thyroid. A review of the abovethe suprasternalnotch. A 10-mmcount imageshowed literature is presented. a functioning intrathoracic goiter on the right side in the position corresponding to that of the mediastinal mass oh served on the chest x-ray. The central area had reduced activity Received Oct. 7, 1985: revision accepted Mar. 31, 1986. consistent with degeneration. Faint radioactivity was observed For reprints contact: Rajeev Prakash, MD, Scientist ‘C',Insti in the normal-sized cervical thyroid. Iodine-131 uptake mea tute ofNuclear Medicine and Allied Sciences, Probyn Rd., Delhi sured with the probe now focused over the mediastinal mass I10007,India. was 32%. @ Volume 27 e Number 9 September1986 1423 r FIGURE 1 Posteroanteriorroentgenogramshowshomogenousmass in superiormediastinumto rightof midlineproducingmm imal impressionon tracheawith no significantdisplace FIGURE 2 ment Lateral view demonstrates mass to be in middle medias tinum with evidence of central calcification. There is no significant tracheal compression A technetium-99m (99mTc)pertechnetate thyroid scan was obtained after i.v. administration of5 mCi ofthe radionuclide. A 400,000-count pinhole image showed intense isotopic up ectopic or so-called primary intrathoracic goiters are take in the intrathoracic nodule with few central areas of reduced, patchy uptake suggestive of multinodularity (Fig. 4). extremely rare (6,12) and presumably originate from Comparatively faint accumulation of the radionuclide was fragmented embryonic thyroid tissue that has seen in the cervical thyroid. descended into the mediastinum ( 7). A diagnosis of hyperthyroidism due to a hyperfunctioning Intrathoracic goiters occur most commonly in the intrathoracic goiter with a normal-sized cervical thyroid gland fifth decade of life (10) with a female predilection of 3 was made. The patient was initially treated with graded doses to 4: 1 (5). These may be completely asymptomatic in of carbimazole with good improvement. As there was no 15—50%ofcases (3,13). Clinical manifestations include obvious tracheal compression, nor any pressure symptoms, hoarseness, cough, dyspnoea, and stridor (5,10,14) and she was subsequently treated with 15 mCi of [‘311]sodiumdysphagia may occur in ½of cases. The rarer presen iodide. Four months after radioiodine therapy the patient was tations include superior vena cava syndrome (15), clinically and biochemically euthyroid (triiodothyronine 200 hypertension (16), and hyperthyroidism (1 7). ng/dl, thyroxine 12 @zg/dl). Earlier reports have shown that fewer than 10% of substernal goiter patients had elevations in thyroid hor DISCUSSION mone levels (4). More recent series have shown only an occasional hyperthyroid patient (10,18). However, all Intrathoracic goiter is one ofthe major considerations these patients had associated cervical thyroid enlarge in the evaluation of superior mediastinal masses. Sub ment and could be classified as having secondary intra sternal and partial intrathoracic goiters generally rep thoracic goiters. In the case cited by Ng Tang Fui et al. resent intrathoracic extensions ofcervical thyroid tissue (18) it is obvious on the thyroid scan performed after (10); 75—80%of these masses descend into the anterior radioiodine therapy that the intrathoracic goiter was an mediastinum while the remainder descend into the extension of the enlarged left lobe of the thyroid gland. posterior mediastinum (11) with middle mediastinal Our patient presented with classic features of hyperthy goiters being rarely encountered. Completely separated, roidism, confirmed by thyroid function tests. Thyroid 1424 Prakash,Lakshmipathi,Jenaetal TheJournalof NuclearMedicine @ %. .‘ .. @ .•• . :@e ...... .. .. ..- @t. .. ,. , . .. .. —.@.. g@ . .@ @ . .. •?‘- @‘. ‘ : . •• @ . ..... • .... :,@ : , @ :t ‘. @“,PJ@' , @ @r @:‘.. •. ••:- ‘ :@@‘@....;@ @ @., @‘•@ @1..'@.‘—•@. a . .. ,. I . .—“@ $• @‘ .. @ ......@ 0• t. .?:.: @ ... .. .‘ ... ... @ @‘:. • . .. @ .. t. .... @ r. ..@ ..@.. @ a :/ .@ .. @ ,;. ,... .. k ‘ •@ @ . @‘ . I@. •. • . @ . g•.@ ••@: FIGURE4 FIGURE3 Technetium-99m pertechnetate thyroid scan shows avid Iodine-i 31 thyroid scan shows hyperfunctioning intratho uptakeby intrathoracicnodulewith centralpatchyareas. racic goiter on right side with comparatively faint uptake Faint continuity with nght lower pole of cervical thyroid is in normal-sizedcerv@althyroid seen scan conclusively demonstrated a normal-sized thyroid in 99mTc images the high blood background from the gland with increased uptake in the intrathoracic goiter cardiovascular blood pool can interfere with the scan located in the superior mediastinum. quality and visualization of a retrosternal thyroid. The The diagnostic procedures currently in use for eval role of isotopes is, however, controversial as negative uation of intrathoracic goiter include chest radiography thyroid scans in retrosternal goiter may occur when (19), radionuclide scintigraphy (20), transmission com there is too little uptake of radioiodine by the goiter puted tomography (21), as well as invasive techniques (10,23). Furthermore, accumulation of these isotopes such as angiography and mediastinoscopic biopsy. The in an intrathoracic location is not specific for goiter as routine chest x-ray is a valuable initial study for com [99mTc]pertechnetate uptake has been reported in sub partmental localization of a mediastinal mass and also sternal parathyroid adenoma (24) and also in an ante demonstrates tracheal displacement or compression nor mediastinal thymoma (25). Iodine-131 mediastinal and areas of calcification. Computerized tomography uptake has also been noted in two cases of bronchi of intrathoracic goiter can note continuity of the me ogenic carcinoma (26,27). However, in the present case diastinal mass with the cervical gland, well-defined bor the clinical features in combination with high thyroid ders, focal calcifications, high contrast attenuation val hormone levels and isotopic uptake in the intrathoracic ues of the goiter
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