Pelvic Radioiodine Uptake in a Rectal Wall Teratoma After Thyroidectomy for Papillary Carcinoma

Mark Lakshmanan*, James C. Reynolds, Silvana Del Vecchio, Maria J. Memo, Jeffrey A. Norton, and Jacob Robbins

Clinical Endocrinology Branch, National Institute ofDiabetes and Digestive and Kidney Diseases, NIH; Nuclear Medicine Department, Warren Grant Magnuson Clinical Center, NIH; Laboratory ofPazhology and Surgery Branch, National Cancer Institute, NIH, Bethesda, Maryland; and Istituto Medicina Nucleare, II Facolta Di Med. E. Chir., Naples, Italy

CLINICAL PRESENTATION A 30-yr-oldwoman with previouslyresected papillarythyroid A 30-yr-oldwoman developeda sorethroat, a painfulthyroid carcinoma was found to have a pelvic lesion which concen nodule and slight hoarseness. A [@mTc]pertechnetatescan showed trated radloiodine. By performing simultaneous 1311whole decreased activity in the lower pole ofthe right lobe ofthe thyroid body and @“Tc-methylenediphosphonate bone scans, we that corresponded to the 2-cm nodule. A fine needle aspirate found the lesion to be in soft tissue between the sacrum and showedpapillarycarcinoma.Alsopalpablewerea 5-mm nodule bladder. Rad@iodine therapy was postponed so that the in the left lobe and a 1-cm movable lymph node in the left lesion, a benign teratoma of the rectal wall, could be surgically posterior cervical chain. removed. Prior to laparotomy, the patient received a second At total thyroidectomy,the right lobe contained a calcified tracer dose of 1311so that the lesion could be located at masswith a proliferationof follicleslined by cuboidalcellswith surgery with a hand-held gamma detector. A postoperative characteristic clear nuclei and occasional papillary formation. whole-body 1311scan confirmed that the lesion had been Elsewhere,the gland contained multiple small tumor foci of removed, thus reducing the absorbed radiation that would similar histology. The diagnosis was multi-focal papillary thyroid have been received by the ovaries during radioiodine therapy. carcinoma,follicularvariant. The nodule in the left lobe was a Althoughthe lesioncontainedboththyroidandgastricepithe follicular adenoma. hum, accumulated 131Iwas limited to the area with thyroid A whole-bodyscan(1.5mCi ‘@‘I),6 wkafter surgeryand 2 wk follicles. after discontinuing triiodothyronine, showed left thyroid bed J NucI Med 1992; 33:1848—1850 activity and another focus in the pelvisjust to the right of midline (Fig lA). Because images 48 hr later and following a cathartic showedthe pelvic focus again, combined 99mTc..MDpand 1311 scanswereobtainedwhichshowedthat the 1311focuswasin soft tissue,anterior to the sacrum and cephaladto the bladder (Fig his report describes a patient with papillary thyroid 1B). Diagnostic considerations included a lymph node metastasis cancer whose initial ‘@‘Iscan after thyroid surgery showed of thyroid carcinoma, Meckel's diverticulum (1), an ovarian a focus ofactivity in the pelvis. Combined ‘@‘Iand @mTc@teratoma (2—4)and an ovarian cystadenoma (5). She had no methylene diphosphonate (MDP) scanning, and intra-op urinary, gynecologic or gastrointestinal symptoms. Pelvic and erative use of a hand-held gamma detector aided in beat barium enema examinations were normal. Ultrasound showed a prominentrightovarywithsmallcysticareas.There wasfluidin ing the lesion in the rectal wall. The lesion concentrated the pelvis. 0. 105% of the administered radioiodine and proved to be A repeatwhole-bodyscan 2 mo later again showedthe pelvic a benign teratoma. Its resection before ‘@Itherapy pre focus. T3 replacement was restarted and the next day a laparot vented excess radiation to the ovaries. omy was performed. A 3-cm cystic mass adherent to the wall of the proximal rectum was identified. A hand-held gamma detector showedthat the masswasintenselyradioactiveand when it was resected the pelvic counts dropped to background. ReCeiVedNov. 6, 1991 ; revision accepted Jun. 2, 1992. The cyst,containingthick creamy fluidand a central massof For reprints contact: Dr. Jacob Robbins, CEB/NIDDK, NIH, 9000 Rockville firm tan tissue, measured 3.2 x 1.4 x 1.3 cm and weighed 2.8 g. Pike, Bethesda, MD 20892. Squamous, transitional and respiratory epithelium lined the cyst . Currentaddress: Departmentsof Medidne and Physiology and Biophysics, School of Medicine, CWRU. wall (Fig. 2). The solid nodule contained gastric and colonic Disclaimer:The opinionsor assertions of this publicationare the private epithelium, skin appendages, smooth muscle, lymphoid aggre views of the authors and are not to be construed as official or reflecting the @ viewsofthe U.S.Government,nordoes mentionoftrade names commercial gates, fibrovascular connective tissue and cartilage. Glandular products ui@plyendorsement by the U.S. Government. structures resembling follicular thyroid epithelium were adjacent

1848 The Journal of Nuclear Medicine•Vol.33 •No. 10 •October1992 1A lB

4,' Iw 4.

@ @,,. ., @,.‘

@ i-,. . . . ‘.‘, FIGURE 1. (A)Posteriorwhole-body1311scan after thyroidec

@ tomy. Besides physiological uptake in the bladder, radioiodine ‘v: @• concentration was present just to the right of the midline in the pelvis (arrow). Iodine-I31 was also present in the left thyroid bed (not shown). The foci along the right leg are 1@Bareference standards.(B)Imagesof the posteriorpeMs (upperpanels),right ) @4L@ lateral peMs (middle panels), and with the patient sitting above

the camera (lower panels). On the left are the @rc-MDPbone 4v4@,, @. scans; on the rightare overlaysof the bone and 1311scans. The arrowspointtothelesionaccumulating1311.

to mucus secreting glands and respiratory epithelium. The diag FIGURE 2. (A) Highpowerviewof the pelviclesion,demon nosis was benign cystic teratoma of the colon. stratingmaturetissuefromthegermlayersincludinggastrictype After the laparotomy, gamma camera images of the pelvis epithelium(H&E,200x).(B)HighpowerviewofthepeMclesion showed that the focus of radioiodine had disappeared. Later, a showing glandular structures resembling thyroid follicles and the 30 mCi ‘@‘itreatment was givento ablate the thyroid remnant; cyst walllinedby maturerespiratoryepithelium(H&E,200x). at 96 hr gamma camera imagesagain showedthe thyroid bed activity, but pelvic activity was normal. areas contained eosinophilic epithelium (Fig. 3). Although the Iodlne-131AssayandQuantftativeAutoradiography 20-sm autoradiographic sections were too thick for precise iden Radioactivitywasmeasuredin a gamma wellcounter and its tification ofcell type, the areas containing radioactivity coincided distribution determined by quantitative autoradiography (6). with anti-thyroglobulin antibody-stained small thyroid follicles Dried frozen sections,20 @mthick, were used to exposex-ray and not with adjacent gastric-like epithelium. film that was later analyzed with a scanning microdensitometer. Adjacentsectionswerestainedwith hematoxylinand eosin. The lesion contained 0.105% of the administered ‘@‘iwith 0.01%ofthis in the cystfluidand wall.Correctedfordecay,solid DISCUSSION tissue contained 1.5 @iCior 3.73 @iCi/g.A comparison of H & E In adults, the ovary is the most common location of and autoradiographicsectionsshowedthat the most radioactive teratomas, although retroperitoneal organs are also com

A B

FIGURE 3. Autoradiograph(A)of a 20- @msection (B) of the pelvic lesion dam C onstratingthe presence of 1311in a limited area. Thiscoincideswith the regionthat contaned thyroid follicles and not with other regionsthat were richingastric epi thelium.

Radioiodine in Rectal Wall Teratoma •Lakshmanan et al 1849 mon sites (7-9). These tumors may arise in the rectum or REFERENCES colon (10—15)or secondarily involve lower bowel that is 1. Caplan RH, Gunderson GA, Abellera RM, et al. Uptake ofiodine-131 by adjacent to a primary tumor in the ovary (16—19)or the a Meckel'sdiverticulummimickingmetastaticthyroid cancer. C/in Nuc/ fallopian tube (20). Almost all are benign. About 10% of Med 1987;12:760—762. 2. Yeh E-L, Meade RC, Ruetz PP. Radionuclidestudy of struma ovarii.J benign cystic teratomas of the ovary contain mature thy Nuc/Med 1973;14:1l8—121. roid tissue (21,22). The frequency ofthyroid tissue occur 3. FalsettiL,SchivardiMR. MairaG, etal.Riscontrodistrumaovariiinuna paziente in trattamento per carcinoma tiroideo. Ann os: Gin Med Penn ring in cobonic teratomas is unknown. 1985;106:290—293. In the present case, a benign cystic teratoma of the 4. 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1850 The Journal of Nuclear Medicine •Vol. 33 •No. 10 •October1992