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LETTER TO THE EDITOR
Year : 2014  |  Volume : 51  |  Issue : 4  |  Page : 613-614
 

Discordant and aggressive tumor biology of solitary scalp metastasis amidst widespread skeletal metastases in differentiated thyroid carcinoma: Functional radionuclide and MR imaging features and clinical correlates


1 Radiation Medicine Centre, Bhabha Atomic Research Centre, Parel, Mumbai, India
2 Department of Radiology, Tata Memorial Hospital, Parel, Mumbai, India

Date of Web Publication1-Feb-2016

Correspondence Address:
Dr. S Basu
Radiation Medicine Centre, Bhabha Atomic Research Centre, Parel, Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175309

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How to cite this article:
Basu S, Mahajan A. Discordant and aggressive tumor biology of solitary scalp metastasis amidst widespread skeletal metastases in differentiated thyroid carcinoma: Functional radionuclide and MR imaging features and clinical correlates. Indian J Cancer 2014;51:613-4

How to cite this URL:
Basu S, Mahajan A. Discordant and aggressive tumor biology of solitary scalp metastasis amidst widespread skeletal metastases in differentiated thyroid carcinoma: Functional radionuclide and MR imaging features and clinical correlates. Indian J Cancer [serial online] 2014 [cited 2019 Dec 13];51:613-4. Available from: http://www.indianjcancer.com/text.asp?2014/51/4/613/175309


Sir,

The functional radionuclide imaging features and clinical correlates of metastatic lesions in a 66-year-old female diagnosed patient of differentiated thyroid carcinoma (DTC) with aggressively behaving scalp lesion (amongst extensive skeletal metastatic lesions) is illustrated in this communication. Four months following the second dose of radioiodine therapy [the post-treatment scan depicted in [Figure 1], she presented to the clinic with complaints of progressively increasing solitary scalp swelling [Figure 2]. The whole body fluorodeoxyglucose positron emission tomography FDG-PET [Figure 3], in contrast to the radioiodine scan, demonstrated solitary focus of abnormal uptake corresponding to the scalp lesion with none of the other skeletal metastatic disease showed any FDG uptake. This was consistent with the fact, that the patient had only complaints with respect to the progressively increasing scalp metastasis with no other obvious clinical complaints with respect to the other metastatic lesions, which matched with the FDG-PET imaging features. The present case highlights different imaging characteristics of different metastatic lesions and the clinical behavior in the same patient. She is presently under follow-up and had undergone treatment with 250 mCi I-131 one more time subsequently to treat the other iodine avid metastatic lesions.
Figure 1: Post-treatment radioiodine scan undertaken just before discharging the patient from the ward following the second dose of I-131, demonstrating extensive skeletal metastases concentrating radioiodine avidly. Incidentally, noted is relatively low uptake in the scalp lesion

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Figure 2: Coronal magnetic resonance MR (a) T2-weighted and (b) post.contrast images demonstrating hyper intense. (on T2-image) well defined invasive and heterogeneously enhancing soft tissue lesion involving both the tables of skull and reaching up to dural lining but, remains extra axial

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Figure 3: The whole body fluorodeoxyglucose positron emission tomography FDG-PET demonstrates no FDG uptake in any of the metastatic lesions in the skeleton except for the scalp lesion. (for which the patient presented to the clinic)

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The flip-flop between radioiodine scan and FDG-PET has been a recognized fact in the parlance of DTC and nuclear medicine imaging procedures are being utilized to explore the various aspects of thyroid cancer including tumor biology and heterogeneity of tumor characteristics.[1],[2],[3],[4] The interesting aspect of this case is the visual demonstration of both well-differentiated asymptomatic metastases and a focus of aggressive poorly differentiated tumor in the same patient. While, this process is most likely present to some extent in practice in a number of patients whose tumors eventually transform into poorly differentiated lesions, the peer reviewed literature at present, primarily describes studies that addresses FDG-PET positive versus 131I positive tumors and tend to describe patients as falling into either of these two imaging categories. There is relatively little information on patients who concurrently manifest both 131I and PET positive lesions. Thus, such presentations and clinical discourse would be more scientifically useful to develop this concept which would hopefully impact the management approach in this group of patients in the future. The finding illustrated would thus call more attention to the fact that clinicians should be aware that varying tumor biology amongst the metastatic lesions can be encountered in the same patient of DTC and neither imaging modality is completely accurate, and that concerning symptoms in an individual patient would warrant further evaluation. The aggressive nature of FDG positive lesions and the associated relatively poor survival with PET positive disease is well recognized in practice. Additionally, the case demonstrates an example of cutaneous metastases from DTC, a relatively uncommon site of disease spread in the setting of well-differentiated thyroid cancer, of which the scalp being the most commonly reported site of skin involvement.

 
  References Top

1.
Grabellus F, Nagarajah J, Bockisch A, Schmid KW, Sheu SY. Glucose transporter 1 expression, tumor proliferation, and iodine/glucose uptake in thyroid cancer with emphasis on poorly differentiated thyroid carcinoma. Clin Nucl Med 2012;37:121-7.  Back to cited text no. 1
    
2.
Borde C, Basu S, Kand P, Arya S, Shet T. Bilateral renal metastases from papillary thyroid carcinoma on post 131I treatment scan: Flip-flop sign, radioiodine SPET, 18F-FDG PET, CECT and histopathological correlation. Hell J Nucl Med 2011;14:72-3.  Back to cited text no. 2
    
3.
Vural GU, Akkas BE, Ercakmak N, Basu S, Alavi A. Prognostic significance of FDG PET/CT on the follow-up of patients of differentiated thyroid carcinoma with negative 131I whole-body scan and elevated thyroglobulin levels: Correlation with clinical and histopathologic characteristics and long-term follow-up data. Clin Nucl Med 2012;37:953-9.  Back to cited text no. 3
    
4.
Feine U, Lietzenmayer R, Hanke JP, Wöhrle H, Müller-Schauenburg W. 18FDG whole-body PET in differentiated thyroid carcinoma. Flipflop in uptake patterns of 18FDG and 131I. Nuklearmedizin 1995;34:127-34.  Back to cited text no. 4
    


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  [Figure 1], [Figure 2], [Figure 3]

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