Mediastinal goiter diagnosed by functional imaging.

0.88 MB·English

by  Michels, Guido

(cid:1)ABC-ARTICLE
Mediastinal goiter diagnosed by
functional imaging
Guido Michels1*, Markus Dietlein2, Carsten Kobe2 and
Roman Pfister1
1Department IIIofInternal Medicine, UniversityofCologne, Cologne, Germany;2Department of
Nuclear Medicine,University ofCologne, Cologne, Germany
A 63-year-old asymptomatic woman with cured Hodgkin diseases presented for restaging. The chest
computed tomography showed a mass at the right side of the upper mediastinum. The benignity and the
originofthetissuewereunknown.First,weperformedabronchoscopy-guidedbiopsybutwithoutsuccess.In
thenextstep,weinitiatedradionuclideimagingwithtechnetium-99mpertechnetate(Tc-99m)andradioiodine
(I-123).LowuptakeofTc-99mandintense accumulationofI-123after2and24htothemediastinalmass
suggestedthatthemasswasamediastinalgoiter.Basedoniodineuptakeandthefactthatourpatienthadno
symptomsof tracheal compression, wedecidetogoforaradioiodine therapy.
Keywords: mediastinalgoiter;mediastinaltumor;scintigraphy;iodine-123;technetium-99mpertechnetate;radioiodineI-131therapy
Received:9 December 2011; Revised:21 December 2011; Accepted:28 December 2011;Published:19January2012
A 63-year-old asymptomatic woman with cured 24 h shows organification of iodine, which is specific for
Hodgkin diseases presented in our hospital for thyroid tissue. Tc-99m uptake stands for trapping of an
restaging. iodine analog in the early phase, but Tc-99m is not used
Thephysicalexaminationandthelaboratorytestswere for the synthesis of thyroid hormone. Thyroid nodules,
withoutpathologicalfindings.Thechestcomputedtomo- which accumulate Tc-99m, but the late I-123 scans are
graphy(CT)showeda54(cid:1)44(cid:1)75mmmassattheright iodinenegative,arecalled‘trappingonlynodules.’Insuch
side of the upper mediastinum (Fig. 1A). The benignity a constellation, the dignityof the tissue remains unclear,
andtheoriginofthetissuewerestillunknown.Therefore, and patients are not qualified for radioiodine therapy.
Based on I-123 uptake and the fact that our patient had
after the CT, we performed abronchoscopy with biopsy
no symptoms of tracheal stenosis such as stridor, we
becauseitwasverydifficultradiologicallytodifferentiate,
decide for a radioiodine therapy. The post-therapeutic
for example, lymphoma (relapse) from other mediastinal
I-131 scans 5 days after I-131 application show the
tumorssuchasgoiter.Thehistopathologicalresultswere
organification of I-131 (E). One year later, magnetic
unfortunately without success. Fine-needle biopsies are
resonance imaging presented goiter shrinkage without
oftendifficultbecauseoftheinaccessibilityofthemassor
narrowingofthetrachea(F).
oftheunreliabilityoftheresults.Inourcase,abroncho-
scopy-guidedrebiopsyaswellafine-needleaspirationwas
Learning points
refused by the patient. In the next diagnostic step, we
initiated radionuclide imaging with technetium-99m per-
1) Mediastinal goiters arethe most frequent masses in
technetate (Tc-99m; Fig. 1B) and radioiodine (I-123;
the superior mediastinum (1(cid:2)3).
Fig.1C,D).LowuptakeofTc-99mandintenseaccumu-
2) The CT and radionuclide imaging can suggest or
lationofI-123after2h(Fig.1C)and24h(Fig.1D)tothe make the diagnosis in most cases.
mediastinal mass suggested that the paratracheal mass 3) Intreatment,theradioactiveI-131therapyhasbeen
wasamediastinalgoiter.TherelativelyexpensivetracerI- effectively used to reduce the size of intrathoracic
123 offers the following advantages compared with Tc- goiters.
99m: I-123 has the higher gamma energy of 159 keV
insteadof141keVandhashigheruptakeintothethyroid, Conflict of interest and funding
which is relevant for the penetration of the gamma The authors have not received any funding or benefits
emitters through the chest wall. The I-123 scan after from industryor elsewhere to conduct this study.
LibyanJMed2012.#2012GuidoMichelsetal.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttribution- 1
Noncommercial3.0UnportedLicense(http://creativecommons.org/licenses/by-nc/3.0/),permittingallnon-commercialuse,distribution,andreproduction
inanymedium,providedtheoriginalworkisproperlycited. Citation:LibyanJMed2012,7:15693-DOI:10.3402/ljm.v7i0.15693
(pagenumbernotforcitationpurpose)
GuidoMichelsetal.
AAA BBB CCC
DDD EEE FF
Fig.1. (A)Contrast-enhancedCTdemonstratesahomogeneousmassattherightsideofthemediastinum(arrow).(B)Thyroid
scintigraphywith75MBqTc-99mpertechnetate.Thescanningshowedonlymarginalactivitythroughoutthemediastinalmass
(arrow).(C)Scintigraphywith10MBqI-1232hpost-injection.(D)Image24hlater.ThelateaccumulationofI-123attheright
thyroid lobe and the mediastinal mass are the direct evidence that both areas are composed of athyroid hormone-producing
tissue. (E) Image5 daysafter I-131therapy.(F) Magnetic ResonanceImaging(MRI)1 yearafterradioiodine therapy.
References
*GuidoMichels
DepartmentIIIofInternalMedicine
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Citation:LibyanJMed2012,7:15693-DOI:10.3402/ljm.v7i0.15693
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