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Preoperative Tc-99m-Pertechnetate Scan Visualization of Gross Neck Metastases From Microcarcinoma Papillare and Another Papillary Carcinoma of Tall Cell Variant Scintigraphically Presented Like Small Warm Nodule in Graves Disease Patient

Marković, Vinko, MD, PhD*; Eterović, Davor, PhD*; Punda, Ante, MD, PhD*; Pešutić-Pisac, Valdi, MD, PhD; Kuna, Tihomir, PhD, DDS

doi: 10.1097/RLU.0b013e3181f4991e
Original Article

Purpose: Preoperative scintigraphic visualization of metastases from well-differentiated thyroid microcarcinoma in patients with Graves disease is extremely rare, as is the scintigraphic visualization of poorly differentiated thyroid carcinoma as a warm nodule. We present a patient with Graves disease and both of these rare entities.

Case Report: A 47-year-old woman complained of a growing left-side neck mass and symptoms of thyrotoxicosis. On clinical examination, the thyroid was palpable without discernible nodularity, while the left side of the neck was occupied by 3 gross, painless nodules. She also had signs of thyrotoxicosis and biochemical parameters of Graves hyperthyroidism. Ultrasound examination showed moderately hypoechogenic thyroid with a small hypoechogenic nodule in the upper pole of the left lobe and 3 gross, almost normoechogenic nodules on the left side of the neck. On Tc-99m-pertechnetate pinhole scintigraphy there was a small, warm nodule in the upper pole of the left lobe and 3 gross metastatic nodules on the left side of the neck. Fine needle aspiration of the neck nodules was consistent with metastases from thyroid papillary carcinoma. After thyrostatic preparation a total thyroidectomy with left modified radical neck dissection was done.

Results and Conclusion: Histopathologic examination disclosed 2 carcinomas in the left thyroid lobe. One of them was a tall cell variant of papillary carcinoma in the upper pole of the left lobe that measured 5 mm and corresponded to the small warm nodule, and the second one was a classic form of papillary microcarcinoma that measured 2 mm. Metastases accrued from the classic form of papillary microcarcinoma. Although the patient had 2 thyroid carcinomas, one with metastases and the other of more aggressive form, which is consistent with advanced stage and aggressiveness, she is now disease-free, 4 years after the operation and radioiodine ablation.

From the *Department of Nuclear Medicine, University Hospital Split, University of Split Medical Faculty, Split, Croatia; †Clinical Department for Pathology, University Hospital Split, University of Split Medical Faculty, Split, Croatia; and ‡School of Dental Dentistry, Department of Oral Surgery, University of Zagreb, Zagreb, Croatia.

Received for publication January 31, 2010; revision accepted March 21, 2010.

Reprints: Vinko Marković, MD, PhD, Department of Nuclear Medicine, University Hospital Split, Spinčićeva 1, 21 000 Split, Croatia. E-mail:

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