IMAGES THAT TEACH Incidental ectopic thyroid follicular adenoma on myocardial perfusion imaging Adam Raskin, MD,a Yulanka Castro-Dominguez, MD,b Neena Mirani, MD,c Justin Sambol, MD,d Alfonso H. Waller, MD,a,e and Nasrin Ghesani, MDa,e a
Division of Cardiology, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ c Department of Pathology, Rutgers New Jersey Medical School, Newark, NJ d Division of Cardiothoracic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ e Department of Radiology, Rutgers New Jersey Medical School, Newark, NJ b
Received Jun 4, 2015; accepted Jun 4, 2015 doi:10.1007/s12350-015-0212-6
CASE PRESENTATION A 50-year-old female with a history of breast cancer underwent myocardial perfusion scan for the evaluation of chest pain. Projection exercise stress technetium-99m tetrafosmin images demonstrated a focus of radiotracer uptake in the mediastinum (Figure 1). Due to her history of breast malignancy and concern for possible metastasis, she underwent F-18 fluorodeoxyglucose PET/CT scan which also demonstrated a similar focus of abnormal radiotracer uptake in the anterior mediastinum (Figure 2). Cervical mediastinoscopy and biopsy was non-diagnostic, with a differential diagnosis that included thyroid follicular adenoma/carcinoma or adenomatoid nodule. With a suspicion of thyroid malignancy, a sternotomy with complete resection of the mediastinal mass as well as a thyroidectomy was performed. The histologic diagnosis
Reprint requests: Adam Raskin, MD, Division of Cardiology, Department of Medicine, Rutgers New Jersey Medical School, 185 South Orange Avenue, MSB I-538, Newark, NJ 07103; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2015 American Society of Nuclear Cardiology.
was ectopic thyroid tissue with follicular adenoma, a benign lesion (Figures 3 and 4). Non-cardiac findings on single-photon emission computed tomography (SPECT) imaging are not uncommon. Williams et al.1 reported that 1.7% of 12,526 dual-isotope perfusion SPECT studies identified extra-cardiac findings. Thyroid abnormalities comprised 3% of these findings. To our knowledge, this is the first reported case of a mediastinal follicular adenoma identified by myocardial imaging. This case illustrates how reviewing rotating projection images of cardiac studies may lead to identifying extra-cardiac findings and should not be overlooked.
Figure 1. Projection technetium-99m tetrafosmin image demonstrating a focal area of radiotracer uptake in the mediastinum (arrow).
Raskin et al Incidental ectopic thyroid follicular adenoma
Journal of Nuclear CardiologyÒ
Figure 2. F-18 Fluorodeoxyglucose (FDG) PET/CT demonstrating a 2.1 cm FDG avid mass in the anterior mediastinum, at the level of the aortic arch (SUV 4.2) (arrow). Figure 4. Histopathology with hematoxylin and eosin staining (9400) of a predominant microfollicular pattern. The uniform tumor cells with round non-overlapping nuclei and small monomorphous follicles with little colloid.
Disclosures None.
Reference 1. Williams KA, Hill KA, Sheridan CM. Noncardiac findings on dualisotope myocardial perfusion SPECT. J Nucl Cardiol 2003;10:395402.
Figure 3. Histopathology with hematoxylin and eosin staining (9100) of thyroid tumor completely surrounded by a thin fibrous capsule (asterisks). There is no evidence of capsular or vascular invasion.
Division of Cardiology, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ c Department of Pathology, Rutgers New Jersey Medical School, Newark, NJ d Division of Cardiothoracic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ e Department of Radiology, Rutgers New Jersey Medical School, Newark, NJ b
Received Jun 4, 2015; accepted Jun 4, 2015 doi:10.1007/s12350-015-0212-6
CASE PRESENTATION A 50-year-old female with a history of breast cancer underwent myocardial perfusion scan for the evaluation of chest pain. Projection exercise stress technetium-99m tetrafosmin images demonstrated a focus of radiotracer uptake in the mediastinum (Figure 1). Due to her history of breast malignancy and concern for possible metastasis, she underwent F-18 fluorodeoxyglucose PET/CT scan which also demonstrated a similar focus of abnormal radiotracer uptake in the anterior mediastinum (Figure 2). Cervical mediastinoscopy and biopsy was non-diagnostic, with a differential diagnosis that included thyroid follicular adenoma/carcinoma or adenomatoid nodule. With a suspicion of thyroid malignancy, a sternotomy with complete resection of the mediastinal mass as well as a thyroidectomy was performed. The histologic diagnosis
Reprint requests: Adam Raskin, MD, Division of Cardiology, Department of Medicine, Rutgers New Jersey Medical School, 185 South Orange Avenue, MSB I-538, Newark, NJ 07103; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2015 American Society of Nuclear Cardiology.
was ectopic thyroid tissue with follicular adenoma, a benign lesion (Figures 3 and 4). Non-cardiac findings on single-photon emission computed tomography (SPECT) imaging are not uncommon. Williams et al.1 reported that 1.7% of 12,526 dual-isotope perfusion SPECT studies identified extra-cardiac findings. Thyroid abnormalities comprised 3% of these findings. To our knowledge, this is the first reported case of a mediastinal follicular adenoma identified by myocardial imaging. This case illustrates how reviewing rotating projection images of cardiac studies may lead to identifying extra-cardiac findings and should not be overlooked.
Figure 1. Projection technetium-99m tetrafosmin image demonstrating a focal area of radiotracer uptake in the mediastinum (arrow).
Raskin et al Incidental ectopic thyroid follicular adenoma
Journal of Nuclear CardiologyÒ
Figure 2. F-18 Fluorodeoxyglucose (FDG) PET/CT demonstrating a 2.1 cm FDG avid mass in the anterior mediastinum, at the level of the aortic arch (SUV 4.2) (arrow). Figure 4. Histopathology with hematoxylin and eosin staining (9400) of a predominant microfollicular pattern. The uniform tumor cells with round non-overlapping nuclei and small monomorphous follicles with little colloid.
Disclosures None.
Reference 1. Williams KA, Hill KA, Sheridan CM. Noncardiac findings on dualisotope myocardial perfusion SPECT. J Nucl Cardiol 2003;10:395402.
Figure 3. Histopathology with hematoxylin and eosin staining (9100) of thyroid tumor completely surrounded by a thin fibrous capsule (asterisks). There is no evidence of capsular or vascular invasion.
