|Year : 2013 | Volume
| Issue : 3 | Page : 490-492
Imaging of dedifferentiated papillary thyroid carcinoma with left ventricular metastasis: A rare presentation of papillary thyroid metastatic disease
Hooman Yarmohammadi1, Vania Tacher1, Peter F Faulhaber2, Robert C Gilkeson2, Recai Aktay2, Abdollah Kamouh3, Chen H Chow3
1 Interventional Radiology Center, Johns Hopkins Medical Institute, Baltimore, Maryland, USA
2 Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Diagnostic Radiology, University Hospitals Case Medical Centre/Case Western Reserve University, Cleveland, Ohio, USA
3 Harrington-McLaughlin Heart and Vascular Institute, University Hospitals Case Medical Centre/Case Western Reserve University, Cleveland, Ohio, USA
|Date of Web Publication||8-Oct-2013|
Interventional Radiology Center, Sheikh Zayed Tower, Suite 7203, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, Maryland 21287
Source of Support: None, Conflict of Interest: None
Cardiac metastasis in thyroid cancer is extremely rare. Iodine-131-d whole-body scan has been used widely to detect thyroid metastasis. However, in dedifferentiated cases, iodine scan has low diagnostic value particularly for diagnosing cardiac metastasis. In the absence of 131 I uptake, 18 F-fluoro-2-deoxyglucose positron emission tomography ( 18 F-FDG PET) can be used as an alternative and has a high sensitivity for thyroid metastasis, but still low sensitivity for cardiac metastasis. Therefore, meticulous attention to the pattern of uptake and comparison with patients' previous studies is critical. Additionally, cardiac magnetic resonance imaging (MRI) can provide additional and critical information.
Keywords: Cardiac metastasis, 18 F-fluoro-2-deoxyglucose positron emission tomography, thyroid cancer
|How to cite this article:|
Yarmohammadi H, Tacher V, Faulhaber PF, Gilkeson RC, Aktay R, Kamouh A, Chow CH. Imaging of dedifferentiated papillary thyroid carcinoma with left ventricular metastasis: A rare presentation of papillary thyroid metastatic disease. J Can Res Ther 2013;9:490-2
|How to cite this URL:|
Yarmohammadi H, Tacher V, Faulhaber PF, Gilkeson RC, Aktay R, Kamouh A, Chow CH. Imaging of dedifferentiated papillary thyroid carcinoma with left ventricular metastasis: A rare presentation of papillary thyroid metastatic disease. J Can Res Ther [serial online] 2013 [cited 2019 Nov 12];9:490-2. Available from: http://www.cancerjournal.net/text.asp?2013/9/3/490/119307
| > Introduction|| |
Cardiac metastases occur in less than 1% of patients who die of thyroid carcinoma.  Histologically, follicular cell carcinoma is the most common type of thyroid carcinoma with metastasis to the heart.  Only a few cases of papillary carcinoma have been reported to metastasize to the heart.  Additionally, anaplastic, Hurtle cell, medullary, and poorly differentiated thyroid carcinoma have been reported with cardiac involvement.  The most common location for cardiac metastasis is the central veins and the right atrium.  To our best knowledge, this case represents the first documented incidence of a papillary thyroid carcinoma demonstrating metastasis to the left ventricle.
| > Case Report|| |
A 76-year-old man underwent total thyroidectomy for a stage IV papillary carcinoma of the thyroid 7 years ago. Prior to his most recent admission he noticed fever. He had an abnormal elctrocardiogram (ECG). Screening cardiac echocardiography revealed normal left ventricular systolic function and ejection fraction, with no segmental wall abnormality; however, there was a question of thrombus in the apical septum [Figure 1]. Cardiac catheterization did not provide additional information and was grossly normal therefore cardiac magnetic resonance imaging (MRI) was performed. On cardiac MRI a 4.4 × 3.4 cm, nonmobile mass was detected in myocardium in the apical, apical inferior, apical septum, and likely mid to inferoseptal segments of the left ventricle. This mass enhanced with a few foci of nonenhancement [Figure 2]. A small adherent component was noted in the left ventricle cavity that did not enhance and was diagnosed as a thrombus. Coumadin with bridging enoxaparin was initiated. In retrospect, this abnormal finding was also present in contrast-enhanced chest computed tomography (CT) and restaging whole body PET/CT scan [Figure 3] and [Figure 4].
|Figure 1: Cardiac echocardiogram, four chambers view, showing a large heterogeneous mass with regular borders occupying the apex, measuring 2.2 × 2.6 cm (white arrow)|
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|Figure 2: (a) Cine gated steady-state free precession (SSFP) image of four chambers demonstrates an ill-defined mass within the left ventricle with invasion into the interventricular septum (solid arrow). Low signal mass arising from this ventricular mass is noted (dotted arrow) which does not enhance on post gadolinium images (c and d). (b) SSFP axial (two chambers) view demonstrates the ventricular mass (solid arrow) and the overlying adherent thrombi (dotted arrow). (c) and (d) Late gadolinium enhancement view of four chambers demonstrating a 4.4 × 3.4 cm, nonmobile mass of the left ventricle (solid arrows)|
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|Figure 3: (a-c) Multiple axial images and (d) single coronal image of contrast CT scan of the heart. Soft tissue attenuating mass is seen within the cardiac muscle with invasion into the septum (black arrows). Adjacent to this is an area of low-attenuated intraluminal filling defect, which represents an overlying adherent thrombus (white arrow)|
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|Figure 4: (a) PET/CT scan of the patient demonstrates normal cardiac muscular metabolic activity and uptake in image with no evidence of metastasis (black arrow). (b) PET/CT scan study performed 8 months after the initial study and demonstrates abnormal metabolic activity in the left ventricular septal muscle (black arrow) corresponding to findings described on MRI and CT scan and consistent with cardiac muscle metastasis|
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Our patient kept returning with different metastasis in different locations like lung, axillary lymph nodes, mediastinum, and adrenal glands. All of these metastases were identified using PET/CT and were all biopsied and proved to be papillary thyroid metastasis. He had been getting treatment for them and the last metastasis that was treated was his lung metastasis (vaguely seen in [Figure 4]a in the right lower lung). The patient refused any further invasive diagnostic procedures after we had identified his cardiac metastasis and therefore, we were not able to do a biopsy on him. However, the pattern and degree of uptake observed on his most recent PET/CT was very similar to prior metastasis and therefore we concluded it originated from papillary thyroid cancer.
| > Discussion|| |
Possible routes of tumor dissemination consist of blood, lymph, infiltration by continuity or direct extension of neoplastic thrombus through the thyroid vein, superior vena cava to the heart, or implantation by pericardial effusion. Follicular thyroid carcinoma is known for hematogenous spread and is frequently reported in the literature with regard to intraluminal vascular involvement; however, papillary carcinoma, Hurthle cell, insular, and anaplastic carcinoma have also been reported.  Papillary thyroid carcinomas (PTC) tend to metastasize through lymphatic system and mostly to the right side of the heart.  PTC rarely metastasizes through microscopic vascular invasion. Additionally, PTC frequently metastasis to the heart when there is disseminated disease.  However, Kaul et al.,  reported a case of isolated cardiac muscle metastases without any evidence of disseminated disease or angioinvasion. Our patient is unique because the left side of the heart was involved and therefore, we speculated that microscopic vascular invasion was the method of metastasis.
CT has been reported to be useful for diagnosing great vein thrombosis and is the most common method of diagnosis.  Non-ECG-gated multidetector CT with intravenous contrast provides adequate information and definition of the mass extend. Typical findings include a soft tissue attenuating mass within the cardiac muscle and adjacent low-attenuated intraluminal filling defect, which can be accompanied by adjacent soft tissue swelling.  Three-dimensional reconstruction provides more information and assists in surgical planning.
Iodine-131-d whole-body scan has been widely used to detect thyroid metastasis.  However, multiple reports have shown it to have a low diagnostic value particularly for cardiac metastasis.  In the absence of 131 I uptake, 18 F-FDG-PET can be used as an alternative and has a high sensitivity for thyroid metastasis but still low sensitivity for cardiac metastasis.  In our patient, 18 F-FDG-PET/CT demonstrated the metastasis within the left ventricle [Figure 3]. However, this mass demonstrated similar uptake to the patient's previous PET/CT of 8 months earlier, in which the patient did not have the metastasis [Figure 3].
Cardiac MRI has become the reference technique for evaluation of a suspected cardiac mass.  It provides high temporal resolution and an exceptional soft tissue contrast. Therefore, cardiac MRI is a very helpful modality in characterization of cardiac masses.  Metastatic tumors are low signal on T1 and high signal on T2-weighted images with heterogeneous enhancement [Figure 2].
In conclusion, spiral CT scan with 3-D reconstruction is an efficient modality to detect cardiac metastasis however; cardiac MRI is particularly valuable in confirming the diagnosis.
| > Acknowledgement|| |
No funding was received for this case report. The authors would like to thank all the radiology technicians at the Department of Radiology, University Hospitals Case Medical Centre, for preparing the images.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]