British Journal of Radiology (2005) 78, 1038-1041
© 2005 British Institute of Radiology
doi: 10.1259/bjr/24024066
Adrenal and renal metastases from follicular thyroid cancer
A Kumar, MD, DNB1,
M Nadig, MD1,
V Patra, MD2,
D N Srivastava, MD2,
K Verma, MD3 and
C S Bal, MD, DNB1
Department of 1 Nuclear Medicine, 2 Radiology and 3 Pathology, at All India Institute of Medical Sciences, New Delhi, India
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Abstract
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Patients with differentiated thyroid cancer may have asymptomatic involvement of renal and/or adrenal gland, particularly if they are elderly and have associated metastases to other organs, which may remain undetected if these patients are not subjected to radioiodine treatment. Our experience also emphasises the role of routine post-radioiodine therapy whole body scan with high degree of clinical suspicion, which may reveal lesions otherwise not discernable in low dose whole body scan. All suspicious lesions should be subjected to structural imaging like ultrasound, CT or MRI for confirmation. In this setting, the role of radioiodine therapy is primarily aimed at palliation that might prolong their survival, probably reduce further spread and thus overall improve the quality of life.
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Introduction
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The thyroid gland is an uncommon site for cancer. Differentiated thyroid cancer (DTC) accounts for most of them. Usually they behave indolently with good prognoses and survival rates. Follicular thyroid cancer (FTC) is a distinct histological and clinical entity of DTC which is slightly more aggressive than the more common papillary thyroid cancer. FTC has a propensity for vascular invasion and haematogenous metastases, most commonly to bone and lungs. However, they rarely spread to involve other organs such as liver, brain, kidneys, skin or even adrenals [1].
We report a rare case of FTC with both renal and adrenal metastases. The patient had synchronous involvement of neck nodes and bone also. These functioning metastases were successfully managed by radioiodine alone.
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Case report
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A 66-year-old female patient with a painless scalp swelling in the left parieto-occipital region suddenly developed giddiness and gait instability. CT scan revealed soft tissue swelling in the left parieto-occipital region with erosion of underlying bone. Excision biopsy of the scalp mass was done and histopathology turned out to be metastatic adenocarcinoma probably arising from the thyroid. On examination, she was found to have a small, firm, non-tender and mobile 1 cm x 2 cm nodule in the right lobe of the thyroid gland. Ultrasound revealed mildly enlarged right lobe of the thyroid with heterogeneous echotexture with increased vascularity and calcification. Technetium pertechnetate thyroid scan showed a "cold nodule" in the right lobe. She underwent total thyroidectomy and histopathology revealed widely invasive follicular carcinoma in the right lobe of the thyroid gland.
After surgery, she was referred to the Department of Nuclear Medicine for a 131I whole body scan (WBS) and subsequent 131I therapy. Low dose (111 MBq) 131I WBS did not reveal any radioiodine uptake in the skull (the entire lesion was probably removed during excision biopsy). However, there was radioiodine uptake in the left shoulder, second right rib anteriorly and right iliac bone (Figure 1
). She was administered 7.4 GBq of 131I for therapeutic purposes. Post-radioiodine therapy WBS (PTS) revealed radioiodine uptake in the thyroid bed and intense radioiodine accumulation below the liver in the right adrenal/renal region (Figure 2). When pre-therapy WBS was reviewed again with bias, it also revealed faint radioiodine accumulation in the same region, which would have been overlooked otherwise. Ultrasound and contrast enhanced CT of the abdomen revealed a large heterogeneous mass in the right adrenal gland and an isodense focal lesion in the interpolar region of the left kidney (Figure 3). Ultrasound guided fine needle aspiration cytology done from the adrenal and renal regions showed metastatic follicular thyroid cancer, which was positive for thyroglobulin immunostaining (Figure 4).
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Figure 1. Low dose (3 mCi) radioiodine whole body scan showing radioiodine uptake in the left shoulder (arrow 1), 2nd right rib anteriorly (arrow 2) and right iliac bone (arrow 3). There is a faint radioiodine accumulation in the adrenal region (arrow 4), which was, however, overlooked at that time.
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Figure 2. Post-radioiodine therapy whole body scan showing radioiodine uptake in thyroid bed and intense radioiodine accumulation below the liver in the right adrenal (arrow 4) and left renal (arrow 5) region, besides showing other lesions as depicted in Figure 1 .
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Figure 3. Contrast enhanced CT abdomen showing a large, heterogeneous mass in the right adrenal gland (arrow 1) and an isodense focal lesion in the interpolar region of the left kidney (arrow 2).
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Figure 4. Ultrasound guided fine needle aspiration cytology from the adrenal and renal regions showing tumour cells lying adjacent to normal adrenal cortical cells (arrow). (May Grunwald Giemsa x 100).
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After two doses of radioiodine therapy, the patient is doing well in spite of extensive metastases and is ambulatory. She is due for her next radioiodine therapy.
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Discussion
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Around 10% of patients with DTC present with multiple sites of distant metastases other than lung, bone and lymph nodes, 50% of which involve the brain, 25% the liver and 25% other sites [1]. Reported incidence of renal involvement from thyroid primary is very rare, being only about 4.5–5.9%, whereas out of all secondaries to the kidneys from all cancers, thyroid cancer constitutes about 2.5–2.7% only [2–5]. However, the detection of these metastases during life is extremely rare. Furthermore, involvement of both the renal and adrenal regions appears to be even rarer as there is no such case reported so far. The variable expression of sodium iodide symporter (NIS) among different metastatic sites or selective loss of NIS function in various metastatic sites may be the cardinal reasons for which adrenal/renal metastatic lesions from thyroid primaries are only rarely detected in life, but rather found at autopsy [6].
In our case, both adrenal and renal metastases were solitary and unilateral (although in opposite sides) in contrast to the fact that most adrenal and/or renal metastases are multiple and bilateral. The mode of spread of FTC to distant metastases is usually considered to be haematogenous. However, the phenomenon of unilateral and isolated metastases may be explained by the possibility of the tumour having spread through minor venous or lymphatic collaterals between the thyroid gland and the kidney.
Usually adrenal and/or renal metastases from DTC are asymptomatic as in our case [6–15]. The metastases may develop several years (occasionally decades) after the removal of the primary thyroid malignancy. Furthermore, they may remain undetected for a long time if no radioiodine intervention is done, or even after radioiodine intervention if they are not concentrating radioiodine as usually is the case. Also, these metastases are usually present with lung and bone metastases, and in such cases the presence of neighbouring metastases (which are usually more intense) coupled with normal physiological uptake/excretion of radioiodine in the kidney and gut masks their presence and makes their detection very difficult even if they are radioiodine concentrating.
In our case, there was intense abdominal radioiodine uptake, which led to the detection of the adrenal and renal metastases in this patient. Intense radioiodine uptake in the upper abdomen should not be assumed to be physiological gastrointestinal tract uptake or a false-positive finding [16–18] and the presence of a "star" effect, as it was in our case, in the abdomen should alert the clinician to the presence of functioning metastatic thyroid carcinoma, as physiological radioiodine activity in the gastrointestinal, biliary or urinary tract is usually much more diffuse and rarely gives the star effect [17]. The location of any radioiodine activity in radioiodine WBS should be further characterized as anterior or posterior, depending upon its relative intensity in the anterior or posterior views of the scan, respectively. Lateral views may also be obtained, as they could prove helpful in distinguishing gastric or hepatic uptake from renal/adrenal uptake, which should be more posteriorly located. Relative localization of the uptake from the midline can further help in differentiating renal/adrenal metastases from vertebral metastases with similar uptake features. Alternatively, a single-photon emission computed tomography (SPECT) radioiodine scan of the suspected area may be obtained [19]. However, one has to interpret and further evaluate any such findings against the possibility of radioiodine localization in a renal cyst or the biliary tract, which have both been described as rare occurrences [18–20].
Hence, in the presence of a positive radioiodine scan with foci of radioiodine accumulation in the abdomen, the high index of suspicion of metastases to an intra-abdominal organ should be raised and effectively excluded by correlative anatomical imaging (CT, ultrasound, MRI). CT scan revealed a hyperdense mass in both the adrenal and kidney in our case. Hyperdensity of the renal/adrenal metastases is usually caused by haemorrhage and calcification within the mass [21]. As a highly differentiated FTC can incorporate iodine by its follicular structures [22], the hyperdensity on CT scan in our case was probably caused by well-differentiated follicular thyroid tissue that increased iodine content in the tumour [14].
In our case, the low-dose radioiodine whole body scan was unrevealing (until it was reviewed with bias) and the metastases could be strongly suspected only in the post-therapy radioiodine whole body scan. This emphasises the importance of the routine post-radioiodine therapy whole body scan and high degree of clinical suspicion.
Management of DTC patients with adrenal and/or renal metastases includes surgical resection of the metastatic foci [23, 24] combined with repeated high-dose radioiodine therapies, possibly guided by whole-body and blood dosimetry [25, 26]. However, our patient could undergo only high dose radioiodine therapy as she refused surgery, and is presently doing fine. Therefore, if surgical excision is not possible for any reason, such patients might be subjected to the high-dose radioiodine therapy followed by a suppressive dose of L-thyroxine. This approach can prolong the survival by delaying the disease progression or ablating it.
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Conclusion
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Patients with differentiated thyroid cancer may have asymptomatic involvement of the kidney and/or adrenal glands, particularly if they have extensive metastases. A high degree of suspicion with liberal use of anatomic imaging will be rewarding. It would not be out of place to emphasise the role of routine post-radioiodine therapy whole body scan in each and every case to detect any significant number of occult metastases otherwise not discernable in low-dose scan.
Received for publication January 14, 2005.
Revision received April 13, 2005.
Accepted for publication April 19, 2005.
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Abstract
Introduction
