Thyroid "Hot Spots" Incidentally Detected Research Paper

Pages: 10 (2832 words)  ·  Bibliography Sources: 5  ·  File: .docx  ·  Level: College Senior  ·  Topic: Anatomy

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The FDG-PET scan indicated improved bone marrow uptake and a left cervical hot spot. FNAC of an hypoechoic nodule in the left thyroid lobe pointed to papillary carcinoma. Total thyroidectomy was carried out. The diagnosis of a PTC was ascertained. Even though small, measuring 13 mm in diameter, there was attack via the thyroid capsule in the strap muscles. Anemia endured, and a second bone marrow target and biopsy suggested the second difficulty: numerous myeloma.

Subject F

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A 63-yr-old women presented to the oncology department complaining of low back pain in December 1999. Her past medical history comprised of a right mastectomy in 1988 and left breast carcinoma removal and adjunctive irradiation in 1996. Spinal MRI images pointed to metastatic lesions to the sacrum and the eighth dorsal vertebra. In the lack of proof of other metastatic lesions, an FDG-PET scan was carried out to ascertain the findings of MRI. It indicated a sacral lesion and an unpredicted right anterior cervical lesion. The patient was referred for FNACof an hypoechoic nodule in the right thyroid lobe having some microcalcifications. FNAC was poorly cellular and indicated sheets of distended follicular cells with large eccentric nuclei. Intranuclear pseudoinclusions were observed in some of the cells. A small amount of colloid was present. Cell margins were emphasized. The diagnosis of papillary carcinoma was put forward. Total thyroidectomy was carried out and final histology has been debated. Atypia, intranuclear pseudoinclusions, and nuclear grooves were there in some cells but were less prominent in comparison to the nuclear atypia in the cytology sample. Negative immunohistochemistry for thyroid peroxidase and positive immunostaining for HBME1 confirmed further the final diagnosis of a PTC.

Subject G

Research Paper on Thyroid "Hot Spots" Incidentally Detected Assignment

A56-yr-old man was referred to the pneumology department due to small peripheral lung nodules on chest x-ray noticed in the course of preoperative screenings for a hernia. A FDG-PET scan was ordered to find an unknown primary tumor or other metastatic lesions. A hot spot in the right lung top or anterior mediastinum was spotted. A thoracoscopic lung biopsy of the peripheral nodules was carried out and indicated varied dust fibrosis. The interest was then drawn to the thyroid lesion and the patient was referred for FNAC of an unpalpable retroclavicular nodule in the inferior right thyroid lobe. Cytology disclosed sheets and groups of Hurthle cells with a large quantity of cytoplasm, distended nuclei, and anisokaryosis. Colloid was profusely available. The diagnosis of follicular neoplasm, most likely Hurthle cell adenoma, was made. During this Hurthle cell tumor, surgery was considered and ascertained the diagnosis of a Hurthle cell adenoma.

Subject H

An 80-yr-old man was referred for examination of a large necrotic, pointing to a liver metastasis. Ten years before, in 1991 a left upper lung lobectomy was carried out for a squamous cell carcinoma. A FDG-PET scan indicated a hot spot in the liver and a second one in the right anterior cervical region. FNAC of a hypoechoic nodule in the right thyroid lobe was carried out: cell groups and some rosettes were there. The nuclei of the follicular cells were a little blown up A small quantity of colloid was available, and multinucleated giant cells and calcifications. It was categorized as a follicular neoplasm, most likely follicular adenoma. A liver biopsy indicated a large cell undifferentiated carcinoma. Immunostaining was positive for keratine and negative for thyroglobulin. The histology specimen of the lung carcinoma resected in 1991 was reworked and diagnosed as a well differentiated squamous cell carcinoma. The liver mass was thought of as a likely metastasis of the lung tumor. The thyroid lesion is left without treatment.

FDG-PET method

The PET imaging was carried out with a CTI-Siemens HR+ scanner (Knoxville, TN) having an axial field of view of 15 cm, and a spatial resolution of 6 mm. All patients fasted during 6 hours prior to the tracer administration. Sixty minutes after the iv injection of 6.5 megabecquerels/kg 18F-FDG with a possiblea maximum of 555 megabecquerels, a whole-body emission scan was carried out. The raw imaging data were recreated in a 128x128 matrix using an in-house iterative recreation algorithm without reduction correction.

Discussion

Eight successive cases of thyroid FDG-PET incidentaloma have been described. Ultrasound examination and FNAC were acquired in all, at this phase surgery and histology has been carried out in seven of them. The study suggests a high malignancy rate in thyroid PET-incidentaloma. Malignancy was accurately identified in five of seven patients in whom histology is achieved: two cases of MTC (subject A and B) and three cases of PTC (patient C, E, and F) caused focally amplified FDG-uptake in the thyroid area. In patient D, a lymphoma patient, the positive PET scan having bilateral and diffuse FDG uptake and bilateral suspicious FNAC were, nonetheless, because of thyroiditis additional to follicular adenoma.

Diffuse thyroidal FDG uptake has in fact been explained in a cancer screening study in Japan in 0.4% of male and 8.9% of female subjects. In the 36 subjects having dispersed thyroidal FDG uptake in that study, it was credited to chronic thyroiditis. In fact, it was established by pathology in 2 subjects; in the rest, clinical follow-up indicated steady size of thyroid and in the majority antithyroid antibodies were positive (Yasuda et al., 1998). Severe thyroiditis is likely the most recurrent benign cause of diffuse thyroidal FDG-uptake, even though it can also be seen in Graves' disease. Independent adenoma can lead to focal uptake in circumscript hypermetabolic areas.

In addition to a high malignancy rate, the current study also points to a high rate of clinically important malignancies; in other words, malignancies with an anticipated clinically relevant malignant biological behavior in the life span of the patient. Of the MTC cases, there was lymph node attack in one (subject B) of two. Of the three PTC cases there was attack of the thyroid capsule in two of them. Furthermore mediastinal lymph node attack having undifferentiated tumor, most likely dedifferentiated thyroid carcinoma was there in case C, and there was attack of the strap muscles in subject E.

The high rate of thyroid malignancy and the high rate of clinically significant malignancies in thyroid PET-incidentaloma can be explained in two ways. The most palpable elucidation is the FDG-PET principle in itself. FDG-PET rather picks up malignant lesions due to the increased rates of glycolysis and glucose uptake. One of the glucose transport proteins, GLUT 1 has been found to be exhibited at high levels in a selection of cancers. By immunostaining, GLUT 1 expression was often visible in differentiated and anaplastic thyroid carcinoma, save for benign nodules or normal thyroid (Haber et al., 1997).

Conclusion

A conclusion has been reached by a number of authors that high FDG uptake in a thyroid tumor pointed to malignancy albeit low levels could not totally rule out malignancy (Sasaki et al., 1997). Next at this stage, histology is not taken in one patient with a follicular lesion. In wrapping up, but U.S. thyroid incidentaloma more often than not represent benign or occult malignant lesions, thyroid PET incidentaloma spot mostly malignancies having a predictable clinical significance rather than occult carcinoma. Potential FDG-PET studies considering quantitative or semiquantitative uptake parameters are essential to assess the factual occurrence and clinical significance of malignancies in this new category of thyroid incidentaloma.

References

Burguera, B., & Hossein G. (2000). Thyroid incidentalomas: prevalence, diagnosis, significance and management. Endocrinology Metab Clin North Am 29:187 -- 203

Fischman, A.J., (1993). FDG-PET in oncology: There's more to it than looking at pictures. J

Nucl Med 34:6

Haber, R.S., et al.,(1997). GLUT1 glucose transporter expression in benign and malignant thyroid nodules. Thyroid 7:363 -- 367

Sasaki, M., et al. (1997). An evaluation of FDG-PET in the detection and differentiation of thyroid tumours. Nucl Med Commun 18:957 -- 963

Wang, W. et al.(2000). Prognostic value of [18 F] fluorodeoxyglucose positron emission tomographic scanning in patients with thyroid cancer. J Clin Endocrinol Metab 85:1107… [END OF PREVIEW] . . . READ MORE

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