Ectopic thyroid tissue: anatomical, clinical, and surgical implications of a rare entity

Diffuse 131I lung uptake in bronchiectasis: a potential pitfall in the follow-up of differentiated thyroid carcinoma

BACKGROUND

Iodine-131 ((131)I) total-body scintigraphy is a commonly used post-thyroidectomy imaging procedure in the management of differentiated thyroid cancer (DTC), in particular in patients with an intermediate or high risk of persistent or recurrent disease, in combination with serum thyroglobulin (Tg) determinations and ultrasonography of the neck. It can show the persistence of residual thyroid tissue after thyroidectomy and local and distant metastases. Although this is a highly sensitive method for detecting normal and pathologic thyroid tissue, especially when performed after an ablative dose of (131)I, false-positive scans (i.e., uptake in the absence of residual thyroid tissue or metastases) can occur in different situations.

PATIENT FINDINGS

We report a case of a 42-year-old woman with recurrent chest infections and bronchiectasis, who had a total thyroidectomy and (131)I treatment because of a papillary thyroid carcinoma. She presented with marked bilateral (131)I uptake in the lungs mimicking metastatic involvement of the lungs by thyroid cancer, but interpreted as nonspecific bilateral uptake by her bronchiectatic bronchial tree.

SUMMARY

Our case, as well as others reported in the literature, calls attention to the fact that (131)I lung uptake may be related to chronic inflammatory lung disease, thus representing a potential diagnostic pitfall in patients with DTC.

CONCLUSIONS

(131)I uptake should be interpreted on the bases of clinical context, imaging, and laboratory findings (serum Tg). Recognition of potential false-positive (131)I scans is critical to avoid unnecessary exposure to further radiation from repeated therapeutic doses of (131)I with possible side effects and even worsening of lung disease itself.

Dual thyroid ectopia with graves' disease: a case report and a review of the literature

Ectopic thyroid or thyroid ectopia is a rare developmental anomaly with the prevalence of 1 per 100,000-300,000 population. Even rarer, such an anomaly manifests as dual thyroid ectopia. To our best knowledge, only one case has been reported on dual thyroid ectopia with Graves' disease in the English literature. We present here a case of dual thyroid ectopia complicated by Graves' disease, whereby the diagnosis was rendered through judicious use of various diagnostic modalities coupled with a close clinical follow-up. In this case, therapeutic consideration should be personalized with proper informed consent of the patient.

Detection of ectopic thyroid remnants: a serious diagnostic dilemma. When molecular biology and immunohistochemistry can solve the problem

The presence of ectopic thyroid tissue is a frequent diagnostic feedback related to a possible histogenetic abnormality or a result of post-surgical seeding. The important challenge is the diagnostic definition of its nature, which could lead to a different therapeutic approach. We describe a case with all the possible implications and differential diagnoses supported by the application of immunohistochemistry and BRAF-V600E molecular detection. A 36-year-old girl with a left thyroid nodule underwent surgery with a diagnosis of angio-invasive tall cell variant of papillary carcinoma without lymph-node metastases. The patient history revealed a previous right lobectomy in another institution ten years before. The right neck dissection was histologically characterized by the presence of thymic residual and evidence of microfollicular microfoci (less than 1mm) of thyroid tissue. Thyroid tumor cells were positive for thyroglobulin, TTF-1, HBME-1 and Galectin-3, while the residual ectopic thyroid tissue showed positivity only for TTF-1 and thyroglobulin. The molecular tests on the thyroid nodule revealed the presence of BRAF-V600E mutation, but wild type BRAF in the ectopic tissue. The histo-morphological definition of these remnants plays the most important role, but the application of immunohistochemistry and molecular biology may help to reach a conclusive diagnosis.

Transgenic zebrafish illuminate the dynamics of thyroid morphogenesis and its relationship to cardiovascular development

Among the various organs derived from foregut endoderm, the thyroid gland is unique in that major morphogenic events such as budding from foregut endoderm, descent into subpharyngeal mesenchyme and growth expansion occur in close proximity to cardiovascular tissues. To date, research on thyroid organogenesis was missing one vital tool-a transgenic model that allows to track the dynamic changes in thyroid size, shape and location relative to adjacent cardiovascular tissues in live embryos. In this study, we generated a novel transgenic zebrafish line, tg(tg:mCherry), in which robust and thyroid-specific expression of a membrane version of mCherry enables live imaging of thyroid development in embryos from budding stage throughout formation of functional thyroid follicles. By using various double transgenic models in which EGFP expression additionally labels cardiovascular structures, a high coordination was revealed between thyroid organogenesis and cardiovascular development. Early thyroid development was found to proceed in intimate contact with the distal ventricular myocardium and live imaging confirmed that thyroid budding from the pharyngeal floor is tightly coordinated with the descent of the heart. Four-dimensional imaging of live embryos by selective plane illumination microscopy and 3D-reconstruction of confocal images of stained embryos yielded novel insights into the role of specific pharyngeal vessels, such as the hypobranchial artery (HA), in guiding late thyroid expansion along the pharyngeal midline. An important role of the HA was corroborated by the detailed examination of thyroid development in various zebrafish models showing defective cardiovascular development. In combination, our results from live imaging as well es from 3D-reconstruction of thyroid development in tg(tg:mCherry) embryos provided a first dynamic view of late thyroid organogenesis in zebrafish-a critical resource for the design of future studies addressing the molecular mechanisms of these thyroid-vasculature interactions.

Ectopic lingual thyroid

Thyroid ectopy is characterized by the presence of thyroid tissue outside its normal position resulting from a defect of the thyroid diverticulum migration from the base of the tongue until its final pre-tracheal position. One case is presented in a 12-year-old girl patient who consults for a failure to thrive estimated at less than three standard deviations (SD). Bone age was estimated at 8 years late compared to chronological age. The hormonal assessment showed hypothyroidism with negative thyroid antibodies. Cervical ultrasound was revealed thyroid parenchyma pre-dominantly left in place while sweeping the area under chin showed a nodular formation of the base of the tongue. Thyroid scan with technetium 99 m showed a selective uptake of radiotracer in sublingual position. Cervical computed tomography revealed a posterior median sublingual mass spontaneously hyperdense and enhancing sharply after injection of contrast. Treatment with thyroxine allowed obtaining euthyroidism. This case asks us to be careful before aetiological diagnosis of hypothyroidism in children, because although this is rare, the presence of a thyroid parenchyma up to the cervical ultrasound does not eliminate the presence of ectopic tissue.