20140904疑难病例讨论

疑难病例讨论,核医学科,现病史,自诉2003年因“发现颈部肿块1月”在当地医院行“甲状腺肿块切除术”，术后病理示甲状腺乳头状癌（具体不详）。2005年颈部肿块复发，再次于当地医院手术（具体不详），术后口服甲状腺片治疗（不详）。2008年09月发现右侧颈部淋巴结肿大，2008-10-9在淮安市第一人民医院行“甲状腺左叶切除+右侧功能性颈淋巴结清扫”，术后恢复好。2011年6月复查发现Tg升高(不详），在该院服131I 60mCi治疗,治疗后服优甲乐抑制治疗。2011年6月再次发现颈部肿物，CT检查示右侧肿大淋巴结，两肺弥漫性小结节。诊断为“甲状腺癌术后复发，肺转移瘤”。2011-6-30再次在该院手术，行“颈部肿块切除术”，术后病理示乳头状腺癌。分别于2012年3月131I 80mCi及2012年11月复查CT示“两肺多发小结节”并服 131I 160mCi治疗，治疗后一直服优甲乐100ug/日抑制治疗。2014-6-8再次在淮安市第一人民医院住院，抑制状态下查游离甲状腺素:16.49pmol/L、甲状腺球蛋白:455ug/L。甲状旁腺素:3.98pg/ml。磷:2.0 mmol/L,钙:1.49mmol/L。胸部CT示两肺弥漫性结节，考虑转移瘤可能性大。甲状腺术后改变，右侧颈部淋巴结肿大？诊断“甲状腺肿瘤术后复发并肺转移、甲状旁腺功能减退”。为再次行131I治疗，已停优甲乐21天，自觉胸闷、手足麻木，今日门诊以“甲状腺癌术后复发”收入院。无发热、咳嗽、咳痰、胸痛、气促等，无饮水呛咳等，面部无浮肿、无梗阻感、吞咽困难，双下肢无水肿，精神食欲可，睡眠可，大小便无异常。近3个月内未食用海带、紫菜、海藻等富碘食物药物。,TG-Ab+FT3.FT4.TSH+HTG+PTH(2014-08-11 16:05:54 ):促甲状腺激素:135.662 mIU/L、游离三碘甲状腺原氨酸:1.46 pmol/L、游离甲状腺素:4.86 pmol/L、抗甲状腺球蛋白抗体:73.90 IU/ml、甲状腺球蛋白:14688.00 ug/L、甲状旁腺素:3.00 pg/ml。胸部CT(2014-06-09淮安市第一人民医院):胸部CT示两肺弥漫性结节，考虑转移瘤可能性大。甲状腺术后改变，右侧颈部淋巴结肿大？,初步诊断,1.甲状腺癌（乳头状癌，TXN1M1，IVc期） 2.甲状腺癌并右侧颈部淋巴结转移术后复发 3.甲状腺癌并右侧颈部淋巴结转移？ 4.甲状腺癌并两肺转移 5.甲状腺癌第3次131I治疗后 6.甲状旁腺功能减退,2014-8-13 小剂量131I扫描结果：,患者于2014-8-13 服131I 180 mCi，过程顺利，安返病房。2014-8-18 131I全身显像：(2014-08-19):1.甲Ca伴多发颈淋巴结、左锁骨下、纵膈淋巴结及双肺转移可能性大。2.右肾囊肿？右肾积水？回盲部囊肿可能性大。建议：定期复查。现一般可，予以出院。,病史,A 63-year-old woman diagnosed with differentiated papillary thyroid carcinoma underwent a total thyroidectomy followed by I-131 ablative therapy of residual thyroid tissue (3.7 GBq). Besides diffusely increased uptake of I-131 in lungs, intense I-131 accumulation was also demonstrated in upper right abdomen, of similar shape and location, on I-131 whole body planar scan (WBS) 5 days after the secondary and third time I-131 administration (5.55GBq). I-131 SPECT/CT revealed solitary abdominal cyst and subsequently confirmed by needle aspiration biopsy. The exact mechanism of intense I-131 distribution in abdominal cyst was still incompletely known. Posttherapy I-131 SPECT/CT was particularly useful for the exclusion of false-positive findings on WBS in the setting of elevated thyroglobulin levels.,回顾性随访6个月前,可能疾病及机制？,Renal cyst,cervical nabothian cysts,It is caused by chronic inflammation of cervix, with interstitial or epithelial squamous metaplasia, which clogs the glandular tuber, leading to cystic dilation of the endocervical glands and enlargement of the cervix.,分析,Normal physiological radioiodine uptake is observed in the salivary glands, oropharynx, gastrointestinal and genitourinary tracts, and breast tissue.Some benign lesions too, such as cysts, infections, and inflammations, can cause nonspecific concentration of radioiodine,The uptake of 131I has been reported in many kinds of cysts, including hepatic cysts, renal cysts, lacteal cysts, thyroglossal duct cysts , nasolacrimal sac cysts, pleuropericardial cysts , benign epithelial cysts , ovarian endometrial cysts , and sebaceous cysts.Reasons: (a) elimination of iodine in body fluids; (b) inflammation or infection; (c) transudates or cysts; (d) nonthyroid neoplasms. cyst : remains unclear. the exchange of