1、疑難病例討論,核醫(yī)學科,現病史,自訴2003年因“發(fā)現頸部腫塊1月”在當地醫(yī)院行“甲狀腺腫塊切除術”，術后病理示甲狀腺乳頭狀癌（具體不詳）。2005年頸部腫塊復發(fā)，再次于當地醫(yī)院手術（具體不詳），術后口服甲狀腺片治療（不詳）。2008年09月發(fā)現右側頸部淋巴結腫大，2008-10-9在淮安市第一人民醫(yī)院行“甲狀腺左葉切除+右側功能性頸淋巴結清掃”，術后恢復好。2011年6月復查發(fā)現Tg升高(不詳），在該院服131I 60mCi治療,治療后服優(yōu)甲樂抑制治療。2011年6月再次發(fā)現頸部腫物，CT檢查示右側腫大淋巴結，兩肺彌漫性小結節(jié)。診斷為“甲狀腺癌術后復發(fā)，肺轉移瘤”。2011-6-30再次在該

2、院手術，行“頸部腫塊切除術”，術后病理示乳頭狀腺癌。分別于2012年3月131I 80mCi及2012年11月復查CT示“兩肺多發(fā)小結節(jié)”并服 131I 160mCi治療，治療后一直服優(yōu)甲樂100ug/日抑制治療。2014-6-8再次在淮安市第一人民醫(yī)院住院，抑制狀態(tài)下查游離甲狀腺素:16.49pmol/L、甲狀腺球蛋白:455ug/L。甲狀旁腺素:3.98pg/ml。磷:2.0 mmol/L,鈣:1.49mmol/L。胸部CT示兩肺彌漫性結節(jié)，考慮轉移瘤可能性大。甲狀腺術后改變，右側頸部淋巴結腫大？診斷“甲狀腺腫瘤術后復發(fā)并肺轉移、甲狀旁腺功能減退”。為再次行131I治療，已停優(yōu)甲樂21天，

3、自覺胸悶、手足麻木，今日門診以“甲狀腺癌術后復發(fā)”收入院。無發(fā)熱、咳嗽、咳痰、胸痛、氣促等，無飲水嗆咳等，面部無浮腫、無梗阻感、吞咽困難，雙下肢無水腫，精神食欲可，睡眠可，大小便無異常。近3個月內未食用海帶、紫菜、海藻等富碘食物藥物。,TG-Ab+FT3.FT4.TSH+HTG+PTH(2014-08-11 16:05:54 ):促甲狀腺激素:135.662 mIU/L、游離三碘甲狀腺原氨酸:1.46 pmol/L、游離甲狀腺素:4.86 pmol/L、抗甲狀腺球蛋白抗體:73.90 IU/ml、甲狀腺球蛋白:14688.00 ug/L、甲狀旁腺素:3.00 pg/ml。 胸部CT(2014-

4、06-09淮安市第一人民醫(yī)院):胸部CT示兩肺彌漫性結節(jié)，考慮轉移瘤可能性大。甲狀腺術后改變，右側頸部淋巴結腫大？,初步診斷,1.甲狀腺癌（乳頭狀癌，TXN1M1，IVc期） 2.甲狀腺癌并右側頸部淋巴結轉移術后復發(fā) 3.甲狀腺癌并右側頸部淋巴結轉移？ 4.甲狀腺癌并兩肺轉移 5.甲狀腺癌第3次131I治療后 6.甲狀旁腺功能減退,2014-8-13 小劑量131I掃描結果：,患者于2014-8-13 服131I 180 mCi，過程順利，安返病房。 2014-8-18 131I全身顯像：(2014-08-19):1.甲Ca伴多發(fā)頸淋巴結、左鎖骨下、縱膈淋巴結及雙肺轉移可能性大。2.右腎囊腫？

5、右腎積水？回盲部囊腫可能性大。建議：定期復查?，F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

6、 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 ex

7、act 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.,回顧性隨訪6個月前,可能疾病及機制？,Renal cyst,cervical nabothian cysts,I

8、t 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, oro

9、pharynx, 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

10、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