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Hepatic metastases in medullary thyroid carcinoma: possible pitfall with MR imaging
European Journal of Radiology, I1 (1990) 107-109
107
Elsevier
EURRAD
00086
Hepatic metastases in medullary thyroid carcinoma: possible pitfall with MR imaging B. Van Beers, J. Pringot and D. Defalque Department
of Radiology. Louvain University, St-Luc University Hospital, Brussels, Belgium
(Received 23 February
1990; accepted
after revision 17 May 1990) -_-
Key words: Liver metastases;
Liver, MRI; Thyroid neoplasm,
radiography;
diagnosis;
Magnetic resonance
metastatic medullary thyroid carcinoma calcification.
Introduction Hepatic metastases occur in approximately 25-30x of cases of medullary thyroid carcinoma. The primary lesion and the metastases may calcify. Calcification may be massive in liver metastases, and small round calcifications without surrounding abnormalities may then be visible on CT scans [ 1,2]. We report the MR findings of two cases of metastatic medullary thyroid carcinoma in the liver, with special emphasis on the possible pitfalls when calcifications without a defined mass are present. Case reports Case 1 A 23-year-old woman complained of chronic diarrhea. Physical examination revealed thyroid nodules and cervical lymph nodes. Plasma calcitonin level was over 1000 rig/l (normal, < 50 ng/l). A CT scan of the liver showed multiple round calcifications < 1 cm in diameter, without surrounding abnormalities. An MR examination was performed on a 1.5 T imaging system (Gyroscan S 15, Philips, The Netherlands). Tl- (TR = 295 ms, TE = 15 ms) and T2weighted (TR = 2180 ms, TE = 50 and 100 ms) spinecho images showed a discretely heterogeneous pattern in the liver but failed to show definitively any focal lesion (Fig. 1). The patient underwent total thyroidectomy, neck dissection and surgical liver biopsy. The biopsy showed
Address for reprints: B. Van Beers, M.D., Department of Radiology, Mont-Godinne University Hospital, B-5180 Yvoir, Belgium. 0720-048X/90/$03.50
Calcinosis,
0 1990 Elsevier Science Publishers
imaging, liver
with extensive
Case 2 A 53-year old woman had a total thyroidectomy elsewhere in 1985 for medullary carcinoma of the thyroid. Over the next 4 years, serial calcitonin levels were below 200 rig/l.. In 1989, the patient complained of diarrhea. Her plasma calcitonin level increased to 835 rig/l and her carcinoembryonic antigen level was 69 pg/l (normal < 5 pug/l). Examination of the neck was negative; however, sonographic and CT examinations performed at another institution showed several hepatic masses. An MR performed at our institution confirmed the presence of multiple liver masses, compatible with metastases (Fig. 2). Liver biopsy was not performed. Because of the diarrhea, symptomatic treatment with somatostatin was started. Discussion Medullary thyroid carcinoma is an uncommon neoplasm, accounting for less than 10% of cases of malignant thyroid disease [3]. It occurs in a sporadic form or in about 25% of cases in a familial form as a component of the multiple endocrine neoplasm (MEN) II syndrome [ 41. Medullary thyroid carcinoma arises from the parafollicular C cells of the thyroid, and produces a variety of biologically active compounds. These include calcitonin, histamine, adrenocorticotropic hormone, prostaglandins, prolactin, serotonin, vasoactive intestinal polypeptide and carcinoembryonic antigen. The synthesis of all but calcitonin is variable. Calcitonin is used as a biochemical marker for the presence of disease [5].
B.V. (Biomedical
Division)
Fig. 1. (a) CT scan shows multiple small round calcifications without unequivocal surrounding abnormalities. (b and c) Spin-echo images do not demonstrate confidently any focal lesion in the liver despite slightly heterogeneous pattern (b: TR 2180 ms, TE 50 ms; c: TR 2180 ms, TE 100 ms).
Fig. 2. Case 2: TZ-weighted (TR 2180 ms, TE 100 ms) spin-echo image shows multiple solid masses in the liver.
Calcitonin levels may remain moderately elevated after treatment, without clinical or radiological evidence of disease. However, a sudden marked rise in calcitonin levels may herald the appearance of metastases [6]. Carcinoembryonic antigen is used as another marker for medullary thyroid carcinoma [ 71. Cervical lymphadenopathy is a common finding at the time of diagnosis but the presence of cervical lymph node metastases does not affect the survival adversely. Distal metastases occur in advanced stages of disease and the prognosis of patients with distant metastases is significantly altered [ 61. The tumor does not respond to chemotherapy and radiation therapy, and surgery is the treatment of choice, both for initial therapy and for local tumor recurrence [ 631. Radiological examinations are important for accurate determination of the extent of disease and for detection of a local or distant recurrence if calcitonin or carcinoembryonic antigen levels rise after surgery. With regard to the examination of the thyroid and the cervical lymph nodes, ultrasonography [8], CT scanning and MR imaging [9] have been advocated. The same techniques can be used for the detection of liver metastases. The CT appearance of liver metastases from medullary thyroid carcinoma has been described as solid sometimes calcified masses, or small, round calcifications without a defined mass [ 1,2]. With MR, solid masses are imaged without difficulty, but small calcifications may escape detection if only spin-echo sequence are used [lo]. Gradient-echo sequences might detect these calcifications, because these sequences are more sensitive to magnetic susceptibility variations because of the lack of a 180 degrees refocusing pulse [ 111. Punctate calcifications without a defined mass are not pathognomonic of metastatic medullary thyroid carcinoma in the liver. It is also a delayed finding of various granulomatous diseases [ 121.
109
References 1 McDonnell CH, Fishman EK, Zerhouni EA. CT demonstration of calcified liver metastases in medullary thyroid carcinoma. J Comput Assist Tomogr 1986; 10: 976-978. 2 Bankoff MS, Tuckman GA, Scarborough D. CT appearance of liver metastases from medullary carcinoma of the thyroid. J Comput Assist Tomogr 1987; 11: 1102-l 103. 3 McCook TA, Putman CE, Dale JK, Wells SA. Medullary carcinoma of the thyroid: radiographic features of a unique tumor. AJR 1982; 139: 149-155. 4 Bergholm U, Adami HO, Bergstrom R, Johansson H, Lundell G, Telenius-Berg M, Akerstrom G and the Swedish MTC Study Group. Clinical characteristics in sporadic and familial medullary thyroid carcinoma. A nationwide study of 249 patients in Sweden from 1959 through 1981. Cancer 1989; 63: 1196-1204. 5 Stepanas AV, Samaan NA, Hill CS, Hickey RC. Medullary thyroid carcinoma. Importance of serial serum calcitonin measurement. Cancer 1979; 43: 825-837. 6 Saad MF, Ordonez NG, Rashid RK, Guido JJ, Hill CS, Hickey RC, Samaan NA. Medullary carcinoma of the thyroid. A study of the clinical features and prognostic factors in 161 patients, Medicine 1984: 63: 319-342.
7 Rougier P, Calmettes C, Laplanche A, Travagli JP, Lefevre M, Parmentier C, Milhaud G, Tubiana M. The values of calcitonin and carcinoembryonic antigen in the treatment and management of nonfamilial medullary thyroid carcinoma. Cancer 1983; 5 1: 855-862. 8 Gorman B, Charboneau JW, James EM, Reading CC, Wold LE, Grant CS, Gharib H, Hay ID. Medullary thyroid carcinoma: role of high-resolution US. Radiology 1987; 162: 147-150. 9 Crow JP, Azar-Kia B, Prinz RA. Recurrent occult medullary thyroid carcinoma detected by MR imaging. AJR 1989; 152: 1255-1256. 10 Oot RF, New PF, Pile-Spellman J, Rosen BR, Shoukimas GM, Davis KR. The detection of intracranial calcifications by MR. AJNR 1986; 7: 801-809. 11 Atlas SW, Grossman RI, Hackney DB, Gomori JM, Campagna N, Goldberg HI, Bilaniuk LT, Zimmerman RA. Calcified intracranial lesions: detection with gradient-echo-acquisition rapid MR imaging. AJNR 1988; 9: 253-259. 12 Friedman AC, Johns T, Levy DW, Rindsberg S, Markle BM. Granulomatous diseases of the liver. In: Friedman AC., ed. Radiology of the liver, biliary tract, pancreas and spleen. Baltimore: Williams & Wilkins: 1987: 120-123.
107
Elsevier
EURRAD
00086
Hepatic metastases in medullary thyroid carcinoma: possible pitfall with MR imaging B. Van Beers, J. Pringot and D. Defalque Department
of Radiology. Louvain University, St-Luc University Hospital, Brussels, Belgium
(Received 23 February
1990; accepted
after revision 17 May 1990) -_-
Key words: Liver metastases;
Liver, MRI; Thyroid neoplasm,
radiography;
diagnosis;
Magnetic resonance
metastatic medullary thyroid carcinoma calcification.
Introduction Hepatic metastases occur in approximately 25-30x of cases of medullary thyroid carcinoma. The primary lesion and the metastases may calcify. Calcification may be massive in liver metastases, and small round calcifications without surrounding abnormalities may then be visible on CT scans [ 1,2]. We report the MR findings of two cases of metastatic medullary thyroid carcinoma in the liver, with special emphasis on the possible pitfalls when calcifications without a defined mass are present. Case reports Case 1 A 23-year-old woman complained of chronic diarrhea. Physical examination revealed thyroid nodules and cervical lymph nodes. Plasma calcitonin level was over 1000 rig/l (normal, < 50 ng/l). A CT scan of the liver showed multiple round calcifications < 1 cm in diameter, without surrounding abnormalities. An MR examination was performed on a 1.5 T imaging system (Gyroscan S 15, Philips, The Netherlands). Tl- (TR = 295 ms, TE = 15 ms) and T2weighted (TR = 2180 ms, TE = 50 and 100 ms) spinecho images showed a discretely heterogeneous pattern in the liver but failed to show definitively any focal lesion (Fig. 1). The patient underwent total thyroidectomy, neck dissection and surgical liver biopsy. The biopsy showed
Address for reprints: B. Van Beers, M.D., Department of Radiology, Mont-Godinne University Hospital, B-5180 Yvoir, Belgium. 0720-048X/90/$03.50
Calcinosis,
0 1990 Elsevier Science Publishers
imaging, liver
with extensive
Case 2 A 53-year old woman had a total thyroidectomy elsewhere in 1985 for medullary carcinoma of the thyroid. Over the next 4 years, serial calcitonin levels were below 200 rig/l.. In 1989, the patient complained of diarrhea. Her plasma calcitonin level increased to 835 rig/l and her carcinoembryonic antigen level was 69 pg/l (normal < 5 pug/l). Examination of the neck was negative; however, sonographic and CT examinations performed at another institution showed several hepatic masses. An MR performed at our institution confirmed the presence of multiple liver masses, compatible with metastases (Fig. 2). Liver biopsy was not performed. Because of the diarrhea, symptomatic treatment with somatostatin was started. Discussion Medullary thyroid carcinoma is an uncommon neoplasm, accounting for less than 10% of cases of malignant thyroid disease [3]. It occurs in a sporadic form or in about 25% of cases in a familial form as a component of the multiple endocrine neoplasm (MEN) II syndrome [ 41. Medullary thyroid carcinoma arises from the parafollicular C cells of the thyroid, and produces a variety of biologically active compounds. These include calcitonin, histamine, adrenocorticotropic hormone, prostaglandins, prolactin, serotonin, vasoactive intestinal polypeptide and carcinoembryonic antigen. The synthesis of all but calcitonin is variable. Calcitonin is used as a biochemical marker for the presence of disease [5].
B.V. (Biomedical
Division)
Fig. 1. (a) CT scan shows multiple small round calcifications without unequivocal surrounding abnormalities. (b and c) Spin-echo images do not demonstrate confidently any focal lesion in the liver despite slightly heterogeneous pattern (b: TR 2180 ms, TE 50 ms; c: TR 2180 ms, TE 100 ms).
Fig. 2. Case 2: TZ-weighted (TR 2180 ms, TE 100 ms) spin-echo image shows multiple solid masses in the liver.
Calcitonin levels may remain moderately elevated after treatment, without clinical or radiological evidence of disease. However, a sudden marked rise in calcitonin levels may herald the appearance of metastases [6]. Carcinoembryonic antigen is used as another marker for medullary thyroid carcinoma [ 71. Cervical lymphadenopathy is a common finding at the time of diagnosis but the presence of cervical lymph node metastases does not affect the survival adversely. Distal metastases occur in advanced stages of disease and the prognosis of patients with distant metastases is significantly altered [ 61. The tumor does not respond to chemotherapy and radiation therapy, and surgery is the treatment of choice, both for initial therapy and for local tumor recurrence [ 631. Radiological examinations are important for accurate determination of the extent of disease and for detection of a local or distant recurrence if calcitonin or carcinoembryonic antigen levels rise after surgery. With regard to the examination of the thyroid and the cervical lymph nodes, ultrasonography [8], CT scanning and MR imaging [9] have been advocated. The same techniques can be used for the detection of liver metastases. The CT appearance of liver metastases from medullary thyroid carcinoma has been described as solid sometimes calcified masses, or small, round calcifications without a defined mass [ 1,2]. With MR, solid masses are imaged without difficulty, but small calcifications may escape detection if only spin-echo sequence are used [lo]. Gradient-echo sequences might detect these calcifications, because these sequences are more sensitive to magnetic susceptibility variations because of the lack of a 180 degrees refocusing pulse [ 111. Punctate calcifications without a defined mass are not pathognomonic of metastatic medullary thyroid carcinoma in the liver. It is also a delayed finding of various granulomatous diseases [ 121.
109
References 1 McDonnell CH, Fishman EK, Zerhouni EA. CT demonstration of calcified liver metastases in medullary thyroid carcinoma. J Comput Assist Tomogr 1986; 10: 976-978. 2 Bankoff MS, Tuckman GA, Scarborough D. CT appearance of liver metastases from medullary carcinoma of the thyroid. J Comput Assist Tomogr 1987; 11: 1102-l 103. 3 McCook TA, Putman CE, Dale JK, Wells SA. Medullary carcinoma of the thyroid: radiographic features of a unique tumor. AJR 1982; 139: 149-155. 4 Bergholm U, Adami HO, Bergstrom R, Johansson H, Lundell G, Telenius-Berg M, Akerstrom G and the Swedish MTC Study Group. Clinical characteristics in sporadic and familial medullary thyroid carcinoma. A nationwide study of 249 patients in Sweden from 1959 through 1981. Cancer 1989; 63: 1196-1204. 5 Stepanas AV, Samaan NA, Hill CS, Hickey RC. Medullary thyroid carcinoma. Importance of serial serum calcitonin measurement. Cancer 1979; 43: 825-837. 6 Saad MF, Ordonez NG, Rashid RK, Guido JJ, Hill CS, Hickey RC, Samaan NA. Medullary carcinoma of the thyroid. A study of the clinical features and prognostic factors in 161 patients, Medicine 1984: 63: 319-342.
7 Rougier P, Calmettes C, Laplanche A, Travagli JP, Lefevre M, Parmentier C, Milhaud G, Tubiana M. The values of calcitonin and carcinoembryonic antigen in the treatment and management of nonfamilial medullary thyroid carcinoma. Cancer 1983; 5 1: 855-862. 8 Gorman B, Charboneau JW, James EM, Reading CC, Wold LE, Grant CS, Gharib H, Hay ID. Medullary thyroid carcinoma: role of high-resolution US. Radiology 1987; 162: 147-150. 9 Crow JP, Azar-Kia B, Prinz RA. Recurrent occult medullary thyroid carcinoma detected by MR imaging. AJR 1989; 152: 1255-1256. 10 Oot RF, New PF, Pile-Spellman J, Rosen BR, Shoukimas GM, Davis KR. The detection of intracranial calcifications by MR. AJNR 1986; 7: 801-809. 11 Atlas SW, Grossman RI, Hackney DB, Gomori JM, Campagna N, Goldberg HI, Bilaniuk LT, Zimmerman RA. Calcified intracranial lesions: detection with gradient-echo-acquisition rapid MR imaging. AJNR 1988; 9: 253-259. 12 Friedman AC, Johns T, Levy DW, Rindsberg S, Markle BM. Granulomatous diseases of the liver. In: Friedman AC., ed. Radiology of the liver, biliary tract, pancreas and spleen. Baltimore: Williams & Wilkins: 1987: 120-123.