papillary thyroid carcinoma being the most common type of differentiated thyroid malignancy has a predilection for spread through the lymphatic system and thus commonly involves the central and lateral compartmental lymph nodes of the cervical region . soft tissue metastasis is even rarer and amenable to radioiodine treatment similar to metastatic lesions in the lung and bones when they concentrate iodine . the concerned case is unique in the sense that the involvement simultaneously of three soft tissue organs is present with different iodine - concentrating abilities , whereas a review of the literature did not find the simultaneous presence of iodine - concentrating metastasis in one organ , iodine - nonconcentrating metastasis in another organ , and multiorgan soft tissue metastasis in the same patient . the case report also emphasizes possible hematogenous route of metastasis which is rare in papillary thyroid malignancy . a 42-year - old male patient with a history of total thyroidectomy and bilateral cervical nodal dissection positive for papillary carcinoma thyroid was referred to our department for a follow positron emission tomography - computed tomography ( pet - ct ) scan for evaluation of lung nodules and muscle lesions that he developed five years after primary treatment . during the follow - up , prompted by elevated thyroglobulin levels , an iodine-131 whole body scan and single photon emission tomography - computed tomography ( spect - ct ) [ figure 1 ] showed positive lesions , one in the liver and another in the left gluteal region . a fludeoxyglucose ( fdg ) pet - ct scan [ figure 2 ] was done to find more lesions and revealed metabolically active lesions in liver segment vi [ figure 3 ] and the left gluteus and a new paraspinal muscle lesion at the nape of the neck [ figure 4 ] , whereas the lung nodules were metabolically inactive [ figure 5 ] . a post - therapy scan [ figure 6 ] at a therapeutic dose of 200 mci of iodine-131 revealed iodine concentration in the liver and a gluteal lesion , whereas there was no concentration in lung nodules and neck lesion . the present fdg pet ct scan [ figure 7 ] as a response evaluation six month post treatment revealed a metabolic response in the liver and gluteal lesion [ figure 8 ] , but an increasing size of the neck lesion [ figure 9 ] and lung nodules [ figure 10 ] . presently , the patient is put on redifferentiation therapy with sorafenib and suppressive doses of thyroxin . the single photon emission tomography - computed tomography ( spect  ct ) scan shows iodine - concentrating lesion in left gluteal muscle left gluteal lesions were metabolically active in pretherapy positron emission tomography - computed tomography ( pet  ct ) study the new lesion at nape of neck fludeoxyglucose ( fdg ) activity but not lung nodules the 200 mci post - therapy scan concentration in liver and gluteal lesion but no concentration in neck lesion and lung nodules . the positron emission tomography - computed tomography ( pet  ct ) scan after six months iodine therapy shows treatment response in liver soft tissue deposit in the neck demonstrating increase in size and fdg uptake ( disease progression ) papillary thyroid carcinoma is the most common type of differentiated thyroid carcinoma accounting for at least 70% of all follicular cell - derived thyroid malignancies and is considered to be a relatively indolent tumor in which distant metastasis and death are rare . the five - year survival rate for papillary thyroid cancer according to the stage is 100% for stage i and ii , 93% for stage iii , and 51% for stage distant metastasis is the principal cause of death in cases of well - differentiated thyroid carcinomas . about 10% of papillary carcinomas develop distant metastasis , with about 50% of patients having such metastasis at the time of diagnosis . the prognosis of these patients is poor , and over 50% of the patients are likely to die within five years , irrespective of the histology of the tumor . distant metastasis , although relatively uncommon , has been known to occur most commonly in the lungs , followed in frequency by bone and brain ( 0.1 to 5.0% ) . isolated cases of soft tissue metastasis have been documented in the orbit , skull , skin , muscles , liver , spleen , pancreas , and adrenal gland.[613 ] metastatic lesions have also been documented in silent or occult thyroid neoplasms . radioactive iodine treatment is considered to be the first line of treatment for distant metastasis from thyroid carcinomas that concentrate a significant amount of radioiodine . unlike our patient who developed metastatic disease and related symptoms five years after treatment of primary disease , for patients who develop distant metastatic disease at the time of initial diagnosis , a positive iodine-131 whole body scan post treatment of primary lesions in the neck makes way for successful radioiodine treatment of metastasis . however , solitary metastatic lesions which do not concentrate radioiodine can be dealt with surgical removal and/or external beam radiation . to add to the confusion , our patient showed radioiodine concentration in one of the muscle lesions and liver but no concentration in another muscle lesion and lung nodules . consequently , the muscle lesions responded to radioiodine treatment , whereas the neck lesion and lung nodules showed progression over the period of treatment . the patient has been put on a suppressive dose of thyroxin and redifferentiation therapy . in the past , retinoic acid , thalidomide , and rosiglitazone showed efficacy in redifferentiation therapy of iodine - nonconcentrating thyroid malignancy metastatic lesions ; however , currently , sorafenib ( 400 mg twice daily ) and sunitinib ( 50 mg daily for 28 days followed by 14 days of no treatment per cycle ) , approved for other indications , show promise for thyroid cancer .