Peritoneal and mediastinal highly differentiated follicular carcinoma of ovarian origin
Here we report a gravida 3, para 2 Caucasian 70-year-old female patient who was evaluated at an outside institution for persistently elevated alkaline phosphatase levels with no clinical complaints. A bone scan was obtained at that time and demonstrated abnormal uptake in the cranium, long bones and pelvis, raising the possibility of metastatic disease and the patient was referred to our institution. The patient demonstrated an elevated thyroglobulin level of 101.5 ng/ml (normal 0-33.0 ng/ml). In addition, the tumor marker CA 15-3 was also elevated at 34.7 u/ml (normal 10-19.9 u/ml).\nContrast enhanced computed tomography scan of the chest, abdomen and pelvis demonstrated multiple peritoneal nodules, the largest of which measured 3.2 cm × 2.2 cm []. In addition, hyperenhancing epicardial nodules were also noted []. Biopsy of one of the peritoneal lesions revealed thyroid tissue without atypia and we investigated whether struma ovarii was possible. The patient had undergone an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis at age 39 years. The pathology findings were not available. The patient reported being told of a left ovarian cyst without the need for follow-up.\nGiven the number of lesions associated with the omentum, the patient underwent a diagnostic laparoscopy and partial omentectomy. Pathology from the excised omental nodules demonstrated histologically benign appearing thyroid tissue with multiple thyroid follicles of various sizes []. Pelvic washings were negative for malignant cells.\nAs part of the diagnostic evaluation a bone marrow biopsy was performed and was negative for malignancy. In addition, a thyroid ultrasound was performed that demonstrated multiple small nodules with a dominant nodule in the right upper thyroid lobe. Three of the nodules were biopsied and the cytologic findings were consistent with benign nodules.\nGiven the patient's extensive extra-ovarian struma ovarii, a total thyroidectomy was recommended prior to radioiodine therapy. Pathological evaluation of the thyroid revealed a 0.5 cm focus of well-differentiated papillary carcinoma (a microcarcinoma) without lymphovascular invasion, stage PT1 [].\nTotal body I-123 uptake scan was performed for treatment planning purposes and demonstrated innumerable areas of uptake within the chest, abdomen and pelvis []. A discussion was held regarding the appropriate I-131 treatment dose. Given concerns about bowel radiation injury, the patient was treated with 30.5 mCi of radioiodine 131.\nA follow-up I-123 uptake scan 4 months later showed resolution of the chest uptake and significant decline in the number of lesions throughout the abdomen and pelvis that were consistent with a short-term positive response []. Thyroglobulin tumor marker at the follow-up scan was elevated at 91 ng/ml. Plans were made for continued follow-up.