Left Supraclavicular Lymph Node Metastasis from Ovarian

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Left Supraclavicular Lymph Node Metastasis from Ovarian

Transcript Of Left Supraclavicular Lymph Node Metastasis from Ovarian

diagnostics
Case Report
Left Supraclavicular Lymph Node Metastasis from Ovarian Cancer Associated with Papillary Thyroid Microcarcinoma, a Confusing Pathology-Essential Role of Functional Imaging
Doina Piciu 1,2 , Alexandru Mes, ter 3,*, Calin Căinap 4, Elena Bărbus, 2, Dragos-Stefan Morariu 5 and Andra Piciu 4
1 Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; [email protected]
2 Department of Endocrine Tumors and Nuclear Medicine, “Prof. Dr. I. Chiricut,ă” Institute of Oncology, 400015 Cluj-Napoca, Romania; [email protected]
3 Department of Oral Health, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
4 Department of Medical Oncology, “Iuliu Hat,ieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; [email protected] (C.C.); [email protected] (A.P.)
5 Department of Surgical Oncology, “Iuliu Hat,ieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; [email protected]
* Correspondence: [email protected]
Received: 2 April 2020; Accepted: 29 April 2020; Published: 30 April 2020
Abstract: The revolution of imaging in medicine leads to new standards of care, mostly in specialties like oncology, neurology, or endocrinology. We present a review of the literature and a case report of a 62-year-old patient initially treated for a benign gynecologic pathology and followed-up for 7 years clinically, with serologic and with multiple imaging techniques. There is an actual growing use of highly sensitive functional imaging methods, like fluoro-deoxy-glucose (F18-FDG) positron emission tomography/computed tomography (PET/CT) in the evaluation of oncologic pathologies, staging, follow-up, and therapy response monitoring. This is the first case report described in the literature presenting the association of thyroid papillary microcarcinoma (MPTC) and supraclavicular metastasis of ovarian cancer. The study aims to underline the necessity of a complex and careful evaluation of each oncologic patient, due to the unexpected clinical presentation and rare association of diseases, sometimes leading to confusing management.
Keywords: ovarian carcinoma; supraclavicular metastasis; 18F-fludeoxyglucose positron emission tomography-computed tomography; papillary thyroid microcarcinoma

1. Introduction
Ovarian cancer (OC) spreads most frequently through the intra-peritoneal channels in such way that, in the majority of cases, the disease remains at the pelvic and abdominal levels [1–6]. Ovarian cancer may also metastasize through lymphatic channels, extremely rarely, in the supraclavicular lymph node (in the so-called Virchow node) [7,8].
Papillary thyroid cancer (PTC) is the most common thyroid malignancy [9–11] and is defined as a malignant epithelial tumor. Papillary thyroid microcarcinoma (MPTC) is a PTC with a maximum diameter of < 1 cm. The incidence of MPTC is increasing due to a real increase of the malignant thyroid pathology and also to the improved, more sensitive diagnostic methods [12,13]. Despite its minimal

Diagnostics 2020, 10, 270; doi:10.3390/diagnostics10050270

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minimal size, MPTC is capable to metastasize frequently in the cervical lymph nodes, less commonly
isnizoet,hMerPsTiCtesis, acnadpahbalse aton mexectealslteanstizperofrgenqouseisn.tly in the cervical lymph nodes, less commonly in other
sites,Tahnedphraeseanncexocfelalesnutpprraocglanvoisciusl.ar lymph node in a case of known thyroid carcinoma is highly
suggeTshtievperoesfemnceetaosftaasissufprroamclatvhiecuthlayrrolyidm; pithins oledsesinpraobcasbeleotfokncoonwsnidtehryarnooidthcearrcciannocmeratios hbeigthhlye
souugrgceestfiovretohfismmeteatsatsatsaisifsroamndthime pthryorboaibdl;eitfoisrlietstsopbreobfraobmle toovcaorinasnidcearnacneor.thInerthcaisncsietrutaotiboent,htheesomuorcset
lfiokretlhyicslimniectaalstdaesciissaionndwimouplrdobbaebtlheefodriaitgntoosbies forfotmhyorvoaidriacnanccaenrcweri.thInletfhtisuspitruaactliaovnic, uthlaermmoesttalsitkaesliys
acnlidnicthael dfiercsitstiohnerwapoeuultdicbdeetchiseiodnia—gntootsailstohfytrhoyidroecidtocmayncweritwh istehlelcetfitvseulpyrmacplhavadiceunleacrtmometya.sAtacstiusaalnlyd,
the lfierfsttstuhperraacpleauvtiiccudlaercliysimonp—h tnootdaletmhyigrohitdbeectaomsitye wofitmhestealsetcattiviceslpyrmeapdhabdoethnefcotroMmPy.TACcatunadllOy,Cth; tehluesft,
asucplerarcleavvaiclualatirolnymofpthhenocdlienimcailghtisbtoeraysoitfethofempaetiaesntat taicndsparneaedxtbeontshivfoerimMaPgTiCnganpdroOtoCco; tlhnuese,da tcolebaer
aepvaplluieadtioton aovfothide aclicnoincaful shiinsgtopryatohfotlhoegpy.atient and an extensive imaging protocol need to be applied to
avoid a confusing pathology.
2. Case Report 2. Case Report
We present the case of a 62-year-old Caucasian woman, who underwent a total hysterectomy in 2012,Wfoer pberensiegnntuttheericnaesfeiborfoaid6s2, -wyheaicrh-opldroCdauucecdashiaenavwyopmeraiond, swahnodupnedlveircwpeanint.aNtootmalahliygsntaenret cistosumeys wine2r0e1c2o, nfofirrmbeendigant uthteartinme ofimbreonitd. sT, whehipcahtipernotdhuacsedsihgenaevdyapneriinofdosrmanedd pceolnvsiecnpta, ianc.cNorodimngalitgonathnet iinsssutietus twioenrael cpornofitormcoelsd oaft tthheat“mProomf.eDntr.. TI.hCehpiraitciuențăt”haInssstiigtunteedoafnOinncfoorlomgeydCclounj-sNenatp,oaccac,obrdoitnhgfotor mtheediincsatlituptrioonceadl uprreostocaonlds otfhtehe u“sPerofo.fDmr. eId. Cichailricruect,oă”rdIsnstiintutsecioefnOtifniccolpougrypCosluesj-,Nraepsopceac,tibnogthtfhoer cmoendfiidcaelnptiraolciteyd.ures and the use of medical records in scientific purposes, respecting the confidentiality.
TTwwoo yyeeaarrss llaatteerr,, tthhee ppaattiieenntt wwaass sseenntt ttoo tthhee eennddooccrriinnoollooggiisstt,, bbeeccaauussee ooff aa lluummpp iinn tthhee lleefftt ssuupprraaccllaavviiccuullaarr ffoossssaa.. TThheetthhyyrrooiidd uullttrraassoouunndd((UUSS)) sshhoowweedd aa hhyyppooeecchhooiicc nnoodduullee iinn tthhee lleefftt tthhyyrrooiidd lloobbee,, mmeeaassuurriinngg 66..99//44..77//33 mmmm,, wwiitthhoouutt mmiiccrrooccaallcciifificcaattiioonn,, bbuutt ““ttaalllleerr tthhaann wwiiddeerr”” aanndd wwiitthh ppeerriipphheerraall vvaassccuullaarriizzaattiioonn ((FFiigguurree 11)).. TThhee lleefftt ssuupprraaccllaavviiccuullaarr lluummpp wwaass ccoonnssiisstteenntt ffoorr aa llyymmpphhaaddeennooppaatthhyy ooff 1188//1100..55//99..55mmmmwwiitthhhhigighhvvaassccuulalarirzizaatitoionn, ,nnoommicircorcoaclaclicfiicfiactaiotino,np, rperdeodmominiannatnlytlhyyhpyopeochecohicoircelraetliavteivtoe ttohethaedjaadcejanctemntumscuuslactuulraet,urroeu, nrodu-snhda-psehda,paendd, ahnigdhhlyigshulgygesustgivgeesftoirvemfaolirgmnaanlitglnyamnpthlynmodpeh. nTohdees.hTahpee sahnadpteheanindtetnhseeivnatesncuselavriazsactuiolanroizfatthieonlyomfpthhenloydmepwherneosduegwgeesrteivseufgogremstailvigenfoanr cmy;ahliogwnaenvceyr,;mhoetwasetvaetirc, mnoedtaesstafrtiocmnopdaepsifllraormy pcaarpciilnlaormy acaorcfitnhoemthayorfotihde athreyruosiudaalrleyuhsyupaellryechhyopiecr, eacnhdoitch, iasnids tbheilsieisvbeedliteovebde troelabteedretloattehde tionttrhaenoindtarladnoepdoaslidtieopnoosfittihoynroogf ltohbyurloingloorbiugilninatoinriggifnroamtintghefrpormimtahreypturimmoarryantudmthoirs aalnsdo tfhreisqualesnotlfyrehqausemntilcyrohcaaslcmifiiccraoticoanlcsi.fications.

Figure 1. TThhyyrrooiidd uullttrraassoouunndd rreevveeaaling a left lobe hypoechoic thyroid nodule.
The tutummoorrmmarakrekresrws ewreerpeerpfoermfoerdmiendthien stahmeesaacmcreedaictecdreldaibtoedratloarbyoarantdorcyonasnisdtedcoin:sitshtyerdoiidn-: sthtiymrouildat-isntigmhuolramtionngeh(oTrSmHo, neor(mTSalHv,anluoersm0a.2l 7v–a4l.u2ems I0U.2/L7–),4f.r2eemtIhUy/rLo)x,infreee(FtTh4y,rnooxrimneal(vFaTl4u,ens o1r2m–2a2l pvamluoel/sL1)2, –th2y2rpomgloolb/Lu)l,inthaynrtoigbloodbiuelsin(TagnAtibb,ondoierms (aTlgvAablu, enso The thyyrrooiiddhhoorrmmoonneepprorofiflielewwasaws withitihnitnhtehneonrmoraml raalnrgaengweitwh itthhetfhoellofowllionwg vinagluveasl:uTeSsH: TlSeHvelewvaesl w2.2asm2I.U2 /mL,IUin/Lth,einnothrme anlorramnagle,raFnTg4e—, F14T.41—pm14o.1l/Lp,mToglA/Lb,—T7g8AIbU—/m78L,IUan/dmTLg, —an3d4Tngg—/m3L4. nTgh/emthLy. rTohide thhoyrrmooidnehoevrmalounateioenvaislumatainodnaitsomryainndtahteoarylgionritthhemalogfodriathgmnoosifsdoifaegvneorsyisthoyfreovidernyotdhuylreo.idTgn,oadccuolerd. Tingg, atocctohredAinmgetroictahne TAhmyeroricdaAn sTshoyciraotiidonA(sAsoTcAia) tgiounid(eAliTnAes), gisunidoetlainfierss,ti-slinoettuamfirosrt-mlinarekteurmtoorbemaasrskeesrsetdo be assessed in this evaluation, but in the case of metastatic disease, Tg might play a role in orienting

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the therapeutic plan. The thyroid ultrasound description of left thyroid nodule leads to a classification icnorthreisspeovnalduiantgionto, bTuItRinADthSe c3as[e14o]f;mtheetasgtraetiactedrisneaosdeu, lTegdmimigehnt spiloany awraosle6i.n9 omriemnti(n TThhee FF1188--FFDDGGPPEETT/C/CTTwwasaspeprefrofromrmededonoanGaEGOEpOtimptaim56a05e6q0ueipqmuiepnmt,ewnitt,hwainthacatnivaitcytiovfit2y96ofM2B9q6 oMfBFq18-oFfDFG18in-FjeDctGediinnjetrcatevdenoinutsrlayv;etnhoeuismlya;getsheweirmeaagceqsuiwreedreat a5c0qmuiirnedaftaert t5ra0cemr aindmaifnteirstrtartaicoenr, waditmhitnhiestsrtaatniodna,rwdiizthedthuepsttaaknedvaarlduieze(dSUuVp)taekxepvreaslsueed(SinUlVea)nexbpordeyssmedasins (lSeUanVblbomdy). mass (SUVlbm).
TThhee bbaasseelliinnee FF1188--FFDDGG PPEETT//CCTT ((FFiigguurree 22)) wwaass sshhoowwiinngg aa sslliigghhttllyy iinnccrreeaasseedd rraaddiioottrraacceerr uuppttaakkee,, ssuuggggeessttiivvee ffoorr mmeettaassttaasseess iinn tthhee lleefftt ssuupprraaccllaavviiccuullaarr llyymmpphh nnooddee ((SSUUVVllbbmm MMaaxx— —22..6644)),, iinn tthhee lleefftt
llaatteerroo--aaoorrttiicc llyymmpphh nnooddee ((SSUUVVllbbmm MMaaxx——44..7722)) aanndd tthhee bbiillaatteerraall iilliiaacc eexxtteerrnn llyymmpphh nnooddeess ((SSUUVVllbbmm
MMaaxx——44..8811)),, aannddtthheesseecctitoionnininFiFgiugruere2 s2hsohwoswosnolynltyhethleeftleofnteo.nWe.eWfoeunfoduandsuarpsruisripnrgilsyinlgolwy Flo1w8-FFD18G-
uFDptGakuepitnaktehienltehfte sleufpt rsaucplaravciclauvliacrullyarmlpymh pnhodneo,dceo, ncosindseidrienrgintghtehaegaggrgersessisvievneensesssoof fththeettuummoorr aanndd
tthhee llyymmpphh nnooddeess ffrroomm tthhee aabbddoommeenn..

FFiigguurree 22.. ((AA))FF1188-fl-fuluoororoddeoexoyxgylgulcuocsoesepopsoitsriotrnoenmeimssiisosniotonmtoomgroagprhayp/choym/cpoumtepdutteodmotogmraopghryap(Fh1y8-(FFD18GPFDETG/CPTE)Ta/CxiTa)l aCxTiasleCctTiosneccteiorvniccaerlvleicvaell;le(vBe)l;fu(Bse)dfuPsEedT/PCETTi/mCTagime aaxgiealaxseiacltisoenctaiotnceartvcicearvl ilceavlelle; v(eCl); c(Cor)ocnoarlonseacltsioecntiPonETP/ECTT/CimT aimgeagaet aabt dabodmoimnainl alel vleevl;ela;nadnd(D(D) )cocorornonalalsesecctitoionnPPEETT//CCTT iimmaaggee ppeellvviicc lleevveell.. RReedd aarrrroowwss aarree sshhoowwiinngg hhiigghh ttrraacceerr uuppttaakkee iinn tthhee lleefftt ssuupprraaccllaavviiccuullaarr llyymmpphh nnooddee,, iinn tthhee lleefftt llaatteerroo--aaoorrttiicc llyymmpphh nnooddee aanndd tthhee lleefftt iilliiaacc eexxtteerrnn ppeellvviicc llyymmpphh nnooddee..
In 22001144, ,a taottaolttahlyrthoyidreocitdoemctyomwyithwleiftthsulepfrtacsluapvircauclarvibciuolpasry bwioaspspyerfworams epde,rafnodrmtheed,paatnhdolotghye rpeapthoortlopgryovredpoartlepfrtopvaedpilalarlyeftmpicarpoicllaarrcyinmomicarocclaarscsiincomfoarmc,laTss1iacNfxoMrmx, Tan1adNoxvMarxi,anancdarocivnaormiana mcaerctainstoamsias minethasetalesifst isnupthreaclleafvt iscuuplraarclyamvicpuhlanroldyem. pShunrpodries.inSgulryp,raisinthgelyp, astiethnet puantdieenrwt uenndt earwtoetnatl haytostearlehcytosmteyrewctiothmbyowthitohvabroitehs roevmaroiveesdretwmo vyedartswboefyoerea,ras sbeecfonred, oapsienciondwoapsigniivoennwonasthgeivpeanthoonlotghye rpeapthoortloogfythrepsourptroafctlhaveiscuuplarraclylamvipchulnarodlyemsphecnimodeens, pcoecnifimremni,ncgonthfiermdiianggntohseisdoiafgmnoestaisstoaftmic eotvaastraiatinc

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ovarian carcinoma. The histopathology specimen from 2012 was revised and the final pathology rceaprcoirntowmaas.lTefhteohviasrtioapnactahrocliongoymsap.ecimen from 2012 was revised and the final pathology report was left oCvaAri1a2n5ciasrcainvoamluaa.ble specific ovarian tumor marker, a fact which imposed its analysis. CA 125 serumCAlev12e5l wisaasv9a3l2uaUb/lme sLp, evceifiryc oinvcarreiaasnedtu, mcoonrfimrmariknegr,thaefascttawtuhsicohf pimerpsoissteedntitosvaanraialynsicsa.rCciAno1m2a5 dseisrueamsel.evel was 932 U/mL, very increased, confirming the status of persistent ovarian carcinoma disease.
TThhee ccaassee wwaass ccoonnssiiddeerreedd aass mmuullttiippllee mmaalliiggnnaanncciieess wwiitthh ppaappiillllaarryy tthhyyrrooiidd mmiiccrrooccaarrcciinnoommaa TT11aaNNxxMMoo ssttaaggee II,, llooww--rriisskk ggrroouupp,, aanndd oovvaarriiaann ccaarrcciinnoommaa FFIIGGOO IIVVBB..
FFoorr tthheetthhyyrrooididccaarcrcininoommaa, ,thtehepaptaietinetnwt awsaesveavluaaluteadteadftaerftseurrsguerrgyeirnysitnimsutilmatueldatceodndcoitniodnitsi,otnhse, TthSeHTSwHasw4a8sI4U8/ImUL/m(iLnc(irnecarseeads)edan) dantdhethTegTlgevleevlewl wasa0s.00.404ngn/gm/mLL(u(unnddeetetecctatabblele))wwitithhTTggAAbbiinn nnoorrmmaall rraannggee ((TTggAAbb <<1100IIUU//mmLL))..AAccccoorrddiinnggttooAATTAA aanndd EETTAA gguuiiddeelliinneess [[99,,1100]],, nnoo rraaddiiooiiooddiinnee tthheerraappyy wwaass nneecceessssaarryy;; aa wwhhoollee--bbooddyy ssccaann ((WWBBSS)) wwiitthh 118855 MMBBqq II--113311 wwaass ppeerrffoorrmmeedd ttoo eexxcclluuddee tthhee tthhyyrrooiidd oorriiggiinn ooff tthhee llyymmpphh nnooddee lleessiioonnss sseeeenn oonn tthhee PPEETT//CCTT ssccaann ((FFiigguurree 33)),, tthhee WWBBSS bbeeiinngg nneeggaattiivvee.. TThhee ppaattiieenntt ssttaarrtteedd hhoorrmmoonnee rreeppllaacceemmeenntt tthheerraappyy wwiitthh 112255 mmiiccrrooggrraammss ooff LLeevvoo--tthhyyrrooxxiinnee ddaaiillyy,, wwiitthh TTSSHH aanndd FFTT44 aasssseessssmmeennttssaaftfeterr22mmonotnhtsh:sT: STHS—H—0.109.1I9UI/mU/LmaLndanFdT4F—T417—.81p7.m8 opl/mmoLl/;mcoLn;scidoenrsiindgerthinagt tthheadt athiley ddaoisleywdoassecowrarescctoarnredctwaenlld-twoleelrla-ttoedle,raatmedil,dasmupilpdrseusspiponresstsaiotunssotaf tTuSsHofwTaSsHacwhaiesvaecdhi[e1v6e].d [16].

A

B

FFiigguurree 33.. WW hohleolBeoBdoydSycaSncawnitwh iIt-h13I1-1s3o1disuomdiuiomdidioedi(dI-e13(1I-1W31BSW) wBSit)h w18it5hM1B8q5MatB2q4 aht p24osthapdomst-iandismtraintiiostnr,atsihoonw, sinhgowniongthnyorotihdyrreomidnraenmt nuapntatkuepatankde naondabnnoorambnaol rumpatal kueptinakoethinerosthiteers s(i(tAes) a((nAte) rainotre, r(iBo)r,p(oBs)teproiostre)r. ior).
The treatment of ovarian cancer consisted of fifirst-line palliative chemotherapy with Paclitaxel 175 mm//mmppaannddCCaarbrboopplalatitnin(A(AUUCC5)5. )T. hTehetutmumoromr amrkarekrevravluaeludeecdreecarseeadseadt naotrnmoarlmvaluveasluines04in/20146/2(0C1A6 1(C25A—12215U—/2m1LU) a/mndL)thaenpdattiheentpwataisenfotllwowasedfo-ullpowbyedp-eurpiobdyic pserruiomdiCc Ase1r2u5manCdAch1e2s5t aannddacbhdeosmt ainnadl acobndtormasitn-eanl hcoantcreadstC-eTn,hsahnocweidngCTco, mshpolwetiengrecmoimsspiolent.e remission.
The thheerraappyy rreessppoonnssee wwaassaasssseesssseedduussininggCCAA112255ananddF1F81-8F-DFDGGPEPTE/TC/CTT(F(iFgiugruere4)4s)hsohwowinignga caocmomplpetletme meteatbaobloiclircermemissisiosinoninin20210616(th(tehethtihridrdscsacna)nc)ocmompapraartaivtievetoto20210515(t(htehesesceocnodndscsacna)n.).

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A A

B B

FFiigguurree 44.. FF1188--FFDDDGGG PPEETT//CCTT ssccaannss——22001155,, bbeeffoorree cchheemmootthheerrraaapppyyy aanndd 22001166,, aafftteerrttrreeaattmmeenntt,,eevvaalluuaattiinngg tthhee tthheeerrraaapppyyyrreresespsppooonnnssese:e::aaxaxixaiialalslessceetcicottiinoonanbaadbboddmoomimniainnlalaellvlleelvv(eeullp((puuepprppiemerraiigmmeasag)g,eepsse)),l,vppiceelllveviviccelleewvveietlhl wwriigitthhtrrliyiggmhhtpt hllyynmmopdpheh n(nmoodiddeed(l(memiimddddalgleeei)im,maanaggdee)p),,ealavnniddc lppeevellevvliicwc liletehvveellelfwtwliyitthmh lpleehffttnlloyydmmepp(hlhownnooedrdeiem((laloogwwee)e,rrshiimmowaaggiene)g),, tssrhhaocowewriinhngigghttrrauacpceetrrakhheiiggihnh ulueppfttaaakkbeedioinnmlleienfftat alablbaddtoeormmoi-inanoaalrltlilacatteleyrromo--apaohorrtntiioccdllyeymm(SppUhhVnnlobodmdeeM((SaSUxU—VVl5lbb.m1m)M,Maanaxdx——in55.b.11i)l),a, ataennrddaliinpnebblivillaiactteelryraamll ppehellvnvioiccdlleyysmm(p(pBhh) nSnoUoddVeelsbs(m(((BBM))SaSUxU—VVl4lbb.8mmaMMndaaxx(—A—)44S..88UaaVnnlddbm((AAM))SaSUxU—VVl3lbb.9mm),MMwaaixtxh——c3o3..m99)),p,wlweititethhrcecomommisppslileoetnteeirrneemm20iis1ss6siiooonnniiannll22s00i1t1e66so.onnaallllssiitteess..

TThhee pppaaattiteiienenntttcoccnootninnttiuinneuudeedtdhetthfhoeelloffowolll-louowpw-a-uutpp3–a6attm33o––n66thmsmuoosnnitnthhgsscluuinssiincn,ggsecrcloliilnnoiigcc,i,c,ssceeerrorovlloiocggaiilcc,a,nccdeerarvvbiidccaoalml aiannnaddl auablbtddroaosmmoiuinnnaadll,uuallnttrrdaasstohouounrnaddx,, aannddattbhhdooorramaxxinaananlddCaaTbb,ddboeomimniginnaianll cCCoTTm,, pbbleeeiitnneggreiinmn cicsoosmimopnpllefeottere 1rreeymmeaiisrss.siiIoonnnFffeoobrrru11ayyreyeaa2rr0..1IIn7n, FCFeeAbbrr1uu2aa5rryyro22s00e1177s,l,iCCgAhAt1l1y2255artroo4ss1eesUslli/igmghhLttlly(yFaaitgt4u411reUU5//m,msLLh(o(FFwiiggiunurgreet5h5,,esshhCooAwwi1inn2gg5 ttehhveeoCCluAAti1o122n55) eeavvnoodlluuattniiooonnt)h)aeanrnddF1aa8nn-ooFttDhheGerr FPF1E188T--/FFCDDTGG, thPPeEETfTo//uCCrTTth,, ttohhneeeffodouuurrrtithnhgoontnheeeddduuisrrieinnagsget,thhaeeskddeiidsseebaasyseet,,haaesskokenedcdobbloyygttihshtee, oiosnnscchooollowoggniissittn,, iiFssisgshuhoroeww6nn. iMinneFFaiingguwurrheeil66e.., MtMheeaatnhnwwyrhhoiiilldee,,cttahhreecittnhhoyymrrooaiiddwccaaasrrccdiinencoolmmaraaedwwiaansscddoeemccllpaarlreedtdeiirnnemccooimsmspipollenet:teecrlreienmmiciisassls,iiooTnng:: cucllniinndiiecctaaell,c,tTTagbglueunnidndeesttteeicmcttaaubbllaleeteiindn scstotiimnmduuiltlaiaottenedsd (ccTooSnnHddiit>tiioo3nn5ssI(U(TT/SSmHHL>)>, 33n55egIIUUat//immveLL)T),,gnnAeegbga,atatiinvvdee TnTgeggAAabbt,i,vaaenndId-1nn3ee1ggWaattiBivvSee. II--113311 WWBBSS..

FFFiiiggguuurrreee555...SSSeeerrruuummmCCCAAA111222555llleeevvveeelllsssdddeeettteeerrrmmmiiinnneeedddddduuurrriiinnngggttthhheeefffooollllllooowww---uuuppp...

Diagnostics 2020, 10, 270 Diagnostics 2020, 10, x FOR PEER REVIEW

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A

B

Figure 6. FF1188-F-FDDGGPPEETT/C/CTTscsacnasnsinin2021071a7ftaefrtetretaretmatemnet,netv, aelvuaaltuinatginthgethCeAC1A251i2n5crienacsreeadsueridnugritnhge ftohlelofowll-ouwp:-uspag: istataglitsteacl tsieocntioabndaobmdoinmailnlaelvleelv(eAl ()A, p),eplveilcvilcevleevle(lB()Bs)hsohwowinigngtrtaracecrerhhigighhuuppttaakkee iinn left abdominal latero-aortic lymph node (SUVlbm Max—4.43), with recurrence after complete remission in 2016.

SSeeccoonndd--lliinnee cchheemmootthheerraappyy wwaass ddeebbuutteedd iinn 22001177,, wwiitthh tthhee ssaammee ppllaattiinnuumm rreeggiimmeenn,, aass tthhee ppaattiieenntt pprreesseenntteedd aa ddiisseeaassee--ffrreeee iinntteerrvvaall ooff mmoorree tthhaann aa yyeeaarr,, ccoonnssiiddeerriinngg tthhaatt iitt wwaass aa ppllaattiinnuumm--sseennssiittiivvee ttuummoorr,, ffoolllloowweeddbbyymmaainintetnenanancecethtehrearpaypywiwthitPhAPRAPR-iPn-hinibhitiborit,oars, BaRs CBARC1A/2 w1/a2swparesspenret.seTnhte.rTapheyrwapays wadams iandimsteinreisdtearcecdoradcicnogrdtointghetogtuhiedegluinideeslainnedstarneadtmtreeanttmavenatilaabvialiiltaybailtittyhaattttihmaet t[i1m7]e. [17].
33.. DDiissccuussssiioonn AAnn oonnlliinnee sseeaarrcchh oonn tthhee PPuubbMMeedd ddaattaabbaassee wwaass ppeerrffoorrmmeedd uussiinngg tthhee ffoolllloowwiinngg tteerrmmss:: ““oovvaarriiaann””,,
““ccaanncceerr””,, ““ssuupprraaccllaavviiccuullaarr””,, ““lylymmpphhnnoodde”e”, ,anadnd“m“meteatsatastsaiss”is.”I.n tIontatlo,t3a5l, a3r5ticalretsic(lceasse(craespeorretspoanrtds raenvdiewresv)iewwerse) owbetarieneodb.tAaifnteedr .appAlyfitnegr tahpepfliyltienrgs “tfhuell tfielxtet”rsan“dfu“lhl utmexatn”s”a,nwde“hhaudmaasnesle”c, tiwone ohf a1d7 aarstieclleecsti[o1n8–o3f41].7Aamrtoicnlegsth[1e8s–e3a4r]t.icAlems,othnegrethweseerearotniclylesfo, uthrerreefewrreirnegotonlFy1f8o-uFDr rGefPeErrTin/CgTtoevFa1l8u-aFtDioGn [P1E8T,2/5C,2T6,e2v9a].luAatcicoonrd[1in8,g25t,o26a,2ll9]t.heAmcceonrtdioinnegdtostuadllieths ewmhiecnhtiwoneerde asntuadlyiezsedw, hthicehewxterare-abadnaolmyzineadl, sthpereeaxdtroaf-aobvdaroimanincaalnscperreisadraoref ionvtahreiacnlincaicnaclesrciesnraarrioe,ibnutthveercylinchicaalllesncgeninagr.ioD, abtuatfrvoemrythchealiltleenragtiunrge. cDoantcaefrrnoimngthexetrliat-earbadtuorme icnoanlcleyrmnipnhg neoxtdrea-ianbvdoolvmeimnaelnltyamrephvenroydpeoionrv, othlvuesmthenetianrteerveestryofpostourd, ythinugs tthhiesiwntaesrejuststoiffisetdu.dFyainntgi etht iasl.w[2a9s]juwsetrifieeadm. oFnagnttiheet failr.s[t2w9]hwo esrpeecaumlaotnegd tthheatfiFrs1t8w-FhDoGspPeEcTu/lCaTtemd itghhatt bFe18a-FuDseGfuPlEtoTo/Cl tTomdeigtehcttbuenauususeafluelxttoroa-latboddoemteicntaulnnuosduaallienxvtoralv-aebmdeonmt iinnatlhnisopdaatlhinovlooglvye. mInetnhteinlatthesist pyeaathrso,lothgey.reInsetahrechlaetresstuynedaerrsl,intheedrtehsaetarthcheemrseuthnodderilsinmedantdhaattotrhye tmo ebtehoadppislimedanmdaaitnolryyiftothbeereapisplainedy smuasipnilcyioinf tohfepreerissiasnteynstuosrpriecciounrroefnpt derissiesatseent[1o8r].recurrent disease [18].
AAccccoorrddiinnggtotothtehreecroemcommemndeantdioantiopnrovpirdoevdidbeydthbeyNCthCeNNCCliCnNicalCPlrinacictiacle PGruaicdtiecleineGsuinidOelnincoelsoginy (ONnCcoClNogyG(uNidCeCliNneGs)ufiodreloivnaesr)iafnorcoavnacreiranVecrasniocenr 1V.2e0rs2i0on[117.]2,0P2E0T[1/C7]T, PisETin/CdTicaisteidnddicuartiendgdtuhreiningittihael ienviatilaulateiovnal,umatoionnit,omrinogn/iftoolrlionwg/-fuopllo(cwh-euspt/a(bcdhoesmt/ianbadl/opmelivniacl/CpTel,vMicRCI,TP, EMT/RCIT, , PoErTP/CETT, aosrclPinEiTcalalys cinlidniiccaatlelyd)i,nadnidcaftoerd)r,eacunrdrefonrt dreisceuarsreenint dainsyeassteaginesaanfytesrtapgriems aarftyertrpearitmmaernyt itnretahtemfeonlltoiwn itnhge sfiotluloatwioinnsg: sriistuinagtiConAs-:25riwsiintgh nCoAp-r2e5viowuisthchenmo otphreervaipoyu,sclicnhiecaml orethlaeprasepyw,itchlinnoicparlevrieolaupsscehewmioththenroapyp,rcelvinioicuasl crehleampsoethaeftrearppyr,ecvliinouicsalchreelmaposthe earfatepry,parnedvisoeursiaclhlyemrisoitnhgerCaApy-1,2a5nvdasluereisalalfyterrispinregvCioAus-1ly25advmaliuneisstaefrteedr pchreevmiootuhselyrapayd.mOinnitshteeroetdhecrhheamndo,ththeirsapimy.agOinng mtheethootdheisr rhoauntidn,eltyhriescoimmamgeinngdemd einthtohde eivsalruoauttioinneolyf rmecaolimgnmanent dtheydroinidthpeatehvoallougaytio[3n5o–3f 7m].alignant thyroid pathology [35–37].
IInn ppaattiieennttss wwiitthh oovvaarriiaann ccaanncceerr,, tthhee iimmppoorrttaannccee ooff eexxtteennssiivveellyy iimmaaggiinngg ffoollllooww--uupp ooff tthhee lleefftt ssuupprraaccllaavviiccuullaarrsseeeemmsstotobebbeebneenfiecfiaiclitaol dtoiscdoivsceorvoecrcuolctcduislteadsies,eaansed,tahnedpotshseibpleossistiebsleofstiutems oorfmtuamrkoerr mCAar1k2e5r CriAses1.25 rises.
IInn 22001100,, BBiilliicciieettaal.l.[3[388] ]ppuublbilsihsehdedthtehieriwr worokrrkefreerfreirnrgintgo ttohethime pimacptaocft Fo1f8F-F1D8-GFDPGETP/ECTT/ConTtohne mthaenmagaenmageenmt oenf tpoaftipenattsiewntisthwsiuthspseucstpeedctreedcurrerceunrtreonvtaroivaanricaanrccinarocminao.mTah.e Trheseurletssuslhtsowsheodwtehdatththaet sthenessietinvsiittyivoitfyFoDfGFDPEGTP/CETT/iCnTdientedcetitnecgtitnhge trheceurrerceunrtrednistedaisseeawsaesw9a5s.59%5.c5o%mcpoamrepdarwedithw5it5h.55%5.5fo%r CfoTr scans; the specificity was 93.3% for PET/CT and 66.6% for CT, and the accuracy was 95% for PET/CT and 58.3% for CT scans. Similarly, Gu et al. [39] published a meta-analysis comparing the value of

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CT scans; the specificity was 93.3% for PET/CT and 66.6% for CT, and the accuracy was 95% for PET/CT and 58.3% for CT scans. Similarly, Gu et al. [39] published a meta-analysis comparing the value of CA 125, PET alone, PET/CT, CT, and MRI in diagnosing of recurrent ovarian carcinoma. The authors reviewed 34 studies and concluded that CA 125 had the highest pooled specificity of 0.93 (95% CI) and PET/CT had the highest pooled sensitivity of 0.91 (95% CI: 0.88–0.94). They concluded that PET/CT might be a useful supplement to the current surveillance techniques, particularly for those patients with an increasing CA 125 level and negative CT or MRI.
Caobelli et al. published [40], in 2016, that in the same FIGO groups the progression-free survival and the overall survival were significantly lower at 2 years and at 4 years, respectively, for FIGO I–II with PET/CT positive, compared with the groups with PET/CT negative, similarly as for FIGO groups III–IV.
F18-FDG PET/CT is more accurate than CT and MRI identification of extra-abdominal metastatic lymphadenopathy. Mediastinal metastatic lymphadenopathies were associated with higher mortality. A preoperative PET/CT in patients with advanced ovarian cancer may alter therapy, direct surgery, and provide a baseline for subsequent treatment monitoring.
Functional imaging using F18-FDG PET/CT succeeded in this case to be an essential tool in the differential diagnosis of the thyroid pathology, in the correct assessment of primary cancer, to evaluate the treatment response, and to change to another strategy, when the relapse was observed.
4. Conclusions
According to the literature search, this is the first case report of an association of MPTC and supraclavicular metastasis of ovarian cancer. The study has the aim to underline the necessity of complex and careful evaluation of each oncologic patient, due to the unexpected clinical presentation and rare association of diseases, sometimes leading to a confusing management. The growing evidence available for functional imaging, as F18-FDG PET/CT, in onco-gynaecology will impose new standards both in the initial diagnostic, staging, and in the imaging-based criteria for noninvasive response evaluation.
Author Contributions: Conceptualization, D.P. and C.C.; methodology, D.-S.M.; validation, D.P., A.P. and A.M. formal analysis, A.P.; investigation, E.B.; resources, E.B.; writing, D.P and A.P.; supervision, C.C.; funding acquisition, E.B. and D.P. All authors have read and agreed to the published version of the manuscript.
Funding: The study was supported by PN-III-P1-1.2-PCCDI2017-0737: Genomic population mapping of radioactively and heavy metals contaminated areas in order to increase national security-ARTEMIS.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.
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CrossrefCancerPubmedGynecolOncol