Papillary thyroid cancer with simultaneous iodine-avidity and iodine-resistance in a pregnant patient

Objective: To report the case of a 21-year-old pregnant woman, who was diagnosed with papillary thyroid cancer (PTC) and lytic bone lesions ten years after chemotherapy (CHOP) and mini-mantle field radiation for Hodgkin’s lymphoma; To discuss the association of second malignant neoplasms in childhood Hodgkin’s lymphoma survivors, and to hypothesize on the possible etiology and significance of the lack of radioiodine avidity in our patient’s bony lesions. Methods: We describe the patient’s symptoms as well as the laboratory, radiographic and histopathology results leading to the diagnosis of PTC. Results: After having been diagnosed with PTC, our patient elected to undergo abortion prior to total thyroidectomy. Iodine-123 scan after surgery showed uptake in the thyroid bed, but none in the bony lesions raising concern for a second primary malignancy, possibly originating from the organs that had been in the field of her previous radiation. However, biopsy confirmed PTC as the cause for the bone destructions. Palliative external beam radiation of the bony lesions was performed. Sorafenib treatment was offered to her, but declined. She died a few months later of respiratory failure secondary to pronounced muscle weakness. Conclusion: The concomitant presence of iodine-avidity and –resistance reflects de-differentiation of the tumor cells, and it is associated with poor prognosis. We hypothesize that the combination of pregnancy and previous radiation may have caused the cancer’s marked aggressiveness.