Joint Program in Nuclear Medicine
Hurthle Cell Tumor
Kavitha Vadde, MD
J. Stevan Nagel, MD
November 23, 1999
A 57 year old white female presented with a 5 cm right thyroid mass. Fine
needle aspiration cytology was consistent with Hurthle cell tumor.
Collimator: medium energy
Adult dose 6.0 mCi IV over 1-2 minutes.
Patient Preparation: Confirm injection time with patient. Each dose costs
~$800 and expires in 2 hours of scheduled injection time. Hydration before
and after injection and Golytely bowel prep for evening of injection are
Views: At 4 hours: Anterior and posterior images of the abdomen are collected
for 15 minutes with a 128x128 matrix. At 24 hours: Anterior and posterior
chest, abdomen, and pelvis images are collected for 15 minutes with a 128x128
matrix. Single Photon Emission Computed Tomographic (SPECT) images of the
chest, abdomen and pelvis are collected for 64 stops at 35 seconds per
stop with a 64x64 matrix. Delay planar or SPECT imaging up to 48 hours
can be obtained if there is a large amount of bowel activity.
Octreotide scintigraphy shows uptake in the
right anterior neck in the region of the right lobe of the thyroid (shown
Total thyroidectomy was performed. Pathology showed a 3.5 cm colloid nodule
with Hurthle cell change and nodular hyperplasia (goiter).
Hurthle cell tumor is an uncommon and controversial thyroid neoplasm. Hurthle
cells, also known as oxyphil cells, are large polygonal cells with pleomorphic
hyperchromatic nuclei and eosinophilic granular cytoplasm. They are thought
to arise form follicular thyroid epithelium. The World Health Organization
(WHO) classifies malignant Hurthle cell tumors as follicular carcinoma,
oxyphilic cell type (1). Hurthle cells are seen in association with a number
of benign thyroid conditions including nodular hyperplasia, Gravesí disease,
and thyroiditis. Hurthle cell tumors are nodular aggregates of Hurthle
cells that may or may not be encapsulated. Hurthle cell carcinoma occurs
with an incidence ranging form 13 - 35% in various series of these tumors.
The pathologic determination of malignancy is difficult as the architectural
and cytological features of the benign and malignant tumors overlap. Fine
needle aspiration is useful only to establish the presence of a Hurthle
cell neoplasm. The final diagnosis is dependent on histological analysis
of the surgical specimen. If vascular invasion, invasion of adjacent tissues
or complete capsular penetration (if the tumor is encapsulated) is demonstrated
the tumor is considered malignant. The size of the tumor is not an independent
predictor of malignancy but large (> 4 cm) tumors are more likely to be
Hurthle cell carcinoma accounts for approximately 6% of all differentiated
thyroid cancers. It is primarily a disease of adults with a mean age at
diagnosis of 50 years. Hurthle cell tumors occur more commonly in women
than men (>2:1), but the relative incidence of carcinoma is greater in
men. The most common clinical presentation is a single palpable, cold nodule.
It can occur concurrently with benign thyroid disease, e.g. multinodular
goiter, Gravesí disease. Some case series have reported an association
with prior head and neck irradiation.
Hurthle cell carcinoma is a more aggressive neoplasm than papillary
or other follicular cancers. Distant metastatic disease is seen in 10-15%
of patients at initial diagnosis of the tumor in the neck. The lungs and
bone are the most frequent sites of distant metastases. Distant metastatic
disease is seen in approximately one third of patients and has a five year
mortality rate of 80%.
The only effective treatment for Hurthle cell neoplasm is surgery, due
to the difficulty in making the pathologic diagnosis of malignancy from
fine needle aspiration. Total thyroidectomy is advised for all malignant
tumors possibly with internal jugular node sampling. Hurthle cell adenomas
are treated by some surgeons with lobectomy and close follow up. Chemotherapy
and external radiation treatment have not proven effective. The overwhelming
majority of Hurthle cell carcinoma is not iodine avid, so I-131 is ineffective
in treating or diagnosing metastatic disease. Prognosis depends mainly
on extent of disease at initial diagnosis and the adequacy of surgical
intervention. There is no effective treatment for metastatic disease.
In-111 Octreotide Scintigraphy
Indium-111 labeled octreotide has proven useful in identifying the extent
of tumor burden. Hurthle cell tumors (adenomas and carcinomas) express
somatostatin receptors (2, 3). Normal thyroid tissue also expresses somatostatin
receptors. However, the concentration of somatostatin receptors is higher
in Hurthle cell tumors. False positives can result with excessive uptake
of tracer in benign thyroid disease. In one series of 10 patients there
is no difference in octreotide uptake between Hurthle cell adenomas and
The main role of octreotide scintigraphy in the management of Hurthle
cell carcinoma is to assess for metastatic disease. Possibly in the future
somatostatin receptor analogs can be used to direct radiotherapy to treat
metastatic disease, similar to I-131 treatment of metastatic thyroid follicular
and papillary cancer.
1. Cooper DS and Schneyer, CR. Follicular and Hurthle cell carcinoma of
the thyroid. Endocrinol Metab Clin North Am. 1990: 577-91.
2. Carcangiu ML, Bianchi S, Savino D, Voynick IM, Rosai J. Follicular
Hurthle cell tumors of the thyroid gland. Cancer 1991;68:1944-1953.
3. Chen H, Nicol TL, Zeiger MA, Dooley WC, Ladenson PW, Cooper DS, Ringel
M , Parkerson S, Allo M, Udelsman R. Hurthle cell neoplasms of the thyroid.
Are there factors predictive of malignancy? Ann Surg, 1998;227:542-546.
4. Gulec SA, Serafini AN, Kasi SS, Peker KR, Gupta A, Goodwin WJ, Sfakianakis
GN, Moffat FL. Somatostatin receptor expression in Hurthle cell cancer
of the thyroid. J Nucl Med 1998;39:243-245.
5. Wilson CJ, Woodroof, JM, Girod DA. First report of Hurthle cell carcinoma
revealed by octreotide scanning. Ann Otol Rhinol Laryngol, 1998; 107:847-849.
6. Tisell LE, Ahlman H, Wangberg B, Kolby L, Fjalling M, Forssell-Aronsson
E, Molne J, Nilsson O. Expression of somatostatin receptors in oncocytic
(Hurthle cell) neoplasia of the thyroid. British Journal of Cancer, 1999;
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J. Anthony Parker, MD PhD, Tony_Parker@CareGroup.Harvard.edu