Midline or near-midline radioiodine uptake in the oropharyngeal region in patients of differentiated thyroid carcinoma: Differential diagnosis between lingual thyroid and retropharyngeal nodal metastasis, the subtle clues in the scan and their implications for patient management

98 metastasis), the patient had undergone treatment with 2.0 GBq I-131 6 months previously. The follow-up radioiodine scan demonstrated focal tracer concentration [Figure 1a] just right to midline in the oral region, which persisted at the same location on repeat scan the next day. The lateral images [Figure 1b and c] confirmed tracer concentration posterior to the oral cavity, which raised the suspicion of either lingual thyroid or iodine concentrating the retropharyngeal lymphadenopathy. A plain computed tomography (CT) [Figure 2] of neck undertaken to clarify the exact nature of the uptake showed a right sided large retropharyngeal lymph node (3.5 cm × 3.0 cm × 2.8 cm); in the setting of intense radioiodine uptake, this suggested metastatic retropharyngeal lymph node. Serum thyroglobulin level at this time was 3.2 ng/ml. A surgical opinion was sought, but he declined surgery and was treated with 5.5 GBq of I-131. The posttreatment study [Figure 3a] demonstrated solitary focus of uptake in oropharyngeal location intense in both anterior and posterior views. The single‐photon emission computed tomography (SPECT) images [Figure 3b] further confirmed this. One subtle clue on the planar radioiodine scan is that lingual thyroid is typically midline while retropharyngeal node focus appears slightly lateral to the midline. In the given setting, the lateral views and SPECT helped in confirming its location in posterior oral region. In our case, the follow‐up scan [Figure 1] showed a focal tracer concentration just right to the midline and was finally proven to be iodine concentrating the retropharyngeal lymphadenopathy. A plain CT was undertaken to prevent iodide interference from the contrast so that radioiodine therapy could be undertaken if decided for. The current consensus suggests that in case of lingual thyroid in operated DTC, the primary treatment modality being surgery, followed by radioiodine treatment.[1] In the case of retropharyngeal lymphadenopathy, the primary approach should be surgical resection. If not feasible, other treatment modalities may be considered such as radioiodine therapy. [2] Thus, Midline or near‐midline radioiodine uptake in the oropharyngeal region in patients of differentiated thyroid carcinoma: Differential diagnosis between lingual thyroid and retropharyngeal nodal metastasis, the subtle clues in the scan and their implications for patient management DOI: 10.4103/2278-330X.155700 Dear Editor, Either lingual thyroid (associated with normal thyroid) or iodine concentrating retropharyngeal lymphadenopathy in patients of differentiated thyroid cancer (DTC) is relatively rare but important clinical entities, that present with remarkably similar finding in postablation radioiodine study. An accurate diagnosis is of pivotal importance particularly in view of the diagnostic challenge they pose and different management strategies between the two. In a recently described report,[1] Song et al. described incidental uptake in the oropharynx that turned out to be an associated lingual thyroid. We herein illustrate an alternate diagnosis through a clinical example that led to the diagnosis of a solitary metastatic retropharyngeal lymphadenopathy from DTC. A 26-year-old male, initially presented with right sided neck swelling and was evaluated with contrast enhanced computed tomography which showed right thyroid lobe nodule (1.3 cm × 1.9 cm in size) with ipsilateral cervical level II–VI lymphadenopathy. Fine-needle aspiration cytology from the nodule and lymph nodes was suspicious of differentiated procalcitonin (PCT). Following total thyroidectomy and nodal dissection (histopathology was classical PCT with nodal Letters to Editor

metastasis), the patient had undergone treatment with 2.0 GBq I-131 6 months previously. The follow-up radioiodine scan demonstrated focal tracer concentration [ Figure 1a] just right to midline in the oral region, which persisted at the same location on repeat scan the next day. The lateral images [ Figure 1b and c] confirmed tracer concentration posterior to the oral cavity, which raised the suspicion of either lingual thyroid or iodine concentrating the retropharyngeal lymphadenopathy.
A plain computed tomography (CT) [ Figure 2] of neck undertaken to clarify the exact nature of the uptake showed a right sided large retropharyngeal lymph node (3.5 cm × 3.0 cm × 2.8 cm); in the setting of intense radioiodine uptake, this suggested metastatic retropharyngeal lymph node. Serum thyroglobulin level at this time was 3.2 ng/ml. A surgical opinion was sought, but he declined surgery and was treated with 5.5 GBq of I-131. The posttreatment study [ Figure 3a] demonstrated solitary focus of uptake in oropharyngeal location intense in both anterior and posterior views. The single-photon emission computed tomography (SPECT) images [ Figure 3b] further confirmed this.
One subtle clue on the planar radioiodine scan is that lingual thyroid is typically midline while retropharyngeal node focus appears slightly lateral to the midline. In the given setting, the lateral views and SPECT helped in confirming its location in posterior oral region. In our case, the follow-up scan [ Figure 1] showed a focal tracer concentration just right to the midline and was finally proven to be iodine concentrating the retropharyngeal lymphadenopathy. A plain CT was undertaken to prevent iodide interference from the contrast so that radioiodine therapy could be undertaken if decided for.
The current consensus suggests that in case of lingual thyroid in operated DTC, the primary treatment modality being surgery, followed by radioiodine treatment. [1] In the case of retropharyngeal lymphadenopathy, the primary approach should be surgical resection. If not feasible, other treatment modalities may be considered such as radioiodine therapy. [2] Thus, Midline or near-midline radioiodine uptake in the oropharyngeal region in patients of differentiated thyroid carcinoma: Differential diagnosis between lingual thyroid and retropharyngeal nodal metastasis, the subtle clues in the scan and their implications for patient management DOI: 10.4103/2278-330X.155700 Dear Editor, Either lingual thyroid (associated with normal thyroid) or iodine concentrating retropharyngeal lymphadenopathy in patients of differentiated thyroid cancer (DTC) is relatively rare but important clinical entities, that present with remarkably similar finding in postablation radioiodine study. An accurate diagnosis is of pivotal importance particularly in view of the diagnostic challenge they pose and different management strategies between the two. In a recently described report, [1] Song et al. described incidental uptake in the oropharynx that turned out to be an associated lingual thyroid. We herein illustrate an alternate diagnosis through a clinical example that led to the diagnosis of a solitary metastatic retropharyngeal lymphadenopathy from DTC.
A 26-year-old male, initially presented with right sided neck swelling and was evaluated with contrast enhanced computed tomography which showed right thyroid lobe nodule (1.3 cm × 1.9 cm in size) with ipsilateral cervical level II-VI lymphadenopathy. Fine-needle aspiration cytology from the nodule and lymph nodes was suspicious of differentiated procalcitonin (PCT). Following total thyroidectomy and nodal dissection (histopathology was classical PCT with nodal Letters to Editor We believe that the article entitled "smoking trends among women in India: Analysis of nationally representative surveys (1993-2009)" published in year 2014 in your esteemed journal, is an honest effort of bringing an overview of the serious problem, which is often overlooked. [1] The authors have pointed out that in India the trend of smoking is increasing among women. This may act as a hint of upcoming public health problem as these can be attributed to rising cases of infertility and higher cancer incidences among women. The current study has found its impact on global media also. A news article in BMJ December 2014 issue [2] has also highlighted the findings of the article.
The findings of the article was similar to a study titled "Smoking prevalence and cigarette consumption in 187 countries, 1980-2012." published in JAMA, [3] which showed a marginal increase in prevalence of smoking among Indian females from 2.7% (2.3-3.1) in year 1996 to 3.3% (2.8-3.9) in year 2012. Interestingly, the article mentioned that in between 1996 and 2006, there was a rapid decline in smoking trend globally combining both sexes and a slower decline trend from 2009 to 2012.

The recent publication of findings of pan India District
Level Household Survey-IV (DLHS) (2012-2013), [4] has thrown more light on the current debate of trends in female smoking. Findings of DLHS-IV (2013) actually supplement the findings of the study by Goel et al. [1] (1993-2009). As per DLHS-IV, fewer states especially north eastern states (Sikkim, Arunachal Pradesh, Tripura, Nagaland, Manipur), northern states (Haryana, Punjab, Chandigarh) and Andhra Pradesh have shown a decline in female smoking whereas south-western states (Pondicherry, Tamil Nadu, Karnataka,  Table 1]. Both the surveys (DLHS-IV and GATS) can be compared as both had large sample size with proportionate allocation to various states of India, and had employed multistage stratified sampling methodology and uniform sampling techniques. However, interestingly, the increase of female smoking across different states was minimal whereas the decrease of female smoking was substantial. These recent changes in prevalence of female smoking may