Total body I-131 scanning done on a 67-year-old woman with thyroid cancer revealed abnormal tracer uptake within the mid-thorax, thought to represent metastasis in the mediastinum or thoracic spine. Single-photon emission computed tomography images of the thorax showed contiguity between the thoracic uptake and the normal, physiologic uptake of radioiodine in the stomach, suggesting physiologic accumulation within a hiatal hernia. To confirm the alimentary tract location of the radioiodine, a study using orally administered Tc-99m SC in water was performed. The images were similar to the iodine images and revealed a pattern consistent with hiatal hernia. A hiatal hernia was also observed as an incidental finding on chest radiographs and an MRI. This case illustrates the potential for an abnormal anatomic configuration to mimic metastatic thyroid cancer and shows how SPECT and oral Tc-99m SC images may be useful in making this distinction.