Venous extension of a thyroid follicular carcinoma

TNM staging

Discussion

Thyroid carcinoma usually presents as an asymptomatic thyroid nodule.

Thyroid cancer may show microscopic vascular invasion; however, internal jugular vein tumor thrombus is a rare complication of thyroid cancer.

Thyroid carcinomas with massive intralumen invasion of the great veins are extremely rare and reported to have poor prognosis.

Thyroid carcinoma causing tumor thrombus in the great veins is a rare situation and has been reported to have poor prognosis.

It can cause sudden death due to pulmonary embolism, and the management requires exclusive care.

Solitary internal jugular vein invasion of thyroid cancer has been occasionally reported, but tumor thrombi extending to the mediastinum great veins is extremely rare.

In the past, cases receiving palliative management have been reported due to the difficulty of surgical approach resulting in poor outcome.

In general, patients can eventually come down with symptoms of SVC syndrome, which would be critical.

Surgical treatment is necessary in collaboration with head and neck surgeons and cardiothoracic surgeons.

Thompson et al. reported the first case of follicular thyroid carcinoma with extended tumor thrombus in the mediastinum great veins that was operated successfully.

Thrombectomy is the most effective surgical treatment if possible.

In the English language literature, 11 cases of differentiated thyroid cancer invasion in the mediastinum great veins have been reported that were treated by thrombectomy.

Most of the previously reported cases revealed angio-invasion into a single vein.

Reconstruction of the vessels is necessary for cases with massive invasion and adhesion to the great veins.

Cases utilizing expanded polytetrafluoroethylene grafts or autologous tissue6 for reconstruction of mediastinum great veins are reported.

Appropriate preoperative vascular imaging is important whenever angio-invasion is suspected.

Enhanced CT and ultrasonography is reported to be useful for detecting tumor thrombi of thyroid malignancies.

Taib and Hisham described the importance of the positive ring sign, which is a rim of contrast around the tumor thrombus on enhanced CT examination.

This sign indicates the possibility of removing the thrombus by thrombectomy (without reconstruction) and is useful in deciding the surgical strategy.

Multimodality treatment is recommended including surgery, external beam radiotherapy (EBRT), and RI therapy for aggressive thyroid cancer with great vein involvement.

Links

 Venous obstruction of thyroid malignancy origin: the Antoine Lacassagne Institute experience. Marcy PY et al. http://www.wjso.com/content/7/1/40

References

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 Mishra A, Agarwal A, Agarwal G, Mishra SK. Internal jugular vein invasion by thyroid carcinoma. Eur J Surg 2001; 167: 64–67.

 Lalak NJ, Campbell PR. Infiltrating papillary carcinoma of the thyroid with macroscopic extension into the internal jugular vein. Otolaryngol Head Neck Surg 1997; 117: S228–S230.

 Wiseman O, Preston PG, Clarke JM. Presentation of thyroid carcinoma as a thrombosed external jugular vein, with intraluminal tumour thrombus in the great veins. Eur J Surg Oncol 2000; 26: 816–817.

 Kim RH, Mautner L, Henning J, Volpe R. An unusual case of thyroid carcinoma with direct extension to great veins, right heart, and pulmonary arteries. Can Med Assoc J 1966; 94: 238–243.

 Thompson NW, Brown J, Orringer M, Sisson J, Nishiyama R. Follicular carcinoma of the thyroid with massive angioinvasion: extension of tumor thrombus to the heart. Surgery 1978; 83: 451–457.

 Wada N, Masudo K, Hirakawa S, et al. Superior vena cava (SVC) reconstruction using autologous tissue in two cases of differentiated thyroid carcinoma presenting with SVC syndrome. World J Surg Oncol 2009; 7: 75.

 Motohashi S, Sekine Y, Iizasa T, Nakano K, Numata T, Fujisawa T. Thyroid cancer with massive invasion into the neck and mediastinal great veins. Jpn J Thorac Cardiovasc Surg 2005; 53: 55–57.

 Taib NA, Hisham AN. Follicular thyroid carcinoma with direct tumour extension into the great cervical veins and right atrium: is transcervical thrombectomy a safe option? Asian J Surg 2007; 30: 216–219.

 Kobayashi K, Hirokawa M, Yabuta T, et al. Tumor thrombus of thyroid malignancies in veins: importance of detection by ultrasonography. Thyroid 2011; 21: 527–531.

 Hyer SL, Dandekar P, Newbold K, et al. Thyroid cancer causing obstruction of the great veins in the neck. World J Surg Oncol 2008; 6: 36.