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Tumor thromboembolization into the internal jugular vein through its draining vein: A preoperative radiologic feature of high-risk thyroid cancer

2012; Elsevier BV; Volume: 155; Issue: 1 Linguagem: Inglês

10.1016/j.surg.2012.08.006

1532-7361

P. R. K. Bhargav,

Cardiac tumors and thrombi

This section features outstanding photographs of clinical materials selected for their educational value or message, or possibly their rarity. The images are accompanied by brief case reports (limit 2 typed pages, 4 references). Our readers are invited to sumit items for consideration. This section features outstanding photographs of clinical materials selected for their educational value or message, or possibly their rarity. The images are accompanied by brief case reports (limit 2 typed pages, 4 references). Our readers are invited to sumit items for consideration. A 52-year-old woman presented with a progressively enlarging goiter for 6 years with rapid increase in past 8 months. On clinical examination, a grade 3 multinodular goiter with a predominant right lobe involvement was found. There was no cervical lymphadenopathy. Cytology was suggestive of a follicular neoplasm and metastatic work-up revealed no lung or skeletal or other distant metastases. She was euthyroid. Contrast enhanced computed tomography (CT) scan was done for operative planning. Apart from large goiter with heterogeneously enhancing nodular mass, CT demonstrated a filling defect in the right internal jugular vein (IJV) and a distended middle thyroid vein (MTV; Figure). This radiologic sign was pathognomonic of a tumor thrombus spreading from cancer mass in to IJV through its draining vein, the MTV. She underwent total thyroidectomy with en bloc removal of the right IJV and MTV (tumor thrombectomy). Her postoperative period was uneventful and histopathology was suggestive of a widely invasive follicular thyroid cancer with focal poorly differentiated areas. At 1-year follow-up, she was clinically euthyroid with normal post-radioiodine ablation scan and on suppressive thyroxine therapy. Occasionally, both high-risk papillary and follicular thyroid cancer invades great vessels of neck and upper mediastinum.1Mishra A. Agarwal A. Agarwal G. Mishra S. Internal jugular vein invasion by thyroid carcinoma.Eur J Surg. 2001; 167: 64-67Crossref PubMed Scopus (26) Google Scholar, 2Motohashi 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: 55-57Crossref PubMed Scopus (16) Google Scholar The various mechanisms of vascular invasion are embolization, direct tumor thrombus, or infiltration with encasement. This extrathyroidal vascular invasion is associated with aggressive disease and chances of higher recurrence.3Gardner R.E. Tuttle M. Burman K.D. Haddady S. Truman C. Sparling Y.H. et al.Prognostic importance of vascular invasion in papillary thyroid carcinoma.Arch Otolaryngol Head Neck Surg. 2000; 126: 309-312Crossref PubMed Scopus (87) Google Scholar This phenomenon is more frequently encountered in widely invasive follicular thyroid cancer as seen in this case. The best way of diagnosing this feature of thyroid cancer is CT or magnetic resonance imaging of the neck, although color Doppler ultrasonography can be contributory.4Panzironi G. Rainaldi R. Ricci F. Casale A. De Vargas Macciucca M. Gray-scale and color Doppler findings in bilateral internal jugular vein thrombosis caused by anaplastic carcinoma of the thyroid.J Clin Ultrasound. 2003; 31: 111-115Crossref PubMed Scopus (23) Google Scholar The treatment is surgical with resection of the tumor involved vascular segment with safe margins (tumor thrombectomy).1Mishra A. Agarwal A. Agarwal G. Mishra S. Internal jugular vein invasion by thyroid carcinoma.Eur J Surg. 2001; 167: 64-67Crossref PubMed Scopus (26) Google Scholar, 5Wada N. Masudo K. Hirakawa S. Woo T. Arai H. Suganuma N. 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: 75Crossref PubMed Scopus (16) Google Scholar However, this procedure can only be contemplated in operable cases with good anesthetic risk. Major vascular resections needs reconstruction with either heterotopic autograft (eg, spiraled saphenous vein) or prosthetic graft (eg, Goretex or Teflon),5Wada N. Masudo K. Hirakawa S. Woo T. Arai H. Suganuma N. 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: 75Crossref PubMed Scopus (16) Google Scholar although unilateral sacrifice of the IJV without reconstruction is not associated with major morbidity. Involvement of the carotid artery, multiple great vessels, or mediastinal vessels is a relative contraindication for vascular resection and is considered to be at an unresectable stage (IVB), but involvement of neck viscera (stage IVA) is considered as resectable malignancy. Although carotid reconstruction is feasible, it can be associated with high rates of neurologic morbidity and mortality. A thorough preoperative radiologic evaluation of thyroid cancer can detect this grave prognostic sign and guides in planning the thyroidectomy procedure with optimal thrombectomy and vascular resection in operable cases. The radiologic images presented in this paper, highlights this crucial component of thyroid cancer management.