KEYWORDS
Thyroid cancer, Atrium, Tumor thrombusLearning Points:
- Tumors with radiological evidence of thrombus reflects metastatic
nature
- Advanced tumors of thyroid needs multidisciplinary management
- Even with advanced nature of disease specially differentiated
malignancies of thyroid the post of period remains uneventful if
managed in tertiary care centre
Introduction
Malignant diseases like thyroid carcinoma, renal cell carcinoma, renal
transitional cell carcinoma, uterine carcinosarcoma, Wilms’ tumor,
testicular tumor, adrenal cortical carcinoma, lymphoma, pancreatic
cancer, osteosarcoma and Ewing’s sarcoma can lead to the development of
tumors in the great veins known as tumor thrombus [1]. Papillary,
follicular, insular, and anaplastic thyroid cancers have all been linked
to the thyroid malignancies that typically cause such tumor thrombus.
Direct extension of the tumor or concealed vascular spread both result
in tumor thrombus [2]. Ultrasonography used for preoperative imaging
frequently finds thrombus by accident but CT or MRI scan should be
performed on the suspected patient to provide an accurate diagnosis
[3].In our case study, we described a rare presentation of an
advanced thyroid cancer with tumor thrombus in the great veins extending
upto right atrium.
Case report
A 78 year old female known history of hypertension and diabetes
presented with swelling in front of neck from 2 months, insidious in
onset gradually progressive. swelling was more prominent over right side
of face & right upper limb. With no history of stridor difficulty in
swallowing,fever, pain or swelling anywhere in the body,loss of appetite
and weight loss. On examination there was a swelling in front of the
neck especially on the right side moving with deglutition, swelling was
firm around 10x8 cm without retrosternal extension. No gross lymph node
palpable on examination. Gross swelling of face and right arm was
present. On investigations FNAC revealed papillary carcinoma (TIRADS 5
LESION). Suspecting advanced nature of pathology CT angiogram revealed
large ill defined infiltrative heterogenously enhancing mass in neck on
right side extending from the level of oropharynx superiorly to the
level of thoracic inlet inferiorly. Epicenter of the lesion appears
right lobe of thyroid gland 10.6 x 5.7 x 5.2cms.Right internal jugular
vein thrombosis and Inferiorly thrombosis is extending into right
brachiocephalic vein, SVC and right atrium.
Figure: 1 Pre-operative CT-MRI findings revealing tumor thrombus
reaching up to right atrium with a large thyroid lesion.
Figure: 2 Intra-operative findings of the location of thrombus in the
right atrium.
Figure: 3 Demonstrating the final excised main specimen with tumor
thrombus at various locations.
Patient went for complete major pre-surgical assessment and discussion
with multidisciplinary team patient was planned for surgery.NECK EXPLORATION + TOTAL THYROIDECTOMY + B/L NECK DISSECTION +
STERNOTOMY + ATRIOTOMY + THROMBUS EXTRACTION was done under general
anaesthesia. Intraoperative found an 10x8cms right lobe of
thyroid adherent to strap muscles, internal jugular vein (IJV), carotid,
left lobe normal, IJV thrombus, subclavian junction into right atrium,
multiple level V nodes present in neck, bilateral parathyroids &
recurrent laryngeal nerve (RLN) identified & preserved. Postoperative
patient was shifted to ICU without any significant event. Patient was
extubated on first day of Post-Operative. Histopathological findings
showed follicular carcinoma, solid, insular and follicular patterns,
right lobe of thyroid with capsular and vascular invasion (mitotic
activity <3/10 HPF, no necrosis, no significant nuclear
atypia) measuring 6 cms in greatest dimension with tumor thrombosis in
SVC and right atrium, no extrathyroidal extension, no metastatic
deposits, staging was pT3aNO.
Discussion
A known risk factor for venous thromboembolism is cancer. Patients who
have an unintentional venous thromboembolism appear to have lower (4%)
prevalence of occult malignancy [4]. The annual incidence of thyroid
cancer, which accounts for around 1% of all new malignant diseases, has
increased over the past ten years, primarily as a result of better
diagnostic tools for detecting malignant tumors in small thyroid
nodules. The majority of nodules that are thyroid carcinoma are
asymptomatic. It is still unclear how exactly thyroid cancer affects the
possibility of venous thrombosis. Through compression, angioinvasion, or
maybe a prothrombotic condition, thyroid malignancy induced thrombosis
[5]. The location will affect the symptoms of a tumor
thrombus.Internal jugular veins have a high incidence of tumor thrombus
first, followed by other veins extending to other large veins, such as
the axillary, brachiocephalic, subclavicular, and SVC.Patients who
simply had an internal jugular vein thrombosis did not exhibit any overt
symptoms, but half of those who also had an SVC thrombus experienced SVC
syndrome [6].Conclusion:Tumor thrombus with intravascular tumor extension, can develop in a
variety of cancer forms. Wilm’s tumor, renal cell carcinoma (RCC),
adrenal cortical carcinoma (ACC), and hepatocellular carcinoma (HCC) are
those with the highest propensity. The prognosis is significantly
worsened and the therapeutic strategy is affected by tumor thrombus.
Multidisciplinary team management is essential for a good outcome.