Vol 43 # 2 June 2011 - Kma.org.kw

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140 Macroinvasive Papillary Thyroid Carcinoma Presenting as Internal Jugular Vein Tumor Thrombus June 2011 Fig. 2: Axial CT showing thyroid nodule (asterisk) and filling defect of the tumoral thrmobus within the internal jugular vein Fig. 1: Sagittal CT reformate showing thrombosed jugular vein (asterix) and partially thrombosed superior thyroid vein (hollow arrow) within all removed lymph nodes; levels 2, 3, 4, 5A, 6; and IJV invasion with malignant thrombus (Fig. 6). Six weeks after operation, whole body iodine 131 scanning showed two metastatic foci of intense I 131 accumulation in the chest and abdomen. Patient is now a candidate for radioactive iodine (RAI) ablation and thyroxine supplementation. DISCUSSION Thyroid carcinoma usually presents as a painless thyroid nodule and has low morbidity and mortality. Thyroid cancer may show microscopic vascular invasion but rarely causes tumor thrombus in the IJV or other great veins of neck [1] . Only 29 cases have been documented in the literature untill April, 2008 [2] . Follicular and Hurthle cell carcinoma are most common pathological type of thyroid carcinomas that invade cervical veins and possess angio-invasive features. Our case was of the papillary type. It is uncommon to have micro-invasion and macroinvasion of the neck veins is even rarer [1] . According to Graham, Kaufmann was the first to report a case of thyroid cancer thrombi in 1879 at autopsy; the tumor was found to extend into the jugular, subclavian and innominate veins on both sides [3] . Fig. 3: Distended internal jugular vein with thrombus The symptoms and signs of a tumor thrombus in IJV and other great veins depend on site and degree obstruction of the lumen. The most common clinical manifestation of such condition is dilated veins of the neck. Because the IJV is located deep to the sternocledomastoid muscle, a typical palpable cord is not a common presentation of thrombosed IJV. In the present case, patient complaint was left neck pain with palpable mass, without signs of dilated veins over the neck [4] . The common causes of IJV thrombosis are previous catheterization, trauma, radiotherapy, neck surgery, and hypercoagulation conditions. When
June 2011 KUWAIT MEDICAL JOURNAL 141 Fig. 5: Microscopic picture of the thyroid with papillary carcinoma Fig. 4: Opened internal jugular vein and tumor thrombus within IJV obstruction is found without obvious cause, compression by thyroid enlargement and infiltration by thyroid carcinoma should be considered in the differential diagnosis [5] . Color Doppler ultrasound may be helpful, especially for excluding thrombus in the IJV. But the structures deep to the mandible and the clavicle are difficult to scan, and SVC may be obscured by osseous structures or lung parenchyma [6] . CT venography has the advantage over digital subtraction venography in its ability to evaluate the proximal extent of obstruction or thrombosis. The advantage of MRI over CT and ultrasound are a superior soft tissue contrast, and the fact that intravenous contrast is unnecessary. Also Gallium-67 scintigraphy has been used successfully in diagnosing tumor thrombus in a patient with anaplastic thyroid cancer [7] . Management of these patients is challenging as they typically present with advanced and rapidly progressive disease. Complete resection is recommended where possible to reduce tumor burden. The presence of massive intravascular invasion should not be a contraindication for resection to palliate impending SVC obstruction [8] . Without surgery the prognosis is bleak and death follows from tumor embolism or obstruction of the right atrium [9] . During segmental vein resection, the involved vein is ligated before handling to prevent tumor embolization [10] . Fig. 6: Microscopic picture of the internal jugular vein completely occluded by the tumor Surgery should be complemented with radioiodine in iodine-avid tumors as this may reduce the risk of recurrence. The value of external beam radiotherapy (EBRT) in the management of thyroid cancer remains controversial because published data are conflicting and there are no prospective randomized controlled trials. There is good evidence that EBRT improves local control in patients with gross macroscopic residual disease following surgery [11] . Although there was no extra-thyroid extension and complete resection of the tumor was done, our patient is still in the high risk group. Final TNM categorization was stage IV (T2 N1 M1, > 45 years). We are following this patient carefully for RAI ablation response and thoroughly checking for recurrence. CONCLUSIONS Papillary thyroid carcinoma with massive invasion into the great veins of the neck and mediastinum has rarely been reported. But every patient with spontaneous IJV thrombosis must undergo careful history and complete physical examination and a thorough investigation to exclude infiltration from thyroid carcinoma as a differential diagnosis.
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Vol 43 # 2 June 2011 - Kma.org.kw

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