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Follicular Thyroid Carcinoma in Internal Jugular Vein: Direct Extension or Thrombus?

 A Report of Two Cases

 

 

 

Reynaldo O. Joson, MD, FPCS
Arlene T. Fajardo, MD

 

 

Manila Doctors Hospital

2002

 

rjoson@maniladoctors.com.ph

 

 

 

 

 

 

 

Follicular Thyroid Carcinoma in Internal Jugular Vein: Direct Extension or Thrombus?

A Report of Two Cases

 

 

 

Abstract

           Follicular thyroid carcinoma is known to spread by the hematogenous route.  Usually, the cancer spreading through the blood stream is not grossly visible.  This paper reports on 2 cases of follicular thyroid carcinoma with the spreading cancer grossly palpable and visible inside the internal jugular vein. The segment of the vein where the tumor was detected intraoperatively was adjacent to the primary cancer in the thyroid gland.  However, the venous wall was completely intact.   On the other hand, the tumor inside the vein was attached to the endothelium preventing it from floating freely in the blood stream.  In both cases, the segment of the internal jugular vein containing the tumor was resected.  This report is intended for surgeons so that they may be aware of such an uncommon intraoperative situation that may be encountered during operations in patients with follicular thyroid carcinoma.

 

 

Introduction

 

Follicular thyroid carcinoma is known to spread by the hematogenous route.  Usually, the cancer spreading through the blood stream is not grossly palpable and visible to the naked eyes of the surgeons and pathologists.  This paper reports on 2 cases of follicular thyroid carcinoma operated by the senior author (ROJ) in which the tumor was grossly palpable and visible inside the internal jugular vein. It is the intention of the authors in making this report to share experiences with surgeon-colleagues so that they will be made aware of such an unusual situation in patients with follicular thyroid carcinoma and on what to do when they encounter such a situation.

 

The most recent case was encountered in 2002 and the other case, about 20 years ago.  The authors have details of the most recent case and only pictures of the first case.

 

Case Report

Case 1.

A 53- year- old female presented with a 2-year history of a palpable mass on the right side of her neck without any accompanying signs nor symptoms. She consulted a physician who did a needle biopsy, result of which was made known to the patient as a benign mass.  No other work-up nor follow-up was done.

 

Four months prior to admission, she started experiencing low back pain which was subsequently attributed to gallbladder stones.  Cholecystectomy was done.  Inspite of this, patient was still symptomatic with the pain becoming more severe and progressing to numbness and inability to ambulate, urinary retention, dysuria and constipation.  Consult with another physician, diagnosing her as a case of urinary tract infection, did not relieve her condition, prompting her to confinement to a hospital.

 

Essential physical examination findings showed bilateral lower extremity motor and sensory deficits for which a magnetic resonance imaging was done which showed a compressive lesion on the T8 level. (Fig.1).  She was referred to an orthopedic surgeon who did a T8 vertebrectomy with multiple rib grafting, at T7 to T9.  Histopathologic result of the vertebral specimen showed  “metastatic adenocarcinoma, consider follicular carcinoma”.  She was subsequently referred to a general surgeon-head and neck surgeon whose preoperative plan was to do a total thyroidectomy.  Intraoperative findings showed a  5-cm hard tumor on the right lobe of the thyroid gland which was adherent to the right sternocleidomastoid and internal jugular vein (Fig.  2).  A 1-cm mass was noted to be inside the internal jugular vein. A total thyroidectomy with partial resection of the right sternocleidomastoid muscle and segmental resection of the right internal jugular vein that contained the tumor was done.  Post-resection dissection of the internal jugular vein showed the external wall to be intact and the intraluminal mass to be adherent to the endothelium (Fig.  3).   Postoperatively, there was no complication from the neck operation and the patient was subsequently discharged and scheduled for radioactive iodine therapy.

 

Case 2.

This was an adult female patient with follicular thyroid carcinoma in whom the senior author did a total thyroidectomy and segmental resection of the internal jugular vein which contained a tumor.  Intraoperative findings were essentially the same as those in Case 1 – there was a tumor in one lobe of the thyroid gland which was adherent to the internal jugular vein (Fig. 4); there was an intraluminal tumor in the internal jugular vein (Fig. 5); and the wall of the vein was intact.

 

Discussion

Angioinvasion is a well- documented microscopic characteristic of follicular carcinoma of the thyroid.  More commonly, they metastasize to the lungs, bones, or other organs. Less recognized as a possible cause of morbidity and mortality is its invasion of the cervical veins.  Since 1879, Kauffman (1) and Graham (2) reported the first cases of thyroid cancer thrombi, one in the jugular vein.  In the review of literature (3), there are 19 reported cases of great vein tumor thrombus since it was reported in 1879 by Kauffman.  Of the 19, 10 cases are reported as intraluminal invasion of the internal jugular vein.  All 10 cases had histopathologic diagnosis of either follicular or Hurtle cell variant.  The other cases of great vein tumor thrombi involved other great veins on the neck like the innominate vein, brachiocephalic vein and the superior vena cava (4-7).

 

Patients with cervical vein involvement from follicular thyroid cancers are frequently asymptomatic.  The worst symptoms reported that these patients may have are those of a superior vena cava syndrome. In general, though, the symptomatology lies in the obstructive ratio of cervical vein cavity.  The most common earlier symptom is a dilated vein (3).  Thomas  et al documented one such case through a computed tomography  (4).  

 

In the 2 cases reported here, the patients were asymptomatic as far as the internal jugular vein involvement is concerned.  The situation was discovered only during the operation. There were two concerns faced by the senior author during the operation of these 2 cases.  The first concern was diagnostic and the second, therapeutic. 

 

While doing the thyroid lobectomy, the senior author noticed a mass adjacent to the involved thyroid lobe and the mass was near the internal jugular vein or carotid sheath. Thus, the question was, is this mass a lymph node metastasis or an extension of the primary thyroid tumor.  This question had to be settled because treatment would differ in the two possible situations.  If the mass were a metastatic lymph node, some form of neck node dissection would have to be done.  On the other hand, if the mass were an extension of the primary thyroid tumor, a wide en-bloc resection of the primary thyroid cancer together with the involved adjacent neck structures would have to be done.  The question was settled through more dissection until the senior author was certain of the real situation.  In the 2 cases, the real situation was assessed to be that the said mass was not a metastatic lymph node because on gross inspection, the mass seemed to be inside the vein and there were no grossly evident lymph nodes along the length of the internal jugular vein or carotid sheath.  Thus, in both cases, the senior author decided to resect the segment of the internal jugular vein that contained a tumor en-bloc with the primary thyroid cancer.

 

After the en-bloc resection, the specimen was studied.  The wall of the internal jugular vein was completely intact and the mass inside the vein was adherent to the endothelium. Thus, another question arose.  Is the tumor inside the vein really a direct extension of the primary thyroid cancer or is it a tumor thrombus?  Some of the authors reporting such kind of cases used the term “thrombus” while some, used  “invasion”.  Based on traditional medical parlance, between a thrombus and an embolus, a thrombus is the case because the tumor was not floating in the blood stream.  Between a direct extension and a thrombus, one can argue that the tumor is a thrombus because there was no gross evidence of invasion of the external wall of the vein although the thyroid lobe containing the primary tumor was adherent to it.  One can also argue that there could be a microscopic invasion of the internal jugular vein to cause the development of a thrombus inside the vein.   The authors feel that no absolute conclusion can be arrived at no matter how long and extensive a debate will be undertaken.  What suffices is that surgeon-colleagues are made aware of such a situation when they operate on patients with follicular thyroid carcinoma, that the tumor in the internal jugular vein could either be a direct extension or a thrombus, and that the vein with the tumor should be segmentally resected, if there are no contraindications to doing it.

 

References

1.    Holt WL. Extension of malignant tumors of thyroid into great veins and heart.  JAMA.  1934; 102:1921-4.

2.    Graham A.  Malignant epithelial tumors with special reference to invasion of blood vessels.   Surg Gynecol Obstet. 1924; 39; 781-90.

3.    Koike E, et al. Brachiocephalic vein thrombus of papillary thyroid cancer: report of a case.  Surg Today 2002; 32(1): 59-62.

4.    Thomas S, Sawhney S, Kapur BM.   Case report: Bilateral massive internal jugular vein thrombosis in carcinoma of the thyroid: CT evaluation.  Clin Radiol. 1991; 43: 433-4.

5.    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(4):451-7.

6.    Puglionisi A, Picciocchi A, D'Ugo DM, Bruni V, Lemmo GM. Venous involvement by follicular carcinoma of the thyroid gland.  Ital J Surg Sci 1986;16(2):133-7.

7.    Onaran Y, et al.  Great cervical vein invasion of thyroid carcinoma.  Thyroid. 1998; 8: 59-61.

 

FIGURES:

Fig. 1. MRI  showing the lesion in the T8 vertebra  (Case 1).

Fig. 2. Thyroid gland with the adjacent segment of internal jugular vein containing an intraluminal tumor (Case 1).

Fig. 3. Segment of the internal jugular vein with the intraluminal tumor (Case 1).

Fig. 4. Thyroid gland with the adjacent segment of internal jugular vein containing an intraluminal tumor (Case 2).

Fig. 5. Segment of the internal jugular vein with the intraluminal tumor (Case 2).

 

 

 

Fig. 1. MRI  showing the lesion in the T8 vertebra  (Case 1).

 

 

 

 

Fig. 2. Thyroid gland with the adjacent segment of internal jugular vein containing an intraluminal tumor (Case 1).

 

 

 

Fig. 3. Segment of the internal jugular vein with the intraluminal tumor (Case 1).

 

 

 

 

 

 

 

 

 

 

 

 

Fig. 4. Thyroid gland with the adjacent segment of internal jugular vein containing an intraluminal tumor (Case 2).

 

 

 

 

 

 

 

 

 

Fig. 5. Segment of the internal jugular vein with the intraluminal tumor (Case 2).