Thyroid carcinoma with extensive tumor thrombus in the atrium

To our knowledge, only a few cases of thyroid carcinoma with an extensive tumor thrombus in the atrium have been reported in literature. We describe a unique case of papillary carcinoma of the thyroid with extensive tumor thrombus in the atrium. A 74-year-old man consulted our hospital because of thyroid carcinoma with an extensive tumor thrombus in the atrium. Computed tomography (CT) revealed a 2-cm tumor with extensive continuous tumor thrombus in the left jugular vein, innominate vein, superior vena cava, and atrium. The tumor was resected to reduce the risk of sudden death from tumor embolism into the pulmonary arteries. Histologically, the diagnosis was papillary carcinoma of the thyroid. Thyroid carcinoma, especially papillary carcinoma, rarely develops a macroscopic tumor thrombus. Patients with an extensive tumor thrombus generally have poor prognoses and high mortality. This patient has been followed for 7 months after successful operation without recurrence.     

Renal cell carcinoma with tumor thrombus: is cytoreductive nephrectomy for advanced disease associated with an increased complication rate?

PURPOSE: We examined whether cytoreductive nephrectomy in patients with venous tumor thrombus and metastatic disease is associated with more complications than in those with thrombus without metastatic disease. MATERIALS AND METHODS: Between 1989 and 2000, 74 patients with renal vein extension, 87 with inferior vena caval extension and 491 without tumor thrombus underwent nephrectomy at our institution. Metastatic and nonmetastatic renal vein extension in 51 and 23 cases, inferior vena caval extension in 54 and 33, and nontumor thrombus in 171 and 320, respectively, were compared for symptoms at presentation, surgical data, mortality and complications. RESULTS: For nonmetastatic and metastatic inferior vena caval extension presenting symptoms, hospital stay, surgical time and the number of patients undergoing thoraco-abdominal incision, lymph node dissection, venacavotomy alone for thrombus and adrenal sparing surgery were similar. Five patients with thrombus died intraoperatively or postoperatively, including 3.1% with and 0.8% without thrombus (p = 0.03), while 3 had metastatic (2.3%) and 2 (2.6%) had nonmetastatic disease. The rate of postoperative complications was higher in thrombus cases overall but there was no difference in nonmetastatic and metastatic disease with thrombus. On multivariate analysis inferior vena caval thrombus (odds ratio 10.5), adjacent organ resection due to locally advanced tumor (odds ratio 6), partial nephrectomy (odds ratio 3.8), regional lymph node involvement (odds ratio 1.7) and lower preoperative hemoglobin (odds ratio 1.6) were independent variables predicting bleeding requiring transfusion. Inferior vena caval thrombus (odds ratio 1.7) and adjacent organ resection (odds ratio 2) were also associated with nonhemorrhagic complications. Systemic metastasis was not an independent risk factor in either analysis. CONCLUSIONS: To our knowledge there are no published data comparing surgical complications in patients with metastatic and nonmetastatic renal cell carcinoma who have gross tumor thrombus. Cytoreductive surgery in patients with thrombus and metastasis is not associated with an increase in the extent of surgery, morbidity or mortality compared with their counterparts with nonmetastatic disease.     

Insular carcinoma of the thyroid with jugular vein invasion

BACKGROUND: Gross angioinvasion with intraluminal tumor thrombus is rarely seen in thyroid cancer, with few cases reported in the literature. METHODS: We report an insular carcinoma of the thyroid displaying this aggressive local invasion and angioinvasion of the internal jugular chain. Complete surgical removal of the intraluminal disease, regional metastasis, and primary tumor was carried out. RESULTS: Adjuvant external beam radiation therapy and iodine-131 were administered, and the patient died with pulmonary metastases 30 months after surgery. No locoregional recurrence was noted at last follow-up. CONCLUSIONS: Treatment of insular carcinoma of the thyroid with invasion of the internal jugular vein is amenable to surgical resection. Postoperative radioactive iodine and external beam radiotherapy can achieve locoregional disease control and prolonged survival.     

甲状腺恶性肿瘤并发颈内静脉瘤栓2例并文献复习

目的 探讨甲状腺肿瘤并发颈静脉瘤栓病人的临床特征及诊治方式。方法 检索2000年 1月至2018年10月国内期刊发表的关于甲状腺肿瘤并发颈静脉瘤栓病人的个案报道,并结合贵州省人民医院血管甲状腺外科收治的2例病人病例资料,分析病人的临床特征及其治疗方案。结果 文献检索获得相关文献10篇,包括23例病人。25例病人中男14例,女11例,年龄44~84（62.9±9.8）岁,瘤栓同侧的甲状腺肿瘤最大径在2.8~8.0 cm。全组病人瘤栓长度在1~30 cm,19例病人中血管内蔓延型瘤栓14例,直接侵犯型瘤栓5例。全组病人肿瘤病理学类型中甲状腺乳头状癌4例,滤泡状癌6例,低分化癌5例,未分化癌8例,肌源性低度恶性肉瘤及硬化性上皮样纤维肉瘤各1例。13例病人中9例病人行颈内静脉切除,4例病人行颈静脉切开取栓术。结论 甲状腺肿瘤并发颈静脉瘤栓病人多为血管侵袭能力极强的肿瘤,病人远期预后很差,应积极采取手术治疗去除瘤栓,改善病人的预后。     

Laparoscopic radical adrenalectomy with adrenal vein tumor thrombectomy: technical considerations

PURPOSE: We describe the technique of adrenal vein tumor thrombectomy during laparoscopic radical adrenalectomy for cancer. MATERIALS AND METHODS: During laparoscopic adrenalectomy for a heterogeneous 7 cm left adrenal mass an adrenal vein thrombus was detected intraoperatively. Laparoscopic ultrasonography was used to delineate precisely the tumor thrombus and its extension into the left main renal vein. The left renal artery and vein were transiently controlled with atraumatic vascular clamps. The renal vein was incised and the intact tumor thrombus was removed en bloc with the radical adrenalectomy specimen. The renal vein was suture repaired with 4-zero prolene and the kidney was revascularized. RESULTS: Renal warm ischemia time was 21 minutes, blood loss was 300 cc and operative time was 6.2 hours. Pathological evaluation revealed a 7.5 cm 68 gm adrenal cortical cancer with tumor thrombus. Soft tissue and adrenal vein margins were negative for cancer. CONCLUSIONS: Laparoscopic radical adrenalectomy with en bloc adrenal vein tumor thrombectomy can be exclusively performed intracorporeally, while respecting oncological principles. Essential technical steps include wide margin excision of the adrenal gland, intraoperative ultrasonography, renal vascular control, en bloc tumor thrombectomy and renal venous suture repair in a bloodless field.     

肾癌并静脉癌栓的影像学诊断与手术方法选择

目的：探讨肾癌并静脉癌栓的影像学诊断与治疗及方法的选择。方法：回顾性分析我科收治的肾癌伴静脉癌栓患者21例的临床资料。结果：MRI精确地诊断出癌栓的范围；20例肾癌根治性切除加癌栓取出术的患者取得了满意的效果。结论：MRI可替代创伤性大、不良反应多的下腔静脉造影，用于确诊肾癌并静脉癌栓；应依据癌栓的类型选择手术方法。     

Surgical Approach to Tumor Thrombus of Renal Cell Carcinoma at the Level between Hepatic Vein and Diaphragm

Background The curative resection of tumor thrombus of renal cell carcinoma often provides a good prognosis, but the best surgical method for resection at the level between hepatic vein and diaphragm is still a matter of controversy.
Methods We performed transabdominal surgery without cardio-pulmonary bypass on 4 patients with tumor thrombus at the level between hepatic vein and diaphragm. The surgical procedures were as follows: The right lobe of the liver was separated and detached from the retroperitoneum, and then the vena cava was clamped just below the diaphragm simultaneous with clamping the porta hepatis. After complete circulatory isolation of the vena cava, the tumor thrombus was resected. Results: There were no severe complications postoperatively. Two patients died of cancer 18 and 38 months after surgery, and the other 2 are alive without evidence of disease after 62 and 66 months. Conclusion: This anatomically rational approach is thought to be a good alternative to the pull-through method or cardio-pulmonary bypass for removing a tumor thrombus at this level.     

Portal vein tumor thrombus from colorectal cancer with no definite metastatic nodules in liver parenchyma

Portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) is a common entity. In colorectal liver metastasis, microscopic tumor invasion into the intrahepatic portal vein is also usually observed, but the incidence of macroscopic tumor thrombus in the first branch and trunk of the portal vein is rare. Most reported cases of PVTT from colorectal cancer had concomitant metastatic nodules in liver parenchyma, and the PVTT was continuous with the liver nodule, like PVTT in HCC. We present a case of PVTT from colorectal cancer with no definite metastatic nodules in liver parenchyma. A 58-year old man underwent laparoscopic high anterior resection for rectosigmoid carcinoma accompanied by bulky tumor thrombus in the branch of the inferior mesenteric vein. Six months later, he received left lobectomy and left caudate resection for liver metastasis. The resected specimen demonstrated there was no metastatic nodule in liver parenchyma and that the left portal system was filled with the tumor thrombus. The patient is alive with no sign of recurrence 66 months after hepatectomy. Even if there is a macroscopic PVTT from colorectal cancer, a better prognosis may be expected when the tumor can be completely resected en-bloc by anatomic hepatectomy including PVTT.     

A case report of retroaortic left renal vein with tumor thrombus of renal cell carcinoma

A 75-year-old woman was referred to our department for evaluation of a left renal tumor. Computed tomography and other imaging studies demonstrated a left renal mass and tumor extension into the left renal vein passing caudally behind the aorta. We clinically diagnosed the tumor as renal cell carcinoma (RCC) associated with a retroaortic left renal vein thrombus, and performed a radical nephrectomy. Pathological examination of the surgical specimen showed a grade 2, clear cell carcinoma with a renal vein thrombus and negative surgical margin. Retroaortic left renal vein is a rare anomaly with a prevalence of 1.8–2.4%. RCC associated with a retroaortic left renal vein thrombus is rarer still. To our knowledge, this is only the third case report to describe an RCC associated with a tumor thrombus in the retroaortic left renal vein.     

Thymic carcinoma with tumor thrombus into the superior vena cava

Tumor thrombus into the vena cava have been reported in cases with renal cell carcinoma, thyroid tumor and in those with thymoma. These tumors are frequently invasive and continuous from the main tumor that shows direct vessel wall invasion. Here, we report a case of thymic carcinoma with superior vena cava syndrome, which was caused by a tumor thrombus in the superior vena cava without vessel wall invasion. The main mediastinal tumor did not show innominate vein invasion, and the superior vena cava syndrome was a result of separate tumor thrombus that was free of vessel wall invasion. The tumor thrombus could be removed through a simple venotomy. To prevent stenosis in the superior vena cava and the left innominate vein, we used a pericardial patch to close the venotomy site.     

甲状腺癌累及气管、喉及重要血管处理策略

侵犯周围器官结构的甲状腺癌的外科治疗对于医师仍是挑战。气管和喉是常见的受累器官，彻底切除仍能带来最大的生存获益。但术后生活质量可能受较大影响，因此可以通过Ⅰ期或Ⅱ期修复尽可能提高病人生活质量。甲状腺乳头状癌侵犯颈内静脉或颈内静脉瘤栓病例仍可比较安全地彻底切除。部分颈总动脉受侵病例可以尝试彻底切除，应同期请血管外科进行血管重建。局部晚期甲状腺癌应强调综合治疗。术后应考虑放射性碘治疗、外照射放疗、内分泌治疗等辅助治疗，以期减少局部复发。对于部分无法手术的病人可考虑参加临床研究或尝试靶向治疗，延缓肿瘤进展。一般状况不佳的病人可给予姑息治疗，目的是减轻病人症状。     

Renal pelvic cancer with tumor thrombus in the vena cava inferior: a case report

We report a case of right renal pelvic cancer with tumor thrombus in the inferior vena cava. A 65-year-old man with right flank abdominal pain and high fever was reffered to our hospital. Computed tomography showed right renal mass. Magnetic resonance imaging revealed tumor thrombus extending into the renal vein and the inferior vena cava. Preoperative diagnosis was renal cell carcinoma with vena caval thrombus. Radical nephrectomy with thrombectomy and lymphodenectomy was performed. Pathologic evaluation revealed transitional cell carcinoma with tumor thrombus into the vena cava. One course of M-VAC chemotherapy was added and he has been alive for 56 months without recurrence. A literature review of 15 cases of renal pelvic cancer with tumor thrombus in the vena cava in Japan revealed that 7 cases were diagnosed as renal cell carcinoma preoperatively.     

原发性肝癌合并癌栓的研究进展

原发性肝癌是由肝细胞或胆管细胞异常增生、分化所形成的恶性肿瘤。影响原发性肝癌预后的一个重要因素是癌栓的形成,所以充分认识癌栓（包括门静脉癌栓和胆管癌栓）对临床的治疗及判断预后尤为重要。笔者就原发性肝癌合并癌栓的研究进展进行综述。     

Clinical study of operative therapy for renal cell carcinoma. 2. Intravenous tumor thrombectomy

Twenty-eight patients with a tumor thrombus 914 in the inferior vena cava and 14 in the renal vein), among a series of 170 renal cell carcinoma patients receiving hospital treatment at the Gunma University during the period from 1961 to 1989, were explored for clinical features, with the results leading to the following conclusions: 1) There were 19 male and 9 female with respective mean ages of 62.1 and 54.4 years. 2) The disease was right-sided in 16 patients and left-sided in the other 12, but there were no striking left-to-right difference in tumor location. 3) The most frequent chief complaint was symptoms arising from the urinary tract. Among symptoms and sings occlusion of the inferior vena cava or renal vein, proteinuria was most frequent, being present in 56% of patients with clinical evidence of occlusion, followed by tortuosity of veins of the abdominal wall and edema in the lower extremities noted in 3 patients. 4) Selective renal arteriography demonstrated tumor hypervascularity in all 22 patients (except for one with a hypovascular tumor mass) and A-V shunt at a high percentage. Profuse striated vascular pattern representing arterialization of an extensive tumor thrombus was also noted, particularly with intra-caval involvement. Venacavography demonstrated neoplastic thrombi in the inferior vena cava as filling defects, thus proving the diagnosis. CT also provided diagnostic evidence of a tumor thrombus in all cases except for one in which it failed to detect a tumor thrombus in the renal vein preoperatively, with an accurate diagnosis rate of 100% for intra-caval tumor thrombi and 83% for tumor thrombi in the renal vein.(ABSTRACT TRUNCATED AT 250 WORDS)     

An Obstructed Venous Aneurysm Presenting as an Abdominal Mass: Report of a Case

We report herein the case of a 32-year-old woman found to have a venous aneurysm originating from the ovarian vein. The patient presented with a 9-cm abdominal tumor, and surgery was performed under the preoperative diagnosis of a mesenteric cyst. The tumor was easily ablated from the mesentery and resected with the right ovarian artery and vein. His-tologically, the wall of the cyst showed the structure of a vein, and the diagnosis of a venous aneurysm was made. This disease is difficult to diagnose preoperatively when a patient presents with no symptoms other than a palpable mass, or when the lumen is obstructed by thrombus. This report serves to demonstrate that a venous aneurysm should be considered in the differential diagnosis of an asymptomatic abdominal mass. Received: December 20, 1999 / Accepted: November 20, 2000     

A contemporary evaluation of cytoreductive nephrectomy with tumor thrombus: Morbidity and long-term survival

BACKGROUND: Metastatic renal cell carcinoma (RCC) is an aggressive entity that frequently invades the venous system. We evaluated the morbidity and survival of patients with tumor thrombus who undergo cytoreductive nephrectomy. MATERIALS AND METHODS: We identified 56 patients from our institution's database who had a primary renal tumor in place and documented metastases at the time of surgery. We reviewed demographic and pathologic characteristics from these patients as well as complications and overall survival. RESULTS: Median age was 58 (37-77). There were 33 patients (59%) who had tumor thrombus with 21 (64%) involving the renal vein, 10 (30%) involving the infradiaphragmatic inferior vena cava (IVC), and 2 (6%) involving the supradiaphragmatic IVC. Median tumor size for thrombus patients was 12 cm (5-29). There were 8 (14.2%) who had complications, including 1 death. Thrombus patients were significantly more likely to have a complication (P = 0.008). Median survival for all patients was 10.7 months (0.3-61). There was no significant difference in overall survival between patients with and without thrombus (P = 0.76). CONCLUSIONS: Patients who undergo cytoreductive nephrectomy with a tumor thrombus have a higher rate of complications as compared to patients undergoing cytoreductive nephrectomy without tumor thrombus. The long-term survival, however, was not statistically different and thus aggressive surgery for select metastatic RCC patients is warranted.     

Initial division of the left renal vein before dissection of left renal vein occluded by intracaval tumor thrombus

Between November 2008 and March 2010, we performed initial division of the left renal vein occluded by the tumor thrombus in six cases of left renal cancer at Toranomon Hospital. The left renal vein was completely occluded by the tumor thrombus in all cases. In order to ligate the left renal artery first behind the dilated left renal vein, we must dissect the left kidney with arterial blood flow. Massive bleeding from the numerous engorged collateral veins around the left kidney is inevitable. Furthermore, access to the left renal artery is difficult because of the large tumor. We therefore initially divided the left renal vein without arterial blood flow followed by division of the left renal artery. After nephrectomy by dissecting the tumor without blood flow we extirpated the intracaval tumor thrombus. The median time of the operation was 7 hours 35 minutes and the median amount of blood loss was 2,869 ml. The tumor stage was pT3b in four cases and pT3c in two cases. No complications were observed during and after surgery except for one case of lymphocele and another case of chylous ascites. The initial division of the left renal vein is considered to be a useful surgical approach in left renal cancer with occluded left renal vein, especially when the tumor is large.     

Resected acinar cell carcinoma of the pancreas with tumor thrombus extending into the main portal vein: Report of a case

The incidence of acinar cell carcinoma has been reported to be about 1% of all pancreatic neoplasms, and pancreatic cancer combined with tumor growth extending into the portal vein is a rare condition. We herein report a case of acinar cell carcinoma of the pancreas with a tumor thrombus extending into the main portal trunk. Preoperative imaging of the portal vein, consisting of computed tomography (CT), magnetic resonance imaging (MRI), and angiography, revealed an oval shadow defect in the main portal trunk along with an irregular mass in the pancreatic head. At operation, we confirmed a tumor thrombus extending from a tumor in the pancreatic head into the main portal trunk via the pancreatoduodenal veins. A pancreatoduodenectomy combined with partial resection of the portal vein was thus performed under a temporary portal vein shunt from the ileocecal vein to the umbilical vein. Immunohistochemical examination for ₁-antichimotrypsin and electron microscopic examination confirmed the diagnosis of acinar cell carcinoma of the pancreas with a tumor thrombus in the portal vein. Surgical excision combined with portal vein resection may therefore improve the prognosis of selected patients with portal tumor thrombus.     

Intraatrial extension of thyroid cancer: technique and results of a radical surgical approach

An occlusion of the superior vena cava by a tumor thrombus extending into the right atrium was diagnosed in three patients with a follicular thyroid cancer. All patients showed the typical clinical picture of the superior vena cava syndrome. A right parasternal thoracotomy was performed for preparation of the major vessels. The superior vena cava was opened and the entire intravascular tumor thrombus was removed. The cavotomy was closed directly in two patients. In the third patient the left brachiocephalic trunk was resected and reconstructed with a vascular (polytetrafluoroethylene) graft. This patient had bone and brain metastases and an occlusion of the graft 3 months after surgery after anticoagulation was stopped. The other two patients were clinically symptom free without local recurrence 13 and 50 months after surgery. An aggressive surgical approach is justified in grossly invasive thyroid cancer to decrease local recurrence and death rates, to correct the disturbing clinical symptoms of superior vena caval occlusion, and to prevent tumor embolism and the development of distant metastases. By reducing tumor mass, an even better basis for radioiodine treatment can be prepared.