Venous obstruction of thyroid malignancy origin: the Antoine Lacassagne Institute experience
© Marcy et al; licensee BioMed Central Ltd. 2009
Received: 17 February 2009
Accepted: 17 April 2009
Published: 17 April 2009
Background and aims
To show the benefits of Ultrasonography in the diagnosis of great vein involvement in the neck and mediastinum in thyroid malignancies (primary or secondary) in our experience and to report patient outcomes.
Clinical data were collected from the thyroid unit database of the Antoine Lacassagne Institute.
Of 1171 patients with thyroid cancer treated at our institution over the last 18 years, we retrospectively identified nine patients (0.8%), three women and six men, aged 34–81 years (median age: 70 years) presenting with malignant thyroid tumor of median diameter 45 mm (range: 23–87) having venous obstruction of thyroid malignancy origin. Two patients underwent multimodal therapy. All other patients underwent external beam radiation therapy alone ± chemotherapy or palliative care. Ultrasound (US) provided particularly useful information on venous involvement characteristics. Median survival was 7 months and median progression-free survival was 6 months. Survival in our series was worse than that of previously reported series despite diagnosis of vein involvement at an early stage in 2/3 cases using US.
Despite small numbers of patients, it seems that aggressive treatment modalities including surgery are required to improve survival. In our experience, US was a useful non-invasive method to describe tumor extensions to great veins of the neck (invasion versus compression, tumor thrombus versus blood clot) and should be recommended to depict early venous invasion in cases of suspected thyroid malignancy.
Superior vena cava (SVC) obstruction is associated with lung cancer, malignant lymphoma and mediastinal metastases. In less than 1% of the cases, SVC syndrome (SVCS) is due to massive invasion into the great veins or compression of the SVC by a thyroid cancer . Only 29 cases have been reported in the literature so far. We hereby report on the Antoine Lacassagne Institute's experience and provide additional data on neck Ultrasonography (US) and patient outcomes in our series, in which most of patients could not undergo curative treatment. Clinical features, tumor size, histological types, and outcomes to therapy are presented.
Materials and methods
From 1991 to 2008, clinical and radiological data were collected from the thyroid unit database of the Antoine Lacassagne Institute. All patients had vein assessment on systematic Doppler US of the neck at initial diagnosis work-up and follow-up, and cross-sectional imaging scans to assess tumor extensions.
Cases of great vein involvement by thyroid malignancy at the Antoine Lacassagne Institute since 1991
(Case) TNM stage
Gender Age (years)
Status at Diagnosis
Histology Lobar tumor Size (mm)
Vein Involvement (Imaging)
Progression-Free Survival (months)
IJV, SCV, BCV
IJV, BCV, SVC, RA (CT, US)
IJV, BCV, SVC
EBRT + 131I
S * +
IJV resection + 131I
Arm § neck swelling
TNM staging for thyroid cancer
T: Primary tumor
All categories must be divided: (A) solitary, (b) multifocal tumor (the largest determines the classification).
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
T1: Tumor ≤ 2 cm (greatest dimension)
T2: 2 cm < Tumor ≤ 4 cm (greatest dimension, limited to thyroid)
T3: Tumor > 4 cm or minimal extrathyroid invasion (eg. Extension to extrathyroid muscle and perithyroid soft tissue)
T4a: Macroscopic invasion of adipose tissue, larynx, trachea, esophagus or recurrent laryngeal nerve
T4b: Macroscopic invasion of prevertebral fascia, carotids, or mediastinal vessels
All anaplastic carcinomas are considered T4 tumors
T4a: Intrathyroid anaplastic carcinoma-surgically resectable
T4b: Extrathyroidal anaplastic carcinoma-surgically unresectable
N: Regional Lymph Nodes
Regional lymph nodes are the central compartment, lateral cervical, and upper mediastinal lymph nodes
Nx: Lymph node status is unknown
N0: No lymph node invasion
N1a: Metastasis to level VI (recurrent nerve, pretracheal, paratracheal, prelaryngeal lymph nodes)
N1b: Other lymphatic invasion (lateral-cervical and/or mediastinal)
M: Distant Metastasis
Mx: Metastasic status is unknown
M0: No metastasis
M1: Distant Metastasis
Separate stage groupings are recommended for papillary or follicular, medullary, and anaplastic (undifferentiated) carcinoma.
Papillary or Follicular Carcinomas
< 45 years
≥ 45 years
Any T, any N, M0
T1, N0, M0
Any T, any N, M1
T2, N0, M0
T3, N0, M0
T1-3, N1a, M0
T1-3, N1b, M0-1
T4a, N0-1a, M0
T1-4a, N1b, M0
T4b, Any N, M0
Any T, Any N, M1
T1, N0, M0
T2, N0, M0
T3, N0, M0
T1-3, N1a, M0
T4a, N0-1a, M0
T1-4a, N1b, M0
T4b, Any N, M0
Any T, Any N, M1
T4a, Any N, M0
T4 b, Any N, M0
Any T, Any N, M1
Venous involvement of thyroid tumors is rare and can be assessed by conventional cross-sectional imaging techniques namely magnetic resonance imaging (MRI) and multi-detector computed tomography (MDCT). Sagittal, coronal and 3D reconstructions along the long axis of the jugular and cava veins may be helpful to define the location, extent and nature (compression or invasion) of SVCS in cervical tumors. Nevertheless, a small thrombus may be missed with contrast-enhanced CT due to partial volume effect. Furthermore, metallic clips or patient swallowing artifacts may lead to misdiagnosis on MRI. High-frequency Doppler US is highly sensitive for thrombus detection in the neck veins since the vein has clear acoustic windows. Thus, at our institution, US has long been the imaging modality of choice for the diagnosis and follow-up of malignant thyroid nodules [2, 3]. Doppler US was performed with Valsalva's maneuver in Trendelenburg's position. Such maneuvers increase the jugular vein's (and tributaries') diameter to differentiate between venous invasion and a strong tumor compression of the cervical vein. Even a small echogenic thrombus can be seen in the venous lumen and it can originate from either efferent thyroid veins such as in cases 6, 8, 9 or from extra-capsular tumor/malignant node spread (Fig 3). Cervical US showed venous thrombus in three asymptomatic patients (cases 6, 8, 9), revealed venous extension in three patients presenting with arm/neck swelling (cases 4, 5, 7) and confirmed superior vena cava syndrome in the remaining three patients (cases 1–3). Not only can cervical Doppler US show vein thrombosis but also its tumoral nature in showing a vascular arterialized invasive thrombus (Fig 3) . Contrary to Hyer et al's assertion, US is an effective screening technique at initial diagnosis work-up and follow-up of thyroid malignancy for the diagnosis of SVC (and tributaries) obstruction despite the presence of nearby osseous structures and lung parenchyma . Firstly, combined diminished respiratory phasicity and cardiac pulsatility of subclavian and jugular vein Doppler waveforms predict SVC obstruction with sensitivity, specificity, positive and negative predictive values of 75%, 100%, 91%, 100%, respectively . Secondly, para-sternal Doppler US of internal thoracic veins is also sensitive to assess bloodstream within the SVC . Thirdly, the use of an "endocavitary" US probe at the patient suprasternal notch, directed toward his upper mediastinum allows for clear depiction of the brachiocephalic veins, SVC flow and mediastinal compression (Fig 2A, B).
According to our experience, patients may present with various symptoms ranging from no symptoms, ipsilateral arm/neck swelling to typical SVC syndrome (one third each in our experience). Gross venous invasion is probably underdiagnosed in the routine practice: it has been reported in up to 1.5% of papillary cancers only . Venous invasion is a poor prognosis factor in follicular neoplasms . It is rather common in anaplastic carcinomas while even bulky cervical lymphoma never display jugular vein invasion . Regarding the last two cases, thyroid masses were strongly hypervascular and invaded the ipsilateral IJV, thus mimicking a primary thyroid tumor. Noteworthy, clear cell renal primary tumors exhibit a venous tropism, leading to inferior vena cava thrombus extension. Thyroid metastases of renal origin behave like primary thyroid tumors and show a propensity to invade the internal jugular vein via the middle and superior thyroid veins (Fig 3B) . Since the clinical presentation may be vague or misleading, we therefore highly recommend early neck US to prevent potential lethal complications such as pulmonary embolism or intracranial/intracardiac propagation of the thrombus (Figure 1A). We think that the low median survival in our study was mostly due to advanced stage diseases including aggressive primary thyroid malignancies contraindicated for surgery. Contraindication to surgical excision at our institution included thyroid cancer staged T4b (cases 1, 2), local recurrence and concomitant metastases, and diffuse metastases from renal cancer. Tracheal invasion was also considered a surgical contraindication at the time these patients were diagnosed with thyroid cancer, especially also as these patients were poorly-differentiated and/or metastatic cancers.
Doppler US is a useful tool for the diagnosis of cervical venous invasion and extension to the central veins at initial work-up and during follow-up of thyroid malignancies, namely in asymptomatic patients or in patients presenting with arm and/or neck swelling (2/3 of patients). According to Hyer's study and our personal results and despite the small size of the series, it raises the question of whether more aggressive treatment modalities including surgery should be recommended in association with EBRT and radioiodine to prolong survival. Such question may be optimally answered with data from a large national registry.
For patients with a history of renal cell carcinoma, thyroid metastases should be ruled out.
Magnetic Resonance Imaging
MultiDetector Computed Tomography
High Frequency Doppler Ultrasonography
External Beam Radiation Therapy
Internal Jugular Vein
External Jugular Vein
Superior Vena Cava Syndrome
Clear Cell renal Carcinoma-Mets Distant diffuse metastases
Dead Of Disease
Alive Without Disease
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