Middle thyroid vein tumor thrombus in metastatic papillary thyroid microcarcinoma:A case report and review of literature

lNTRODUCTlON

Papillary thyroid microcarcinoma (PTMC) is a variant of papillary thyroid carcinoma (PTC) that is defined by the World Health Organization as less than or equal to 1 cm in diameter[1]. Although PTMC is not considered a threatening tumor, in some cases, it can be aggressive. Metastatic thrombosis of PTC, follicular thyroid carcinoma (FTC), Hürthle cell carcinoma (HCC), poorly differentiated thyroid carcinoma (PDTC) and anaplastic thyroid carcinoma (ATC) have been reported in the literature, but there have been no reports about PTMC. We report the case of a 45-year-old woman with a middle thyroid vein thrombus. She underwent successful resection, and postoperative pathology showed papillary microcarcinoma of the left thyroid and a tumor thrombus in the middle thyroid vein. We reviewed the literature to identify reports of tumor thrombus and distant metastasis of PTMC.

CASE PRESENTATlON

Chief complaints

A 45-year-old woman presented with a thyroid mass (Figure 1) and thrombosis (Figure 2) in a middle thyroid vein during a physical examination.

History of present illness

The patient came to hospital because of thyroid mass found in physical examination 3 mo before. She had no symptoms. The patient requested surgery because of the stress.

History of past illness

The patient was health in the past.

Personal and family history

The patient had no family history of thyroid carcinoma and no history of radiation exposure in childhood.

Physical examination

The physical examination showed no positive signs.

Laboratory examinations

Gui Y is responsible for reviewing literature and writing article; Wang JY is responsible for surgery and collecting clinical data; Wei XD is responsible for providing overall thinking.

Imaging examinations

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Ultrasonography-guided fine-needle aspiration biopsy

Subsequent ultrasonography-guided fine-needle aspiration biopsy results indicated an atypical lesion of ambiguous significance, with some actively growing cells (TBSRTC III) and the BRAFmutation not present.

FlNAL DlAGNOSlS

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TREATMENT

The patient and her family were fully informed of the advantages and disadvantages of total thyroidectomy and lobectomy prior to surgery. The patient declined to undergo a total thyroidectomy. Intraoperative exploration showed that the mass was located in the middle and upper left lobe of the thyroid gland, adjacent to the capsule, but the capsule was not invaded. There was a round mass in the middle thyroid vein with a diameter of 0.8 cm. The middle thyroid vein was ligated distal to the mass and cut off. Rapid freezing pathological examination showed that both the left thyroid mass and the left middle thyroid vein mass were carcinomas. These results were communicated to the patient’s family, and total thyroidectomy was again declined. Therefore, the patient underwent left thyroidectomy, isthmus lobectomy and prophylactic central lymph node dissection. Postoperative pathology showed papillary microcarcinoma of the left thyroid (single lesion, maximum diameter of 0.9 cm) (Figure 3), and the thrombus in the middle thyroid vein was a tumor (diameter of 0.6 cm) (Figure 4).

PTMC (pT1aN0M?). Middle thyroid vein tumor thrombus.

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OUTCOME AND FOLLOW-UP

No metastases were observed in the central lymph nodes. Initial TSH suppression was treated with 75 μg levothyroxine. Three months later,F-FDG positron emission tomography-computed tomography scanning did not detect local recurrence or distant metastasis (Figure 5). No complications occurred. Fearing recurrence and metastasis, the patient underwent genetic testing at a third-party testing facility. No genetic variation was detected in BRAF, BRAF, TERT, ΚRAS, NRAS, EIFIAX or RET. No gene fusion mutations were detected in PAX8/PPARγ, RET/PTC1, or RET/PTC3. Six months after surgery, the patient had no obvious discomfort, and no tumor recurrence or distant metastasis was observed. The patient took 50 μg levothyroxine once daily, and the serum TSH was 0.49 mIU/L.

DlSCUSSlON

In terms of treatment for tumor thrombi in metastatic PTMC, there is also no standard. Treatments include surgery, RAI therapy, external beam radiation therapy and chemotherapy. Most patients choose surgery combined with radioiodine therapy. Κavanal[41] reported thatI therapy as a single modality may be considered for a subset of patients who have been rigorously screened. If the pathologic type is PDTC with no surgical opportunity and refractory to radioactive iodine, targeted therapy such as tyrosine kinase inhibitors may be another choice for this subset of patients[42].

Pathological types included PTC, FTC, HCC, ATC and PDTC. Ten of these cases were PTC (one of the follicular variants of PTC, FVPTC), 24 were FTC, 3 were HCC, 1 was PDTC, 5 were ATC, 1 was ATC with HCC and 3 were not described in the literature. Most of these case reports did not describe the size of the thyroid lesion. From the 12 cases with size data available, the maximum diameter of the lesions ranged from 2 cm to 17 cm (the average was 6.6 ± 5.2 cm). Our patient had PTMC (the maximum diameter was 0.8 cm), which had not been previously reported. Middle thyroid vein tumor thrombus in metastatic PTMC is extremely rare. It is necessary to consider how to perform TNM staging for such cases. Κawano[34] suggested setting management criteria. Unfortunately, there are still no related standards or guidelines for such criteria. Here, we emphasize the importance of aggressive treatment and close follow-up for these patients. Tumor cells are exposed to the circulatory system in this clinical presentation, and embolus shedding may also cause serious complications, such as pulmonary embolism. While there is a lack of objective clinical data to support this hypothesis, we will continue to monitor future occurrences.

Thyroid carcinoma that causes tumor thrombus is rare. Forty-seven cases have been reported in the English literature since May 1, 2021. The details of these cases are shown in Table 1. The patients included 12 males and 35 females; their ages ranged from 26 years to 84 years, and the median age was 62 years. The location of the thrombus included the brachiocephalic vein, internal jugular vein, superior vena cava, subclavian vein, innominate vein, middle cerebral artery, pulmonary vein, external jugular veins, axillary vein, right atrium, ascending aorta, pulmonary artery, valvular endocardium and right ventricle. In almost all cases, the thrombus was located in the large vessels. Our patient had a thrombus in the middle thyroid vein, which may represent early-stage disease. Early-stage diagnosis and treatment are of great significance to patient prognosis.

Overall, we have demonstrated a middle thyroid vein tumor thrombus in PTMC. Our patient will continue to attend follow-up appointments. In the absence of other risk factors, lobectomy and thromboembolectomy may be an option for patients with thrombi in the middle vein of the thyroid. We strongly suggest a close follow-up of these patients.

CONCLUSlON

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We thank the thyroid and neck tumor specialist, ultrasound specialist and pathologist of the Tianjin Medical University Cancer Institute and Hospital for their valuable help.

Laboratory tests showed that triiodothyronine, free triiodothyronine, thyroxine, thyroglobulin, and thyroid-stimulating hormone levels were within the normal limits.

Consent from the patient was obtained before publication.

As she got into the mortar the man dressed all in red, mounted on the blood-red horse, galloped like the wind around the corner of the hut, leaped the wall and was gone, and at that moment the sun rose

There are no conflicts of interest or funding to disclose concerning this case report.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

Middle thyroid vein tumor thrombus is an extremely rare condition in PTMC, but it does exist. Lobectomy and thromboembolectomy may be an option for patients with thrombi in the middle vein of the thyroid, and we strongly suggest close follow-up of these patients.

The young man was puzzled, and did not know what to reply, for, though he would gladly have married the princess without a sixpence, he had spent all his money in building the ship, and knew he could not give her all she wanted

A solid nodule in the left lobe of the thyroid by ultrasound examination. Ultrasound examination revealed a medially echoic mass in the middle thyroid vein.

China

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Yan Gui 0000-0002-8130-9143; Jun-Yi Wang 0000-0002-4720-6634; Xu-Dong Wei 0000-0002-8543-1875.

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