Ann Thorac Surg 2009;87:1928-1930. doi:10.1016/j.athoracsur.2008.10.045
© 2009 The Society of Thoracic Surgeons
Case Reports
Unusual Metastasis of the Papillary Thyroid Adenocarcinoma
Soner Sanioglu, MDa,*,
Onur Sokullu, MDa,
Ayca Ozgen, MDa,
Deniz Demirci, MDb,
Murat Sargin, MDa,
Fuat Bilgen, MDa
a Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
b Department of Cardiology, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
Accepted for publication October 14, 2008.
* Address correspondence to Dr Sanioglu, Fenerbahce Mah. Fenerli Reis Sk, No. 5/2, Selamicesme, Kadikoy, 81030, 
stanbul (Email: sanioglu{at}gmail.com).
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Abstract
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Floating thrombus in the ascending aorta is rare and its association with papillary thyroid adenocarcinoma has not been documented. We report a case of a 64-year-old man who was referred to our emergency unit because of suspected type A aortic dissection. Computerized tomographic and transthoracic echocardiographic scans revealed a floating thrombus in the aneurysmatic ascending aorta. The thrombus was removed with the dilated aorta. Although the aortic wall was macroscopically normal, histologic examination revealed metastatic papillary adenocarcinoma.
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Introduction
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A floating thrombus in the ascending aorta represents an emergency situation, and it should be removed before major thromboembolic complications occur. It is rare and mostly associated with an atherosclerotic plaque [1, 2]; it is extremely rare in association with metastatic involvement of the aorta. We are not aware of previous descriptions.
A 64-year-old man receiving antibiotic therapy for an atypic pneumonia was admitted to another hospital because of progressive dyspnea and numbness of the right hand. The computerized tomographic scan demonstrated an image mimicking an intimal flap in the aneurysmatic ascending aorta, bilateral pneumonic infiltration, and pleural and pericardial effusion (Fig 1). He was referred with a suspected acute type A aortic dissection. The history of the patient was not typical for acute dissection. The patient has not complained of any acute severe chest or back pain. The right radial pulse was absent; others were palpable. Transthoracic echocardiography revealed massive pericardial effusion and the intra-aortic, mobile, pedunculated mass. The mass was attached to the right side of the posterior aortic wall and it was located 4 cm away from the aortic valve (Fig 2). A computerized tomographic scan of the patient was re-evaluated through our radiology department, and an intraluminal mass was confirmed. The patient was immediately taken to the operating room.
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Fig 1. Preoperative computed tomographic scan demonstrated an image mimicking an intimal flap in the aneurysmatic ascending aorta and massive pericardial effusion.
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Fig 2. Transthoracic echocardiographic view showed an intra-aortic mass attached to the posterior wall.
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At median sternotomy, a large hemorrhagic pericardial effusion was found. Bypass with moderate hypothermia was initiated using the right atrium and right axillary artery for vascular access. The ascending aorta was clamped below the innominate artery and proximally opened. The thrombus was attached to the posterior aortic wall (Fig 3); both were excised and replaced.
Although macroscopic analysis of the excised aortic segment was normal, microscopic analysis revealed metastatic papillary adenocarcinoma (Fig 4). Tumor cells were not isolated in the specimen of the pericadial fluid. Thyroid ultrasound was performed and a 20 x 15 mm sized, solid nodule was detected in the right lobe of the thyroid gland. Fine-needle aspiration biopsy revealed papillary adenocarcinoma. The patient was discharged from the hospital on postoperative day 12 for subsequent oncologic treatment.
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Fig 4. Microscopic views of the excised aortic tissue. (A) Intravascular tumor cells. (B) Immunohistochemical marker, ceratin (+) tumor cells.
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Comment
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Papillary adenocarcinoma is the most frequent neoplasic tumour of the thyroid gland. Frequent sites of metastasis are bone, lung, skin, brain, and kidney [3]. Massive invasion into the great veins of the neck and mediastinum has rarely been reported [4, 5]. As far as we know, metastasis of the ascending aorta has not been previously described.
Improvements in imaging technology, such as computerized tomographic scanning, are usually sensitive and specific; however, false positive results are occasionally encountered. Firstenberg and colleagues [6] advocate that diagnosis must be supported by at least one different confirmatory study. The preoperative computerized tomographic scan initally led to misdiagnosis in this case, but careful evaluation of the history and transthoracic echocardiographic scan provided a precise diagnosis. Careful preoperative evaluation is essential, not only for accurate diagnosis, but also for planing optimal surgery. In this case, unnecessary hypothermic circulatory arrest was avoided.
Strauch and colleagues [7] recommend using axillary cannulation routinely in aortic surgery. But in this case, the right radial pulse was missing prior to surgery and axillary cannulation might be disadvantageous. However, we were concerned that femoral artery cannulation may increase embolic complications in this instance. For these reasons, we preferred axillary cannulation, and we did not detect any signs of ischemia on the right hand after the surgery.
Aortic intraluminal masses usually consist of thrombus. The main causing factors of thrombotic masses are generalized hypercoagulation, vascular endothelial disorders, or catheter-induced injuries [8]. The present report suggests that metastatic invasion of the aorta can lead to intraluminal thrombotic mass, and occult malignacy should be suspected and investigated.
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References
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- Strauch JT, Spielvogel D, Lauten A, et al. Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement Ann Thorac Surg 2004;78:103-108.[Abstract/Free Full Text]
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Abstract
Introduction
