Ann Thorac Surg 2010;89:296-298. doi:10.1016/j.athoracsur.2009.02.084
© 2010 The Society of Thoracic Surgeons
Case Reports
Thyroid Cancer With a Cystic Mediastinal Tumor Invading the Right Main Bronchus
Ryuichi Suemitsu, MD, PhDa,*,
Sadanori Takeo, MD, PhDa,
Motoharu Hamatake, MD, PhDa,
Tomoya Yamamoto, MD, PhDb,
Kiyomi Furuya, MD, PhDc,
Seiya Momosaki, MD, PhDd
a Department of Thoracic Surgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
b Department of Otorhinolaryngology, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
c Department of Radiology, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
d Department of Pathology, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
Accepted for publication February 26, 2009.
* Address correspondence to Dr Suemitsu, Department of Thoracic Surgery, National Hospital Organization, Kyushu Medical Center, Jigyohama 1-chome, 8-1, Chuo-ku, Fukuoka City, 810-8563, Japan (Email: suemitsu{at}qmed.hosp.go.jp).
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Abstract
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A 55-year-old woman presented with hemosputum. She had noted thyroid swelling and computed tomography was performed by her family physician. The computed tomographic scan revealed a thyroid tumor and a mediastinal cyst connecting to the thyroid tumor. Fiberoptic bronchoscopy showed direct invasion to the right main bronchus. She was preoperatively diagnosed with thyroid cancer combined with a mediastinal tumor and underwent a thyroidectomy and mediastinal tumor resection. These tumors were adherent to the esophagus, trachea, superior vena cava, and azygos vein; however, the mediastinal cyst, despite the fact that it directly invaded the right main bronchus, showed no malignant cells.
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Introduction
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Thyroid cancer is a tumor of relatively good prognosis and survival [1, 2]. These tumors, especially papillary adenocarcinoma, produce a cystic mediastinal tumor, and malignant cells in this cyst occasionally escape because of changes in calcification and hyalinization. This report describes a huge cystic mediastinal tumor originating from thyroid cancer, which was aggressively adherent and had compressed the trachea, furthermore piercing through the right main bronchus.
A 55-year-old woman presented with a history of fever, cough, and hemosputum. She had a medical examination and underwent chest computed tomography by her family physician. A physical examination showed a moderately enlarged right lobe of the thyroid. Blood counts and serum chemistry including tumor markers and thyroid function were normal. A chest computed tomographic scan showed not only the thyroid tumor with calcification but also a mediastinal cyst and this mediastinal tumor was connected to the thyroid tumor (Fig 1A). She was admitted to the hospital for investigation and treatment of these tumors. Fiber optic bronchoscopy revealed the tumor was pressing against the trachea and carina; furthermore, the tumor directly invaded the right main bronchus (Fig 1B). Magnetic resonance imaging of sagittal slices revealed a cystic mediastinal tumor continued from the neck to the carina along with the trachea (Figs 1C and 1D). Fine-needle aspiration cytology of the thyroid gland in the neck showed a papillary carcinoma. Thereafter, the patient underwent a mediastinal tumor resection by the right posterolateral incision for the thoracotomy followed by the neck lateral incision for the thyroidectomy. The intrathoracic finding showed that the mediastinal tumor was adherent to the lung, trachea, and superior vena cava, and involved the azygos vein and the right main bronchus. The tumor continued to the neck without invasion to the carotid and subclavian arteries. A portion of the right main bronchus was repaired because of the direct invasion of the tumor, and the azygos vein was resected. However, no direct invasion to the trachea and superior vena cava was observed. The preoperative decision was that the thyroid and mediastinal tumors should not be resected simultaneously, so the mediastinal tumor was resected at the upper mediastinum near the neck. Next, the thyroidectomy findings revealed that the thyroid tumor was tightly adherent to the trachea and esophagus, and involved the right recurrent laryngeal nerve. The recurrent laryngeal nerve needed to be cut. The connection of the mediastinal tumor was at the posterior of the thyroid tumor, and the thyroid tumor including the end of the mediastinal tumor was resected (Fig 2A). All tumors were completely resected after they were divided into two components. Microscopic findings revealed that the thyroid gland showed a colloid goiter with foci of a follicular variant of papillary carcinoma (Fig 2B), and the mediastinal mass consisted of a fibrous capsule with calcification and necrotic debris inside. However, there was no malignancy in spite of the direct invasion to the right main bronchus. The patient made an uneventful recovery, except for hoarseness after the operation.
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Fig 1. (A) A chest computed tomographic scan showed a solid tumor of the right thyroid lobe and cystic disease of the left thyroid lobe. The tumor revealed calcification. The arrow shows the connection to the mediastinal tumor. (B) Fiber optic bronchoscopy finding shows the right upper bronchus (upper arrow) and the intermediate bronchus (lower arrow). A soft and erosive tumor was detected near the right upper bronchus. (C, D) A chest magnetic resonance image showed a cystic mass in the mediastinum that connected to the thyroid and compressed the esophagus. The tumor size was 11 x 6 x 4 cm in diameter.
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Fig 2. (A) A macroscopic finding of the resected tumors. The mediastinal tumor was below the right lobe of the thyroid (approximately 8 cm in diameter). (B, C) Microscopic findings with hematoxylin & eosin stain: (B) a low-power view (x40) and (C) a high-power view (x200). Atypical columnar cells with irregular nuclei are proliferated and arranged in papillary or glandular structures. The nuclear grooving and inclusions are observed in the tumor cells. Marked stromal hyalinization and calcification are noted. The tumor cells were not invading the capsule nor were they exposed on the resected surface. All surgical margins are negative.
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Comment
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A mediastinal tumor related to thyroid cancer usually originates from an ectopic thyroid [3], and a cystic thyroid lesion straying into a mediastinum is relatively rare, especially a huge cystic lesion such as the one in this case. The intrathoracic goiter and the adenomatous goiter might also be associated with mediastinal tumors [4, 5]. The main clinical problem with respect to these mediastinal tumors is compression of other organs. The primary symptoms are cough, dyspnea, dysphagia, and stridor [3–5]. The current patient presented with hemosputum due to the right main bronchus invasion, and hemosputum has not been reported as an initial symptom [3–5].
The treatment of a thyroid tumor with a symptomatic mediastinal tumor is a surgical resection. A neck lateral incision is often used; however, a case with a large mediastinal tumor often requires a posterolateral incision or sternotomy [5]. A thoracotomy by the posterolateral incision was initially selected in the current case because of the suspicion of an invasion to the trachea and the direct invasion to the right main bronchus. Furthermore, the thoracotomy was performed, followed by the thyroidectomy to resect the mediastinal tumor and improve of symptoms to release the compression of the trachea.
Pathologically, the thyroid tumor was papillary adenocarcinoma; on the other hand, no malignant cells were detected in the cystic mediastinal tumor originating from the thyroid tumor. Papillary carcinoma of thyroid and cystic lesions in the neck or mediastinum are often detected due to calcification and hyalization in the tumor. Occasionally these lesions are changed into calcification and hyalization. The current case revealed a huge cystic mediastinal tumor with nonmalignant cells. The current tumor probably showed an aggressive response of calcification and hyalization, leading to necrosis in the current region of the mediastinal tumor, and finally the absence of most malignant cells in the mediastinal tumor. Although a huge cystic posterior-mediastinal tumor originating from papillary carcinoma of the thyroid was rare, the fact that all the malignant cells of this huge mediastinal tumor had vanished was interesting. As a result, this case enabled us to undergo a complete tumor resection.
This report presented a relatively rare case of papillary carcinoma of the thyroid with a huge cystic mediastinal tumor treated by a curative resection. An aggressive resection is recommended for papillary carcinoma of the thyroid with or without a mediastinal lesion.
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References
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- Schlumberger MJ. Papillary and follicular thyroid carcinoma N Engl J Med 1998;338:297-306.[Medline]
- Carcangiu ML, Zampi G, Pupi A, Castagnoli A, Rosai J. Papillary carcinoma of the thyroid. A clinicopathologic study of 241 cases treated at the University of Florence, Italy. Cancer 1985;55:805-828.[Medline]
- Shah BC, Ravichand CS, Juluri S, Agarwal A, Pramesh CS, Mistry RC. Ectopic thyroid cancer Ann Thorac Cardiovasc Surg 2007;13:122-124.[Medline]
- Ket S, Ozbudak O, Ozdemir T, Dertsiz L. Acute respiratory failure and tracheal obstruction in patients with posterior giant mediastinal (intrathoracic) goiter Interact Cardiovasc Thorac Surg 2004;3:174-175.[Abstract/Free Full Text]
- Katlic MR, Wang CA, Grillo HC. Substernal goiter Ann Thorac Surg 1985;39:391-399.[Abstract/Free Full Text]
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Abstract
Introduction
