Preoperative embolization of thyroid arteries in a patient with large multinodular goiter and papillary carcinoma

Metastatic renal cell carcinoma to the thyroid with cervicothoracic venous tumor thrombosis

INTRODUCTION

Metastatic renal cell carcinoma (RCC) represents 25%-42% of metastatic thyroid malignancies. Propensity for RCC to demonstrate intravascular extension to the inferior vena cava is well documented. We present an analogous phenomenon of intravascular extension to the internal jugular vein (IJV) from thyroid gland metastasis.

METHODS

A 69-year-old male presented with metastatic RCC of the right thyroid lobe. Imaging demonstrated tumor thrombosis of the ipsilateral IJV, extending inferiorly to the junction of the brachiocephalic, subclavian, and internal jugular veins within the mediastinum.

RESULTS

Surgical excision required control of both the IJV in the neck and mediastinal venous great vessels via sternotomy, prior to subtotal thyroidectomy and venotomy for en bloc resection.

CONCLUSION

This case report describes metastatic RCC to the thyroid gland with cervicothoracic venous tumor thrombosis successfully treated with subtotal thyroidectomy, sternotomy for venotomy and tumor thrombectomy, and preservation of IJV conduit.

The calcium-phosphate balance, modulation of thyroid autoimmune processes and other adverse effects connected with thyroid arterial embolization

In search of new treatment options for thyroid diseases, when conventional procedures are ineffective, contraindicated or associated with serious side effects, safety of thyroid arteries embolization in the treatment of particular thyroid diseases was evaluated. The study included eight subjects with retrosternal toxic goiter, six patients affected by Graves' disease, five cases of retrosternal non-toxic goiter, two subjects with post-amiodarone hyperthyroidism, and one patient with severe thyroid-related orbitopathy, who underwent selective embolization of thyroid arteries. The study assessed and compared calcium-phosphate balance, modulation of thyroid autoimmunity and the presence of different side effects in patients who underwent the procedure. In addition, the serum concentrations of thyroid hormones, anti-thyroid autoantibodies and thyroid volume have been measured. Five of all enrolled subjects (22.7 %) experienced transient, not clinically relevant hypocalcaemia with no need for calcium supplementation. There were no significant changes in serum calcium levels in patients after embolization of both inferior thyroid arteries. The transient side effects associated with the treatment were neck pain and a slight increase in body temperature. Noted high concentration of free thyroid hormones immediately after the procedure was not accompanied by worsening of symptoms or signs of thyrotoxicosis. In patients with Graves' disease, a significant decrease in thyrotropin receptor antibodies level was observed. Thyroid arterial embolization does not disturb permanently calcium-phosphate balance, modulates positively thyroid autoimmune processes and is associated with no serious post-procedure side effects. Hence, it may be considered as a safe and effective treatment modality for selected thyroid disorders.

Pre-operative embolisation of the thyroid artery in a patient with a large papillary carcinoma of the thyroid

OBJECTIVE

To demonstrate the usefulness of pre-operative selective embolisation of the thyroid arteries in an unusual case with a large, vascular thyroid tumour.

CASE REPORT

A 29-year-old man presented with a large papillary carcinoma of the thyroid (weighing approximately 300 g on palpation) with extension to the mediastinum and compression of the trachea. A computed tomography scan of the neck and thorax revealed a large tumour the solid part of which was enhanced after contrast medium application, indicating a substantial vascular supply. Pre-operative selective embolisation of both superior thyroid arteries and one inferior thyroid artery, using gelatin sponge particles, was performed 4 days before surgery, under conventional angiography. After selective embolisation of these thyroid arteries, the patient experienced mild anterior neck pain and mild fever. This procedure allowed a significant reduction in blood perfusion to the tumour, which facilitated its surgical removal without blood transfusion.

CONCLUSION

Pre-operative selective embolisation of both superior thyroid arteries and one inferior thyroid artery may be an effective, minimally invasive procedure for patients with a large, vascular thyroid tumour.

Partial thyroid arterial embolization for the treatment of hyperthyroidism

BACKGROUND

Hyperactive thyroid gland in patients that are unable to tolerate or accept standard therapy is a common clinical problem. Aim of the study was to evaluate effectiveness of partial thyroid arterial embolization in patients with hyperthyroidism.

MATERIAL/METHODS

From May 2004 to November 2005 partial thyroid gland embolization was performed in 15 patients. Mean thyroid gland volume was 162 ml. Embolization of one to three thyroid arteries was performed with the mixture of Histoacryl and Lipiodol. Selective angiography was performed after embolization to ensure that the targeted arteries were completely occluded. Follow-up study covered 12 patients.

RESULTS

The embolization procedure was well tolerated by all patients. Three days after embolization fT3 and fT4 levels were higher than before the procedure. Further laboratory tests showed quick reversal to near-normal or normal levels of thyroid hormones. 12 weeks follow-up showed: normal serum levels of fT3, fT4 and TSH in 9 of 12 patients (75%), hyperthyroidism in 3 of 12 patients (25%), goiter volume reduction of approximately 32% of its original volume (from 13 to 76.3%), mean thyroid gland volume of 94ml. One year after embolization 7 of 12 patients required thyreostatic drugs. At two and four years follow-up thyreostatics doses were significantly lower and thyroid tissue was fibrotic.

CONCLUSIONS

Based on our results the treatment of the thyroid gland goiters using arterial thyroid gland partial embolization may be offered as an effective alternative for patients who will not or cannot accept standard therapy.

Selective Embolization of Thyroid Arteries for Preresection or Palliative Treatment of Large Cervicomediastinal Goiters

Background: The authors have applied the selective embolization of thyroid arteries in the treatment of voluminous cervicomediastinal goiters, especially in patients at high surgical risk or reluctant to undergo surgical intervention and radioiodine therapy. Method: Selective arteriography was used to embolize the thyroid arteries in 2 patients with voluminous hyperfunctioning cervicomediastinal goiters and mediastinal compressive symptoms. The first patient had already undergone unsuccessful radioiodine metabolic therapy and had severe left ventricular insufficiency contraindicating surgery. The second patient, despite having no contraindications, declined surgery and radioiodine metabolic therapy. Results: Radiological embolization markedly reduced the goiters in volume, resolved the compressive symptoms, and also normalized thyroid hyperfunction. The second patient needed a second embolization procedure because the embolized arterial branches had partly recanalized. Conclusion: Selective embolization of thyroid arteries can be successfully used to treat selected patients as a preoperative procedure and as an alternative to thyroid resection. Embolization can be repeated to achieve the required therapeutic aims.

Evaluation of selective embolization of thyroid arteries (SETA) as a preresective treatment in selected cases of toxic goitre

Background

in recent years, an increasing interest in the application of selective embolization of thyroid arteries (SETA) in the treatment of thyroid diseases is observed. In the present report, we analyse the value, safety and possible indications for preresective SETA in cases of large toxic goitres.

Patients and method

the study group comprised 10 patients with large toxic goitre (thyroid volume 254 ± 50 mL), including one patient with cervicomediastinal goitre and one patient with anti-thyroid drug intolerance in state of overt thyrotoxicosis. All the patients underwent SETA of the superior and/or inferior thyroid arteries, followed by thyroidectomy, performed up to thirty-six hours after SETA (23.1 ± 11 h). After embolization, selective angiographies of thyroid arteries were performed to ensure that the targeted arteries had been completely occluded.

Results and conclusion

in all the patients, SETA decreased blood flow through the thyroid. Preresective SETA reduced blood loss during and after thyroidectomy and decreased the operating time, but the differences were too small to justify routine applications of preresective SETA as an adjunct to surgical treatment of toxic goitre. On the other hand, SETA is a safe and minimally-invasive technique, which may become an attractive option for quick preparation to surgery in selected patients with toxic goitre, who present anti-thyroid drug intolerance or refuse radioactive iodine treatment.

Embolization therapy of bone metastases from epithelial thyroid carcinoma: effect on symptoms and serum thyroglobulin

BACKGROUND

Selective embolization therapy (SET) has been employed to treat a number of malignant tumors, but experience with its use in metastatic epithelial thyroid carcinoma (ETC) is limited. Here we report our experience with the effect of SET on symptoms and serum thyroglobulin (Tg) in patients with bone metastases from ETC.

METHODS

This was a retrospective study of 13 patients with bone metastases from ETC who underwent 65 embolizations for bone metastases in 43 sessions. In the treated patients, symptoms considered related to bone metastases were compared before and about 4-7 weeks after the embolization session. Embolization sessions were excluded for analysis if concomitant therapy had taken place within 4-7 weeks before and/or after the session. Serum Tg concentrations were employed as an index of tumor debulking by SET. We attempted to estimate the influence of SET on survival time in patients with disseminated ETC who did, and an historical control group of patients with disseminated ETC who did not receive SET.

RESULTS

After exclusion of 12 (of which 3 sessions failed) out of 43 sessions, clinical symptoms, such as pain, and neurological symptoms decreased after 17, increased after 6, and did not change after 8 procedures. In 43 sessions, 20 of which were excluded (including the 3 sessions that failed), serum Tg decreased after 14 and increased after 9. The median standardized survival time of the group that received embolization was not significantly different to that of the group that did not receive embolization.

CONCLUSIONS

Embolization therapy does not appear to improve life expectancy, but in selected patients can achieve palliation of pain, prevent neurological damage, reduce tumor burden, and give devascularization of the tumor before surgery.

Preoperative embolization of thyroid arteries in a patient with a large cervicomediastinal hyperfunctioning goiter

We present the case of a 61-year-old male patient with chronic obstructive pulmonary disease and a large cervicomediastinal multinodular hyperfunctioning goiter that made thyroidectomy a daunting task, especially considering the risk of intraoperative bleeding. The preoperative computed tomographic (CT) scan showed the right thyroid lobe very deeply rooted in the mediastinum, below the horizontal plane passing through the aortic arch. The thyroid mass imprinted the arterious and venous innominate trunks. To avoid a median sternotomy and remove the enlarged thyroid through a cervical approach alone, we decided to reduce the goiter in volume preoperatively by embolizing the thyroid arteries. We embolized the superior and inferior left, and the inferior right thyroid arteries. We spared the superior right thyroid artery because its blood supply contributed little to thyroid perfusion. After embolization, the patient was treated with antithyroid agents and corticosteroid drug therapy. At the same time, severe leukocytosis developed, thyroid hormone values increased, and a CT scan obtained 7 days after embolization showed the thyroid unchanged in volume. We therefore discharged the patient and were waiting for his laboratory blood chemical findings to return to normal. Thirty days later the patient was readmitted to hospital, and a new CT scan showed that the thyroid mass had diminished to half its initial volume. We could therefore perform a total thyroidectomy through a cervical approach alone. The only problem arose in dissecting tight right inferior laryngeal nerve adhesions to the thyroid capsule, probably sequelae of postembolization thyroiditis. Even though preoperative thyroid-artery embolization cannot be considered a routine technique in cervicomediastinal goiter surgery, in a rare patient who presents with a voluminous goiter such as the one we describe here, it is a useful procedure.