SESSION TYPE: Surgery Student/Resident Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Thymoma is an uncommon and slow-growing neoplasm and is the most common primary anterior mediastinal tumors in adults. Patients are usually asymptomatic, but can also present with respiratory symptoms, superior vena cava syndrome, or paraneoplastic syndromes. We present a rare case of an invasive thymoma with intraluminal thrombus involving the left brachiocephalic vein, superior vena cava and right atrium presenting with superior vena cava syndrome and pulmonary embolism.
CASE PRESENTATION: 64 year old male presented to his primary care physician with an acute left upper extremity swelling of two weeks duration. Venous duplex of the upper extremities showed an acute deep venous thrombosis in the left internal jugular, left subclavian and axillary veins. CT of the chest with intravenous contrast revealed a 5 cm anterior mediastinal mass with calcifications and a large sub-occlusive thrombus in brachiocephalic, bilateral subclavian veins, and right atrium and minimal flow through the SVC (Figure 1). MRI confirmed a 6.5 x 3.5 x 3 cm anterior mediastinal mass which did not appear to be compressing or invading the great vessels, in addition there was a thrombus extending from bilateral subclavian, brachiocephalic veins, SVC into right atrium (Figure 2). After suffering from a pulmonary embolus, patient underwent an urgent pulmonary embolectomy, mediastinal mass excision, removal of right atrial, SVC and innominate vein clots and a single vein bypass to LAD as patient had a 70% proximal LAD lesion on preoperative cardiac catheterization. Pathology report indicated a mixed type thymoma (type A and AB for right atrial mass and SVC clot, respectively) according to the WHO histological typing with stage III according to Masaoka’s staging. Postoperatively patient recovered well, and was offerred radiation therapy for local control.
DISCUSSION: Several mechanisms have been proposed to explain the mode of brachiocephalic vein infiltration including extension through the thymic veins, direct invasion, and hematogenous spread. Since no direct invasion was observed, it appears that the mode of extension occurred from the thymic veins and propagated intraluminally through the great veins into the heart. Thus, thymic veins must be carefully examined during the time of resection to warrant absence of residual tumor.
CONCLUSIONS: In conclusion, intraluminal extension of thymic cancer into the great vessels and cardiac cavity is an infrequent occurrence, however, complete excision of the mediastinal mass, evacuation intracardiac thrombi can be performed with cardiopulmonary with excellent outcome.
1) Yamazaki, K., et al., Thymic carcinoma presenting as an intraluminal growth into the great vessels and the cardiac cavity. Ann Thorac Cardiovasc Surg, 2002. 8(3): p. 163-6.
DISCLOSURE: The following authors have nothing to disclose: Mina Guerges, Iosif Gulkarov
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