AJR 2003; 181:272-274
© American Roentgen Ray Society
Sonography of Delayed Thyroid Metastasis from Renal Cell Carcinoma with Jugular Vein Extension
Perry J. Pickhardt1,2 and
Ralph H. Pickard1
1 Department of Radiology, National Naval Medical Center, 8901 Wisconsin Ave.,
Bethesda, MD 20889-5600.
2 Department of Radiology, F. Edward Hémbert School of Medicine,
Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd.,
Bethesda, MD 20814.
Received October 14, 2002;
accepted after revision December 31, 2002.
The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or as reflecting the views of
the Department of the Navy or Department of Defense.
Address correspondence to P. J. Pickhardt.
Introduction
Primary renal cell carcinoma is well known for its predilection to spread
by contiguous venous extension. The typical features and distribution of
distant metastatic spread by renal cell carcinoma are also well documented. We
describe the sonographic appearance of a thyroid metastasis showing direct
extension into the internal jugular vein in a patient with a remote history of
renal cell carcinoma. This peculiar feature, which recapitulates the growth
behavior of the primary tumor, raised suspicion for metastatic disease,
despite the fact that nephrectomy had been performed more than a decade
earlier.
Case Report
A 52-year-old woman was found to have an asymptomatic right-sided thyroid
mass on routine physical examination. The patient had normal thyroid function,
and findings of laboratory analysis, including a thyroid panel, were normal.
Previous medical history was remarkable only for right nephrectomy for renal
cell carcinoma more than 10 years earlier without complication.
Thyroid sonography using a linear transducer showed a well-circumscribed
4-cm hypoechoic mass involving the right thyroid lobe. Direct tumor extension
via an enlarged thyroidal tributary into the right internal jugular vein was
seen (Figs. 1A,
1B,
1C,
1D). The internal jugular vein
was expanded by the intraluminal tumor component, which measured 1.8 cm in
transverse dimension and extended 3 cm in longitudinal dimension. Both
intrathyroidal and intravascular components of the lesion appeared
hypervascular on color Doppler sonography
(Fig. 1B). Prominent
intratumoral vessels that spanned from the dominant mass into the jugular vein
were apparent on both gray-scale and color Doppler sonograms (Figs.
1A and
1B). Although a primary thyroid
neoplasm could not be excluded, metastatic disease from the patient's remote
renal cell carcinoma was considered, because the behavior of the thyroid tumor
was reminiscent of primary renal cell carcinoma.
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Fig. 1A. —52-year-old woman with asymptomatic right-sided thyroid mass
and remote history of renal cell carcinoma. Transverse gray-scale image from
thyroid sonogram shows expansion of right internal jugular vein (V) by tumor,
which has extended directly from dominant thyroid mass (T) via enlarged
thyroidal vein (arrowheads). A = common carotid artery.
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Fig. 1B. —52-year-old woman with asymptomatic right-sided thyroid mass
and remote history of renal cell carcinoma. Color Doppler sonogram obtained in
same plane as A shows prominent tumor vascularity.
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Fig. 1C. —52-year-old woman with asymptomatic right-sided thyroid mass
and remote history of renal cell carcinoma. Longitudinal sonogram obtained
through right thyroid lobe shows hypoechoic tumor (T). Note
tumor–parenchyma interface (arrowheads).
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Fig. 1D. —52-year-old woman with asymptomatic right-sided thyroid mass
and remote history of renal cell carcinoma. Transverse sonogram obtained
caudad to A shows inferior extent of intraluminal tumor component
(arrowheads) within right internal jugular vein.
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Fine-needle aspiration biopsy of the right thyroid mass was performed. The
histologic specimen was diagnostic for a clear cell adenocarcinoma, most
compatible with the patient's renal primary. Gross venous extension of the
tumor was confirmed at surgery (Fig.
1E), at which time right hemithyroidectomy and partial internal
jugular resection were performed. Further pathologic evaluation confirmed the
diagnosis of metastatic renal cell carcinoma. Although findings of initial
workup were otherwise negative, a subsequent abdominal CT scan showed
development of a hypervascular pancreatic mass, which was also consistent with
metastatic renal cell carcinoma.
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Fig. 1E. —52-year-old woman with asymptomatic right-sided thyroid mass
and remote history of renal cell carcinoma. Photograph of gross resected
specimen shows bulbous intravascular tumor component (arrowhead).
Dominant intrathyroid component has been bivalved.
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Discussion
The incidence of renal cell carcinoma in the United States has continued to
increase over the past 60–70 years, with approximately 30,000 new cases
in 1999 alone [1]. The
incidence of metastatic disease at presentation has dropped below 20%, largely
because of increased detection of asymptomatic incidental tumors on
cross-sectional imaging [1].
Involvement by metastatic disease from renal cell carcinoma has been reported
in virtually every organ system, but the most common sites are regional lymph
nodes, lung, and bone. Markedly delayed presentation of renal cell carcinoma
metastases is a well-recognized phenomenon that affects a subset of
patients.
Although metastatic involvement of the thyroid gland by renal cell
carcinoma is considered to be rare, more than 40 cases have been reported in
the literature [2]. In fact,
most clinically recognized thyroid metastases are due to renal cell carcinoma
[2]. Similar to the lesion in
our patient, many of these lesions presented long after radical nephrectomy,
even 20 years later [3]. In a
minority of cases, the thyroid metastasis was discovered before the primary
renal tumor and often misdiagnosed as a primary thyroid malignancy
[4]. Little information is
available on the sonographic features of thyroid metastases, but a
well-demarcated hypoechoic mass with punctate calcification was reported in
one case [4]. A hypervascular
appearance on color Doppler sonography would be expected and was present in
our patient. Overall, the sonographic findings are likely to be nonspecific,
and therefore correlation with the patient's clinical history is paramount for
suggesting the correct diagnosis.
The propensity for primary renal cell carcinoma to extend into the renal
vein and inferior vena cava is well recognized, corresponding to stages IIIa
and T3a disease by Robson and TNM classification
[5], respectively. Renal vein
extension has been reported to occur in approximately 23% of renal cell
carcinomas, and venal caval extension is seen in 7% of cases
[6]. Venous extension of the
primary tumor can be accurately evaluated by current cross-sectional imaging
techniques, particularly MR imaging and multidetector CT. This characteristic
growth feature of the primary tumor, however, is rarely seen with metastatic
renal cell carcinoma. In fact, despite the large collective experience with
metastatic disease from renal cell carcinoma over the years, we were unable to
find any previous report describing direct venous extension from a metastasis.
This finding is perhaps somewhat surprising given the behavior characteristics
of the primary tumor.
Sonography is generally the initial imaging study of choice for a suspected
thyroid nodule, most of which (cysts and adenomas) are benign in nature.
Although papillary and follicular thyroid carcinomas account for less than 5%
of all nodules, they are by far the most common malignancies to involve the
gland [7]. Extrathyroidal
vascular invasion from primary thyroid carcinoma is rare, occurring in
approximately 1.5% of cases
[8]. Unlike cervical lymph node
involvement, vascular involvement from thyroid carcinoma portends a poor
prognosis [8]. Although most of
these cases represent secondary invasion, direct intravascular venous
extension of thyroid carcinoma has also been reported, including presentations
with tumor thrombus in the right heart and even the pulmonary arteries
[9]. Therefore, the sonographic
finding of gross jugular venous extension by a thyroid mass is not specific
for metastatic renal cell carcinoma.
In summary, we describe the sonographic appearance of macroscopic jugular
venous extension from a vascular thyroid mass in a patient with a remote
history of renal cell carcinoma. Given the known tendency of renal cell
carcinoma for delayed metastatic recurrence and the striking venous extension,
metastatic disease was a primary consideration and was subsequently proven at
surgery and pathologic evaluation.
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