Removal of tumor thrombus from theazygos vein in an esophageal squamouscell carcinoma patientQijue Lu, Bowen Shi, Jiang Hong, Hezhong Chen and Chunguang Li*
Abstract
Background: Esophageal squamous cell carcinoma with tumor thrombus in the arch of the azygos vein has notbeen reported to date. Neoadjuvant chemotherapy can decrease the stage in patients with advanced preoperativetumor staging, regaining surgical opportunities and significantly prolonging progression-free survival and overallsurvival. Herein, we present a case of esophageal squamous cell carcinoma accompanied by tumor thrombus in thearch of the azygos vein, and the patient underwent radical surgery after neoadjuvant chemotherapy.
Case presentation: A 63-year-old male with esophageal squamous cell carcinoma was found to have tumorthrombus formation in the arch of the azygos vein. Four courses of neoadjuvant chemotherapy with the TPregimen (paclitaxel plus nedaplatin) were given. Reexamination revealed a significant reduction in tumor and tumorthrombus volume. Therefore, McKeown radical resection for esophageal cancer and removal of the tumorthrombus in the arch of the azygos vein were performed. Postoperative pathology suggested complete remissionof the esophageal tumor and the presence of small focal cancer tissues in the arch of the azygos vein.
Conclusion: We report a case of esophageal squamous cell carcinoma with tumor thrombus formation in the azygosvein. We conducted radical resection after 4 rounds of neoadjuvant chemotherapy, and the pathological results revealedcomplete remission of the tumor. We report our experience addressing this rare case, and we hope to find theunderlying mechanism of tumor thrombus formation and whether it has any effects on prognosis in our future study.
BackgroundClinically, there are several studies in the literatureregarding cases of renal carcinoma accompanied byinferior vena cava tumor thrombus [1, 2] and livercancer with portal vein tumor thrombus [3, 4]; however,esophageal squamous cell carcinoma (ESCC) with tumorthrombus in the arch of the azygos vein has not beenreported to date. In recent years, neoadjuvant chemo-therapy has become increasingly important in the treat-ment of ESCC; in particular, neoadjuvant chemotherapy
decreases the tumor stage in patients with advanced pre-operative tumor staging, regaining surgical opportunitiesand significantly prolonging progression-free survivaland overall survival [5]. Herein, we present a case ofESCC accompanied by tumor thrombus in the arch ofthe azygos vein, and the patient underwent radicalsurgery after neoadjuvant chemotherapy.
Case presentationA 63-year-old male with progressive dysphagia for 15days was found to have thickened walls in the mid-esophageal region and tumor thrombus formation in thearch of the azygos vein (Fig. 1a, S1) according tocontrast-enhanced CT; this was accompanied by
* Correspondence: [email protected] of Thoracic Surgery, Changhai Hospital, The Second MilitaryMedical University, No. 168 Changhai Road, Shanghai 200433, China
Lu et al. Journal of Cardiothoracic Surgery (2020) 15:52 https://doi.org/10.1186/s13019-020-01092-4
mediastinal lymphadenectasis. Gastroscopy confirmed thepresence of a neoplasm in the esophageal lumen located28–35 cm away from the incisor. Biopsy suggested poorlydifferentiated carcinoma of the esophagus, and immuno-histochemistry showed a tendency for basaloid squamouscell carcinoma (Fig. 1b). The patient had smoked for 44years, with 20 cigarettes per day, but had quit smoking for1month; the patient had no history of alcohol consump-tion and denied any history of cardiovascular disease, andno abnormalities were found on the cardiac ultrasound.The patient then received four rounds of neoadjuvantchemotherapy, which consisted of 400mg Abraxane, 120mg nedaplatin via intravenous drip on d1, Q3W. Twenty-five days after the last round of chemotherapy, enhancedCT of the chest suggested a significant reduction in thetumor volume, mediastinal lymph nodes, and tumorthrombus in the arch of the azygos vein (Fig. 1c, S2), andgeneral PET-CT showed no distant metastasis.
One month later, the patient underwent McKeownradical resection. Intraoperative exploration showed atumor located at the level of the arch of the azygos vein,measuring approximately 3 cm in length and 3 cm indiameter, with the tumor invading into the esophagealouter membrane. Two enlarged lymph nodes measuringapproximately 1 cm in maximum diameter were presentaround the tumor, and the tumor had a relatively clearboundary with the surrounding tissues. The arch of theazygos vein was hard in nature, wherein the emboluscould be palpated (Fig. 2a, b and c). The operativeprocess included entering the posterior-lateral 5th inter-costal space of the right chest to expose the esophagealbed and open the mediastinal pleura; the superior venacava at the arch of the azygos vein was first dissociated,and sidewall forceps were used to clip the convergingpoint of the superior vena cava and azygos vein. This, inturn, prevented tumor thrombus detachment, and then
Fig. 1 ESCC was diagnosed by CT and gastroscopy. a Chest enhanced CT before chemotherapy showed thicken walls of the middle esophaguswith tumor thrombus in the arch of azygos vein. b Gastroscopic examination showed irregular protuberance in the esophageal lumen, and itssurface remained anabrotic, and the tumor basically blocked the esophageal lumen. c Chest enhanced CT after neoadjuvant chemotherapyshowed a significant reduction in the esophageal tumor and tumor thrombus at the arch of azygos vein
Fig. 2 Tumor thrombus at the arch of azygos vein. a Intraoperatively, the arch of azygos vein was hard in nature. b tumor thrombus was about3 cm in length. c location of the tumor thrombus in the arch of azygos vein, and the red area represents the tumor thrombus
Lu et al. Journal of Cardiothoracic Surgery (2020) 15:52 Page 2 of 4
the normal azygous vein was dissociated at the T6 leveland blocked. Branches of the intercostal veins were dis-sociated seriatim and underwent ligation to preventtumor thrombus detachment countercurrently. Scissorswere then used to open the azygos vein, and furtherexploration showed a clear boundary between thetumor thrombus and the vascular wall of the arch ofthe azygos vein. There was no invasion or adhesionbetween the thrombus and the vasculature. After that,blunt and complete dissection of the embolus at thearch of the azygos vein was performed, and the em-bolus was approximately 1 cm in diameter and 3 cmin length, with no residual embolus observed. Heparinwater was used for washing to detach the azygos vein,and then a 5–0 Prolene propene line was used for su-turing the azygous vein. We tried to maintain the in-tegrity of the azygos vein during surgery to maintainvenous return and to stabilize the gastric tube be-cause of the relative position in the chest. The totallength of the esophagus was dissociated. A median in-cision in the upper abdomen was performed to makea gastric tube, and esophagogastric anastomosis wascompleted through a right neck incision.Postoperatively, enteral combined with intravenous
nutritional therapy was given. The patient received aclear and liquid diet on day 8 after surgery and was dis-charged without any severe complications. Postoperativepathology revealed the proliferation of fibrous tissue atthe submucosal and muscular layers of the esophagealtumor bed, and a multinucleated giant cell reaction waspartially observed, accompanied by infiltration of a smallnumber of lymphocytes and plasmocytes (Fig. 3a). Therewas no evidence of residual cancer tissue, and completeremission was achieved after neoadjuvant chemotherapy.No metastasis was observed at the mediastinal, celiac, orcervical lymph nodes. Most of the emboli in the azygosvein were necrotic tissues, wherein small focal cancertissues measuring 3 mm in maximum diameter werepresent (Fig. 3b).
Discussion and conclusionsMany studies have mentioned that vascular cancerthrombus is an important factor affecting the lymph nodemetastasis rate and N stage of esophageal cancer in ESCC[6]; however, the occurrence of esophageal squamous cellcarcinoma with tumor thrombus in the arch of the azygosvein or superior vena cava has not been reported to date. Toour knowledge, it is of great importance during surgery toprevent detached tumor thrombi from embolizing in thelung and brain. Therefore, the superior vena cava at the archof the azygos vein was first dissociated, and then sidewallforceps were used for clipping of the converging point of thesuperior vena cava and azygos vein. Branches of the inter-costal veins were dissociated and ligated to avoid tumorthrombus detachment countercurrently. After that, the archof the azygos vein was cut, and the tumor thrombus wasremoved successfully. No recurrence or metastasis wasobserved at 6months of follow-up, providing a clinicalreference for the treatment of similar cases in the future.The specific mechanism of ESCC with tumor thrombus
formation in the azygos vein requires further study. Therehave been several reports regarding liver cancer with portalvein tumor thrombus. This phenomenon is not only relatedto the abnormal vascular structure of the tumor, portal veincountercurrent, and blood coagulation function but also as-sociated with the expression of various genes, microRNAsand abnormal proteins. In addition, cytokines may play animportant role in the process of cancer cell detachment, at-tachment, and seeding [7, 8]. Although the tumor in thiscase was located adjacent to the tumor thrombus of thearch of the azygos vein, its boundary with the arch of theazygos vein remained clear, and direct invasion of thetumor did not cause tumor thrombus formation. Therefore,it was speculated that the mechanism of formation mightbe related to the combined actions of various genes, thetumor microenvironment and coagulation function. Fur-ther accumulation of cases is warranted to determine themechanism of tumor thrombus formation and whether ithas any effects on prognosis.
Fig. 3 Postoperative pathology. a Postoperative pathology suggested complete remission of esophageal tumor. b The presence of small focalcancer tissue in the arch of azygos vein
Lu et al. Journal of Cardiothoracic Surgery (2020) 15:52 Page 3 of 4
Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s13019-020-01092-4.
Additional file 1. The scan version of original chest CT of the patientbefore surgery.
Additional file 2. The scan version of original chest CT of the patientafter 4 rounds of neoadjuvant chemotherapy.
AcknowledgementsWe sincerely appreciated the help from Department of Pathology, ChanghaiHospital.
Authors’ contributionsLi Chunguang: design of the work; Lu Qijue: the acquisition, analysis, Shi Bowen:interpretation of data; Hong Jiang: draft of work; Chen Hezhong: revision of themanuscript. The author(s) read and approved the final manuscript.
FundingOur study was funded by National Natural Science Funding of China.Funding Number: 81472688.
Availability of data and materialsNot applicable.
Ethics approval and consent to participateNot applicable.
Consent for publicationNot applicable.
Competing interestsThe authors declare that they have no competing interests.
Received: 20 November 2019 Accepted: 17 March 2020
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