Selective venous sampling catheterisation for localisation of persisting medullary thyroid carcinoma

Abstract

Summary Selective venous sampling catheterisation was performed in 19 patients with medullary thyroid carcinoma without known distant metastases for persistent hypercalcitoninaemia after surgery. Calcitonin (CT) gradients were found in the neck and/or the mediastinum in 18 patients and in five patients at distant sites also. After venous catheterisation, 13 patients were subjected to repeat surgery. Neck and/or mediastinal tumour foci were found in 12 patients at the sites of the CT gradients. Of Medullary thyroid carcinoma (MTC) spreads early to regional lymph nodes in the neck and mediastinum and to distant sites in the liver, lungs and bones (Grauer et al., 1990).The aim of initial surgery is to remove all neoplastic foci. It consists of a total thyroidectomy with bilateral lymph node dissection in the neck and the upper mediastinum (Wahl & Roher, 1988). The normalisation of the serum calcitonin (CT) level after surgery is a strong indicator that neoplastic tissue has been totally removed. However, this is achieved in only 20% of patients with clinical disease (Parmentier et al., 1985). In others, persistently elevated CT levels indicate the presence of residual disease. If localised, this may warrant further surgery. However, a complete work-up, including ultrasonography, computerised tomography or magnetic resonance imaging and bone scintigraphy, frequently yields no positive evidence of localised tumours in these patients with elevated CT levels. Furthermore, owing to previous surgical procedures, the significance of any abnormality may be ambiguous. Scintigraphic procedures have not proved to be sensitive enough to be useful as a routine.Selective venous sampling catheterisation appeared to be a sensitive and specific tool for localising the origin of serum CT in patients with elevated CT levels and no other evidence of disease (Ben Mrad et al., 1989;Gautvik et al., 1989; Frank-Raue et al., 1992). However, given the slow growth rate of most MTCs, the follow-up was too short in these series to elucidate the significance of extracervical gradients and to conclude that this technique could be useful, in terms of relapse and survival rates.The present study is based on 19 patients, with a mean follow-up of 5.5 years after selective venous catheterisation. Eight of these patients have previously been reported (Ben Mrad et al., 1989).Before selective venous catheterisation, all patients were subjected to a clinical examination, including chest radiography, ultrasonography of the neck and liver, computerised tomography of the neck, chest and abdomen and bone scintigraphy. This work-up only permitted the discovery of involved cervical or mediastinal lymph nodes in six patients (nos. 1, 4, 6, 13, 18 and 19).The selective venous sampling catheterisation procedure has already been reported (Ben Mrad et al., 1989). It was performed by the femoral route using a Cook SF 2-cm-long catheter with a 1200 angle and one side-hole tip (Cook, SARL, Paris, France). A standard procedure was used: a mean of 25 samples was obt...

Long-term outcome of medullary thyroid carcinoma in patients with normal postoperative medical imaging

“…Calcitonin is a highly sensitive marker of persistent disease that is more sensitive than any other imaging modality (Frank-Raue et al, 1992;Abdelmoumene et al, 1994). Elevated postoperative basal CT level was described as a survival prognostic factor (Dottorini et al, 1996;Modigliani et al, 1998).…”

“…Selective venous sampling catheterisation with plasma CT measurements appears to be the most sensitive and specific method for localising persistent disease. However, even after further surgery based on the results of venous sampling, 62 -98% of the patients still have elevated CT levels (Frank- Raue et al, 1992;Abdelmoumene et al, 1994;Moley et al, 1998;Kebebew et al, 2000b).…”

Patients with differentiated thyroid cancer have a venous gradient in thyroglobulin levels

“…5,6 Venous sampling for proteins secreted by endocrine tumors (parathyroid hormone, insulin, aldosterone, and calcitonin) has been used to localize tumors based on gradients in the protein level. [7][8][9][10][11] It is unknown whether there is a venous gradient in the serum Tg level in patients with DTC. For the current study, we measured serum Tg levels in the vein that drained the DTC directly (the internal jugular vein) and in the peripheral vein (the forearm antecubital vein) in 15 patients who were undergoing surgical treatment for DTC.…”

“…Venous sampling and measurement of proteins or peptides secreted by endocrine tumors, such as insulinoma (insulin), parathyroid tumors (intact parathyroid hormone), gastrinoma (gastrin stimulation test), adrenocortical tumors (aldosterone), and medullary thyroid cancer (calcitonin), have been used to localize tumors that cannot be detected by conventional imaging studies. [7][8][9][10][11][12][13][14] Although the half-life of Tg is long (range, 6-96 hours) compared with other proteins that are secreted by endocrine tumors and depends on liver function, Tg levels close to the tumor were significantly higher than Tg levels in the peripheral venous circulation in all but 1 patient who had lung metastasis. 15 The current results suggest that venous sampling for Tg in patients with increasing or high serum Tg levels but negative imaging studies may be useful to localize DTC.…”

Is there any venous gradient in serum thyroglobulin levels in patients with differentiated thyroid cancer?

“…Selective venous sampling for proteins secreted by endocrine tumors (parathyroid hormone, calcitonin, aldosterone, and insulin) has been used to localize tumors in the other studies [4][5][6][7]. However, the role of venous sampling for Tg in patients with DTC is clearly unknown.…”