Response to multidisciplinary therapy of metastatic anaplastic thyroid cancer involving the right internal jugular vein and superior vena cava A 68-year-old female presented with dysphagia, unilateral right upper limb pain, cyanosis, right occipital headache and a 3-month evolving central neck lump. She was otherwise usually fit and well with a background of Graves' disease and radioactive iodine-131 treatment in 2009. Examination revealed a 6-cm firm central neck mass arising from the thyroid and engorged veins over the right supraclavicular fossa. She was euthyroid. On ultrasound, a large multinodular goitre was seen containing a 34-mm Thyroid Imaging Reporting and Data Systems (TIRADS) classification grade 5 nodule in the right lobe, abnormal right cervical lymph nodes (levels 2-4) and occlusive right internal jugular vein (IJV) thrombus (Fig. 1). Fine needle aspiration of the nodule and abnormal lateral neck nodes showed poorly differentiated carcinoma of thyroid origin or squamous cell carcinoma (Bethesda category VI). A working diagnosis of poorly differentiated thyroid carcinoma was favoured over anaplastic thyroid cancer (ATC), given the presence of superior vena cava (SVC) obstruction with central compartment resectable disease and absence of distant metastasis. A total thyroidectomy, central and radical right lateral lymph node clearance, was performed. The right IJV was resected and a thrombectomy was performed. Tumour embolus was evident when the right IJV was transected from the brachiocephalic vein. The right recurrent laryngeal nerve was not involved and preserved, as confirmed with an intraoperative nerve integrity monitor. Post-operatively, her recovery was complicated by pneumonia and a pulmonary embolus which responded well to standard treatments. The patient was successfully discharged home after 5 days.

Advanced Trauma Life Support principles prioritise the management of ‘breathing’ over ‘circulation’ in an acute trauma primary survey. In a tamponaded thoracic aortic rupture, however, this may lead to fatal haemorrhagic shock. In this case, we discuss the resuscitation and management of a patient with a massive left sided haemothorax secondary to a grade four blunt traumatic aortic injury. A 26-year-old male was involved in a high-speed motor vehicle crash and was hypoxic and hypotensive at the scene. His oxygenation and haemodynamics improved with supplemental oxygen and fluid resuscitation. He had a left intercostal catheter inserted after an urgent thoracic endovascular aortic repair was performed to prevent disruption of the contained haemothorax in the presence of a grade four thoracic aortic injury. It is vital to recognise the potential disruption of a tamponaded blunt traumatic aortic injury during consideration of thoracostomy and chest drain decompression.