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Kawasaki Medical Journal 47：69 75，2021doi：10.11482/KMJ-E20214706969〈Case Report〉A Case of Takotsubo syndrome after Surgeryfor Papillary Thyroid CancerYutaka YAMAMOTO１）, Junichi KUREBAYASHI１）, Hiroshi OKAMOTO２）Yuka MIKAMI３）, Takuya MORIYA３）, Yuna FUKUMA１）, Tsuyoshi MIKAMI１）Shiori KAWANO１）, Emi KISHINO１）, Ryohei OGATA１）, Wataru SAITO１）Yoshikazu KOIKE１）, Mai SOHDA１）, Tsunehisa NOMURA１）, Katsuhiro TANAKA１）1) Department of Breast and Thyroid Surgery,2) Department of Cardiology,3) Department of Pathology, Kawasaki Medical SchoolABSTRACTThe patient was an 82-year-old woman undergoing treatment for bronchialasthma. In December 200X, she visited her former doctor because of a left cervical mass andpain, and was referred to our hospital for detailed examination. A 19-mm mass was found inthe left lobe of the thyroid gland and there were many swollen lymph nodes on both sides ofher neck. Fine-needle aspiration cytology revealed malignant and papillary cancer in both theleft lobe and left cervical lymph node, but no lung metastasis was found in chest CT, and itwas judged to be T1bN1bM0 Stage IVa. Total thyroidectomy bilateral cervival lymphnodedissection was performed. The left lobe mass of the thyroid gland invaded the sterno-thyroidmuscle, but no infiltration to other organs, including the lymph nodes on both sides, wasobserved. On the night of the operation, wheezing, dyspnea, lower mandibular breathing,and impaired consciousness suddenly developed, and the oxygen saturation of peripheralartery (SpO2) decreased to 60%. No postoperative bleeding was observed. Chest CTdemonstrated no signs of heart failure, but based on thickening of the bronchial wall, the causeof hypoxemia was considered to be bronchial asthma. Steroids and oxygen (high-dose, 15 L/min) were administered, but respiratory acidosis developed and non-invasive positive pressureventilation (NIPPV) was started. The respiratory condition gradually improved thereafter. Acutecoronary syndrome (ACS) was suspected based on symptoms, increased troponin T, and STelevation on ECG. Echocardiography revealed akinesis and left ventricular apical and basalhypercontractility. No coronary arterial stenosis was noted on coronary angiography and leftventriculography demonstrated Takotsubo-like wall movement (hypercontraction of the baseand contraction failure of the apex), leading to a diagnosis of Takotsubo syndrome (TS). TheCorresponding authorYutaka YamamotoDepartment of Breast and Thyroid Surgery, KawasakiMedical School, 577 Matsushima, Kurashiki, 701-0192,JapanPhone : 81 86 462 1111Fax : 81 86 462 1199E-mail: yamayou@med.kawasaki-m.ac.jp

70Kawasaki Medical Journalsubsequent course was good and she was discharged on the 10th postoperative day. doi：10.11482/KMJ-E202147069(Accepted on April 20, 2021)Key words：Papillary thyroid cancer, Takotsubo syndromeINTRODUCTIONTa k o t s u b o s y n d r o m e ( T S ) i s g e n e r a l l ywith papillary thyroid cancer and referred to ourdepartment for consultation.[Past history] Bronchial asthma and postoperativecharacterized by transient and reversible ventricularwall dyskinesias caused by physical or mental stresscataract１，２）. TS causes symptoms and ECG findings similar[Family history] Not contributoryto acute coronary syndrome (ACS); therefore, an[Physical findings] A tumor of approximately 20accurate diagnosis is essential ３，４）. As there aremm was observed in the left lobe of the thyroidfew reports of TS associated with thyroid cancer,gland and the 15-mm left cervical lymph node waswe report a case of TS after postoperative papillarypalpable.thyroid cancer.[Image findings]Ultrasonography:A 19 18 18-mm hypoechoic mass was foundCASE REPORT[Patient] 82-year-old womanin the middle left lobe of the thyroid gland. The[Chief complaint] Left cervical massmass had a rough boundary and heterogeneous[Present illness] In 201X, she noted a left cervicalinternal structure (Fig. 1a), and the internal bloodmass and visited a neighborhood hospital. Basedflow was abundant (Fig. 1d). Left deep cervicalon detailed examination, she was diagnosedlymph node: Lymphadenopathy was observed andFigure 1acbdFig. 1. Ultrasonographic findings: Lt. lobe mass (a). Lt. cervical lymph node (b). Rt. cervical lymph node (c).Color Doppler (d).

Figure 2Yamamoto Y, et al. : A Case of Takotsubo Syndrome After Surgery for Papillary Thyroid Cancer71abFigure3 MRI (b) showing a lt. lobe mass (white arrow) and a lt. cervical lymph node (gray arrow).Fig. 2. CT(a) andabcdFig. 3. Histopathological examination of the resected specimen: Papillary cell proliferation wasobserved (a), and ground glass-like nuclei (arrowhead), nuclear grooves (white arrow), andintranuclear cytoplasmic inclusion bodies (gray arrow) were noted (b, c). Lymph node metastases (d)were widespread.the maximum diameter was 25 mm, suggestingmetastasis (Fig. 1b). It was in contact with theinternal jugular vein and infiltration was suspected.Right deep cervical lymph node: At least two sitesof lymphadenopathy were found, also suggestingmetastasis (Fig. 1c).internal jugular vein. No lung metastasis was found.[Fine-needle aspiration cytology]Malignant and papillary cancer in both the leftlobe mass and left cervical lymph node[Blood test at first visit]Thyroid function was normal. The thyroglobulinCT (Fig. 2a), MRI (Fig. 2b):level was high at 313 ng/mL, but anti-thyroglobulinNo notable tracheal infiltration of the tumor wasantibody was negative. There were no otherobserved. The tumor may have invaded the leftabnormal findings.

Figure 472Kawasaki Medical JournalFig. 4. Chest CT: Thickening of the tracheal wall was observed (white arrow).[Operation]performed to search for the cause of hypoxemia.Total thyroidectomy bilateral cervical lymphnodeThere was no evidence of heart failure, but baseddissection was performed. The left lobe mass of theon thickening of the bronchial wall (Fig. 4), thethyroid gland invaded the sterno-thyroid muscle,cause of hypoxemia was considered to be bronchialmany sites of bilateral cervical lymphadenopathyasthma.were noted, but there was no infiltration into theinternal jugular vein.[Histopathological examination]Although steroids and oxygen (high-dose, 15 L/min) were administered, respiratory acidosis (pH6.978, pCO2 106.1 mmHg, pO2 138.5 mmHg, BEPapillary cell proliferation was observed (Fig.-10.0 mEq/L) was confirmed on blood gas analysis3a), and ground glass-like nuclei, nuclear grooves,and non-invasive positive pressure ventilationand intranuclear cytoplasmic inclusion bodies(NIPPV) was started. The respiratory conditionwere noted (Fig. 3b, 3c), leading to a diagnosis ofgradually improved thereafter.papillary thyroid cancer (PTC). PTC of the thyroidBlood tests demonstrated an increased troponingland infiltrated the surrounding muscles andT level (0.232 ng/ml). ST elevation in leads V1-adipose tissue, but the surgical margin was negative.V3 and aVR was noted on ECG (Fig. 5b, Fig. 5aLymph node metastases (Fig. 3d) were widespreadshows ECG on admission). Echocardiography(maximum diameter of metastases 27 mm, a total ofdemonstrated akinesis of left ventricular apex, and12 metastatic lymphnodes).basal hypercontractility. Therefore, the differential[Postoperative course]diagnosis included TS and ACS. Because theOn the night of the operation, the patientregional wall motion abnormalities extend beyondsuddenly developed wheezing, respiratory distress,a single epicardial vascular distribution, TS wasmandibular breathing, and impaired consciousness,strongly suspected.and the oxygen saturation of peripheral artery16 hours later after onset, the patient underwent( S p O 2 ) d e c r e a s e d t o 6 0 % a t r o o m a i r. N ocoronary angiography to differentiate acute coronarypostoperative bleeding was observed. Chest CT wassyndrome (ACS) from stress cardiomyopathy.

Figure 5Yamamoto Y, et al. : A Case of Takotsubo Syndrome After Surgery for Papillary Thyroid Cancer73abFigureFig. 5. 6ECG: On admission (a). At sudden change (b).ST elevation was noted in leads V1-V3and aVR (white arrow).abFig. 6. Left ventriculography: Diastolic phase (a). Systolic phase (b).No coronary arterial stenosis was present and leftechocardiography, she was discharged on her ownventriculography (Fig. 6) revealed Takotsubo-on the 10th postoperative day.like wall movement (hypercontraction of the baseand contraction failure of the apex), leading to adiagnosis of TS.DISCUSSIONTakotsubo Cardiomyopathy was first describedThe subsequent course was good. Although shein Japan in 1990 by Dote and colleagues５）. Thehad reduced left ventricular systolic function onname“Takotsubo”was used to describe the