Surgical management of laryngotracheal and esophageal involvement by locally advanced thyroid cancer

Laryngotracheal Resection in Thyroid Cancer - Experience from a Single Centre Series of 22 Cases

Involvement of the aerodigestive tract is reported in one-third of patients with locally invasive thyroid cancer. It is associated with significant morbidity and mortality, with airway obstruction being the immediate cause of death in 50% of patients who die of thyroid cancer. Management is challenging and includes the risks of extensive surgery as well as decisions regarding the type of surgery and adjuvant therapy. Retrospective cohort study, reporting institutional experience with patients who underwent laryngotracheal resection for invasive thyroid cancer over the past 10 years. Twenty-two patients were included in the study. All patients had Shin stage 4 disease. The median follow-up was 18 months. Five patients had systemic metastasis at diagnosis. Nineteen patients underwent tracheal resection and end to end anastomosis, and 3 underwent laryngectomy. The mean length of the resected trachea was 2.94 cm. Tracheal releasing manoeuvres were utilized in 11 patients. Three patients required a tracheostomy postoperatively. Other complications included a temporary vocal cord palsy in 5 patients, temporary hypocalcemia in 6 and permanent hypocalcemia in 1 patient. Adjuvant radiotherapy was utilized in 9 patients and I-131 therapy in 13 patients. Three patients died during follow-up. Two patients developed thyroid bed recurrence, two patients developed systemic metastasis on follow-up. Most patients survived for a prolonged period with only biochemical evidence of disease persistence and three with no evidence of disease. Laryngotracheal resection with primary anastomosis is a safe and effective option, providing adequate symptomatic relief as well as prolonged survival in carefully selected patients with invasive Shin stage 4 disease.

Oncologic and functional outcomes following laryngectomy for locally advanced thyroid cancer

BACKGROUND AND OBJECTIVES

Total laryngectomy in thyroid cancer is controversial. Functional and oncologic outcomes are needed to inform surgical indications in this population.

METHODS

A retrospective cohort study was performed at a tertiary referral center from 1997 to 2018 to identify patients with a diagnosis of thyroid carcinoma who underwent total laryngectomy. Complications, survival outcomes, and functional outcomes were analyzed.

RESULTS

Thirty patients met the inclusion criteria. The mean age was 62 years (range, 30-88 years) and the male-to-female ratio was 1:2.75. The most common diagnosis was well-differentiated thyroid cancer (53.3%), followed by poorly differentiated (30%) and anaplastic (16.7%). Total laryngectomy was performed with a 10% rate of Clavien-Dindo Grade III-V complications. The median overall survival was 40 months (range, 1-237). Five-year overall survival was 39.5% and disease-specific survival was 51.1%. Locoregional control was achieved in 80.0% of patients. Twelve months postoperatively, 100% of surviving patients were taking oral intake and 86.4% had a self-reported functional voice.

CONCLUSION

Total laryngectomy for locally advanced thyroid cancer is safe and provides acceptable rates of locoregional control. While the risk of distant metastases remains high, advances in systemic therapy may justify aggressive local control strategies to improve the quality of life.

Surgical treatment of locally advanced thyroid cancer

Operations in this area are demanding and require special experience in endocrine, thoracic and vascular surgery, an experienced anaesthesiologist, as well as the interdisciplinary cooperation with other medical specialists (nuclear medicine, oncology, radiology, otolaryngology). A reliable system of surgical guidelines has been developed from a few individual publications with special impact.

Complications from tracheal resection for thyroid carcinoma

Thyroidectomy associated to en bloc tracheal resection with end-to-end anastomosis is the treatment of choice of thyroid tumor invading the tracheal wall and is associated with a good prognosis. However, the postoperative morbidity is not irrelevant. The present review aims to discuss the complications occurring after this aggressive surgical procedure. The search was performed using PubMed through an overarching for the following terms: "complication of tracheal resection [AND] invasive thyroid cancer". Postoperative complications rate after tracheal sleeve resection with end-to-end anastomosis for thyroid cancer invading tracheal wall range from 15% to 39%. Postoperative mortality is about 1.2%. The most common postoperative complications are: anastomotic dehiscence, airway stenosis, infections and bleeding. Tumor local recurrence can be considered a late on set complication. To conclude, in locally invasive thyroid cancer, en bloc resection of the thyroid with the tracheal segment interested by the tumor provides a good prognosis despite the non-negligible postoperative morbidity rate. Patients' selection and accurate surgical technique performing a tracheal tension-free anastomosis are mandatory to reduce postoperative morbidity and mortality.

Rare complication after thyroidectomy-cervical esophageal stenosis: a case report and literature review

The most common complications after thyroidectomy are injuries associated with the recurrent laryngeal nerve and parathyroid gland. Cervical esophagus perforation is an exceptionally rare complication after thyroidectomy; it can usually be resolved by conservative care. Cervical esophageal stenosis secondary to intraoperative esophageal injury during thyroidectomy is much rarer and has not been reported in the literature to date. We report a case of esophageal stenosis following thyroidectomy performed at a peripheral hospital. The patient initially underwent a thyroidectomy for papillary thyroid carcinoma involving the cervical esophagus; esophageal perforation was noted intraoperatively, and closed using three number 4 silk sutures. Cervical esophageal stenosis subsequently developed after conservative care. The patient was successfully treated with cervical esophagectomy and reconstruction using a tubed forearm free flap after a failed attempt at endoscopic recanalization. This case is discussed in conjunction with a review of the literature.

Management of invasive well-differentiated thyroid cancer: an American Head and Neck Society consensus statement. AHNS consensus statement

BACKGROUND

Invasive differentiated thyroid cancer (DTC) is relatively frequent, yet there is a paucity of specific guidelines devoted to its management. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to provide clinical consensus statements based on review of the literature, synthesized with the expert opinion of the group.

METHODS

An expert panel, selected from membership of the AHNS, constructed the manuscript and recommendations for management of DTC with invasion of recurrent laryngeal nerve, trachea, esophagus, larynx, and major vessels based on current best evidence. A Modified Delphi survey was then constructed by another expert panelist utilizing 9 anchor points, 1 = strongly disagree to 9 = strongly agree. Results of the survey were utilized to determine which statements achieved consensus, near-consensus, or non-consensus.

RESULTS

After endorsement by the AHNS Endocrine Committee and Quality of Care Committee, it received final approval from the AHNS Council.

Management of locally invasive well-differentiated thyroid cancer

Thyroid carcinoma invasion of the aerodigestive tract and recurrent laryngeal nerve (RLN) are important factors with increase in morbidity and mortality. Primary treatment is surgery; the decision about the extent of surgery is difficult, because preserving function is as essential as removal of the tumor. This article discusses the literature relating to the assessment of disease, surgical management, and adjuvant therapy for invasive thyroid cancer of the aerodigestive tract and RLN and makes suggestions based on the authors' experience.

Long-term results and functional outcome after cervical evisceration in patients with thyroid cancer

BACKGROUND

Surgical strategy in patients with thyroid cancer (TC) infiltrating the aerodigestive system is controversial. This study was undertaken to examine the long-term results of cervical evisceration (CE).

PATIENTS AND METHODS

Since 1995, 14 consecutive patients with advanced TC underwent total laryngectomy (LE, n = 6) or esophagolaryngectomy (ELR, n = 8). Patients with unusual thyroid neoplasms or metastases to the thyroid (n = 3) were excluded. For esophageal reconstruction, free jejunal grafts (n = 6) and gastric tubes (n = 2) were used.

RESULTS

Procedure-related morbidity and mortality were 42% and 14%, respectively. ELR was associated with a significant higher frequency of complications and reoperations compared with LE. Twelve-month and 30-month survival rates were 73% and 55%, respectively; 85% of the patients were satisfied with the surgical results. There were no long-term problems concerning food intake in the ELR patients. Two ELR patients were able to learn a substitutive voice.

CONCLUSIONS

Cervical evisceration in patients with TC is associated with significant perioperative morbidity and mortality requiring careful patient selection. Regarding long-term survival, local tumor control, and patient's satisfaction, however, CE should be taken into account in suitable patients with advanced TC.

Advanced thyroid carcinoma: An experience of 385 cases

AIMS

To report clinical outcomes of a large series of cases with advanced thyroid cancer.

STUDY DESIGN

Three hundred and eighty-five patients at the UICC stages III and IV were selected for the study with thyroid cancer.

RESULTS

Papillary carcinoma and sclerosing carcinoma have better survival than the Hürthle cell and insular types. Lymphatic metastasis does not appear to worsen the prognosis. All the tumour forms offer the chance of long survival.

CONCLUSIONS

Surgical treatment is the primary treatment of thyroid carcinoma. The combined treatments of surgery, metabolic beam therapy, suppressive hormone therapy, radiotherapy and chemotherapy cure a high percentage of patients with the tumour at an advanced stage.

Invasive well-differentiated thyroid carcinoma: effect of treatment modalities on outcome

OBJECTIVE

Well-differentiated thyroid carcinoma is considered an indolent malignant disease. Although rare, extrathyroidal invasion is associated with a worse prognosis and increased risk of morbidity. Management remains controversial, with some authors advocating conservative treatment with preservation of midline structures and others, aggressive extensive en bloc resection. The aim of this study was to report our 40-year experience with invasive thyroid carcinoma, with emphasis on the clinical characteristics and the effect of different treatment modalities on survival.

STUDY DESIGN AND SETTING

A retrospective study including a file review of 1,200 patients with a diagnosis of well-differentiated thyroid carcinoma of whom 49 (5%) showed involvement of an adjacent structure (larynx, trachea and esophagus) (study group). Type of surgery, radiation treatment, radioiodine treatment, and patient demographics were evaluated.

RESULTS

Compared to the rest of the patients, the study group was characterized by a higher rate of male patients (39% vs 25%), and older average age (58 vs 45 years). Average size of the primary tumor was 3.7 cm. Sixteen patients underwent radical surgery and 33 conservative surgery followed by radioiodine treatment. Five-year survival and recurrence rates for the whole group were 78% and 52%, respectively. The only statistically significant factor for survival was large tumor size. Distant metastases developed in 46% of patients, all in the lungs. Ten of 14 deaths were due to distant metastases. External radiation, used in 52% of the patients, was associated with worse prognosis.

CONCLUSION

Conservative procedures followed by radioiodine treatment are associated with similar survival rates as aggressive techniques, with less perioperative mortality and lower overall morbidity.

SIGNIFICANCE

This study provides further evidence that in cases of invasive thyroid tumors the extent of the primary surgery seems to have no influence on survival.

EBM RATING

C-4.

Usefulness of preoperative endobronchial ultrasound for airway invasion around the trachea: esophageal cancer and thyroid cancer

BACKGROUND

It is important to confirm preoperative tracheobronchial invasion to enable the selection of the most appropriate treatment.

OBJECTIVE

This study was performed to compare the usefulness of computed tomography (CT), magnetic resonance image (MRI) and bronchoscopy by endobronchial ultrasonography (EBUS) for the assessment of invasion of thyroid or esophageal cancer in cases with suspected tracheobronchial invasion.

METHODS

In cases with suspected contact between the tumor and tracheobronchial wall, CT, MRI and EBUS indicated deformity of the tracheobronchial wall due to the adjacent mass. The final diagnosis was based on surgical and histological results, and/or clinical follow-up.

RESULTS

Fifty-four patients were included in this study. Based on the findings of CT, MRI and EBUS, invasion was suspected in 29, 28 and 25 patients, respectively. Seventeen patients did not undergo surgery based on the results of CT, MRI and bronchoscopy with EBUS. Final diagnosis was intact trachea or bronchial adventitia in 26 patients and invasion in 28 patients. The sensitivity and specificity of CT, MRI and EBUS for invasion were 59 and 56, 75 and 73, and 92 and 83%, respectively. The accuracy of EBUS was significantly greater than that of CT in the present study (p = 0.0011). The accuracy of EBUS was significantly different from that of CT and MRI in the surgically treated patients (p = 0.005 and p = 0.032, respectively).

CONCLUSION

EBUS is the most useful technique for determining the depth and extent of tumor invasion into the airway wall. The combination of MRI and EBUS will contribute to surgical planning in patients with esophageal and thyroid cancer.

Locally advanced differentiated thyroid carcinoma: a 35-year mono-institutional experience in 280 patients

AIM

Debate exists in the literature about the optimal treatment to be adopted in patients with locally advanced differentiated thyroid carcinoma. We aimed to better define the most appropriate diagnostic and therapeutic protocol for this type of tumour.

METHODS

The clinical and histopathological records of 280 consecutive patients with locally advanced differentiated thyroid carcinoma, studied and operated on by the same surgical team in the period between 1967 and 2002, were reviewed.

RESULTS

With regard to overall survival, at univariate statistical analysis, the patient's age at diagnosis (threshold, 45 years), primary tumour size, local cancer extension at diagnosis (subtypes of T4), extent of thyroidectomy, performance of lymph node dissection and performance of post-surgical external radiotherapy were found to be significant prognostic variables. With regard to the appearance of recurrent disease during follow-up, at univariate statistical analysis, the patient's age at initial diagnosis (threshold, 45 years), primary tumour size, local cancer extension at diagnosis (subtypes of T4), extent of thyroidectomy, performance of lymph node dissection, presence of metastatic lymph nodes, performance of post-surgical 131I therapy and performance of post-surgical external radiotherapy were found to be significant prognostic variables. At multivariate statistical analysis, the patient's age at initial diagnosis, extent of tumour, extent of thyroidectomy and performance of lymph node dissection were the only independent prognostic variables.

CONCLUSIONS

In our experience, an aggressive surgical approach at first diagnosis appears to offer a better prognosis in terms of both overall survival and disease-free time interval in patients with locally advanced differentiated thyroid carcinoma, especially those over 45 years of age.

Locally advanced thyroid cancer

PURPOSE OF REVIEW

The purpose of this review is to summarize existing literature with respect to locally advanced thyroid cancer and define the intricacies of preoperative evaluation, surgical management of involved sites and postoperative treatment.

RECENT FINDINGS

Locally invasive thyroid cancer is an uncommon disease process, which carries significant morbidity and mortality. Current treatment modalities include appropriate surgery, radioactive iodine treatment and external beam radiation therapy. Proper evaluation of the extent of disease, with complete gross tumor removal, is paramount in managing this difficult problem. Surgical treatment is still the mainstay for locally advanced thyroid cancer.

SUMMARY

Little progress has been made in advancing the treatment of locally advanced thyroid cancer. Patient identification, evaluation and proper surgical management with adjuvant therapy, still remain the most effective course of treatment. Aggressive surgical treatment including removal of all gross tumor and still preserving vital structures along with adjuvant therapy is likely to offer the best results. There is a very high incidence of locoregional and distant failure in this group of patients. The understanding and recognition of histopathological variations, such as poorly differentiated thyroid cancer is also important. New molecular markers are needed to help identify and predict aggressive tumor behavior.

Management of the locally aggressive thyroid carcinoma

The management of locally advanced thyroid carcinoma can be challenging. Differing philosophies exist for the treatment of invasive disease affecting the upper aerodigestive tract. The ability to maximize local control and overall survival while minimizing the morbidity of a radical resection is the goal of care in these patients. This article will review the literature concerning the presentation, preoperative evaluation, and the subsite treatment of locally aggressive well-differentiated thyroid carcinoma.

Contemporary management of differentiated thyroid carcinoma

This article reviews the recent changes affecting the care of patients with well-differentiated thyroid carcinoma. The impacts of positron emission tomographic imaging, recombinant human thyroid stimulating hormone,and current surgical management standards are discussed.

Locally advanced differentiated thyroid cancer

Although most patients with differentiated thyroid cancer (DTC) of follicular cell origin enjoy a relatively good prognosis, some patients unfortunately present with or develop locally advanced DTC which leads to significant local morbidity and mortality. DTC accounts for 54-94% of all locally advanced thyroid cancers. DTC invasion of the recurrent laryngeal nerve, strap muscles and trachea are the most common followed by invasion of the esophagus, internal jugular vein and carotid artery. Surgical resection is the primary treatment for locally advanced DTC. Although the optimal surgical approach (ranging from conservative shave excision to aggressive en bloc resection of tumor and vital structures) in patients with locally advanced DTC is controversial, a curative resection should be the goal unless complete tumor resection results in unwanted perioperative morbidity and mortality or widely metastatic disease is present. Postoperative radioiodine ablation with TSH suppression is imperative after surgical resection of locally advanced DTC. Patients with microscopic or small gross residual disease, after surgical resection, may benefit from postoperative external radiotherapy for local control of disease.

Functional results and quality of life after tracheal resection for locally invasive thyroid cancer

BACKGROUND

Local invasion of the upper aerodigestive tract by thyroid cancer, although uncommon, is a serious cause of morbidity and mortality. The impact of aerodigestive tract resection on the functional status and quality of life of the patient has not previously been investigated.

METHODS

Patients with locally invasive thyroid cancer were included in a prospective surgical protocol. Swallowing function was assessed with barium swallow at 7 days and 1 month postoperatively. Postoperative quality of life (QOL) was measured using a validated head and neck QOL instrument.

RESULTS

Seven patients underwent airway resection for locally invasive recurrent thyroid cancer in the period 1999 to 2001. At 1 week postoperative 3 of 7 (43%) had no evidence of aspiration on barium swallow. At 4 weeks 6 of 7 (86%) had no aspiration. Postoperative QOL scores in the domains of eating function (85.2) and emotional status (78.6) were significantly better than those of a comparison group undergoing treatment for cancers of the oropharynx, P = 0.012 and P = 0.0077, respectively.

CONCLUSIONS

Tracheal resection for locally invasive thyroid cancer is associated with a return to full dietary intake within 4 weeks of surgery in most cases. Function and QOL after this type of surgery are acceptable.

Using MR imaging to predict invasion of the recurrent laryngeal nerve by thyroid carcinoma

OBJECTIVE

We evaluated the accuracy of MR imaging findings for predicting invasion of the recurrent laryngeal nerve by thyroid carcinoma and established an optimal criterion on which to base this prediction.

MATERIALS AND METHODS

We reviewed MR imaging findings (lesion size and posterior extension of tumor; encirclement of and invasion into the laryngeal cartilage, trachea, and esophagus by the tumor; and the amount of effaced fatty tissue in the tracheoesophageal groove or between the laryngeal cartilage and hypopharyngeal wall) in 66 patients with thyroid carcinoma. The amount of effaced fatty tissue was classified as one of five grades: 1, normal amount of fatty tissue; 2, partly effaced; 3, completely effaced in one MR imaging slice; 4, completely effaced in two contiguous MR slices; and 5, completely effaced in three or more contiguous MR slices.

RESULTS

Thirty-two (48%) of the 66 patients had surgically or pathologically verified recurrent laryngeal nerve invasion. Logistic modeling revealed that the amount of effaced fatty tissue (p < 0.001) and the lesion size (p = 0.033) were the significant factors. Using the threshold values for the lesion size to predict invasion, we found that a threshold of more than 2.9 cm showed the highest accuracy, 76%, with 78% sensitivity and 74% specificity. For the amount of effaced fatty tissue, a grade of 3 or more had the highest accuracy, 88%, with 94% sensitivity and 82% specificity. Addition of the lesion size to this criterion did not improve the diagnostic accuracy of using the amount of effaced fatty tissue alone.

CONCLUSION

Invasion of the recurrent laryngeal nerve by thyroid carcinoma was accurately predicted by the finding of effaced fatty tissue on MR imaging.

Thyroid carcinoma

Thyroid carcinomas are fairly uncommon and include disease types that range from indolent localised papillary carcinomas to the fulminant and lethal anaplastic disease. Several attempts to formulate a consensus about treatment of thyroid carcinoma have resulted in published guidelines for diagnosis and initial disease management. Multimodality treatments are widely recommended, although there is little evidence from prospective trials to support this approach. Surgical resection to achieve local disease control remains the cornerstone of primary treatment for most thyroid cancers, and is often followed by adjuvant radioiodine treatment for papillary and follicular types of disease. Thyroid hormone replacement therapy is used not only to rectify postsurgical hypothyroidism, but also because there is evidence to suggest that high doses that suppress thyroid stimulating hormone prevent disease recurrence in patients with papillary or follicular carcinomas. Treatment for progressive metastatic disease is often of limited benefit, and there is a pressing need for novel approaches in treatment of patients at high risk of disease-related death. In families with inherited thyroid cancer syndromes, early diagnosis and intervention based on genetic testing might prevent poor disease outcomes. Care should be carefully coordinated by members of an experienced multidisciplinary team, and patients should be provided with education about diagnosis, prognosis, and treatment options to allow them to make informed contributions to decisions about their care.

Esophageal invasion by thyroid carcinomas: prediction using magnetic resonance imaging

PURPOSE

We evaluated the accuracy of magnetic resonance imaging (MRI) in predicting esophageal invasion by thyroid carcinomas and established an optimal criterion for diagnosing esophageal invasion.

METHOD

The MRI findings (size and margins of tumor, ratio of tumor contact to the esophagus, shape and displacement of the esophagus, and tumor invasion to the outer and inner layers of the esophagus) in 67 patients with thyroid carcinomas were retrospectively reviewed and correlated with surgical and pathologic findings. Logistic modeling was used to determine the significant factors for predicting esophageal invasion.

RESULTS

Seventeen (34%) of the 67 patients had pathologically or surgically verified esophageal invasion. The logistic modeling revealed that outer layer invasion (P < 0.001) and poorly defined margins (P = 0.001) were the significant factors. The outer layer invasion showed the highest accuracy of 91%, with 82% sensitivity and 94% specificity. The addition of poorly defined margins to this criterion did not improve its accuracy.

CONCLUSION

Esophageal invasion by thyroid carcinoma was accurately predicted with MRI, and an MRI finding of outer layer invasion was optimal for diagnosing esophageal invasion.

[Results of tracheal or esophageal resections in invasive thyroid carcinomas]

STUDY AIM

The aim of this retrospective study was to report results of 21 tracheal or esophageal resections for invasive thyroid carcinomas.

PATIENTS AND METHODS

Between January 1988 and August 2000, 21 patients (mean age: 66 years) had a tracheal (n = 10) or esophageal (n = 11) resection for involvement by an invasive thyroid carcinoma. There were eight undifferentiated carcinomas, 11 papillary, one follicular and one epidermoid carcinomas.

RESULTS

One patient died from pulmonary embolism during the postoperative period. Complications were: tracheal fistula (n = 2), tracheal stenosis (n = 1), esophageal fistula (n = 2), recurrent nerve palsies (n = 8) and hypoparathyroidism (n = 4). Seven patients presented local recurrence and seven presented distant metastases. Ten patients were alive and ten patients died of their carcinoma. The mean survival in this study was 26 months (21 months for anaplastic carcinomas and 41 months for differentiated carcinomas).

CONCLUSION

Differentiated thyroid carcinomas have to benefit from a complete tumoral resection; tracheal or esophageal resection is indicated in case of involvement. Anaplastic carcinomas have a poor prognosis; complete resection is indicated only for selected patients; radiotherapy and chemotherapy are used, because surgery is often impossible.