Pharyngolaryngoesophagectomy for well-differentiated papillary thyroid carcinoma widely invading the upper aerodigestive tract

Cervical exenteration and its variants for locally advanced thyroid cancer: when, why, and how?

PURPOSE OF REVIEW

To describe the modern surgical approach for management of advanced thyroid cancers infiltrating the cervicovisceral axis with special attention to well differentiated tumors not amenable to organ-sparing techniques. In particular, cervical exenteration, herein defined as the sum of total thyroidectomy, central compartment and lateral neck dissections, variously associated with total laryngectomy and possible partial or total pharyngoesophagectomy, represents an extreme surgical procedure that, in properly selected cases, allows for reasonable palliation of central compartment life-threatening signs/symptoms if not cure for an advanced oncologic condition.

RECENT FINDINGS

Cervical exenteration is not contraindicated by the presence of limited distant metastases at presentation. Even though it requires that the patient is in general good health as it can be associated with a number of complications and long in-hospital stay, when appropriately planned and performed according to the most recent reconstructive nuances, it allows good oncologic outcomes that are not inferior to those described for similarly advanced primaries of the upper aerodigestive tract. In addition, quality of life and functional results are not significantly different from those described after total laryngectomy for primary laryngeal squamous cell carcinomas.

SUMMARY

Cervical exenteration requires a tertiary, expert, multidisciplinary effort in terms of diagnosis, surgical performance, and postoperative care. A patient-centered decision process is strongly warranted taking into consideration alternative therapeutic and symptom-based palliative strategies.

The role of laryngectomy in locally advanced thyroid carcinoma. Review of 16 cases

SUMMARY

Locally advanced disease with larynx invasion is a challenge to the surgeon, but laryngectomy is almost never necessary in thyroid carcinoma. The aim of this study was to review the clinical outcomes of patients with locally advanced thyroid carcinoma invading the larynx who underwent laryngectomy. A case series of patients treated in a tertiary care hospital was reviewed. Data about the type of operation, method of reconstruction, complications and overall survival of 16 patients operated on between 2002 and 2015 with larynx invasion is presented. There were 10 females. The mean age was 63 ± 8.8 years. Besides total thyroidectomy and neck dissection, four patients underwent total pharyngolaryngectomy, 11 total laryngectomy and one hemi-laryngectomy. Reconstruction was made with regional flaps in 10 patients (7 pectoral/Bakamjian flaps and 3 gastric pull-through procedures) and a jejunum free flap in one patient. Two patients needed carotid artery reconstruction. Five tumours were classic (conventional) papillary carcinoma variants, while the others were aggressive histological varieties (insular, tall cell, sclerosing). The mean tumour size was 4.3 ± 1.6 cm. All tumours had lymphovascular invasion and 12 had positive lymph nodes. Concomitantly, oesophageal/hypopharyngeal invasion was present in 7 cases and invasion of carotid vessels in 2 cases. There were two postoperative deaths and two anastomotic leaks that were treated conservatively. The mean overall survival was 31 ± 33 months (median 27.6 months, range 0-120). Laryngectomy is an alternative surgical procedure to control selected cases of advanced thyroid carcinoma that offers good local control and long term survival.

Thyroid cancer: surgery for the primary tumor

Surgery is the mainstay of therapy for most patients who present with thyroid cancer. The surgeon must select an appropriate procedure based upon pre operative factors such as tumor histology, extent of primary disease, the presence of regional or distant metastases, associated disease in the contralateral thyroid lobe and the potential for post operative adjuvant therapy. Preservation of the vital structures in the central neck, including the recurrent and superior laryngeal nerves and the parathyroid glands is critical as is the maintenance of absolute hemostasis. In this review article we describe the management of Well Differentiated Thyroid Cancer (WDTC) presenting as a solitary nodule, WDTC in a background of multinodular disease and the management of WDTC presenting as advanced local disease. We go onto discuss the impact that regional and distant metastases have on the choice of surgical approach. The focus of this article is WDTC, however the principles of management of the primary in medullary and anaplastic carcinoma are also discussed.

Clinical outcome of different modes of resection in papillary thyroid carcinomas with laryngotracheal invasion

AIM

The aim of this study is to evaluate the outcome of different modes of resection in papillary thyroid carcinoma (PTC) with laryngotracheal invasion.

MATERIALS AND METHODS

Sixty-four primary PTCs with laryngotracheal invasion between 1964 and 2003 were retrospectively analyzed (17 men and 47 women; mean age, 61.6 years; mean follow-up, 92.3 months). Thirteen curative resections included six pharyngolaryngoesophagectomies, two total laryngectomies, and five circumferential resections (complete surgery). Eighteen patients who were candidates for curative resection refused to undergo complete surgery to avoid functional impairment, especially laryngeal function (incomplete surgery). Thirty-three patients with minimal invasion underwent shave or partial resection (conservative surgery). Clinical outcomes were compared between the three groups. The influence of different types of surgery and invasion was also evaluated by Cox proportional hazard analysis.

RESULTS

Three (23.1%) complete, 17 (94.4%) incomplete, and 4 (13.8%) conservative surgery patients died of disease (P < 0.0001). The 10-year disease-specific survival (Kaplan-Meier) in complete, incomplete, and conservative surgery patients were 62.9, 11.1, and 87.7%, respectively (log rank test, P < 0.0001). Incomplete surgery related to worse prognosis [p < 0.0001; hazard ratio (HR), 12.9) than complete or conservative surgery. Tracheal deep invasion (p = 0.0019, HR 7.6) and larynx invasion (p < 0.0001, HR 9.9) related to worse prognosis than minimal invasion.

CONCLUSION

Curative resection improves clinical outcomes in PTCs with laryngotracheal invasion. Conservative resection for minimal invasion also can achieve favorable prognosis. The degree of tumor invasion is significantly related to survival.