Resectional treatment for thyroid cancer with tracheal invasion: a long-term follow-up study

Tracheal and Cricotracheal Resection With End-to-End Anastomosis for Locally Advanced Thyroid Cancer: A Systematic Review of the Literature on 656 Patients

Airway involvement by advanced thyroid carcinoma (TC) constitutes a negative prognosticator, besides being a critical clinical issue since it represents one of the most frequent causes of death in locally advanced disease. It is generally agreed that, for appropriate laryngo-tracheal patterns of invasion, (crico-)tracheal resection and primary anastomosis [(C)TRA] is the preferred surgical technique in this clinical scenario. However, the results of long-term outcomes of (C)TRA are scarce in the literature, due to the rarity of such cases. The relative paucity of data prompts careful review of the available relevant series in order to critically evaluate this surgical technique from the oncologic and functional points of view. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement on the PubMed, Scopus, and Web of Science databases. English-language surgical series published between January 1985 and August 2021, reporting data on ≥5 patients treated for TC infiltrating the airway by (C)TRA were included. Oncologic outcomes, mortality, complications, and tracheotomy-dependency rates were assessed. Pooled proportion estimates were elaborated for each end-point. Thirty-seven studies were included, encompassing a total of 656 patients. Pooled risk of perioperative mortality was 2.0%. Surgical complications were reported in 27.0% of patients, with uni- or bilateral recurrent laryngeal nerve palsy being the most common. Permanent tracheotomy was required in 4.0% of patients. Oncologic outcomes varied among different series with 5- and 10-year overall survival rates ranging from 61% to 100% and 42.1% to 78.1%, respectively. Five- and 10-year disease specific survival rates ranged from 75.8% to 90% and 54.5% to 62.9%, respectively. Therefore, locally advanced TC with airway invasion treated with (C)TRA provides acceptable oncologic outcomes associated with a low permanent tracheotomy rate. The reported incidence of complications, however, indicates the need for judicious patient selection, meticulous surgical technique, and careful postoperative management.

Tracheal Resection in the Management of Thyroid Cancer: An Evidence-Based Approach

OBJECTIVE

Determine the effect of patient demographics and surgical approach on patient outcomes after tracheal resection in the management of thyroid cancer.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Systematic review of literature was performed using PubMed, Embase, and Cochrane Library to identify patients with thyroid carcinoma who underwent tracheal resection. Pooled estimates for patient demographics, presenting findings, complications, and outcomes are determined using random-effects meta-analyses.

RESULTS

Ninety-six relevant studies encompassing 1,179 patients met inclusion criteria. Meta-analysis pooled rates of complications: 1.7% (confidence interval [CI] 0.8-2.5; P < .001; I² = 1.85%) airway complications, 2.8% (CI 1.6-3.9; P < .001; I² = 13.34%) bilateral recurrent laryngeal nerve paralysis, 2.2% (CI 1.2-3.1; P < .001; I² = 6.72%) anastomotic dehiscence. Circumferential resection pooled estimates major complications, locoregional recurrence, distal recurrence, overall survival: 14.1% (CI 8.3-19.9; P < .001; I² = 35.26%), 15% (CI 9.6-20.3; P < .001; I² = 38.2%), 19.7% (CI 13.7-25.8; P < .001; I² = 28.83%), 74.5% (CI 64.4-84.6; P < .001; I² = 85.07%). Window resection estimates: 19.8% (CI 6.9-32.8; P < .001; I² = 18.83%) major complications, 25.6% (CI 5.1-46.1; P < .014; I² = 84.68%) locoregional recurrence, 15.6% (CI 9.7-21.5; P < .001; I² = 0%) distal recurrence, 77.1% (CI 58-96.2; P < .001; I² = 78.77%) overall survival.

CONCLUSION

Management of invasive thyroid carcinoma may require tracheal resection to achieve locoregional control. Nevertheless, postoperative complications are not insignificant, and therefore this risk cannot be overlooked when counseling patients perioperatively. Laryngoscope, 131:932-946, 2021.

Tracheal/Laryngeal Infiltration in Thyroid Cancer: a Single-Centre Experience

Around 1/3 of patients of locally advanced carcinoma thyroid present with tracheal infiltration either alone or along with infiltration of other adjacent structures. Even though trachea is infiltrated, adequate resection is the main modality of treatment in these patients. We retrospectively analysed carcinoma thyroid patients who were operated at our institute, between January 2011 and December 2018, and underwent thyroidectomy with tracheal or laryngeal resection. Seventeen patients underwent tracheal/laryngeal resection with thyroidectomy. The mean age of patients was 57 years. Six and eleven were male and female, respectively, 0.14 (82%) patients had dyspnoea on presentation, 6 had hoarseness of voice, 6 had haemoptysis, and in 2 patients, neck swelling was the only complain. Two patients in our study presented with acute stridor, underwent emergency intubation and subsequently surgery. Two other patients had bulky pedunculated tumour in preoperative bronchoscopy and required tracheostomy for intubation before proceeding with surgery. In 11 patients, sleeve resection followed by end-to-end anastomosis was done, window resection was done in 3 patients, partial laryngectomy in 1, and total laryngectomy in 2 patients. In 10 patients (59%), the site of infiltration was in the lateral tracheal wall, with relatively small posterior primary (mean size 3.7 cm) in the thyroid lobe. Two patients developed postoperative complication, one patient with sleeve resection had secondary haemorrhage, and one patient who underwent window resection with myochondrial thyroid lamina flap reconstruction developed salivary fistula. These patients underwent re exploration with tracheostomy and were subsequently decannulated. Preoperative diagnosis of tracheal infiltration helps in better planning of surgery and counseling the patients of any possible complication. Clinical workup and pre-emptive diagnosis is therefore of paramount importance.

A Successful Tracheal Resection and Anastomosis in Papillary Thyroid Carcinoma with Tracheal Invasion

BACKGROUND:

Well-differentiated thyroid carcinoma (DTC) can be locally aggressive, invading aerodigestive tract. The rationale for aggressive surgical resection in this clinical setting is supported by a long-term local control with a positive impact on survival.

CASE REPORT:

A 60-year-old male patient was consulted by a digestive surgeon of unaware thyroid enlargement. Physical and imaging examination showed a suspect of thyroid malignancy. During surgery, we found that a tumour had invaded the anterior side of the trachea. Resection of three tracheal rings was performed, with end-to-end anastomosis. Surgical outcome regarding nervous preservation and parathyroid glands was good as well as cosmetic aspect. During one-year follow-up, no indication of tumour recurrence was found. The management of locally invasive DTC has been controversial yielding the palliative surgery modalities. Advances in surgical technique have given a new perspective of resection in a difficult case. This case report was managed by sleeve resection with end-to-end anastomosis which showed a satisfactory outcome functionally and cosmetically.

CONCLUSION:

Sleeve resection with primary reconstruction of the trachea is a simple one-stage procedure which can adequately address the problem of tracheal invasion by thyroid cancer.

Secondary tracheal tumors: a systematic review

BACKGROUND

Secondary tracheal tumors arise from mural invasion by primary tumors in adjacent organs, metastatic lymph nodes or blood-born metastasis from distant sites. This systematic review aims to assess the presentation, management options, and clinical outcomes of these uncommon non-tracheal malignancies.

METHODS

Electronic searches of the MEDLINE database were performed to identify case series and individual case reports of tracheal invasion by primary non-tracheal tumors or metastatic disease. All English-language studies with available abstracts or articles containing primary data were included.

RESULTS

From 1978 to 2017, a total of 160 case reports or case series identified 2,242 patients with invasion of the trachea by tumors of adjacent organs (n=1,853) or by metastatic lymph nodes or hematogenous spread (n=389). Common primary sites of origin were thyroid, esophagus, and lung, and the most common presentation was metachronous (range of interval: 0 to 564 months) with dyspnea, neck mass, voice change and/or hemoptysis. A majority of patients in case reports (77.9%) and case series (66.0%) underwent resection and the most common reported operation was segmental tracheal resection. Fewer patients underwent bronchoscopic intervention (21.7%) and radiation was used in 32.2% of patients. Complications after bronchoscopic treatment included bleeding, granulation tissue, and retained secretions, while anastomotic leak, unplanned tracheostomy, and new recurrent laryngeal nerve paralysis were observed after surgical resection. The rate of 30-day mortality was low (0.01-1.80%). Median survival was higher in patients with thyroid malignancy and in patients who underwent surgical management. Follow-up time ranged from 0.03 to 183 months.

CONCLUSIONS

Patients with tracheal invasion by metastatic or primary non-tracheal malignancies should be assessed for symptoms, tumor grade, tumor recurrence and concurrent metastases to decide on optimal surgical, bronchoscopic or noninterventional therapy. Clinical experience suggests that palliative endoscopic intervention for tracheal obstruction by metastasis-bearing lymph nodes is underreported.

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.

Sparing Surgery for the Successful Treatment of Thyroid Papillary Carcinoma Invading the Trachea: A Case Report

Published reports on salvage treatment for trachea reconstruction after total thyroidectomy or partial tracheotomy are available, some of them using structures of the trachea itself, auricular cartilage, a musculocutaneous flap, or other methods. In our report, we emphasize the importance of a search for a new material and approach for sparing surgery. The purpose of this article is to describe a case of a successful sparing surgery in a patient with advanced thyroid papillary carcinoma invading the trachea. After total thyroidectomy in 2012, partial resection of the trachea was performed in 2014. The lesion defect was 5.5 × 2.3 cm in size, located between 4 (2nd–6th) tracheal cartilaginous rings and involving about a semicircumference. It was reconstructed with the aid of the knitted TiNi-based mesh endograft, which has been prefabricated in the sternocleidomastoid muscle and further covered with the skin draped over the wound. The tracheostoma was fully closed 6 weeks after the surgery. There were neither side effects nor complications. This kind of tracheal surgery for extensive lesions demonstrates good functional and cosmetic outcomes.

Thyroid cancer with tracheal invasion: a pathological estimation

We review the clinical and pathologic features of seven cases of papillary carcinoma of the thyroid that invaded the trachea and were treated by thyroidectomy, airway resection with reconstructive surgery over an interval of 15 years. We depicted the peculiarity of invasion of well differentiated papillary thyroid carcinoma (PTC) cells is perpendicularly oriented to the tracheal lumen, in between cartilaginous rings, along blood vessels and collagen fibers. Tracheal rings appear non-infiltrated in all histological sections of well differentiated PTC infiltrating the trachea. Similar description of inter-cartilage PTC infiltration into the trachea was first provided by Shin et al. in 1993. Interestingly, our pathological revision support the estimation by Shin et al., though that cartilage rings infiltration did occur in poorly differentiated thyroid cancers with exiguous prognosis.

A Novel Surgical Technique for Thyroid Cancer with Intra-Cricotracheal Invasion: Windmill Resection and Tetris Reconstruction

The most effective treatment for thyroid cancer (TC) invading into the larynx and trachea is a complete surgical resection of the tumor, but currently employed techniques are less than ideal. We report a novel surgical technique, which we named Windmill resection and Tetris reconstruction, for patients with TC invading into the laryngeal lumen. We treated eight cases of TC with invasion into the laryngeal lumen by Windmill resection and Tetris reconstruction. We analyzed complications, clinical data, and pathological findings for all patients. Patients included one man and seven women (mean age 69 ± 10 years). Histopathology of TC indicated papillary cancer in five patients, poorly differentiated cancer in one patient, anaplastic cancer in one patient, and squamous cell carcinoma in one patient. Unilateral recurrent laryngeal nerve (RLN) palsy was confirmed preoperatively by laryngoscope in four patients, and none had bilateral RLN palsy. All patients underwent Windmill resection and Tetris reconstruction along with total thyroidectomy (three patients), subtotal thyroidectomy (three patients), and lobectomy (two patients). Neck dissection was performed in all patients. The average resected length of the larynx and trachea was 29 ± 6 mm. Air leakage at the suture line occurred in three patients; two required further surgery, while the third was closed by insertion of a Penrose drain. Postoperative RLN palsy occurred in five patients. Aspiration was observed in two patients and resolved within 4 weeks. Pneumonia, atelectasis, and pleural effusion occurred in some patients. No other complications, including hemorrhage, wound infection, or airway stenosis, occurred. There was no postoperative mortality and no recurrence at the anastomotic site. Two patients underwent permanent tracheostomy due to permanent bilateral RLN palsy. Two patients, one with anaplastic cancer and the other with poorly differentiated cancer, recurred 13 and 21 months after surgery, while patients with papillary thyroid cancer had no local recurrence. Importantly, laryngeal functions such as phonation and swallowing were preserved in all patients. This novel surgical technique may be as effective as window resection of the larynx for local control of TC and contributes to the quality of life of patients by resulting in a less unsightly surgical wound.

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.

Emergency total thyroidectomy due to non traumatic disease. Experience of a surgical unit and literature review

Background

Acute respiratory failure due to thyroid compression or invasion of the tracheal lumen is a surgical emergency requiring urgent management. The aim of this paper is to describe a series of six patients treated successfully in the emergency setting with total thyroidectomy due to ingravescent dyspnoea and asphyxia, as well as review related data reported in literature.

Methods

During 2005-2010, of 919 patients treated by total thyroidectomy at our Academic Hospital, 6 (0.7%; 4 females and 2 men, mean age: 68.7 years, range 42-81 years) were treated in emergency. All the emergency operations were performed for life-threatening respiratory distress. The clinical picture at admission, clinical features, type of surgery, outcomes and complications are described. Mean duration of surgery was 146 minutes (range: 53-260).

Results

In 3/6 (50%) a manubriotomy was necessary due to the extension of the mass into the upper mediastinum. In all cases total thyroidectomy was performed. In one case (16.7%) a parathyroid gland transplantation and in another one (16.7%) a tracheotomy was necessary due to a condition of tracheomalacia. Mean post-operative hospital stay was 6.5 days (range: 2-10 days). Histology revealed malignancy in 4/6 cases (66.7%), showing 3 primitive, and 1 secondary tumors. Morbidity consisted of 1 transient recurrent laryngeal palsy, 3 transient postoperative hypoparathyroidism, and 4 pleural effusions, treated by medical therapy in 3 and by drains in one. There was no mortality.

Conclusion

On the basis of our experience and of literature review, we strongly advocate elective surgery for patients with thyroid disease at the first signs of tracheal compression. When an acute airway distress appears, an emergency life-threatening total thyroidectomy is recommended in a high-volume centre.

New technology applications: Knotless barbed suture for tracheal resection anastomosis

OBJECTIVES/HYPOTHESIS

Tracheal resection anastomoses are often under tension and can be technically challenging. New suture materials such as V-loc (barbed, knotless wound closure device) may offer advantages over conventional methods. The objective of this study is to determine if a running V-loc suture is of comparable tensile strength to conventional closure.

STUDY DESIGN

Laboratory based study of human cadaveric tissue.

METHODS

Fresh human cadaveric tracheas were dissected and incised into segments. Anastomosis of adjacent segments was then performed with either submucosal interrupted 3-0 Vicryl, or a running submucosal 3-0 V-loc suture. Anastomosed specimens were stretched to failure on an Instron force tension machine. Surgeon satisfaction was recorded by visual analog scale (VAS).

RESULTS

The tensile strength of 12 tracheal anastomoses was tested. Video documentation of V-loc suture technique and anastomosis failure was recorded. In both Vicryl (80%) and V-loc (100%) anastomoses, failure occurred at the membranous intercartilaginous region. In 20% of the Vicryl anastomoses, the suture was noted to break prior to tissue failure. Anastomoses with V-loc suture had equivalent failure force (mean, 59 N) compared to interrupted Vicryl (51 N), with P = .57. On VAS, surgeons were more satisfied with V-loc suture closure compared to interrupted Vicryl closure (paired t test, P = .003).

CONCLUSIONS

Tracheal anastomosis with running v-loc suture is a feasible alternative to conventional closure with interrupted Vicryl suture. V-loc suture provided a surgical advantage by improved ease of use.

The management of thyroid carcinoma invading the larynx or trachea

OBJECTIVES/HYPOTHESIS

To describe the controversies in the management of thyroid carcinoma invading the airway.

STUDY DESIGN

Contemporary review of literature; level of evidence: 5.

RESULTS

Invasion of the larynx or trachea by thyroid carcinoma is uncommon and often identified at the time of operation, when the surgeon must decide the extent of resection. Invasion of the airway is associated with loss of tumor differentiation and a reduction in long-term survival compared to tumors limited to the thyroid gland. Whether or not the invaded airway should be resected remains controversial. Tangential shave excision of tumor is commonly performed, despite a marked risk of local recurrence. Circumferential sleeve resection of the larynx and trachea is safe and lowers the risk of local recurrence. In recurrent disease, laryngotracheal resection provides effective palliation of airway obstruction and hemoptysis.

CONCLUSIONS

Long-term (>10-20 years) prospective studies are required to compare the outcome after shave excision with segmental airway resection for thyroid carcinoma. Based on the current literature and on our experience, we advocate circumferential tracheal resection in the setting of airway involvement.

Surgical approaches to thyroid tumors

This article includes discussions of the surgical approach to benign and malignant disease and the role of prophylactic thyroidectomy and nodal dissection for medullary thyroid cancer. The controversy regarding the extent of dissection for differentiated thyroid cancer and the role of lymph node dissection are reviewed also. A description of the authors' surgical technique for thyroidectomy is detailed. Finally, several emerging technologies are introduced.

Lateral Mobilization of the Recurrent Laryngeal Nerve to Facilitate Tracheal Surgery in Patients with Thyroid Cancer Invading the Trachea Near Berry’s Ligament

BACKGROUND

Thyroid cancer often invades the trachea and the recurrent laryngeal nerve (RLN) at or near Berry's ligament, which fixes the thyroid gland to the trachea. In patients with thyroid cancer invading the trachea near the ligament, preservation of the RLN is very difficult. Regardless of whether the nerve is preserved or is resected and reconstructed, the presence of the nerve interferes with tracheal resection and repair. We proposed a new technique to solve this problem.

METHODS

Before tracheal surgery, the inferior pharyngeal constrictor muscle was divided along the lateral edge of the thyroid cartilage, and the RLN was mobilized and retracted laterally. We applied this technique in 11 patients with papillary thyroid carcinoma invading the trachea. Two patients demonstrated vocal cord paralysis preoperatively. The procedures used for tracheal surgery in this series were partial resection of the trachea with creation of a tracheocutaneostomy, that with direct suture, and shaving off the tumor in 7, 2, and 2 patients, respectively.

RESULTS

The RLN could be preserved and mobilized laterally in eight patients. While three patients demonstrated transient vocal cord paralysis, the remaining five had functioning cords postoperatively. In three patients the RLN was resected, and the remaining distal stump was mobilized and anastomosed with the ansa cervicalis. These patients recovered their voices and maximum phonation time increased to the normal level. The tracheocutaneous stoma was closed with local skin flap about four months later in all patients.

CONCLUSION

Lateral mobilization of the RLN facilitates the preservation of the nerve and the performance of tracheal surgery in patients with thyroid cancer invading the trachea at or near Berry's ligament.

Segmental Laryngotracheal and Tracheal Resection for Invasive Thyroid Carcinoma

BACKGROUND

Laryngotracheal invasion worsens prognosis in patients with thyroid carcinoma. The extent of resection is controversial.

METHODS

We performed a retrospective study of patients with thyroid carcinoma and invasion of the larynx or trachea between 1964 and 2005.

RESULTS

Eighty-two patients, mean age 64 years and 50% female, underwent segmental airway resection. Differentiated carcinoma was present in 76% (62 of 82 patients), prior tracheal "shave" procedures in 40% (33 of 82 patients), transmural invasion in 58% (48 of 82 patients), and preoperative vocal cord paralysis in 35% (29 of 82 patients). There were 29 tracheal and 40 laryngotracheal resections (reconstruction group: 69 patients); 5 underwent laryngectomy, 7 cervical exenteration, and 1 tracheal resection after exenteration (salvage group: 13 patients). Operative mortality was 1.2% (1 of 82 patients) and anastomotic dehiscence 4.3% (3 of 69 patients). Tracheostomy was permanent in 4.3% (3 of 69 patients). Mean follow-up was 6.1 years. After reconstruction, mean survival was 9.4 years and 10-year survival was 40%; after salvage, these were 5.6 years and 15%, respectively. In differentiated carcinoma, thyroidectomy, immediate shave procedure, and delayed (mean, 67 months) resection of airway recurrence in 15 patients resulted in overall and disease-free survival of 13.1 and 5.1 years, respectively, compared with 17.9 and 14.6 years, respectively, after thyroidectomy and early airway resection in 11 patients. Airway symptoms, metastases at presentation, recurrent disease, and salvage operation were associated with decreased survival; airway resection early after thyroidectomy, complete resection, and well-differentiated tumors were associated with improved prognosis.

CONCLUSIONS

Segmental airway resection for invasive thyroid cancer is safe, preserves the voice, and relieves airway obstruction. Complete resection of laryngeal and tracheal invasion during or early after thyroidectomy is associated with improved survival.

A 29-year retrospective review of papillary thyroid cancer in one institution

OBJECTIVE

The goal of this study was to determine whether conservative surgical therapy had been adequate for low-risk patients with papillary thyroid cancer.

STUDY DESIGN AND PATIENTS

1,931 patients were categorized as either low risk or high risk, using tumor-node-metastasis (TNM) staging from the sixth edition of International Union Against Cancer (UICC); TNM stage I was designated low risk during this retrospective review.

MAIN OUTCOMES

After an average follow-up period of 8.7 years, 58 of 1,931 patients (3.0%) died from thyroid cancer. Ten-year survival rates of papillary thyroid carcinoma from sixth edition TNM stages I to IV are 99.7%, 95.6%, 90.7%, and 84.0%, respectively. Age, tumor size, (131)I therapeutic dose, and follow-up status were statistically significant when comparing high- and low-risk groups. Of the 1,432 patients in stage I, 338 underwent conservative surgical procedures. Among 338, 4 patients died of thyroid carcinomas (1.2%) and 15 (4.4%) had persistent or recurrent disease. In contrast, 2 of the 1,094 (0.2%) patients who received near-total thyroidectomy or limited lymph node dissection died from thyroid cancer, and 32 (2.9%) had persistent or recurrent disease.

CONCLUSIONS

TNM stage I papillary thyroid carcinomas were with low cancer-specific mortality rate; otherwise, patients aged 45 years or younger should not be considered a homogeneous low-risk group. Initial extent of disease was an important predictor among these patients. In particular, local invasion with airway compression predicts outcomes.

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.

Inadvertent tracheal perforation during thyroidectomy

Valuable advice for thyroid surgeons

Aerodigestive Tract Invasion by Well-Differentiated Thyroid Carcinoma: Diagnosis, Management, Prognosis, and Biology

OBJECTIVES/HYPOTHESIS

1) To describe the clinical entity invasive well-differentiated thyroid carcinoma (IWDTC), 2) to determine prognostic factors for survival in patients with IWDTC, 3) to describe and compare types of surgical resection to determine treatment efficacy, 4) to offer a staging system and surgical algorithm for management of patients with IWDTC, 5) to examine alterations in expression of E-cadherin and beta-catenin adhesion molecules in three groups of thyroid tissue and propose a cellular mechanism for invasion of the aerodigestive tract.

STUDY DESIGN

Basic science: quantification of expression of E-cadherin and beta-catenin in three groups of thyroid tissue. Clinical: retrospective review of patients with IWDTC surgically treated and followed over a 45-year time period.

METHODS

Basic science: immunohistochemical staining was used with antibodies against E-cadherin and beta-catenin in three groups of tissue: group 1, normal control thyroid tissue (n = 10); group 2, conventional papillary thyroid carcinoma (n = 20); group 3, IWDTC (n = 12). Intensity scores were given on the basis of protocol. One-way analysis of variance (ANOVA) was used to evaluate differences between groups. Post hoc ANOVA testing was completed. P < .05 was significant. Clinical: patients were divided into three surgical groups within the laryngotracheal subset: group 1, complete resection of gross disease (n = 34); group 2, shave excision (n = 75); group 3, incomplete excision (n = 15). Cox regression analysis was used to determine significance of prognostic factors. Kaplan-Meier plots were used to evaluate survival. P < .05 was significant.

RESULTS

Basic science: a significant difference between the three thyroid tissue groups for E-cadherin expression was demonstrated on one-way ANOVA testing. When controls were compared with either experimental group in post hoc ANOVA testing, differences between all groups were demonstrated (P < .001). For beta-catenin, the intensities of the three groups were not different by one-way ANOVA testing. Similar nonsignificant results were found on post hoc ANOVA testing. Clinical: there was a statistically significant difference in survival for patients with and without involvement of any portion of the endolarynx or trachea (P < .01). There was a significant difference among all three surgical groups when compared (P < .001). When complete and shave groups were compared with gross residual group there was a significant decrease in survival in incomplete resection group (P < .01). Cox regression analysis demonstrated invasion of larynx and trachea were significant prognostic factors for poor outcome. The type of initial resection was significant on multivariate analysis. Removal of all gross disease is a major factor for survival.

CONCLUSIONS

Basic science: there is a decrease in membrane expression of E-cadherin in IWDTC, and loss of this tumor suppressor adhesion molecule may contribute to the invasive nature of well-differentiated thyroid carcinomas. Clinical: laryngotracheal invasion is a significant independent prognostic factor for survival. Patients undergoing shave excision had similar survival when compared with those undergoing radical tumor resection if gross tumor did not remain. Gross intraluminal tumor should be resected completely. Shave excision is adequate for minimal invasion not involving the intraluminal surfaces of the aerodigestive tract.

Aggressive resection of the airway invaded by thyroid carcinoma

BACKGROUND

The aim of this study was to investigate the hypothesis that outcome following concomitant airway resection is superior to that after shaving of the tumour in patients with airway invasion of thyroid carcinoma.

METHODS

The records of 34 patients with thyroid cancer with airway invasion were reviewed retrospectively. In addition to total thyroidectomy, airway resection was performed in 18 patients (group 1), whereas the tumour was shaved away from the airway in the other 16 patients (group 2). 131I was used as postoperative adjuvant therapy in all patients. Metastasis and recurrence of the primary lesion were determined by 131I whole-body scans, serum thyroglobulin levels, and computed tomography or ultrasonography of the neck.

RESULTS

In group 1, two anastomotic dehiscences resulted in one death. Patients in group 2 had a higher rate of local recurrence (relative risk 8.0, P = 0.013) and earlier recurrence (mean(s.e.m.) 2.6(0.8) versus 7.0(1.1) years; P = 0.026) than those in group 1. Median survival was 5.8 and 4.3 years in the 18 patients of group 1 and 16 patients of group 2 (P = 0.259), and the respective 5-year survival rates were 88 and 84 per cent (P = 0.783).

CONCLUSION

Aggressive airway resection can minimize local recurrence of thyroid carcinoma with airway invasion.

Ultrasonography as a Method of Screening for Tracheal Invasion by Papillary Thyroid Cancer

PURPOSE

To assess the reliability of ultrasonography (US) for detecting tracheal invasion by papillary thyroid cancer (PTC).

METHODS

We reviewed the clinical and surgical data of 509 patients who underwent surgery for primary PTC during 2003, after routine preoperative US.

RESULTS

Ultrasonography showed possible tracheal invasion in 43 of the 509 patients. However, the US findings could not be evaluated in 32 patients because of high tumor calcification, a tumor diameter greater than 4 cm, or tumor extension inferior to the clavicle. We shaved the tracheal wall in 11 patients and resected the tracheal wall in 2 patients. The sensitivity of US for diagnosing of tracheal invasion was 91%, the specificity 93%, the predictive value of a positive test 25%, the predictive value of a negative test 99%, and the accuracy 93%.

CONCLUSION

Ultrasonography is a useful method of screening for tracheal invasion. A negative sonogram is a reliable indicator of the absence of tracheal invasion, except when tumors are highly calcified or extend inferior to the clavicle.

Surgical management of laryngotracheal stenosis in adults

The purpose was to evaluate the outcome following the surgical management of a consecutive series of 26 adult patients with laryngotracheal stenosis of varied etiologies in a tertiary care center. Of the 83 patients who underwent surgery for laryngotracheal stenosis in the Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital of Lausanne, Switzerland, between 1995 and 2003, 26 patients were adults (> or = 16 years) and formed the group that was the focus of this study. The stenosis involved the trachea (20), subglottis (1), subglottis and trachea (2), glottis and subglottis (1) and glottis, subglottis and trachea (2). The etiology of the stenosis was post-intubation injury ( n = 20), infiltration of the trachea by thyroid tumor ( n = 3), seeding from a laryngeal tumor at the site of the tracheostoma ( n = 1), idiopathic progressive subglottic stenosis ( n = 1) and external laryngeal trauma ( n = 1). Of the patients, 20 underwent tracheal resection and end-to-end anastomosis, and 5 patients had partial cricotracheal resection and thyrotracheal anastomosis. The length of resection varied from 1.5 to 6 cm, with a median length of 3.4 cm. Eighteen patients were extubated in the operating room, and six patients were extubated during a period of 12 to 72 h after surgery. Two patients were decannulated at 12 and 18 months, respectively. One patient, who developed anastomotic dehiscence 10 days after surgery, underwent revision surgery with a good outcome. On long-term outcome assessment, 15 patients achieved excellent results, 7 patients had a good result and 4 patients died of causes unrelated to surgery (mean follow-up period of 3.6 years). No patient showed evidence of restenosis. The excellent functional results of cricotracheal/tracheal resection and primary anastomosis in this series confirm the efficacy and reliability of this approach towards the management of laryngotracheal stenosis of varied etiologies. Similar to data in the literature, post-intubation injury was the leading cause of stenosis in our series. A resection length of up to 6 cm with laryngeal release procedures (when necessary) was found to be technically feasible.

Resection and reconstruction of the airway in patients with advanced thyroid cancer

The prognosis of patients with differentiated thyroid cancer is relatively fair, with a 10-year survival rate above 80%. One of the important prognostic factors is cancer invasion to the airway. For the last 25 years we have been performing combined resection of the trachea and larynx and have reported a relatively good 10-year survival (67.7%) and improved quality of life (QOL). However, operative complications associated with the procedure, especially insufficiency of the anastomosis and bleeding from large vessels, are life-threatening. Of 40 patients who underwent resection of the trachea, insufficiency of the anastomosis occurred in 4 and subsequent massive bleeding from carotid artery due to neck infection in 2. Tracheal resection should be carried out carefully by avoiding insufficiency. We have concluded that combined resection is a good treatment choice for survival and good QOL when performed for local control in patients with differentiated thyroid cancer.

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.

Tracheal reconstruction under tension: an experimental study in sheep

AIMS

Invasion of the trachea by thyroid cancer is a difficult problem. Circumferential resection and end-to-end reconstruction is the treatment of choice. The objective of our study was to investigate the effect of tension on tracheal healing and stenosis formation, and to ascertain the maximum tolerable tension.

METHODS

Tracheal resections of 3, 6 and 9 cm with end-to-end anastomosis were performed on 25 sheep. The intraoperative force required for approximation of the tracheal stumps was measured. Luminal stenosis was determined with the aid of computerized planimetry 1, 2, 4, 8 and 24 weeks post-operatively.

RESULTS

A gradual increase of the stenosis rate occurred with increasing tension on the anastomosis. Acceptable results were achieved in the majority of cases without release techniques or tension suture.

CONCLUSIONS

Tracheal anastomosis under tension does not always lead to disruption or separation of the anastomosis. With the additional use of release manoeuvres and tension sutures, tracheal anastomosis under tension are possible without severe stenosis. The additional use of temporary stenting needs to be elucidated.

Influence of suture material and technique on end-to-end reconstruction in tracheal surgery: an experimental study in sheep

Resection and end-to-end anastomosis of the trachea represent the preferred treatment for various benign and malignant diseases involving the trachea. Various studies have reported conflicting results with alternative techniques and suture materials for tracheal anastomosis. Our objective was to evaluate three frequently used techniques concerning stenosis rate and histological reaction in a large-animal species. Tracheal resection of 3 cm and end-to-end anastomosis were performed in 15 sheep with the use of three different techniques. In the first group, an interrupted suture with polyglactin, in the second group an interrupted suture with polydioxanone, and in the last group a continuous suture with polypropylene were used. The animals were killed 1, 2, 4, 8, and 24 weeks postoperatively. The luminal stenosis was determined by means of computerized planimetry. All three techniques appeared to be appropriate for tracheal anastomosis. The luminal stenosis developed within the first 8 weeks after surgery. A cross-sectional area of approximately 40-70% was finally achieved. Differences dependent on the suture material are less important than the technical details of the operation.