Surgical treatment of invasion of the upper aerodigestive tract by well-differentiated thyroid carcinoma

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.

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.

Tracheal reconstruction using composite nasal septal graft in patients with invasive thyroid carcinoma

OBJECTIVE

This paper presents a series of three patients who were identified as having partial thickness involvement of the laryngotracheal complex secondary to invasive, well-differentiated thyroid cancer. These patients were managed with full thickness window resection and reconstruction using a composite nasal septal graft.

METHODS

A review of the Princess Alexandra Hospital database (comprising prospectively collated data) was undertaken to identify patients who had undergone full thickness tracheal resection and reconstruction using a composite nasal septal graft; demographic, operative technique and survival outcome data were collated.

RESULTS

Three patients had a composite nasal septal graft performed for reconstruction of full thickness laryngotracheal defects following the excision of well-differentiated thyroid cancer. There were no cases of local recurrence after a minimum of 18 months' follow up.

CONCLUSION

This paper describes our surgical technique for reconstruction of these defects using a composite nasal septal graft. It also presents data on our three cases to date, in which the technique has been used safely. A discussion of the surgical management of locally invasive, well-differentiated thyroid cancer is provided.

Risk factors for recurrence of papillary thyroid carcinoma with clinically node-positive lateral neck

BACKGROUND

Papillary thyroid carcinoma (PTC) with clinically node-positive lateral neck is more likely to recur after surgery than node-negative PTC. The present study investigated the risk factors for recurrence in PTC patients with clinically node-positive lateral neck.

MATERIALS AND METHODS

This study involved 136 patients with pathologically confirmed PTC and a clinically lymph node (LN)-positive lateral neck but no initial distant metastasis who underwent total thyroidectomy with therapeutic central and lateral neck dissection. Clinicopathologic characteristics, intraoperative findings, postoperative thyroglobulin (Tg) levels, and post-treatment recurrences were examined. Univariate and multivariate analyses were performed to identify factors associated with recurrence-free survival (RFS).

RESULTS

During a median follow-up of 62 months (range 33-90 months), 27 (19.9 %) patients had locoregional or distant recurrences. Univariate analyses showed that primary tumor size (p = 0.049), recurrent laryngeal nerve invasion (p = 0.035), the maximal size of metastatic LN foci (≥1.5 cm; p = 0.012), extranodal extension (p = 0.025), total LN ratio (≥0.26; p = 0.008), American Thyroid Association (ATA) risk categories (p < 0.001), and stimulated serum Tg level (≥4.4; p < 0.001) at the time of radioactive iodine ablation therapy just after thyroidectomy were significant predictors of RFS. Multivariate analyses showed that the maximal size of metastatic foci (p = 0.037), ATA risk categories (p < 0.001), and stimulated Tg level (p < 0.001) were independent predictors of RFS.

CONCLUSIONS

Maximal size of metastatic foci, ATA risk categories, and stimulated serum Tg levels are predictive of recurrence after surgery. Careful follow-up of patients with these risk factors is therefore recommended.

Classification of aerodigestive tract invasion from thyroid cancer

BACKGROUND

Widely invasive extrathyroidal thyroid cancer invading the aerodigestive tract (ADT) including larynx, trachea, hypopharynx, and/or esophagus occurs in 1-8 % of patients with thyroid cancer and is classified as T4a (current UICC/AJCC system). The T4a stage is associated with impaired tumor-free survival and increased disease-specific mortality. Concerning prognosis and outcome, further subdivisions of the T4a stage, however, have not been made so far.

METHODS

This study is based on a systematic review of the relevant literature in the PubMed database.

RESULTS

Retrospective studies suggest a better outcome in patients with invasion of the trachea or the esophagus when compared to laryngeal invasion. Regarding surgical strategies, ADT invasion can be classified based on a three-dimensional assessment determining surgical resection options. Regardless of the invaded structure, tumor infiltration of the ADT can be subdivided into superficial, deep extraluminal, and intraluminal invasion. In contrast to superficial ADT invasion, allowing tangential incomplete wall resection (shaving/extramucosal esophagus resection), deeper wall and intraluminal invasions require complete wall resection (either window or sleeve). Based on the Dralle classification (types 1-6), particularly airway invasion, can be further classified according to the vertical and horizontal extents of tumor invasion.

CONCLUSIONS

The Dralle classification can be considered as a reliable subdivision system evaluated regarding surgical options as well as oncological outcome. However, further studies determining the prognostic impact of this technically oriented classification system are required.

[Extrathyroidal thyroid cancer : results of tracheal shaving and tracheal resection]

Extrathyroidal thyroid cancer invading the laryngotracheal system (UICC stage pT4a) represents a progressive process of infiltration of the tracheal wall layers from the outer to the inner parts of the trachea. These tumors usually present with high proliferation activity correlating with a reduced long-term prognosis. In contrast to intraluminal manifestation requiring complete wall resection, in cases of non-transmural invasion, complete tumor removal can be sometimes achieved by extraluminal tangential resection (shaving). Tangential resections, however, are associated with a higher frequency of microscopically invaded resection margins (R1 resection rate >40%). The available comparative studies (all retrospective, maximum EBM level 3) analyzing oncological outcome show inconsistent results. In more recently published studies, however, complete wall resection in well-differentiated thyroid cancer with tracheal invasion only was found to be associated with longer recurrence-free and tumor-specific survival when compared to shaving. Deep larynx invasion is associated with reduced long-term prognosis when compared to invasion of the trachea. Salvage resections should therefore be performed in selected cases only.

[Cervicovisceral resection in invasive thyroid tumors]

About 6% of patients with thyroid cancer present with life-threatening tumor invasion of the trachea and/or esophagus. The extent of resection depends on tumor diagnosis and stage (indication only in differentiated and perhaps medullary thyroid cancer without extrapulmonary metastases), extent of aerodigestive invasion, and general health state of the patient. After complete tumor resection, 5-year and 10-year survival rates of 40-75% can be achieved. Incomplete tumor resection however has a negative effect on prognosis. Tangential tumor resection (shaving) is indicated if no transmural invasion of trachea/esophagus has occurred. Tracheal resection can be subdivided into six standard procedures--types 1 and 2: laryngotracheal or tracheal window resection; types 3 and 4: circular resection with primary reconstruction infraglottic or tracheal; and types 5 and 6: laryngectomy and cervical evisceration.

Palliation of advanced thyroid malignancies

While most thyroid cancers are slow-growing and have an excellent prognosis after appropriate treatment, a subset of thyroid cancers behave aggressively, and approximately 1500 individuals in the US will die of the disease in the year 2007. Advanced thyroid malignancies can cause distressing and life-threatening symptoms by local invasion in the neck, growth of distant metastases in the lung, bone, and other organs, and tumor production of bioactive substances in the case of medullary thyroid cancer. This article will review palliative modalities, including surgery, radioactive iodine, external beam radiation, and chemotherapy, as well as novel targeted therapies, for the treatment of patients with advanced thyroid malignancies.

Highly invasive papillary thyroid carcinoma

Papillary carcinoma is the most common malignant tumour of the thyroid gland, accounting for at least two-thirds of newly diagnosed carcinomas. This tumour may be occasionally multicentric in origin. It frequently spreads to regional lymph nodes in the neck and mediastinum, but uncommonly metastasizes outside these regions. Local invasion of this tumour to the upper airway or digestive tract structures is infrequent. However, when that occurs, it is a source of significant morbidityand mortality.

In the last two years four patients suffering from invasive papillary carcinoma to the aerodigestive tract were treated in our department. A short case history of one of them is presented and current trends in management of the disease are reviewed.

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.

The role of postoperative external-beam radiotherapy in the management of patients with papillary thyroid cancer invading the trachea

PURPOSE

To determine the role of adjuvant external-beam radiotherapy (EBRT) in the management of patients with well-differentiated thyroid cancer invading the trachea.

METHODS AND MATERIALS

Of 1,098 thyroid cancer patients, 68 (6%) were found to have tracheal invasion, and they all received "shave" excision of the tracheal cartilage. Among them, 12 patients had no postoperative residuum, 43 patients had microscopic residuum, and 13 patients had macroscopic residuum. All patients were divided into two groups according to treatment modality with or without EBRT; (1) the control group (n = 43) and (2) the EBRT group (n = 25).

RESULTS

The locoregional recurrence rate for EBRT patients was much lower than that of control patients (51% for the control group vs. 8% for the EBRT group) (p < 0.01). The 10-year local progression-free survival rate for the EBRT group was significantly better than that of the control group (89% in the EBRT group vs. 38% in the control group) (log-rank, p < 0.01). The use of adjuvant EBRT after conservative surgery was an independent prognostic factor in univariate and multivariate analyses.

CONCLUSIONS

External-beam radiotherapy was found to be effective, particularly in patients with thyroid cancer invading the trachea with microscopic or gross residuum after conservative surgery.

Differentiated thyroid cancer invading the hypopharynx: A case report

Most thyroid cancers (90-95%) are well differentiated. Well differentiated cancers of the thyroid are usually confined to the thyroid capsule, making them amenable to isolated thyroid resection. Invasion of the upper aerodigestive tract by these cancers is infrequent and hypopharyngeal invasion is still rare. We report a 51 year old man with thyroid cancer invading the hypopharynx, who was successfully managed with complete resection along with a partial pharyngectomy. He is asymptomatic and disease free eighteen months after surgery. We advocate aggressive surgical extirpation of thyroid carcinoma invading the upper 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.

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.

Recurrent laryngeal nerve palsy in well-differentiated thyroid carcinoma: clinicopathologic features and outcome study

Involvement of the recurrent laryngeal nerve (RLN) by well-differentiated thyroid carcinoma may not invariably lead to unilateral cord palsy, although the presence of RLN palsy is associated with locally advanced disease. The present study evaluates the clinicopathologic features and outcomes of patients surgically treated for well-differentiated thyroid carcinoma with documented nonfunctioning RLN at presentation. From 1970 to 2002, 20 of 709 patients undergoing surgical treatment for well-differentiated thyroid carcinoma were found to have ipsilateral unilateral cord palsy by routine preoperative laryngoscopy. There were 5 men and 15 women with a median age of 70 years. Nine patients (45%) did not have a clinically palpable thyroid mass, and hoarseness was the primary presenting symptom. All patients had histologically confirmed pT4 papillary thyroid carcinoma with a median size of 4 cm. Cervical nodal and pulmonary metastases were detected in 14 (70%) and 2 (10%) patients, respectively. The ipsilateral recurrent nerve was transected in all patients because of gross tumor involvement, and 19 patients underwent total or completion total thyroidectomy. Resection was incomplete in 15 patients, including 2 who underwent a debulking procedure and required reoperation for local control. Postoperative radioactive iodine ablation and external-beam irradiation were administered to 18 and 13 patients, respectively. Over a median follow-up of 4.5 years, 10 patients survived without evidence of recurrence, 5 died of disease recurrence, and 5 died of unrelated causes. The 5-year and 10-year cause-specific mortality was 17% and 42%, respectively. Patients developing distant metastasis at presentation or during follow-up had a significantly increased cause-specific mortality (p = 0.002). Preoperative RLN palsy can be the first symptom in patients with locally advanced papillary thyroid carcinoma. Despite the adoption of a relatively conservative surgical treatment, long-term survival can be achieved in selected patients.

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.

Survival analysis of rats implanted with porous titanium tracheal prosthesis

BACKGROUND

Surgical treatment of a malignancy in the trachea may lead to a long resection that has to be reconstructed with an artificial prosthesis. However, most of the available prostheses encounter inflammatory rejection and mechanical constraint problems. To improve tracheal rehabilitation a porous titanium prosthesis was developed. The aim of this study was to test the biocompatibility of this novel material.

METHODS

Seventeen rats had a partial tracheal prosthesis made of porous titanium inserted in the cervical trachea. The histologic analysis of the tissue surrounding the prosthesis was performed in 11 surviving animals after a period of 15 to 41 days.

RESULTS

Fibroblast colonization of titanium pores and a ciliary cylindrical epithelial layer developed on the endoluminal side of the prosthesis and the inflammatory reaction was minimal.

CONCLUSIONS

The results of this short-term study validate, from surgical and histologic standpoints, the usefulness of a porous titanium tracheal prosthesis.

Tracheal invasion by thyroid carcinoma: prediction using MR imaging

OBJECTIVE

The purpose of this study was to evaluate the accuracy of MR imaging in predicting tracheal invasion by thyroid carcinomas and to determine MR imaging criteria for diagnosing tracheal invasion.

MATERIALS AND METHODS

MR imaging was performed on the normal trachea of one cadaver and 30 healthy subjects as a standard of reference. Then, MR imaging findings in 67 patients with thyroid carcinoma were reviewed and correlated with surgical and pathologic findings. A logistic regression model was used to determine which MR imaging features were significant for predicting tracheal invasion.

RESULTS

Twenty-three (34%) of the 67 patients had tracheal invasion. Logistic regression model analysis revealed that significant MR characteristics for determining tracheal invasion included soft-tissue signal in the tracheal cartilage (p < 0.001), intraluminal mass (p < 0.001), and degree of tumor circumference around the trachea (p = 0.001). The highest accuracy (90%) for determining tracheal invasion was achieved using a combination of findings. A case was considered positive for tracheal invasion if there was soft-tissue signal in the cartilage, an intraluminal mass, or a tumor that abutted a circumference of the trachea of 180 degrees or greater. Using these factors resulted in seven false-positive diagnoses because soft-tissue signal in the cartilage was sometimes seen in healthy trachea. Although intraluminal mass invariably reflected deep tracheal invasion, soft-tissue signal in the cartilage rarely indicated actual cartilage invasion but rather indicated tumor extension between the cartilaginous rings.

CONCLUSION

Tracheal invasion by thyroid carcinomas can be accurately diagnosed with MR imaging, and using a combination of criteria is the most accurate method of predicting this phenomenon.

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.

Invasive differentiated thyroid carcinoma: tracheal resection and reconstruction procedures in the hands of the endocrine surgeon

BACKGROUND

Although differentiated carcinoma of the thyroid gland is a relatively benign tumor, up to 20% of patients are endangered by potentially fatal complications resulting from infiltrating tumor growth into the upper aerodigestive tract.

METHODS

This study included 33 patients who underwent 34 tracheal or laryngotracheal procedures for invasive differentiated thyroid carcinoma under the direction of a single surgeon (G.F.W.S.). From 1990 to 1994, radical tumor extirpation was performed by "window" resection, and from 1995 to 1998, radical surgery consisted of either circumferential sleeve resection or laryngotracheal "step" resection--a novel method of reconstruction in cases of unilateral tumor infiltration into the larynx and trachea. Resection was limited to laminar ablation in 17 cases. The mean follow-up of 16 patients who survived was 42.5 months (range, 2 months to 8.9 years).

RESULTS

Procedures resulting in primary end-to-end anastomosis of the upper airways were associated with lower perioperative morbidity and improved recurrence-free survival when compared with "window" resections with muscle flap reconstruction. In cases of superficial tracheal tumor infiltration, laminar ablations were sufficient for local tumor control.

CONCLUSIONS

Radical eradication of differentiated thyroid carcinoma infiltrating the upper airways followed by radioiodine application should be considered the treatment of choice. Laryngotracheal "step" resection allows tumor extirpation with preservation of neural and muscular structures of the larynx.

Analyses of the outcome of locally invasive papillary thyroid carcinomas

We retrospectively analyzed the outcome for patients with locally invasive papillary carcinoma. The study group comprised 40 patients with locally invasive papillary thyroid carcinoma first diagnosed between 1981 and 1995. The enrolled patients were divided into two groups according to whether they underwent complete resection (n = 19) or not (n = 21). All patients were followed-up for a maximum of 206 months and a minimum of 33 months until 1998. There were no significant differences among these two groups with regard to age, sex, or tumor size. Recurrence of the disease was recognized in four patients in the complete resection group and ten in the incomplete group. There were no significant differences in the recurrence rate between both groups. Five patients from the incomplete resection group died of disease, and all patients from the complete resection group were alive. The percentage of surviving patients in the complete resection group was significantly higher than that in the incomplete group. The 15-year survival rates of the complete resection group and incomplete resection group were 100% and 74.2%, respectively. The 15-year survival rate of patients younger than 45 years in the incomplete resection group was 100%. The 15-year survival rate of the complete resection group was significantly higher than that of the incomplete group. In conclusion, complete resection without tumor residue should be performed for patients older than 45 years.

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

Well-differentiated thyroid cancer usually progresses slowly and rarely invades other tissues. However, the rare cases with invasion of local structures, such as the larynx, trachea, or esophagus, present particular management difficulties. In situations with limited involvement of the larynx or trachea, there is controversy over whether a "shave excision" that may leave microscopic disease at the site, or a complete resection that includes removal of a portion of these structures is the better approach. In the case of more extensive involvement of upper aerodigestive tract structures by thyroid carcinomas, the most appropriate method of resection and reconstruction is also at issue. We discuss the literature pertaining to the surgical management of laryngotracheal and esophageal invasion by thyroid carcinoma, review the incidence and presentation of this disease, and make recommendations based on our own experience.

Surgical management of thyroid cancer invading the airway

BACKGROUND

Locally advanced thyroid cancer invading the tracheal cartilage represents a difficult treatment dilemma during thyroidectomy.

METHODS

A retrospective chart review was performed to determine the results of laryngotracheal resection or tracheal cartilage shave with adjuvant radiotherapy in patients with locally advanced thyroid cancer invading the upper airway.

RESULTS

Of 597 patients undergoing thyroidectomy for thyroid cancer, 40 were found to have laryngotracheal invasion. Thirty-five patients with superficial invasion underwent cartilage shave procedures with adjuvant radiotherapy; five with full-thickness invasion underwent radical resection, including tracheal sleeve resection (n = 3) or total laryngectomy (n = 2). Histologic subtypes included papillary (n = 32), follicular (n = 2), Hurthle cell (n = 1), medullary (n = 3), and anaplastic (n = 2). Of the cartilage shave group, 25 are currently alive with no evidence of disease at a mean follow-up of 81 months (range 1-290). Six developed isolated local/regional recurrence and were managed with total laryngectomy (n = 1), tracheal resection (n = 1), cervical lymphadenectomy (n = 1), or repeat radiotherapy (n = 3). All six patients remain free of disease at a mean follow-up of 5 years. Of those who underwent initial laryngotracheal resection, four remain free of disease at a mean follow-up of 5 years. The rates of 10-year disease-free survival and overall survival for all patients were 47.9% (95% confidence interval [CI] 24.8, 71.0) and 83.9% (95% CI 70.3, 97.5), respectively.

CONCLUSIONS

These data suggest that adequate management of thyroid cancer with laryngotracheal invasion can be achieved with a more conservative surgical approach and adjuvant radiotherapy, reserving more radical resections for extensive primary lesions or locally recurrent disease.

Highly aggressive behaviour of occult papillary thyroid carcinoma

Occult papillary thyroid carcinoma is generally associated with an excellent prognosis. Distant metastasis of this tumour is extremely rare. A case of occult papillary thyroid carcinoma with metastases to the lungs, cervical lymph nodes, skeleton, and the brain is reported. The tumour expressed itself in extremely aggressive clinical behaviour and responded only partially to aggressive therapy. The controversial methods of treatment for occult papillary thyroid carcinoma are also discussed.

Management of tracheal wall resection for thyroid carcinoma by tracheocutaneous fenestration and delayed closure using auricular cartilage

BACKGROUND

In the case of advanced thyroid carcinoma invading the trachea, surgical procedures for tracheal resection are selected in relation to the degree of invasion. We created a tracheocutaneous fenestration that was later closed with a free auricular cartilage autograft. We present a simple and effective method for permanent closure of tracheostoma.

METHODS

The surgical procedure for delayed closure consists of three steps: (1) preparing the hinge flap with additional undermining of the subcutaneous layer and the strap muscles; (2) removing a portion of the conchal cartilage from the auricle, which is easily performed with a semicircular skin incision along the anthelix of the ear; and (3) placing the conchal cartilage with its convex surface upward just over the sutured hinge flap layer.

RESULTS

Under local anesthesia, we successfully employed this reconstructive procedure for 5 patients. Unfortunately, however, in one patient, we had to reopen the closed tracheocutaneous fenestration on the second postoperative day because of an acute problem that was independent of the closure surgery. Four patients remain in satisfactory condition for more than 2 years since the closure of tracheostoma.

CONCLUSIONS

The auricular cartilage free graft is a relatively simple procedure which supplies tracheal wall skeletal support for the permanent closure of the tracheocutaneous fenestration.

Surgery for patients with thyroid carcinoma invading the trachea: circumferential sleeve resection followed by end-to-end anastomosis

BACKGROUND

Curative surgery can be accomplished by tracheal resection in patients with thyroid carcinoma invading the trachea; however, there is controversy regarding the extent of the tracheal resection. In this study we investigated by means of histologic examination the mode of tracheal invasion by thyroid carcinoma.

METHODS

Twenty-one patients with thyroid carcinoma invading the trachea underwent circumferential sleeve resection of the involved trachea. The extent of invasion of the tracheal wall on the adventitial and mucosal sides was compared on histologic examination.

RESULTS

Three to nine tracheal rings were resected. Assessment of longitudinal spread showed that one to six rings (mean; 3.1 rings) were invaded on the adventitial side but only zero to four rings (mean; 1.9 rings) on the mucosal side, with invasion on the mucosal side never exceeding invasion on the adventitial side. In contrast, examination of circumferential spread showed invasion on the mucosal side exceeding invasion on the adventitial side in five cases.

CONCLUSIONS

Our results suggest that when the extent of invasion of the adventitia is considered, carcinoma tissue may be left behind on the mucosal side of the trachea when partial wedge resection is performed and that, whenever feasible, circumferential sleeve resection should be performed in patients with thyroid carcinoma invading the trachea.

The Role of Total Laryngectomy in the Management of Intraluminal Upper Airway Invasion by Well-Differentiated Thyroid Carcinoma

Intraluminal invasion of the upper airway by well differentiated thyroid carcinoma is very uncommon, and the management can be problematic. Many conservative, reconstructive-type surgical procedures have been advocated to maintain normal laryngeal function. Although voice preservation is desirable, it may not always be in the patient's best interest and radical surgery, including total laryngectomy, may be necessary. We describe three cases in which total laryngectomy was performed, and review the indicators for this procedure in the treatment of this difficult to manage condition.

Locally invasive papillary thyroid carcinoma: 1940-1990

Well-differentiated thyroid carcinoma infrequently invades the upper aerodigestive tract. However, when invasion occurs, it is the source of significant morbidity. The most common structures invaded by thyroid carcinoma are the recurrent laryngeal nerves, larynx, pharynx, and esophagus. Invasion of these structures produces symptoms of airway insufficiency, dysphagia, and hemoptysis. This study was designed to define more clearly the significance of invasion of papillary thyroid carcinoma on survival. At the Mayo Clinic, 262 patients treated for invasive papillary thyroid carcinoma between 1940 and 1990 were retrospectively evaluated. In this group the sites of invasion were muscle 53%, trachea 37%, laryngeal nerve 47%, esophagus 21%, larynx 12%, and other sites 30%. Complete tumor removal was accomplished in 56% of cases. Kaplan-Meier survival curves were calculated for the population. The overall survival was 79% at 5 years, 63% at 10 years, and 54% at 15 years. When the Cox proportional hazard model was applied to the survival data, the factors that had significant influence on survival were invasion of the trachea and the esophagus. Completeness of resection approached statistical significance. Muscle invasion, laryngeal invasion, and recurrent laryngeal nerve invasion had no significant independent influence on survival. These data suggest that when papillary thyroid carcinoma extends beyond the thyroid capsule and invades adjacent structures, the site invaded will influence survival. Survival may be improved in those cases in which complete surgical excision of the tumor is performed.

Upper airway invasion by well-differentiated thyroid carcinoma

Invasion of the upper airway by well-differentiated thyroid carcinoma is very unusual. Treatment is primarily surgical resection, but the extent of the resection has been controversial. Adjuvant treatment using I131 or radiotherapy also has an important role in management. We describe two cases of direct infiltration of the larynx and trachea by well-differentiated thyroid carcinoma and discuss the current recommendations for the management of this difficult problem.

Cartilage-shaving procedure for the control of tracheal cartilage invasion by thyroid carcinoma

This study was carried out to ascertain whether the cartilage-shaving procedure is appropriate to control thyroid carcinoma with tracheal cartilage invasion. Of 432 thyroid carcinoma patients treated between 1979 and 1988, 16 had tracheal cartilage invasion only. This patient population was made up of 3 men and 13 women, with a mean age of 55.8 years. Fourteen were diagnosed histologically as having papillary carcinoma and the remaining two as having follicular carcinoma. Cartilage shaving was the primary treatment in all the patients, and subsequent radioactive iodine (131I) or external-beam radiotherapy was administered to control any possible residual disease. Lifelong thyroid hormone replacement was instituted in all patients, and the follow-up period averaged 70.7 months. Only four of the 16 patients remained disease free; the disease was not controlled in the other 12, and seven of this latter group eventually died of their disease. We feel that a more extensive resection procedure than cartilage shaving should be considered, even in patients with superficial tracheal invasion, to increase the disease-free survival rate.