Obstructive endotracheal lesions of thyroid cancer

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.

Surveillance for Differentiated Thyroid Cancer Recurrence

Serum thyroglobulin monitoring along with anatomic and functional imaging play key roles in the surveillance of patients with differentiated thyroid cancer after initial treatment. Among patients with a disease stage justifying thyroid remnant ablation or with suspected metastatic disease, radioiodine whole-body scans are essential in the months after surgery. For patients with low to moderate-risk cancers, ultrasonography of the neck (with measurement of serum thyroglobulin on thyroid hormone replacement) are the best initial diagnostic modalities, and are often the only tests required. In individuals suspected of having distant metastases, CT, MRI, and 18F-FDG PET can make important contributions in localizing residual disease and monitoring its progression and responses to therapy, provided they are used in the appropriate setting.

Aggressive differentiated thyroid cancer

Differentiated thyroid cancer is characteristically associated with an innocuous clinical course, but a minority of cases may manifest surprisingly aggressive behaviour. Such aggressive DTC are directly responsible for the majority of thyroid cancer related deaths. Moreover, they contribute indirectly to increased DTC-related morbidity, because our inability to differentiate these tumours from innocuous DTC at an early stage fuels a significant degree of DTC overtreatment around the globe. In the present paper we describe how improved understanding of the clinicopathological thyroid tumour progression model and optimization of clinical staging systems continues to improve our ability to diagnose and treat aggressive DTC. Early recognition of aggressive DTC allows instillation of an aggressive management strategy which is based upon surgical-oncologic completeness, and minimization of treatment-related sequelae through continued development of reconstructive options and focussed delivery of adjuvant treatments.

Airway stenting for the treatment of laryngotracheal stenosis secondary to thyroid cancer

BACKGROUND AND OBJECTIVE

Airway stenting can be a valuable therapeutic option for symptomatic airway stenosis, but its role in the palliation of advanced thyroid cancers invading the upper airway is unclear. This study examined the hypothesis that durable and replaceable silicone stents would give better results than self-expanding metallic stents.

METHODS

A retrospective analysis was conducted of consecutive patients stented for laryngotracheal obstruction due to thyroid cancer. Stenting was performed via a rigid bronchoscope when airway patency after dilatation was <or=50% of normal. Symptomatic improvement, Hugh-Jones (H-J) classification, Eastern Cooperative Oncology Group performance status (PS), and complications were analysed.

RESULTS

There were 37 stenotic lesions treated in 35 patients. The most common sites for these lesions were in the inclusive area extending from the cricoid cartilage to the first tracheal ring (26/37 lesions, 70%). Forty-five stents (12 silicone, 20 metallic, 13 T-tubes) were used in 43 interventions. All patients showed immediate symptomatic relief and significant improvement in both PS and H-J classifications. Critical complications were supraglottic stenosis (5/43 interventions, 12%) and, of those same five cases, stent migration was seen in all but one (4/45 implantations, 9%). As these complications occurred only in patients in whom the silicone stents had been placed in close proximity to the cricoid cartilage (5/10 patients, 50%), this emphasizes the unsuitability of silicone stents in such cases. The median survival time from stenting was 8 months. The 1-year survival rate was 40%.

CONCLUSIONS

Airway stenting can achieve significant palliation in patients with thyroid cancer and airway obstruction. The study showed that for the most common lesions, the uncovered Ultraflex stent is associated with fewer critical complications than the silicone stents.