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Overall survival of well-differentiated versus poorly differentiated malignancies involving the thyroid gland and the airway (excluding distant metastases to the thyroid) according to the Kaplan-Meier survival estimates.
Source publication
To evaluate outcomes in different malignancies involving the thyroid and infiltrating the airway submitted to tracheal (TRA) or crico-tracheal resection and anastomosis (CTRA).
Retrospective charts review of 27 patients affected by thyroid malignancies involving the airway treated by TRA/CTRA in a single academic institution. Kaplan-Meier curves we...
Context in source publication
Context 1
... oncologic outcomes were significantly linked to the presence of undifferentiated areas within the tumor (P < .001). Patients with well-differentiated carcinoma had an OS of 89.1% at 3 years and 83.7% at 5 years, while in patients with poorly differentiated lesions, a survival of 33.3% at 3 years was observed (otherwise not calculable at 5 years) (Figure 1). ...
Citations
... Despite comparable survival rates, local recurrence was 8 times more likely in shave resection compared to laryngotracheal resection [10]. Thus, airway resection gives better tumor clearance but comes at the cost of higher airway complications such as edema, bleeding, infection, and anastomosis dehiscence [11]. Hence, following laryngotracheal resection, good postoperative monitoring and care preferably in an intensive care unit (ICU) is imperative. ...
Advanced thyroid carcinoma involving the upper aerodigestive tract confers a poor prognosis mainly due to airway complications. The management of thyroid carcinoma with infiltration to the aerodigestive tract has been widely discussed with no consensus regarding the best surgical technique. Complete surgical resection is the aim of the surgery. However, it has high morbidity if the postsurgical care is compromised, which will lead to airway obstruction, bleeding, infection, and anastomotic dehiscence. In our center, complete resection was achieved through cricotracheal window resection with partial closure and tracheostomy tube insertion. This procedure was chosen due to the time-sensitive nature of surgery in these patients with airway compromise and postoperative limitation of intensive care unit (ICU) bed availability. In our case series, we present six cases of papillary and follicular thyroid carcinoma complicated with intraluminal laryngotracheal infiltration and discuss its management and outcome.
... Additionally, papers with duplicated or overlapping data from the same center were excluded, maintaining, when possible, the largest and more recent study among those available. Finally, a case series published by the first author (C.P.) (26), already included in this systematic review, was updated with data of patients treated from the time of the article publication (2016) to date, and their oncologic outcomes updated accordingly. ...
... From the remaining 110 full-text articles, 73 were excluded because they did not meet the eligibility criteria. Finally, 37 papers (3,26, were considered appropriate for the present systematic review ( Figure 1, Table 2). ...
... The Shin classification was explicitly used to quantify the depth of airway invasion by TC in 10 manuscripts (26,37,38,40,41,44,51,57,62,67), for a total of 148 patients subdivided as Table 2. The overall summary estimate of the proportion of patients who developed any complication after (C)TRA for TC was 27.0% (95% CI, 20.0-36.0%) ...
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.
... According to literature, postoperative complications with this procedure are seen in 15 to 39% of patients. A perioperative mortality of 1.2 to 15% is reported [8,[31][32][33]. Anastomotic dehiscence is the most frequently observed life threatening complication with an incidence ranging from 4 to 14% [34]. ...
... Tracheal resections of longer than 4 cm are found to be associated with a higher risk of dehiscence. Bilateral vocal cord palsy is seen in 4 to 10% of patients [8,31] and necessitates a tracheostomy. Tracheostomy may in turn delay wound healing at the anastomotic site. ...
... Gaissert et al. reported airway recurrence requiring tracheostomy in 12.3% of patients [8]. Factors associated with tumour recurrence include poorly differentiated histological type, presence of nodal metastasis, esophageal involvement and history of previous thyroid cancer surgery [20,24,31]. Locoregional recurrences were observed in 2 patients in this series, one of whom developed a local recurrence after 50 months and underwent tracheostomy and the second had local recurrence and systemic metastasis and succumbed to the disease. ...
Involvement of the aerodigestive tract is reported in one-third of patients with locally invasive thyroid cancer. It is associated with significant morbidity and mortality, with airway obstruction being the immediate cause of death in 50% of patients who die of thyroid cancer. Management is challenging and includes the risks of extensive surgery as well as decisions regarding the type of surgery and adjuvant therapy. Retrospective cohort study, reporting institutional experience with patients who underwent laryngotracheal resection for invasive thyroid cancer over the past 10 years. Twenty-two patients were included in the study. All patients had Shin stage 4 disease. The median follow-up was 18 months. Five patients had systemic metastasis at diagnosis. Nineteen patients underwent tracheal resection and end to end anastomosis, and 3 underwent laryngectomy. The mean length of the resected trachea was 2.94 cm. Tracheal releasing manoeuvres were utilized in 11 patients. Three patients required a tracheostomy postoperatively. Other complications included a temporary vocal cord palsy in 5 patients, temporary hypocalcemia in 6 and permanent hypocalcemia in 1 patient. Adjuvant radiotherapy was utilized in 9 patients and I-131 therapy in 13 patients. Three patients died during follow-up. Two patients developed thyroid bed recurrence, two patients developed systemic metastasis on follow-up. Most patients survived for a prolonged period with only biochemical evidence of disease persistence and three with no evidence of disease. Laryngotracheal resection with primary anastomosis is a safe and effective option, providing adequate symptomatic relief as well as prolonged survival in carefully selected patients with invasive Shin stage 4 disease.
... Tracheal resections longer than 4 cm are associated with a remarkable increase in the rate of anastomotic dehiscence. Thus, in these cases, it is important to dissect the suprahyoid muscles from the hyoid bone to release the larynx to perform end-toend tension-free anastomosis [78]. Chen et al. [74] noted that end-to-end anastomoses might not require suprahyoid muscle release when <8 tracheal rings have been resected. ...
Simple Summary
Tracheal invasion is a poor prognostic factor in well-differentiated thyroid cancer. Appropriate resection can improve the prognosis and maintain the patient’s quality of life. Shaving resection for superficial tracheal invasion is minimally invasive because it does not involve the tracheal lumen, despite the problematic risk of local recurrence. Window resection for tracheal mucosal and luminal invasion provides good tumor control and does not cause postoperative airway obstruction; however, the need for surgical closure of the tracheocutaneous fistula is a disadvantage of this method. Circumferential (sleeve) resection and end-to-end anastomosis are highly curative, but the risk of fatal complications, such as anastomosis dehiscence, is a concern.
Abstract
Well-differentiated thyroid carcinoma (WDTC) is a slow-growing cancer with a good prognosis, but may show extraglandular progression involving the invasion of tumor-adjacent tissues, such as the trachea, esophagus, and recurrent laryngeal nerve. Tracheal invasion by WDTC is infrequent. Since this condition is rare, relevant high-level evidence about it is lacking. Tracheal invasion by a WDTC has a negative impact on survival, with intraluminal tumor development constituting a worse prognostic factor than superficial tracheal invasion. In WDTC, curative resection is often feasible with a small safety margin, and complete resection can ensure a good prognosis. Despite its resectability, accurate knowledge of the tracheal and peritracheal anatomy and proper selection of surgical techniques are essential for complete resection. However, there is no standard guideline on surgical indications and the recommended procedure in trachea-invading WDTC. This review discusses the indications for radical resection and the three currently available major resection methods: shaving, window resection, and sleeve resection with end-to-end anastomosis. The review shows that the decision for radical resection should be based on the patient’s general condition, tumor status, expected survival duration, and the treating facility’s strengths and weaknesses.
... Patients with tumors invading the trachea require a full-thickness window or sleeve resection of the trachea [24]. These surgical procedures, however, are challenging and are accompanied by high rates (15-39%) of comorbidities, including vocal cord paralysis, tracheal anastomotic leakage, and mediastinitis and a postoperative mortality rate of 1.2% [25][26][27]. Our findings suggest that RFA, a minimally invasive technique, is useful for the treatment of recurrent thyroid cancer invading the airways. ...
Objectives:
To evaluate the efficacy of radiofrequency ablation (RFA) in patients with recurrent thyroid cancer invading the airways.
Methods:
We reviewed patients who had undergone RFA for recurrent thyroid cancer in the central compartment after total thyroidectomy between January 2008 and December 2018. All tumors were classified according to their association with the laryngeal structure and trachea. The volume reduction rate (VRR) and complete disappearance rate were calculated, and their differences were determined relative to the association between the tumor and trachea. Complication rates associated with RFA were evaluated.
Results:
The study population included 119 patients with 172 recurrent tumors. Mean VRR was 81.2% ± 55.7%, with 124 tumors (72.1%) completely disappearing after a mean follow-up of 47.9 ± 35.4 months. The complete disappearance rate of recurrent tumors not in contact with the trachea was highest, followed by tumors forming acute angles, right angles, and obtuse angles with the trachea, and tumors with intraluminal tracheal invasion (p value < 0.001). The overall complication rate was 21.4%.
Conclusions:
RFA is effective and safe for the local control of recurrent tumors in the central neck compartment after total thyroidectomy, even for tumors invading the airways, and may be considered an alternative to surgical resection. The inverse relationship between RFA efficacy and airway invasion suggests that early RFA may benefit patients with recurrent tumors in the central neck compartment.
Key points:
• RFA achieved a mean VRR of 81.2% ± 55.7% and complete disappearance of 124 tumors (72.1%) after a mean follow-up of 47.9 ± 35.4 months. • The complete disappearance rate of recurrent tumors not in contact with the trachea was the highest, followed by tumors forming acute angles, right angles, and obtuse angles with the trachea, and tumors with intraluminal tracheal invasion. • Stent-assisted RFA may be a good alternative for palliative treatment of recurrent tumors with intraluminal tracheal invasion.
... In the case of trachea involvement, the exeresis includes total thyroidectomy in a block, with tracheal resection (up to 4-5 tracheal rings) and anastomosis with the inferior part of the cricoid [24]. In the case of laryngeal extension pharyngolaryngectomy, total laryngectomy or hemy-laryngectomy can be performed followed by reconstruction with regional flaps (pectoral/Bakamjian flaps, gastric pull-through procedures or the jejunum free flap) [25]. ...
Background:
Well-differentiated thyroid carcinoma is defined as locally advanced in the presence of an extra thyroid extension, e.g., when the surrounding structures such as the trachea, larynx, esophagus and main blood vessels are invaded by cancer. The 8th edition AJCC Cancer Staging Manual states that this is the main characteristic to evaluate for the staging and consequently for the prognosis in patients over 55 years old.
Main body:
Distinguishing different forms of locally advanced thyroid cancer is essential, and the various anatomical structures and the clinical and therapeutic consequences must be taken into account. An accurate diagnosis of the organs invaded by thyroid cancer is necessary for the planning of surgical treatment, and both aspects are crucial to improving the patients' survival. Patients affected by thyroid cancer with extra thyroid extension have a poor prognosis and the removal of the entire neoplasm represents a key factor for better disease-free survival.
Conclusions:
We discuss the changes introduced by the 8th edition AJCC Cancer Staging Manual, in terms of the diagnostic and surgical management of extra thyroid extension, in patients affected by papillary and follicular thyroid cancer.
... 6 Other primary reconstructive options consist of local flaps such as sternocleidomastoid muscle or myoperichondral flap. 7 We presented a method of using a free autologous tracheal composite graft to simplify reconstruction of the cricoid (subglottic) defect and produce an adequate subglottic airway. The success of this procedure may have been facilitated by ready availability of the tracheal cartilage composite graft in the same surgical field for repair of the subglottic area. ...
Objective: To present a function-preserving surgical technique of post-laryngotracheal resection reconstruction of the subglottic airway using autologous tracheal cartilage composite graft.
Methods:
Design: Case Report
Setting: Tertiary Government Training Hospital
Participants: One
Results: A 77-year-old woman diagnosed with papillary thyroid carcinoma with laryngotracheal invasion underwent total thyroidectomy with laryngotracheal resection. The tracheal defect was reconstructed using end-to-end anastomosis of the trachea to the remaining cricoid. The cricoid (subglottic) defect was repaired using the harvested tracheal cartilage with mucosa. Post-operatively, the patient was maintained on nasogastric tube feeding and tracheostomy tube for 2 weeks. Subsequently, the nasogastric tube and tracheostomy tube were removed and the patient tolerated oral feeding without any airway problem. The last follow-up of the patient was 6 months post-operatively without complications.
Conclusion: Autologous tracheal cartilage may be a potentially promising composite graft for reconstruction of the cricoid (subglottic) defect in a patient following laryngotracheal resection for invasive papillary thyroid carcinoma of the larynx and trachea.
Keywords: tracheal composite graft; laryngotracheal resection; crico-tracheal anastomosis; papillary thyroid carcinoma; subglottic defect
... Subglottic lesions are commonly diagnosed at an advanced stage, thus requiring total laryngectomy extending to the first tracheal rings. In rare cases with limited cricoid arch involvement, at least one functioning cricoarytenoid unit, and longitudinal tracheal involvement less than 4.5-5 cm, a conservative approach (cricotracheal resection and anastomosis) may be performed [104]. ...
Malignant tumors of minor salivary glands (MiSGMTs) are rare, the majority of them being located in the oral cavity and oropharynx. Adenoid cystic carcinoma (AdCC) is the most frequently encountered histologic type followed by mucoepidermoid carcinoma (MEC); however, many other malignant salivary tumor types have also been described. Presenting complaints of MiSGMT depend on the anatomic site of origin. A painless submucosal swelling is the most frequent finding, possibly associated with obstructive symptoms when the tumor is located in the sinonasal cavities, pharynx, larynx, or trachea; pain or nerve impairment may also be reported.
... For Ben Gamra and al [10], the sensitivity of the extemporaneous examination for thyroid cancers was 78% for all histologic types, and 89% for papillary carcinoma. However, Cesare P and al [11] found in their study 60% of papillary carcinoma and 7% of mixed papillary-follicular Carcinoma, 4% of anaplastic thyroid carcinoma and a reported 11% of remote Metastases of the thyroid gland, two of which resulting from an adenocarcinoma and one from a psoas Leiomyosarcoma. However, the location of an adenocarcinoma in the thyroid gland is unusual. ...
... However, the survival rate was only 15-39% with 1.2% mortality, worse that incomplete resection [14], [15]. The most common surgical complications were airway obstruction, infection, bleeding, and anastomotic dehiscence [18]. This made the surgery for locallyinvasive DTC has been controversial. ...
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.
