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Preoperative MRI (a), video-assisted right parapharyngeal mass dissection (b), endoscopic view after tumour excision (c), excised tumour (d).
Source publication
Metastases to parapharyngeal or retropharyngeal lymph nodes are rare in well-differentiated thyroid cancers. A review of English literature found only 112 cases reported in the last two decades, with an incidence of parapharyngeal lymph nodes metastases ranging from 0.43 to 2.5%. Surgical resection is the most effective treatment for patients with...
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AIM
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METHODS
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Citations
... In particular, prestyloid tumors are usually from salivary origin, with pleomorphic adenoma (PA) as the most common one; conversely, poststyloid neoplasms are often neurogenic [3,5]. Malignancies represent only 20% of all PPS tumors, with salivary histologies as leading cause [3,5]; also metastatic lesions may occur due to the direct lymphatic connection between the PPS nodes and other nodal relays in the neck, as commonly happens for differentiated thyroid cancer [7,8]. ...
Background and purpose
Parapharyngeal space (PPS) neoplasms represent 1% of all head and neck tumors and are mostly benign. Surgery is the mainstay of treatment and the transcervical–transparotid (TC–TP) corridor still represents the workhorse for adequate PPS exposure. Our series investigates strengths and limits of this approach on a multi-institutional basis.
Methods
We reviewed consecutive patients submitted to PPS surgery via TC–TP route between 2010 and 2020. Hospital stay, early and long-term complications, and disease status were assessed.
Results
One hundred and twenty nine patients were enrolled. Most tumors were benign (79.8%) and involved the prestyloid space (83.7%); the median largest diameter was 4.0 cm. The TC–TP corridor was used in 70.5% of patients, while a pure TC route in about a quarter of cases. Early postoperative VII CN palsy was evident in 32.3% of patients, while X CN deficit in 9.4%. The long-term morbidity rate was 34.1%, with persistent CN impairment detectable in 26.4% of patients: carotid space location, lesion diameter and malignant histology were the main independent predictors of morbidity. A recurrence occurred in 12 patients (9.4%).
Conclusions
The TC–TP corridor represents the benchmark for surgical management of most of PPS neoplasms, though substantial morbidity can still be expected.
... Previous lateral neck dissection is considered a risk factor for the development of PS/RPS metastases from thyroid cancer [15]. Kaplan et al. concluded that RP nodal metastases may be more frequent in patients who have previously undergone treatment for thyroid cancer, whereas parapharyngeal nodal metastases are more likely to occur in untreated patients [16]. ...
Papillary carcinoma is the most frequently encountered differentiated thyroid carcinoma. Usually, metastasis occurs along lymphatic pathways in the central compartment and along the jugular chain. Nevertheless, lymph node metastasis in the parapharyngeal space (PS) is a rare but possible event. In fact, a lymphatic pathway has been identified that connects the upper pole of the thyroid and the PS. We describe the case of a 45-year-old man with a two-month history of a right neck mass. He underwent a complete diagnostic path that highlighted the presence of a parapharyngeal mass associated with the presence of a thyroid nodule suspected to be malignant. The patient underwent surgery (thyroidectomy and removal of the PS mass that was found to be a metastatic node of papillary thyroid carcinoma). The aim of this case is to underline the importance of detecting these kinds of lesions. Nodal metastasis in PS from thyroid cancer is a rare occurrence that is not easily detectable by a clinical examination until the metastasis reaches a considerable dimension. Computed tomography (CT) and magnetic resonance imaging (MRI) permit early identification, but unfortunately, these are not usually employed as a first-level imaging technique in patients with thyroid cancer. The treatment of choice is surgery with a transcervical approach that allows for better control of the disease and of the anatomical structures. Non-surgical treatments are usually reserved for patients with advanced disease, with satisfactory results.
... Newer approaches include transcervical approach assisted with endoscopic visualization, allowing better visualization of anatomical structures and minimization of complications [1,2]. However there is no study comparing outcomes between open surgical approaches VS video assisted or endoscopic approaches. ...
... Here the term parapharyngeal space is used loosely to cover both spaces [1]. 20-50% of well-differentiated thyroid cancers have regional lymph node metastasis, normally along the internal jugular and recurrent laryngeal lymph nodes [2]. Lymphatic metastasis of thyroid cancer normally occurs initially to central neck levels 6 and 7, then to lateral neck levels 3, 4 and 5 [3]. ...
... Parapharyngeal and retropharyngeal metastasis are very rare, with a reported incidence of 0.43% to 12.5% [2]. 64% of parapharyngeal lymph nodes metastasis are found in the context of recurrence after previous surgery [2]. ...
... Based on the literature, only 112 cases of metastases from DTC to parapharyngeal spaces reported in the last two decades (Giordano et al. 2015). Perfect surgical excision favors response to RAIT with even complete resolution as in our cases. ...
Background
Being aware of the unusual or rare location of thyroid metastases helps in early diagnosis and proper patient management. Rare metastases (RM) can be missed resulting in diagnostic pitfalls and delayed treatment. The use of single-photon emission computed tomography/computed tomography (SPECT/CT) imaging in the follow-up of differentiated thyroid cancer (DTC) patients provides precise anatomical localization and characterization of RM that may be missed or misinterpreted in planar whole body iodine-131 (WBI) scan. There is a lack of knowledge about dealing with such patients, the treatment they should receive, and therapy response due to the rarity of such cases. In this work, we reported these rare cases increasing awareness about them and their methods of treatment with response to therapy and evaluated the added value of SPECT/CT imaging in changing patients’ management.
Materials and methods
In this study we reviewed all patients with DTC referred to our unit either for initial radioactive iodine-131 therapy (RAIT) or under follow-up from January 2019 to January 2022. When a suspected lesion was detected in a conventional planar WBI scan whether follow-up scan or post-therapeutic scan, SPECT/CT was acquired immediately in the same session for that region. Additional imaging modalities were performed for confirmation. Response to the given treatment either disease progression (DP) or favorable response which include complete response (CR), partial regression (PR) and stable disease (SD) recorded for each patient.
Results
Two hundred and forty patients with DTC referred to our unit over a three-year period (from January 2019 to January 2022) were reviewed. Forty patients developed lung and bone distant metastases. Twenty-one patients were thought to have metastases at unusual sites. Due to incomplete data (no SPECT/CT pictures or confirmatory imaging), 6/21 patients were eliminated. We studied 15 patients with RM (9 females, 6 males) with a median age of 52 years (range 27–79). All patients received the initial RAIT after thyroidectomy in addition to other therapeutic modalities, e.g., radiotherapy (RTH), chemotherapy (CTH) or surgical tumor excision after detection of RM. Ten out of 15 patients (66.67%) showed favorable response to therapy (2 patients had CR, 6 patients had PR and 2 patients had SD), whereas only 5 patients had DP. Additional SPECT/CT changed management in 10/15 patients (66, 67%) of patients.
Conclusion
RM identification is mandatory to avoid misdiagnosis and delayed therapy. Increasing the awareness about such rare cases allows for better management. SPECT/CT could significantly impact patients' management through its precise anatomic localization and lesion characterization.
... L. Giordano и соавт. описали минимально инвазивную видеоассистированную технику удаления метастазов [19]. Так, S. T. Yu и соавт. ...
Introduction. Papillary thyroid cancer (PTC) usually metastasizes into the central and lateral lymph nodes (LNs) of the neck. Metastases into the retropharyngeal and parapharyngeal LNs are rare. Their presence attests to aggressive PTC.
The study objective is to describe a rare case of metastases of papillary radioiodine-refractory PTC into the parapharyngeal LN.
Clinical case . In 2015, female patient K., 40 years old, underwent thyroidectomy due to PTC. Histological examination verified papillary PTC with growth through the capsule and ingrowth into the surrounding tissues and muscles. In a separately admitted LN, metastases of the same cancer were observed. One year later, regional metastases in the lateral neck LNs were detected. Radioiodine therapy (activity 131I 4.5 GBq) was performed followed by fascial circular section of the neck tissues on the right per thyroid type. Morphological examination verified presence of papillary PTC metastases in 4 LNs. In January of 2018, positron emission tomography showed metastases in the paratracheal LNs. Central neck lymph node dissection was performed. Per histological conclusion, fat tissue and LN contained multiple metastases of papillary PTC. In October of the same year, repeat radioiodine therapy (activity 131I 3.0 GBq) was performed. Thyroglobulin levels increased. In June of 2020, repeat positron emission tomography showed a single metastasis in the parapharyngeal LN. Due to small size of the metastasis and absence of signs of progression, dynamic follow-up and hormone therapy were suggested to the patient.
Conclusion. Metastatic involvement of parapharyngeal LNs is rare, especially in radioiodine-refractory PTC. They can be detected both during primary diagnosis and after the treatment during dynamic follow-up, as well as a single manifestation of PTC, which should be taken into account during differential diagnosis.
... Surgical excision is usually performed using a transcervical or transoral approach. 55 A thorough understanding of the anatomy of the neck and parapharyngeal space is required to undertake this approach safely. 56 The transoral approach can be performed either by direct excision if accessible, 57 or it can be robotically assisted. ...
The incidence of thyroid cancer has been increasing over the past few decades, and although the majority of cases are localized to the thyroid, the number of patients with lateral neck disease at first presentation has increased. Although an abundance of literature exists about the patterns of metastasis for thyroid carcinoma, some controversy remains surrounding the extent of neck dissection in patients who have suspicious or confirmed metastasis to the lateral neck. However, there is near universal agreement that lateral neck dissection for metastatic thyroid cancer should follow principles of compartment-based neck dissection with resection of involved and at-risk neck levels, most commonly a level II through VB selective lateral neck dissection. This chapter will address the indications and considerations of a lateral neck dissection for thyroid cancer, followed by the surgical approach for an oncologic resection of lateral neck disease.
... Because of the aggressive behavior of the ATC, between 20% and 50% of cases present distant metastasis at the time of diagnosis [5]: the most common sites are the lungs (80%), followed by bones (6-16%) and brain (5-13%) [6,7], while cutaneous and subcutaneous metastasis are rare and usually occur in the setting of disseminated neoplastic disease [8]. ...
Simple Summary
The therapeutic strategies employed for anaplastic thyroid cancer patients seems to be insufficient to prolong their survival, but some characteristics could predict a good prognosis, so that, starting from our experience we offer a systematic review of the literature to better understand anaplastic thyroid cancers behavior and their prognostic factors, in order to recognize and select the patients with the higher probability of better outcome even if metastatic. Moreover, we described an uncommon site of metastasis in order to improve scientific knowledge about this rare and highly aggressive pathology.
Abstract
Anaplastic thyroid carcinoma (ATC) is a very rare, highly aggressive malignant thyroid tumor with an overall survival from 3 to 5 months in most of the cases. Even the modern and intensive treatments seem not to be enough to provide a cure, also for the resectable ones, and the role of chemotherapy is still unclear but does not seem to prolong survival. Nevertheless, some patients survive longer and have a better outcome, even in the presence of metastasis, than what the literature reports. We present the case of a 64-year-old female affected by ATC, treated on February 2018 with surgery followed by chemoradiation. One year after surgery, the patient developed a subcutaneous recurrence that was radically resected and is still alive 29 months after the diagnosis. We propose a systematic review of the literature to deepen the knowledge of the prognostic factors of ATC with the aim to recognize and select the patients with a better outcome, even if metastatic, and to describe a very uncommon site of metastatization.
... 3A and 5B, the prognosis of pulmonary metastasis cases treated with TKI was the best, so such introduction criteria seemed to be successfully approved so far. If possible, surgical resection should be performed for local and lymph node recurrence including parapharyngeal metastasis (20); however, cases recurring multiple surgeries or those diagnosed as unresectable had previously undergone external irradiation or additional RAI therapy. Lamartina et al reported that the rate of CR following the first reoperation due to persistent/recurrent DTC was 53% at the last assessment after a median of 5 years (21). ...
In patients with distant metastasis, treatment for differentiated thyroid cancer (DTC) includes complete total thyroidectomy, followed by radioactive iodine (RAI) therapy for metastatic lesions. Tyrosine kinase inhibitor (TKI) treatment is the final treatment option for metastatic lesions, which is incurable with surgery/RAI therapy. The present study examined whether treatment outcomes for DTC in patients with distant metastasis improved following TKI treatment. This study included 147 patients (median age, 71; range, 33-91 years) who underwent surgery in our hospitals and were diagnosed with distant metastasis. Disease progression was observed in 70 patients, of whom 56 were treated with TKI (TKI group); 14 refused TKI treatment or showed no treatment indication [untreated (UT) group]. Disease progression and treatment outcomes were assessed using imaging evaluations. The present study investigated thyroglobulin doubling time (Tg-DT) and Tg antibody presence/absence and their relation to disease progression. Overall survival following disease progression between the two groups was compared. The study included 22 cases of sorafenib, 49 of lenvatinib, and 15 involving TKIs. The mean dosing period for sorafenib was 153 days and for lenvatinib was 462 days. In the TKI group, 16, 26, and 9 patients exhibited partial responses (PRs), stable disease (SD), and progressive disease (PD), respectively, whereas 5 patients were not evaluable. The disease control rate (DCR) (PR+SD) was 75.0%. A total of 16 patients died in the TKI group, whereas 10/14 patients in the UT group died. Survival curves for the groups were significantly different. TKI treatment improved the prognosis of patients with distant metastasis and PD.
... The endoscope allowed the surgeon to improve the visualization and to have a better understanding of the important anatomical structures adjacent to the tumours. This permits a more meticulous and precise dissection and thus allows adequate and safer surgery [14]. The adjunct of neuronavigation also improves the applicability of such a corridor. ...
The parapharyngeal space (PPS) is a challenging anatomical region, rich in vascular and nervous vital structures. Surgery is considered the treatment of choice for the majority of PPS lesions. Herein, we present a retrospective evaluation on ten patients with various types of lesions of the parapharyngeal and infratemporal fossa (ITF) regions operated on via an endoscopic-assisted transoral-transpharyngeal approach (EATTA), focusing on feasibility and safety. A retrospective evaluation of patients treated by means of EATTA to PPS and/or ITF lesions was carried out. The clinical records of patients who were operated on with EATTA for PPS and/or ITF lesions between March 2009 and October 2015 at two referral centres were reviewed and the intra-operative and post-operative complications were analysed. Ten patients who underwent EATTA on the PPS and ITF were included in this series. The procedure was performed in six patients for tumour removal, in three patients for diagnostic purposes and in one patient for pain control. No major complications occurred. No conversion to external approach was required. We observed only two minor complications which were promptly solved. No dysphagia or other problems during the food intake were observed in our series. One day after surgery all patients, except one, referred a value of VAS minor than 4. To date, no evidence of disease recurrence has been assessed in all six oncological cases. Although preliminary, our experience seems to demonstrate the feasibility and safety of EATTA when properly planned and performed.
Papillary thyroid cancer is the most common type of differentiated thyroid cancer (DTC) and in most cases, disease is localized to the neck and remission of disease is common. Though distant metastasis of DTC is unusual; involved sites are more often the lungs and bones, while less common sites include the liver and kidney. No case of metastasis to both intraocular choroid and the pituitary gland has previously been reported. We describe a case of a 58-year-old man who presented with multifocal papillary thyroid carcinoma (PTC) with cervical node metastasis. According to risk stratifications in DTC, the patient stratified as low risk of recurrence. Five years after initial presentation, he was found to have mediastinal lymph node metastasis. Fifteen years post diagnosis, his PTC metastasized to his liver, bone, lung, pituitary gland, orbital choroid and choroid plexus. Remarkably, the only symptom the patient developed as a result of this metastasis was alteration in his vision, which was treated with bevacizumab. Despite initial improvement, he developed ptosis and third nerve symptoms. His pituitary metastasis was treated with Cyber-Knife Surgery and his systemic metastasis was treated with the tyrosine kinase inhibitor (TKI) lenvantinib, resulting in new improvement of his vision. Lenvantinib treatment led to a very marked decrease in the size of his intraocular and choroid plexus lesions and stabilization of his pituitary mass size. The patient developed central hypoadrenalism that required treatment with glucocorticoid replacement.
A review of literature for the past 5 decades revealed that metastasis of DTC to the orbital choroid and the pituitary gland have been reported in 17 and 16 cases, respectively. This report is unique as it presents the first case of metastatic PTC to both the intraocular choroid and the pituitary gland. Furthermore, no prior study reported simultaneous DTC metastasis to intraocular choroid and the ventricular choroid. This case highlights that despite their rarity, intraocular and pituitary metastasis of DTC should be considered as potential causes of atypical symptoms such as visual changes or hypopituitarism. Finally, use of TKI therapy for DTC with metastasis to the intraocular choroid and pituitary gland can improve the disease course.
