Locally advanced differentiated thyroid cancer
Introduction
Although most patients with differentiated thyroid cancer (DTC) have a relatively good prognosis, some patients present with locally advanced DTC. Up to 22% of patients with DTC have direct tumor extension with invasion of surrounding tissue [1], [2]. The presence of extrathyroidal invasion is one of the main risk factors for developing DTC recurrence and mortality from DTC [3]. Most individuals who die from DTC have significant local complications from locally advanced disease such as airway obstruction, vascular invasion and hemorrhage [4].
Locally advanced DTC may involve the central neck, lateral neck and/or mediastinum by direct tumor invasion or by lymphatic invasion. The presence of extrathyroidal invasion and extracapsular lymph node metastasis (locally advanced DTC) in patients with DTC is associated with a higher risk of aerodigestive invasion than in patients with intrathyroidal DTC and no lymph node metastasis [1], [5]. In fact, patients with invasive DTC involving more than four adjacent structures have a uniformly lethal clinical course [1].
Locally advanced DTC most commonly occurs in patients who present with recurrent DTC, extensive nodal metastasis and distant metastasis [6], [7], [8], [9], [10]. Surgical resection is the primary treatment in patients with locally advanced DTC. Postoperative radioiodine ablation with thyroid hormone for TSH suppression is also imperative after surgical resection in order to decrease the risk of recurrence and improve survival [3]. Rarely, when there has been incomplete resection or positive margins after surgical resection, external radiotherapy may be useful [11]. The optimal surgical approach for locally advanced DTC is controversial. Some experts support a “shave” resection whereas others advocate an en bloc resection of involved structures when technically feasible [8], [12]. Because locally advanced DTC can involve vital structures such as the laryngotracheal tree, esophagus and carotid artery, the trade-off of achieving a complete resection with negative margins at the expense of significant perioperative or long-term morbidity and mortality is unclear. In this article, the presentation and work up of patients with locally advanced DTC is discussed as well as the different surgical approaches and adjuvant therapy that may be utilized in managing these patients with a difficult problem.
Section snippets
Clinical features and preoperative evaluation
Most patients who present with locally advanced DTC have clinical evidence of a palpable neck mass in the central or lateral neck compartments (Fig. 1A). Although locally advanced DTC is infrequent, a high index of suspicion is necessary to identify such patients preoperatively, which allows for planning of the optimal surgical approach. In patients with locally advanced DTC, the neck mass is often hard on palpation and fixed to surrounding structures. Although, in general, DTC is more common
Recurrent laryngeal nerve invasion
The recurrent laryngeal nerve is the most commonly involved structure in patients with locally invasive DTC [1], [5], [6], [10], [13], [14], [28], [34]. Recurrent laryngeal nerve palsy occurs as a result of direct primary tumor extension or from involved tracheoesophageal lymph nodes. Patients with recurrent laryngeal nerve palsy due to tumor invasion usually have dysphonia or voice fatigue [3], [12], [14]. Some patient may also have stridor due to recurrent laryngeal nerve palsy but it may
Vascular invasion
The carotid artery is rarely invaded by advanced DTC whereas the internal jugular vein is frequently involved by poorly DTC. Limited data exist in the literature that compares surgical approaches in patients with DTC invasion of the lateral neck vascular structures [29], [30], [31], [32], [46]. In most cases, although there is no clear direct vascular invasion of the lateral neck vascular structure, bulky extranodal extension of DTC lymph node metastasis are intimately adherent to these
Adjuvant therapy
Although surgery remains the most effective treatment for thyroid cancer, patients with locally advanced DTC warrant additional treatment (Fig. 5). Postoperative radioiodine treatment and thyroid hormone for TSH suppression decreases the risk of recurrence and may increase survival [3], [48]. Particularly in high-risk patients with DTC, a general consensus exists that radioiodine therapy and TSH suppression are beneficial. Thus total or near-total thyroidectomy should be done so that the 131-I
References (53)
- et al.
Differentiated thyroid carcinoma with airway invasionindication for tracheal resection based on the extent of cancer invasion
Journal of Thorac and Cardiovascular Surgery
(1997) Thyroid carcinoma invading the cervicovisceral axisroutes of invasion and clinical implications
Surgery
(2001)Therapeutic dilemmas in the management of thyroid cancer with laryngotracheal involvement
Otolaryngology—Head and Neck Surgery
(2000)- et al.
Surgical treatment of invasion of the upper aerodigestive tract by well-differentiated thyroid carcinoma
American Journal of Surgery
(1987) - et al.
Locally invasive, well-differentiated thyroid cancer. 22 years’ experience at Memorial Sloan-Kettering Cancer Center
American Journal of Surgery
(1981) Intraluminal involvement of the larynx and trachea by thyroid cancer
American Journal of Surgery
(1974)- et al.
Resectional management of airway invasion by thyroid carcinoma
Annals of Thoracic Surgery
(1986) - et al.
Positron emission tomography in thyroid cancer management
Seminars in Roentgenology
(2002) - et al.
The role of external beam radiotherapy in the management of differentiated thyroid cancer
Biomedicine and Pharmacotherapy
(2000) - et al.
Infiltrating papillary carcinoma of the thyroid with macroscopic extension into the internal jugular vein
Otolaryngology—Head and Neck Surgery
(1997)
Pathologic staging of papillary carcinoma of the thyroid with airway invasion based on the anatomic manner of extension to the tracheaa clinicopathologic study based on 22 patients who underwent thyroidectomy and airway resection
Human Pathology
Surgical management of thyroid carcinoma with laryngotracheal invasion
Otolaryngology Clinics of North America
Resections of the upper aerodigestive tract for locally invasive thyroid cancer
American Journal of Surgery
Surgery for patients with thyroid carcinoma invading the tracheacircumferential sleeve resection followed by end-to-end anastomosis
Surgery
Case report: bilateral massive internal jugular vein thrombosis in carcinoma of the thyroidct evaluation
Clinical Radiology
Combination adriamycin and radiation therapy for locally advanced carcinoma of the thyroid gland
International Journal of Radiation Oncology Biology and Physics
Treatment of locally invasive carcinoma of the thyroidhow radical?
American Journal of Surgergy
Differentiated thyroid cancer“complete” rational approach
World Journal of Surgery
Prognostic factors for thyroid carcinoma. A population-based study of 15,698 cases from the surveillance, epidemiology and end results (SEER) program 1973–1991
Cancer
Resectional management of thyroid carcinoma invading the airway
Annals of Thoracic Surgery
Resection of the trachea infiltrated by thyroid carcinoma
Annals of Surgery
Locally aggressive differentiated thyroid carcinoma
Journal of Surgical Oncology
External-beam radiation therapy in the treatment of differentiated thyroid cancer
Seminars in Surgical Oncology
Surgical management of laryngotracheal and esophageal involvement by locally advanced thyroid cancer
Seminars in Surgical Oncology
Thyroid carcinoma invading the upper aerodigestive system
Laryngoscope
Clinicopathologic study of thyroid carcinoma infiltrating the trachea
Cancer
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