Elsevier

Surgical Oncology

Volume 12, Issue 2, August 2003, Pages 91-99
Surgical Oncology

Locally advanced differentiated thyroid cancer

https://doi.org/10.1016/S0960-7404(03)00032-XGet rights and content

Abstract

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.

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

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