Principles of Surgical Treatment

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The currently accepted principles of surgery for differentiated thyroid cancer call for complete removal of the local lesion and extensions in the neck. Longer survival and better control of symptoms are obtained if gross tumor is fully removed. This is usually interpreted to mean thyroidectomy and excision of involved regional lymph nodes, with persisting differences of opinion about the need for total thyroidectomy. Because of the pathological behavior of these tumors, nodal metastases are excised by limited regional dissection rather than by standard radical neck dissection. Even in extended node dissection, adjacent structures, such as the sternocleidomastoid muscle and internal jugular vein, are spared whenever possible. The submandibular triangle is rarely involved, but on the other hand, positive nodes do occur pretracheally, in the tracheoesophageal groove, along the length of the internal jugular chain, in the "V" between the innominate and left carotid arteries, and in the posterior cervical triangle. The goal of surgery, in addition to cure, is to prevent airway obstruction and death from asphyxiation.

The otherwise guiding surgical principle of complete local removal of thyroid neoplasm is all too often broken when a tumor invades the upper trachea or the junction of the larynx and trachea. Frequently unfamiliar with techniques of airway surgery, the thyroid surgeon regards the addition of tracheal resection as "radical surgery," potentially fraught with morbid or fatal consequences. Hence, "shave" techniques have been advocated.12-16 In experienced hands, however, airway reconstruction is not radical surgery. Addition of

figure 8-3 A, Surgical specimen (mixed papillary and follicular carcinoma) of a patient, whose x-rays are shown in Figure 8-4, viewed from above. The broad arc of the partially resected cricoid is above in the photograph. Invading tumor is just below. B, The tumor extends between and through the cartilages. Seven years after resection of the obstructing tumor, the patient developed pulmonary metastases, which were treated with 131I.

figure 8-4 Radiologic delineation of linear extent of tracheal invasion by thyroid carcinoma. A, Filtered view of tracheal invasion by mixed papillary and follicular carcinoma in a 59-year-old man with identified pulmonary metastases. Arrow marks the glottis. Nonetheless, the patient enjoyed 14 years of life after tracheal resection and reconstruction, and had no further airway disease. B, Tomographic cut showing high invasion in the subglottic larynx by papillary carcinoma in a 36-year-old man. The right vocal cord is paralyzed.

figure 8-4 Radiologic delineation of linear extent of tracheal invasion by thyroid carcinoma. A, Filtered view of tracheal invasion by mixed papillary and follicular carcinoma in a 59-year-old man with identified pulmonary metastases. Arrow marks the glottis. Nonetheless, the patient enjoyed 14 years of life after tracheal resection and reconstruction, and had no further airway disease. B, Tomographic cut showing high invasion in the subglottic larynx by papillary carcinoma in a 36-year-old man. The right vocal cord is paralyzed.

tracheal resection following dissection for thyroidectomy adds little length or complexity to the operation and does not increase morbidity or mortality much.17,18 Voice, airway, and deglutition are all preserved.

What is lacking are firm criteria about what constitutes an adequate "shave," histologic identification of complete or incomplete tumor removal by shaving, the decades of follow-up necessary to validate this unusual oncologic approach, or consideration of the potential for change in the histology and aggressiveness of thyroid cancer.8,9 Many of our patients had been previously subjected to shaving procedures as initial and ultimately unsuccessful treatment, years before recurrence.17 Added to these considerations is the indication from our data that excision of airway involvement at initial thyroidectomy, or immediately thereafter, leads to better long-term results than late removal of a recurrent invasive tumor.17 The purposes of complete resection of thyroid cancer that invades the airway are, therefore, 1) to relieve or prevent airway obstruction in patients with slowly progressing neoplasm, 2) to prevent tortured death by asphyxiation or hemorrhage, and 3) perhaps to achieve cure by early complete resection of the tumor (Figure 8-7).

figure 8-5 Vocal cord paralysis or dysfunction due to recurrent laryngeal nerve invasion by papillary thyroid carcinoma, in a 36-year-old man, is well demonstrated on fluoroscopy or by direct examination. On these spot films taken during fluoroscopy, A, a paralyzed right cord is evident on attempted cord adduction. Note the asymmetry of the vocal cords. B, On inspiration, the tumor is also seen just below the glottis.

Radical removal of the larynx, trachea, and other affected tissues en bloc may be justified only in rare cases of seemingly confined undifferentiated carcinoma (Figure 8-8) and for palliation of longstanding massively recurrent and severely symptomatic differentiated carcinoma (Figure 8-9).17

figure 8-6 Computed tomography scans of invasion by differentiated carcinoma. A, In a 65-year-old woman with papillary carcinoma invading the trachea, esophagus, cricoid, and right recurrent laryngeal nerve. Treated by thyroidectomy, with tracheal resection and reconstruction. B, In a 51-year-old man with a very large papillary lesion invading and compressing the trachea. Resection with reconstruction was nonetheless possible because the length of trachea invaded was less than the total extent of tumor apparent on the scan. Six years later, the patient remained free of recurrence.

figure 8-7 Severely obstructive papillary carcinoma in a 62-year-old man who had undergone thyroidectomy 6years and 4 years earlier, followed by 131I. A, Tomogram shows marked occlusion of the proximal trachea (arrow). B, Resected specimen includes a portion of the cricoid cartilage.

figure 8-8 A, Computed tomography scan showing massive invasion of larynx, trachea, and esophagus by rapidly growing thyroid carcinoma of mixed Hurthle cells and anaplastic histopathology. This 71-year-old man was effectively palliated by cervicomediastinal exenteration for airway obstruction, with voice loss, total dysphagia and odynophagia, and head and neck pain. Mediastinal tracheostomy was established. With this histology, palliation was alone the goal. B, Gross surgical specimen of poorly differentiated squamous carcinoma of the thyroid in a 69-year-old man, similarly treated. He learned to use an electronic larynx well enough to continue to serve as town moderator. He died 6 years later of coronary disease, without recurrence of the thyroid cancer.

figure 8-9 A 62-year-old man with massive recurrent papillary thyroid carcinoma following thyroidectomy, 4 years previously, and subsequent treatment with 131I The disease progressed to cause pain, bleeding, airway and esophageal obstruction, and loss of voice. The operative photograph shows the mass specimen including thyroid, larynx, trachea, and esophagus being removed by en bloc dissection. The neck is at the left. On the right, the upper sternum, heads of clavicles, and upper two costal cartilages have been excised to provide access for mediastinal tracheostomy. The flexible endotracheal tube in the right lower corner is in the proximal end of the trachea (arrow). The floor of dissection reveals carotid arteries, internal jugular veins, and prevertebral fascia. Good palliation was attained for a number of years. Pulmonary metastases appeared.

figure 8-9 A 62-year-old man with massive recurrent papillary thyroid carcinoma following thyroidectomy, 4 years previously, and subsequent treatment with 131I The disease progressed to cause pain, bleeding, airway and esophageal obstruction, and loss of voice. The operative photograph shows the mass specimen including thyroid, larynx, trachea, and esophagus being removed by en bloc dissection. The neck is at the left. On the right, the upper sternum, heads of clavicles, and upper two costal cartilages have been excised to provide access for mediastinal tracheostomy. The flexible endotracheal tube in the right lower corner is in the proximal end of the trachea (arrow). The floor of dissection reveals carotid arteries, internal jugular veins, and prevertebral fascia. Good palliation was attained for a number of years. Pulmonary metastases appeared.

Resection and reconstruction of the involved airway as part of a complete local excision of thyroid cancer, especially as an initial procedure, accomplishes the primary goals of conventional thyroid cancer surgery. It does not represent a radical extension of surgery attended by great hazards. Follow-up results strongly suggest that the best long-term results are obtained either 1) in those patients in whom the involved airway is removed at the initial resection of tumor or 2) where invaded airway is removed as soon as possible after identification at initial thyroidectomy. Prolonged palliation has been achieved by late removal of the airway invaded by a recurrent tumor, but it rarely provides a cure, even though patients had appeared earlier to run an indolent course. Palliative resection of an obstructed airway seems justified, even in the face of pulmonary metastases when the tumor is known to be slowly progressive.17 Pulmonary metastasectomy has not been shown to be of value in thyroid cancer.19 Most often, the recurrent laryngeal nerve that has to be sacrificed is already involved by tumor, and so no further functional loss follows.

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