Invasive thyroid cancer: management of the trachea and esophagus

Abstract

Well-differentiated thyroid cancer most commonly presents as an intrathyroidal tumor; however, extrathyroidal extension occurs in approximately 6% to 13% of patients and carries a significant negative impact on survival. Extrathyroidal disease may involve critical structures in the central neck, including the recurrent laryngeal nerves, trachea, esophagus, and larynx, requiring surgery extending significantly beyond the thyroid gland. Appropriate surgical management is of great importance and can normalize survival curves, whereas gross residual disease postoperatively may lead to recurrence and decreased survival. Adjuvant postoperative therapies for thyroid cancers with extrathyroidal extension include thyroid hormone suppression, radioactive iodine therapy, and external beam radiotherapy. This summary reviews approaches to the management of invasive thyroid cancers involving the aerodigestive tract.

Fig. 1

Recurrent laryngeal nerve (RLN) management flow chart.

Fig. 2

Staging system for tracheal invasion as devised by Shin and coworkers. (From Shin DH, Mark EJ, Suen HC, et al. Pathologic staging of papillary carcinoma of the thyroid with airway invasion based on the anatomic manner of extension to the trachea: a clinicopathologic study based on 22 patients who underwent thyroidectomy and airway resection. Hum Pathol 1993;24(8):866–70; with permission.)

Fig. 3

Partial window-type tracheal resection for invasive thyroid cancer. Such a defect can be closed with a regional muscle flap without tracheotomy. Care must be taken to ensure that malignancy has not tracked circumferentially around the involved tracheal rings, which may require a sleeve resection rather than window resection.