A novel procedure for transtracheal resection for recurrent thyroid cancer involving a trachea and esophagus

Abstract

Background: Surgery remains the main treatment for locally advanced thyroid cancers invading the trachea, esophagus, and recurrent laryngeal nerve. However, extensive resection of such tumors can sometimes involve difficulties and may result in the deterioration of the patient's quality of life. The surgeon should consider not only the patient's prognosis but also the preservation of postoperative function.

Methods: This report describes a minimally invasive surgical procedure for recurrent poorly differentiated papillary thyroid carcinoma involving the trachea and esophagus. To decrease the potential for recurrent laryngeal nerve injuries and to preserve both the tracheal and esophageal blood supply, we adapted a transtracheal approach; the recurrent tumor was safely and completely removed without causing a dysfunction. After a tracheotomy to the right, the tumor was easily detected through the tracheostoma and delineated by palpation. The mucous membrane of the trachea was minimally incised along the right-hand border of the tumor and a mucosal flap was elevated. The left side of the trachea including the membranous wall and cartilage of the tracheal mucosa was maximally preserved, to maintain the vascular supply to the trachea. Finally, the membranous wall of the trachea was preserved to within one-third of the left-hand side. Furthermore, the risk of bleeding from major lateral vessels was reduced. A sternocleidomastoid muscle flap was elevated and inserted into the cavity resulting from the tumor resection and sutured between the esophagus and trachea. The membranous wall of the tracheal mucosa was also sutured submucosally.

Results: The tumor was removed completely with the muscular layer of the esophagus without injury to the intact recurrent laryngeal nerve and lateral major vessels. The patient started oral nutritional intake on the first postoperative day and was discharged without any significant postoperative complications.

Conclusions: This new procedure for transtracheal resection for recurrent thyroid cancer involving the trachea and esophagus was useful and safe.

Figure 1

CT of neck with contrast medium, showing heterogeneous enhanced mass between trachea and esophagus. (A) axial section; (B) sagittal section.

Figure 2

PET/CT and pathological findings. (A) Axial view of PET/CT study shows the recurrent tumor mass between the trachea and esophagus with high uptake of FDG at a peak standardized uptake value of 15.45. (B) Low-power magnification; arrow shows extracapsular extension. (C) High-power magnification. Pathological findings demonstrate poorly differentiated thyroid carcinoma.

Figure 3

Intraoperative findings. (A) The tumor was detected just under the tracheal mucosa. Dashed circle: tumor behind the membranous wall of the trachea. (B) The tumor was resected with minimal additional incision of the membranous wall of the trachea. Arrow: pulling out the tumor from between the membranous portion of the retracted trachea and the esophagus.

Figure 4

Surgical procedure and postoperative endotracheal finding. (A) Surgical procedure. (B) Endotracheal finding 3 months after the surgery. There is no granulation formation. Arrow indicates the left-hand end of the surgical scar on the membranous wall of the trachea.