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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 57-59

Cricotracheal resection and thyrotracheal anastomosis for thyroid carcinoma invading airway


Regional Cancer Centre, Trivandrum, Kerala, India

Date of Web Publication29-Jun-2018

Correspondence Address:
Dr. Jeyashanth Riju
Regional Cancer Centre, Trivandrum - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_34_17

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  Abstract 


Papillary carcinoma thyroid (PCT) invading airway is rare, and the treatment for the same is challenging for the surgeon. We reported a 56-year-old female who presented with a history of blood-tinged sputum and dyspnea. Fine-needle aspiration cytology from thyroid was suggestive of PCT. Imaging showed the involvement of trachea and cricoid cartilage. The patient underwent total thyroidectomy with neck dissection and cricotracheal resection followed by thyrotracheal anastomosis. Surgery with the resection of involved structures is the treatment option for thyroid malignancy invading the airway, being said extend of surgical treatment should be crafted on individual case basis.

Keywords: Airway stenosis/reconstruction, thyroid cancer, tracheal infiltration


How to cite this article:
Varghese BT, Riju J. Cricotracheal resection and thyrotracheal anastomosis for thyroid carcinoma invading airway. J Head Neck Physicians Surg 2018;6:57-9

How to cite this URL:
Varghese BT, Riju J. Cricotracheal resection and thyrotracheal anastomosis for thyroid carcinoma invading airway. J Head Neck Physicians Surg [serial online] 2018 [cited 2018 Dec 14];6:57-9. Available from: http://www.jhnps.org/text.asp?2018/6/1/57/235629




  Introduction Top


Differentiated thyroid carcinomas (DTCs) are usually slow-growing, indolent tumors. Local invasion is, therefore, uncommon. Invasion to upper aerodigestive tract is reported in up to 20% of cases. Trachea is the most common site for infiltration amounting to 35%–60% of tumor infiltration followed by larynx and esophagus. Local tumor invasiveness with concomitant asphyxia or devastating hemorrhage is held responsible for disease-related death in up to 47% of patients with invasive tumors.[1],[2]

Malignancies involving upper aerodigestive tract remain a challenging problem for surgeon and extent of resection remains controversial. More so when cricoid cartilage is additionally involved, a total laryngectomy is preferred most often. However, this might reduce the quality of life of the patient, thus warranting a conservative approach such as cricotracheal resection (CTR) and anastomosis.


  Case Report Top


A 56-year-old female presented with complaints of dyspnea, blood-stained sputum, and swelling in front of neck for 2 months [Figure 1]. CT scan showed thyroid mass with tracheal and cricoid cartilage infiltration [Figure 2]. On presentation, she had stridor, which warranted emergency tracheostomy. Fine-needle aspiration cytology from lesion was papillary carcinoma thyroid (PCT). Magnetic resonance imaging [Figure 3] showed 40 mm × 18 mm lesion replacing isthmus of thyroid and infiltrating anterior and right lateral aspect of the trachea and cricoid cartilage with significant luminal narrowing. No significantly enlarged neck nodes were noted. Flexible endoscopy showed mobile vocal cords and a reddish subglottic mass. She was planned for optimal surgery under frozen control, with consent for total laryngectomy.
Figure 1: Patient at presentationexternal

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Figure 2: Computed tomography showing cricoid cartilage infiltration

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Figure 3: Magnetic resonance imaging showing mass infiltrating the trachea with tracheostomy tube in situ

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On examination, tracheostomy tube was in situ and a 4 cm × 4 cm mass was palpable in the isthmus region of thyroid and it was fixed.

Total thyroidectomy with neck dissection and CTR followed by thyrotracheal anastomosis was carried out [Figure 4]. Tracheostoma was refashioned without any sacrifice of additional trachea cartilaginous rings, and tracheostomy tube was placed. Intraoperatively, thyroid mass was infiltrating to underlying upper three tracheal rings and cricoid cartilage. There were few enlarged lymph left Level II nodes. Recurrent laryngeal nerves and parathyroids were identified and preserved.
Figure 4: Following surgical resection

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Following surgery, the patient was kept with neck flexion with chin-to-chest “guardian” sutures, for 14 days. She was able to take food orally and able to speak by occluding tracheostomy tube, at the time of discharge. We were not able to decannulate her because of persistent subglottic narrowing. She was given adjuvant radiotherapy 60 Gy in 30 fractions, 2 months after the procedure. She is on regular follow-up for the past 1 year with no further disease [Figure 5].
Figure 5: Following surgical resection

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  Discussion Top


DTC, well-encapsulated tumors, has a survival of 91% but when it is associated with extrathyroidal extension overall survival drops to 45%. Trachea is the most common structure involved, next to strap muscle and recurrent laryngeal nerve. Prevalence of tracheal infiltration is 37%. Tracheal invasion is an indicator of aggressive tumor behavior and the most common cause of mortality, due to airway obstruction and/or massive bleeding.[1],[3],[4],[5]

Tumor invasion through trachea was staged according to Shin et al., in which Stage I includes lesion which extends through the thyroid capsule and abuts the airway external perichondrium; Stage II, it destroys the cartilage or penetrates between the tracheal rings; Stage III, it extends through the cartilage or between the tracheal rings into the lamina propria of the tracheal mucosa, without its invasion; Stage IV, it penetrates the entire thickness of the tracheal wall, presenting inside the airway with ulceration or nodules.

A study by Shin showed that tracheal invasion is attributed due to proximity peritracheal fascia with thyroid capsule. Peritracheal fascia was found to be virtually continuous with the dense fibrous tissue between the tracheal cartilaginous rings. Blood vessels within this dense fibrous tissue run perpendicular to the lumen of the trachea, serving as potential lines of weakness and allowing cancer cell invasion by mechanical shearing forces. Once DCT has invaded the trachea, they tend to grow along the trachea instead of actually invading the lumen, implying a circumferential spread of tumor. This implies that morbidity due to window resection may be significantly higher, with complications more serious and low disease-free survival, when compared to tracheal and cricotracheal resection and anastomosis (TRA/CTRA).[3],[4],[5]

Intraluminal invasion is often suspected on the basis of clinical symptoms such as hemoptysis or dyspnea.[6] Intraluminal invasion can be confirmed by imageological studies or endoscopy. In PCT, the sensitivity of preoperative ultrasound to detect tracheal invasion was 42.9%. Bronchoscopic examination might show luminal compression, erythema and edema, neovascular formation, or a frank mucosal invasion.[6],[7]

TRA/CTRA, which was introduced for airway stenosis, is a single-stage procedure which circumferentially resects the involved airway tract and reestablishes its continuity by direct anastomosis between the healthy proximal and distal stumps. The complication rate is high, 15%–39%, implying that this surgical procedure should always be considered as a major intervention and it is potentially associated with life-threatening perioperative events.[4],[5],[8]

Various studies have noted tracheotomy if done is performed two tracheal rings below the anastomotic line. It is generally agreed that 30% or less of cricoid ring can be safely removed, and the remaining portion can provide normal airway caliber if it is reconstructed appropriately. Two chin-to-chest “guardian” sutures were placed in all patients and removed on the 8th postoperative day.[5],[8],[9]

Piazza et al. showed all three patients with previous radiotherapy who underwent TRA/CTRA experienced major complications. Similar complication was also found by Ch'ng et al., who suggested that four tracheal rings (around 2 cm) are the maximum limit for segmental resection and primary anastomosis. It is quite possible that radiotherapy might be a contributing factor preventing decannulation of our patient, although she is able to phonate and able to swallow with ease.[8]

TRA/CTRA procedure preserves airway, voice, and swallowing in sharp contrast to total laryngectomy, which will have an impact on quality of life, with no impact on overall survival.[9],[10]


  Conclusion Top


The surgery of choice for locally advanced DTC with infiltration into airway should always include attempts to preserve speech, airway, and swallowing. Proper selection of patient, meticulous surgery, and careful postoperative management are mandatory to maximize the functional outcome and quality of life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Musholt TJ, Musholt PB, Behrend M, Raab R, Scheumann GF, Klempnauer J, et al. Invasive differentiated thyroid carcinoma: Tracheal resection and reconstruction procedures in the hands of the endocrine surgeon. Surgery 1999;126:1078-87.  Back to cited text no. 1
    
2.
Peng A, Li Y, Yang X, Xiao Z, Tang Q, Wang Q, et al. A review of the management and prognosis of thyroid carcinoma with tracheal invasion. Eur Arch Otorhinolaryngol 2015;272:1833-43.  Back to cited text no. 2
    
3.
Chernichenko N, Shaha AR. Role of tracheal resection in thyroid cancer. Curr Opin Oncol 2012;24:29-34.  Back to cited text no. 3
    
4.
Nishida T, Nakao K, Hamaji M. Differentiated thyroid carcinoma with airway invasion: Indication for tracheal resection based on the extent of cancer invasion. J Thorac Cardiovasc Surg 1997;114:84-92.  Back to cited text no. 4
    
5.
Piazza C, Del Bon F, Barbieri D, Grazioli P, Paderno A, Perotti P, et al. Tracheal and crico-tracheal resection and anastomosis for malignancies involving the thyroid gland and the airway. Ann Otol Rhinol Laryngol 2016;125:97-104.  Back to cited text no. 5
    
6.
McCarty TM, Kuhn JA, Williams WL Jr., Ellenhorn JD, O'Brien JC, Preskitt JT, et al. Surgical management of thyroid cancer invading the airway. Ann Surg Oncol 1997;4:403-8.  Back to cited text no. 6
    
7.
Honings J, Stephen AE, Marres HA, Gaissert HA. The management of thyroid carcinoma invading the larynx or trachea. Laryngoscope 2010;120:682-9.  Back to cited text no. 7
    
8.
Piazza C, Del Bon F, Paderno A, Grazioli P, Mangili S, Lombardi D, et al. Complications after tracheal and cricotracheal resection and anastomosis for inflammatory and neoplastic stenoses. Ann Otol Rhinol Laryngol 2014;123:798-804.  Back to cited text no. 8
    
9.
Czaja JM, McCaffrey TV. The surgical management of laryngotracheal invasion by well-differentiated papillary thyroid carcinoma. Arch Otolaryngol Head Neck Surg 1997;123:484-90.  Back to cited text no. 9
    
10.
Piazza C, Bolzoni A, Peretti G, Antonelli AR. Thyroid metastasis from rectal adenocarcinoma involving the airway treated by crico-tracheal resection and anastomosis: The role of palliative surgery. Eur Arch Otorhinolaryngol Head Neck 2004;261:469-72.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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