Abstract:
Background: Locally recurrent papillary carcinoma of thyroid is a
treatable disease. Tracheal infiltration is associated with impaired
tumor free survival and increased disease specific mortality. Advanced
surgical technique has now allowed tracheal reconstruction with extended
tracheal resection at the same time preserving vocal cord function and
increasing survival.
Case presentation: A 46-year female patient with a history of total
thyroidectomy + bilateral neck dissection for carcinoma thyroid two
years back presented with recurrent thyroid mass in neck with
endotracheal invasion. This was successfully treated with segmental
tracheal resection with end-to-end anastomosis after 4 cm defect. Post
– operative course was uneventful.
Conclusion: Endotracheal invasion of recurrent carcinoma thyroid is not
a contraindication for surgery. Full circumferential resection and end
to end anastomosis is preferred to shaving trachea. It can be safely
anastomosed up to 5 cm defect length. Apart from giving immediate relief
of intratracheal bleeding and obstructive airways, it gives long-term
disease-free survival.
Key words: Thyroidectomy, Tracheal resection, Anastomosis.
Introduction: Papillary carcinoma has an excellent survival.
This cancer presents relatively low malignancy, good prognosis and a
ten-year survival rate of over 90% [1]. Recurrent papillary thyroid
cancer mainly refers to localized and distant recurrence, including
recurrence of the primary tumor, lymph node metastasis, invasion of the
esophagus and trachea, invasion of muscles, soft tissue and nerves and
distant metastases. Different theory has been proposed for etiology of
recurrence in the PTC. Pathological type, staging, degree of extra
thyroid invasion, lymph node metastatic rate, age and type of surgery
may be related to recurrence of cancer [2-4]. That’s why patient is
kept on lifelong follow up. Current ATA guideline defines “disease free
status” as the following: 1. No clinical evidence of tumor, 2. any
evidence of tumor of RAI imaging and / or neck ultrasound, 3.
Unstimulated TG <0.02 ng/ml or stimulated Tg<1 ng/ml
in the absence of interfering antibodies [5].The prognosis for well
differentiated carcinoma worsens when neoplasm invades the trachea. The
cause of death in nearly half of the fatal cases of papillary carcinoma
is caused by obstruction of the trachea [6, 7]. For many years only
palliative surgery was employed in the treatment of patients with
tracheal invasion by thyroid carcinoma [8, 9]. However, with
progress in tracheal surgical techniques, resection of portions of the
trachea with primary anastomosis is feasible. Hence, we are presenting a
case of recurrent papillary thyroid cancer invading tracheal lumen with
signs of obstruction, which was successfully treated with surgical
resection along with segment of trachea and end to end primary
anastomosis.
In this case there was intraluminal tracheal tumor infiltration with
tracheal stenosis (90%) and poor planes with esophagus and cricoid body
erosion. Layered closure technique was applied with complete muscle
release and successfully covering the anastomosis with
sternocleidomastoid muscle.
Case Presentation: We are presenting a case of recurrent
follicular thyroid cancer invading tracheal lumen with signs of
obstruction, which was successfully treated with surgical resection
along with segment of trachea and end to end anastomosis. A 46-year
female patient initially presented to the hospital with complaints of
swollen neck for three years in October 2016, when she was evaluated for
thyroid cancer patient had no particular past or family history of
thyroid disorder or neoplasm. Clinical examination and USG of neck
suggested neoplastic thyroid lesion. FNAC turned out to be follicular
neoplasm. Complete blood count and thyroid function test was normal.
Chest X ray posterior-anterior view was also normal. Patient had no
particular past or family history of thyroid disorder or neoplasm. Total
thyroidectomy + bilateral neck dissection was performed in November
2016. Histopathology report revealed of follicular cancer of thyroid
with, capsular invasion + vascular invasion. Post operative course was
uneventful.WBI Scan report revealed of remnant positive in neck
dissection. Radioactive therapy high dose administered to the patient on
27-02-2017. She was advised to do SPECT CT on 28-02-2017 showed of
remnant activity on thyroid bed. Patient was put on tablet Eltroxin 200
mg once daily till follow up. Cancer recurrence was not observed for a
period of two year after surgery. Patient was on regular follow up and
asymptomatic for two years (from 2018 – 2020).
After two years of treatment and regular follow ups, patient turned up
to our cancer hospital with chief complaints of difficulty in breathing
on 21-05-2021. On clinical examination there was midline neck swelling
measuring 3 x 3 cm at the level of second tracheal ring. CBC, LFT, KFT,
BT, CT, PT INR were normal. TSH was 21.5 IU/L, T3, T4 were normal. 2D
Echo: Ejection Fraction 57%, mild concentration LVEF. CECT neck showed
left paratracheal mass from cricoid to suprasternal notch with tracheal
infiltration and polypoidal projection into lumen of trachea with narrow
airways. There was poor plane with esophagus and erosion was there in
left cricoid body. PET CT scan suggested 3.5 x 4.8 x 4 cm recurrent
disease in thyroid bed abutting sternocleidomastoid extending into
tracheal lumen and causing luminal narrowing. Patient was planned for
surgery after pre anesthetic preparation. Intra operative bronchoscopy
performed. There was 90% obstruction of trachea with luminal bulge
(bilobular within length of 3 tracheal rings). Tracheostomy was
performed between 3-4th tracheal ring. Neck was
explored through previous incision. Mass was isolated and dissected from
trachea. Tracheal incision was made vertical anterior wall. Then trachea
was excised from cricoid to 3rd ring below. 3.5 – 4
cm defect was observed. Post resection trachea was mobilized till
innominate vessel. Suprathyroid release of strap muscle was done.
Posterior layer anastomosis with 3.0 PDS was performed first and then
anterior layer with 3.0 PDS was done and knot was kept outside.
Anastomosis was covered with SCM. Small tear in anterior esophageal wall
was repaired. Written informed consent was taken from the patient for
paper publication and use of images.
Post surgery neck was kept flexed 45° for next 3 days. Post operative
recovery was good. Ryle’s tube feed was started next day. Vitals were
stable. Liquids were administered orally at 5th POD.
Physiotherapy was advised to the patient and active neck exercise was
started. There was small leak from esophagus and oral feed was hold for
ten days. Tracheostomy was blocked on 13th day and RT
feed was continued for few more days.
Post operative RI scan was performed on 7-7-2021 and the report revealed
no abnormal traced uptake in neck. Anti TG <15 U/ml
(clinically non-significant) and TG 0.6 ng/ml (non-significant). Final
histopathology report revealed of papillary thyroid cancer. LVI +ve
tracheal wall was involvedcricoid cut margin was +ve. Patient was
advised for follow up at nuclear medicine department. Follow up of the
patient was done three monthly for the last one year. Patient was doing
well with no evidence loco regional recurrence. Quality of voice and
swallowing was normal. USG neck with thyroid function test was done at
each follow up.