https://openworks.mdanderson.org/sumexp22/1134/thumbnail.jp

Hyde, Emily K.

Maniakas, Anastasios

Xu, Li

Zafereo, Mark E.

English

OpenWorks @ MD Anderson

Segmental Tracheal Resections in Thyroid Cancer PatientsEmily K. Hyde, BS, Anastasios Maniakas, MD, PhD, Li Xu, PhD, Mark E. Zafereo, MDDepartment of Head and Neck Surgery, MD Anderson Cancer Center, Houston, TexasINTRODUCTIONThyroid cancer is a common cancer inthe US, with a good prognosis and highoverall survival. In less than 1% ofadvanced thyroid cancer patients,however, extrathyroidal extension of thetumor can lead to invasion of thetrachea, which leads to a significantincrease in morbidity and mortality.Often, tracheal resection via windowresection or segmental resection withreanastomosis is the only treatmentoption available to control local diseaseand decrease the risk of recurrence.These procedures are amongst the mosttechnically challenging and high risk inthyroid and neck surgery.In a landmark 1991 study, Ishihara andcolleagues provided the first significantexperience with segmental trachealresection for 60 advanced thyroid cancerpatients from 1973-1988, and thisremains the largest experience in thepublished literature to this date. Hereinwe describe a contemporary high-volume experience with segmentaltracheal resection for advanced thyroidcancer, evaluating perioperativeoutcomes and survival.METHODSWe retrospectively reviewed allconsecutive patients undergoing thyroidcancer surgery at MD Anderson CancerCenter from 2016 – 2022, using thefollowing criteria:Included:• Patients who underwent either segmental or window tracheal resection at MDACCExcluded:• Patients who underwent tracheal shave excisionSurvival was analyzed using the Kaplan-Meier method. Primary endpoints wereoverall and progression free survival.CONTACTemily.hyde@uth.tmc.edu713-594-6967RESULTS53 patients received tracheal resection for intraluminally invasivethyroid cancer over a 6-year period, with 51 segmentalresections and 2 window resections (see Table 1). The mediannumber of tracheal rings resected was 5 (range 1-12) rings, withmedian 5 (range 2-36) days hospital stay. 11 (21%) patientsreturned to the OR within 30 days of tracheal resection.Table 1, Segmental vs Window Tracheal ResectionType of Resection # of Patients (%)Segmental 51 (96%)Window 2 (4%)Total 53 (100%)Figure 1, Patients by Major Histologic Tumor Type. Pathologyincluded 37 patients with papillary thyroid cancer, 7 with Hurthle cellcancer, 6 with anaplastic cancer (ATC), 2 with poorly differentiatedcancer, and 1 with medullary cancer.70%13%11%4%2%0510152025303540Papillary Hurthle Cell Anaplastic PoorlydifferentiatedMedullary# OF PATIENTSMajor Histologic Type of TumorPatients by Major Histologic Tumor Type45%9%9%8%6%4%4%2%2%0 5 10 15 20 25HypoparathyroidismAirway obstructionAir leakArrhythmiaTracheoesophageal FistulaWound infectionHematomaPneumothorax/PneumoperitoenumPartial Dehiscence# OF PATIENTSFigure 3, Occurrence of Postoperative Complications. 35 (66%)patients had at least one postoperative complication, the most commonbeing either temporary or permanent hypoparathyroidism (21 and 3respectively), obstructive airway event requiring intervention (5), and airleak from primary anastomosis site (5).Table 2, New Tracheostomy Tube Placed Intra/postoperativelyType of Tracheostomy # of Patients (%)Temporary 6 (11%)Permanent 1 (2%)Total 7 (13%)Table 3, Concomitant ProceduresProcedure # of Patients (%)Esophageal Resection 24 (45%)Laryngectomy 4 (8%)Sternotomy 2 (4%)DISCUSSIONThe technical challenges and high risk ofperioperative complications associatedwith tracheal resection are evident in ourcohort, as two-thirds of patientsexperienced at least one complicationafter surgery. However, the most commoncomplication was temporaryhypoparathyroidism, and 50% of patientswere discharged after 5 days or less,indicating a relatively uncomplicatedpostoperative course for many patients.High overall survival rates indicate thattracheal resection is associated withmultiyear survival in thyroid cancerpatients with intraluminal disease. It isalso associated with locoregional diseasecontrol, as less than 10% of patientsexperienced local recurrence, and nonehad recurrent disease in the trachea.However, risk of local and distantrecurrence slightly increased over time.This is the largest tracheal resectioncohort since 1991. Additionally, this is oneof the only tracheal resection cohorts todate to include non-differentiated thyroidcancer patients, which comprised 17% ofthis cohort.CONCLUSIONIn the largest contemporary experience with segmental tracheal resection for advanced thyroid cancer, we highlight the complexity and significant perioperative risks associated with these surgeries, with minority of patients requiring return to the OR, and very rare perioperative death.  The vast majority of patients remain alive and locoregionally disease-free several years following surgery.REFERENCES1) NCI. SEER Program, 2022.2) Kim et al. Eur Arch Otorhinolaryngol, 2016.3) Matsumoto et al. Cancers, 2021.4) Allen et al. The Laryngoscope, 2020.Figure 2, Preoperative Patient Vocal Cord Mobility as Seen onFlexible Laryngoscopy. 18 patients had a preoperative unilateral vocalcord paralysis, 15 in the right and 3 in the left. No patients hadpreoperative bilateral cord paralysis.60%34%6%Preoperative Patient Vocal Cord Mobilityas Seen on Flexible LaryngoscopyBilateral Cord MobilityUnilateral ParalysisNot StatedTime (year)Overall Survival Probability (%)Figure 4, Overall Survival. Overall, 5 (9%) patients are deceased, 3 ofwhich had ATC, and 48 (91%) are alive. One patient (2%) died within 30days of surgery due to respiratory distress. Median follow-up time was2.3 years (range 11 days to 6 years).Overall SurvivalEvent: DeathOS (95% CI)1-year 93.6% (86.6%-100%)3-year 88.1% (78.2%-98.1%)5-year 88.1% (78.2%-98.1%)Time (year)Figure 5, Local Recurrence Free Survival. 5 (9%) patients developedlocoregionally recurrent disease, all in the central neck. Of these 5patients, only 1 is deceased. Median follow-up time was 2.3 years(range 11 days to 6 years).Local Recurrence Free SurvivalEvent: Death or Recurrence to NeckRFS (95% CI)1-year 91.5% (83.4%-99.5%)3-year 79.7% (66.9%-92.6%)5-year 74.4% (58.7%-90.1)Recurrence Free Survival Probability (%)Time (year)Progression Free Survival Probability (%)Figure 6, Local and Distant Recurrence and Progression FreeSurvival. 11 (21%) patients had recurrence of distant metastases (DM),and 12 (23%) had progression of pre-existing DM. Median follow-up timewas 2.3 years (range 11 days to 6 years).Local/Distant Recurrence/Progression Free SurvivalEvent: Death, Recurrence to Neck, or Recurrence of Progression of Distant DiseasePFS (95% CI)1-year 67.5% (53.8%-81.2%)3-year 44.4% (27.0%-61.8%)5-year 23.7% (0%-47.2%)POSTOPERATIVECOMPLICATIONSOccurrence of Postoperative Complications

Segmental Tracheal Resection in Advanced Thyroid Cancer Patients

https://openworks.mdanderson.org/cgi/viewcontent.cgi?article=1134&amp;context=sumexp22

Segmental Tracheal Resection in Advanced Thyroid Cancer Patients

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