Abstract
Well-differentiated thyroid carcinoma (WDTC) represents the most common endocrine malignancy. Despite excellent prognoses exceeding 90% in 10-year follow-up, there are clinically controversial issues. One of these is extrathyroidal tumour extension invading recurrent laryngeal nerve (RLN). The spread outside of the thyroid parenchyma and invasion to the surrounding structures, classified as always T4a, are the most important negative prognostic factor for the WDTC. Conversely, resection of the RLN leads to vocal cord paralysis with hoarseness, possible swallowing problems, and finally decreased quality of life. We propose a new algorithm for intraoperative management based on the MACIS classification, which would allow swift status evaluation pre/intraoperatively and consider a possibility to preserve the infiltrated RLN without compromising an oncological radicality. In the case of a preoperative vocal cord paralysis (VCP) and confirmation of the invasive carcinoma, a resection of the RLN and the nerve graft reconstruction are indicated. Preoperatively, unaffected vocal cord movement and intraoperatively detected RLN infiltration by the invasive WDTC require an individual assessment of the oncological risk by the proposed algorithm. Preservation of the infiltrated RLN is oncologically acceptable only in specific groups of patients of a younger age with a minor size of primary tumour.
Highlights
Despite rapidly growing global incidence, well-differentiated thyroid carcinoma (WDTC), arising from follicular cells, papillary and follicular, remains one of the most treatable malignancies [1].Papillary thyroid carcinoma (PTC) is the most common malignancy of the thyroid gland representing about 83% of all thyroid cancers
Apparent metastatic involvement of the lateral cervical region represents a significant negative prognostic factor as the invasion to the aerodigestive tract, while micrometastases to the central or lateral regions do not affect the prognosis of patients with WDTC [10]
Because the intraoperative management of the infiltrated recurrent laryngeal nerve (RLN) by the WDTC is still controversial issue, we propose a new algorithm based on the MACIS classification [20], which would allow swift evaluation preoperatively and consider the possibility of preserving the infiltrated RLN without compromising oncological radicality
Summary
Despite rapidly growing global incidence, well-differentiated thyroid carcinoma (WDTC), arising from follicular cells, papillary and follicular, remains one of the most treatable malignancies [1]. In stage I, when the tumor is located entirely within the thyroid gland capsule with no airway invasion, therapeutic recommendation is a total thyroidectomy. The same therapeutic recommendation is for stage III, when the tumor invades through the airway perichondrium and to the cartilage or to the muscle deeply, but not into the submucosa. Apparent metastatic involvement of the lateral cervical region represents a significant negative prognostic factor as the invasion to the aerodigestive tract, while micrometastases to the central or lateral regions do not affect the prognosis of patients with WDTC [10]. It is shown that a crucial step of the WDTC therapy is a complete surgical removal of the tumor tissue [11, 12] and macroscopically radical resection is the main parameter determining the survival of the patient [13]
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