Surgical Treatment of a Patient with Invasion of Multiple Organs Including the Common Carotid Artery by Papillary Thyroid Carcinoma: Surgical Management for Invasion of the Aerodigestive Tract

Abstract

Background: Extrathyroidal invasion has the greatest negative prognostic impact among several adverse prognostic factors of differentiated thyroid carcinoma (DTC). Surgical treatment for locally advanced DTC is challenging. In particular, the presence of great vessel involvement makes it more challenging, with vessel rupture and infection being common occurrences, especially in patients with laryngotracheal or esophageal intraluminal invasion.1 Locoregional tumors presenting with great vessel and/or multiple organ invasion have been deemed to be unresectable. However, there has been little discussion regarding which types of locoregional tumor are unresectable. Regarding the surgical management of aerodigestive invasion, the 2015 American Thyroid Association management guidelines state that surgical decision making can be complex and must balance oncologic surgical completeness with preservation of the upper aerodigestive tract head neck function. However, surgical management of aerodigestive tract invasion remains controversial.2 Materials and Methods: A right thyroid tumor was unexpectedly detected in a 77-year-old man by computed tomography images. The man was found to have papillary thyroid carcinoma (PTC) by fine needle aspiration biopsy. He was referred for the surgical treatment of multiple organ invasion by PTC. Tumor encasement of about 180° of the right common carotid artery and aerodigestive tract invasion were suspected on pre-operative magnetic resonance imaging. We performed total thyroidectomy, including resection of multiple organ infiltration and right lateral neck dissection. Our surgical strategy for locally advanced DTC is implemented with curative surgical intent for all patients and functional preservation or reconstruction, if possible. Results: The thyroid tumor infiltrated the right common carotid artery, internal jugular vein, prevertebral fascia, pharyngoesophagus, laryngotrachea, and right recurrent laryngeal nerve (RLN). We performed subadventitial resection of the common carotid artery, partial prevertebral fascia resection, muscle layer resection of the pharyngoesophagus, framework resection of the larynx, window resection of the trachea from first to fourth ring, and resection and intralaryngeal reconstruction of the right RLN.3 After tumor resection, the right common carotid artery was covered using a deltopectoral flap and separated from the tracheacutaneous fistula. Pathology analysis confirmed well-differentiated PTC, which was classified as pT4bN1bM0. The tracheocutaneous fistula was closed 2 months after surgery. The patient underwent radioactive iodine (RAI) adjuvant therapy of 100 mCi, 6 months after surgery. RAI uptake was noticed in only the thyroid bed. Maximum phonation time was 10 seconds, 6 months after surgery. Conclusions: This video illustrates the technical details of surgical management for invasion of the aerodigestive tract. These surgical techniques are effective for improving surgical curability and functional preservation. No competing financial interests exist. Runtime of video: 9 mins 29 secs