Jorge Rosa SantosServiço de Cirurgia de Cabeça e Pescoço

Instituto Português de OncologiaLisboa

Estratégia terapêutica nas formas localmente

invasivas das VADS por CPT

Alternativas à resignação

23 de Abril 2015Sem conflito de interesses

Apesar da quase benignidade da evolução tumoral do carcinoma

diferenciado da tiroideia

23 de Abril 2015 IPOFG / JRS 2

• A invasão laringo-traqueal é da ordem dos 7%.

• A invasão local das vias aéro-digestivas superiores é causa de

uma considerável morbilidade e mortalidade.

• 95% dos doentes falecidos, apresentam uma doença local

activa.

IPOFG / JRS 323 de Abril 2015

23 de Abril 2015 IPOFG / JRS 4

Formas comuns de progressão tumoral, nos casos de invasão laringo-traqueal

Czaja and McCaffreyArch Otol. Head and Neck

Surgery - May 1997

Langenbecks Arch Surg. 2014 Feb;399(2):209-16. Classification of aerodigestive tract invasion from thyroid cancer.Brauckhoff M1.

Estadios da invasão laringo-traqueal no carcinoma da tiroideia (modificada por Shin e col.)

Estadio 1 Invasão adjacente Adesão perilaringotraqueal

Estadio 2 Invasão superficial Invasão da cartilagem

Estadio 3 Invasão profunda Invasão dos espaços intercartilaginosos e da mucosa sem manifestações intraluminais

Estadio 4 Invasão intraluminal Tumor intraluminal

23 de Abril 2015

23 de Abril 2015 IPOFG / JRS 6

II

Tratamento Paliativovs.

Ressecção radical

CONCLUSIONSOnly with proper preoperative evaluation, a high index of suspicion for invasion, and the surgical expertise for complete resection with low morbidity, patients with invasive well-differentiated thyroid cancer are likely to be given the best opportunity for survival and low risk of recurrence. Gross disease resection is an underlying theme throughout the literature for thyroid cancer in general and for invasive disease specifically, which is reflected in the statements offered here for which consensus was achieved. For invasive disease, complete resection can result in a plethora of important functional deficits, which must be considered as the surgical plan is engaged, especially as it relates to the commonly affected recurrent nerve and airway. Such decision-making is best formatted by an experienced surgeon in the context of a multidisciplinary team including endocrinology, laryngology, radiology, nuclear medicine, radiation oncology, medical oncology, and, most importantly, the patient and their family. In these discussions, oncologic completeness is balanced with surgical morbidity, with an understanding of the patient's disease status, distant progression, comorbidities, and wishes.

Head Neck. 2014 Oct;36(10):1379-90. doi: 10.1002/hed.23619. Epub 2014 Aug 23.Management of invasive well-differentiated thyroid cancer: AHNS consensus statement.Shindo ML1, Caruana SM, Kandil E, McCaffrey JC, Orloff LA, Porterfield JR, Shaha A, Shin J, Terris D, Randolph G.

Extrathyroidal thyroid cancer : results of tracheal shaving and tracheal resection].Brauckhoff M1, Dralle H.1Department of Surgical Sciences, University of Bergen, Norway. michael.brauckhoff@helse-bergen.noAbstractExtrathyroidal thyroid cancer invading the laryngotracheal system (UICC stage pT4a) represents a progressive process of infiltration of the tracheal wall layers from the outer to the inner parts of the trachea. These tumors usually present with high proliferation activity correlating with a reduced long-term prognosis. In contrast to intraluminal manifestation requiring complete wall resection, in cases of non-transmural invasion, complete tumor removal can be sometimes achieved by extraluminal tangential resection (shaving). Tangential resections, however, are associated with a higher frequency of microscopically invaded resection margins (R1 resection rate >40%). The available comparative studies (all retrospective, maximum EBM level 3) analyzing oncological outcome show inconsistent results. In more recently published studies, however, complete wall resection in well-differentiated thyroid cancer with tracheal invasion only was found to be associated with longer recurrence-free and tumor-specific survival when compared to shaving. Deep larynx invasion is associated with reduced long-term prognosis when compared to invasion of the trachea. Salvage resections should therefore be performed in selected cases only.

Molecular, morphologic, and outcome analysis of thyroid carcinomas according to degree of extrathyroid extension.Rivera M1, Ricarte-Filho J, Tuttle RM, Ganly I, Shaha A, Knauf J, Fagin J, Ghossein R.1Department of Pathology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA.AbstractBACKGROUND: The impact of varying degrees of extrathyroid extension (ETE), especially microscopic ETE (METE), on survival in thyroid carcinomas (TC) has not been well established. Our objective was to analyze ETE at the molecular and histologic levels and assess the effect of its extent on outcome.CONCLUSION: (i) PTCs with METE have an extremely low recurrence rate in contrast to tumors with gross ETE. (ii) High mitotic activity and/or tumor necrosis confers worse DSS even in patients stratified for gross ETE in trachea/esophagus. (iii) BRAF positivity correlates with the presence of ETE in PTC, but this relationship is lost within classical/tall cell PTC if follicular variants are excluded from the analysis.

IPOFG / JRS 1023 de Abril 2015

The management of thyroid carcinoma invading the larynx or trachea.Honings J1, Stephen AE, Marres HA, Gaissert HA.1Division of Thoracic Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA.RESULTS: Invasion of the larynx or trachea by thyroid carcinoma is uncommon and often identified at the time of operation, when the surgeon must decide the extent of resection. Invasion of the airway is associated with loss of tumor differentiation and a reduction in long-term survival compared to tumors limited to the thyroid gland. Whether or not the invaded airway should be resected remains controversial. Tangential shave excision of tumor is commonly performed, despite a marked risk of local recurrence. Circumferential sleeve resection of the larynx and trachea is safe and lowers the risk of local recurrence. In recurrent disease, laryngotracheal resection provides effective palliation of airway obstruction and hemoptysis.CONCLUSIONS: Long-term (>10-20 years) prospective studies are required to compare the outcome after shave excision with segmental airway resection for thyroid carcinoma. Based on the current literature and on our experience, we advocate circumferential tracheal resection in the setting of airway involvement.

Laryngoscope. 2006 Jan;116(1):1-11.Aerodigestive tract invasion by well-differentiated thyroid carcinoma: McCaffrey JC1.1Department of Interdisciplinary Oncology, University of South Florida School of Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida 3612, USA. mccaffrj@moffitt.usf.eduRESULTS: Basic science: a significant difference between the three thyroid tissue groups for E-cadherin expression was demonstrated on one-way ANOVA testing. When controls were compared with either experimental group in post hoc ANOVA testing, differences between all groups were demonstrated (P < .001). For beta-catenin, the intensities of the three groups were not different by one-way ANOVA testing. Similar nonsignificant results were found on post hoc ANOVA testing. Clinical: there was a statistically significant difference in survival for patients with and without involvement of any portion of the endolarynx or trachea (P < .01). There was a significant difference among all three surgical groups when compared (P < .001). When complete and shave groups were compared with gross residual group there was a significant decrease in survival in incomplete resection group (P < .01). Cox regression analysis demonstrated invasion of larynx and trachea were significant prognostic factors for poor outcome. The type of initial resection was significant on multivariate analysis. Removal of all gross disease is a major factor for survival.

RESSECÇÕES LARINGO-TRAQUEAIS

TRATAMENTO CIRURGICO DAS FORMAS INVASIVAS DE CARCINOMA DIFERENCIADO DA

TIROIDEIA1990-2011

Sobrevida média - 31,5 mêsesMortalidade op. – (3/35) 8,6%

Paralisia bilateral dos recorrentesEstenoseFistulaDeiscência da anastomose traquealMediastinite e complicações pulmonaresDeiscência dos retalhosSupuração da ferida operatóriaHemorragia IRA e MOF (Multiple Organ Failure)

COMPLICAÇÕES

23 de Abril 2015 IPOFG / JRS 13

TRATAMENTO CIRURGICO DAS FORMAS INVASIVAS DE CARCINOMA DIFERENCIADO DA TIROIDEIA

•A ressecção laringotraqueal e a reconstrução aerodigestiva, evita a morte por

asfixia e permite uma paliação prolongada, com boa qualidade de vida dos

doentes.

•Nos doentes que apresentam uma invasão da traqueia, deveremos encarar a

possiblidade de uma ressecção mais ampla que o “shaving” da cartilagem

(R1>40% - Henning Dralle) com a objectivo de aumentarmos a probabilidade de

cura dos doentes.

•Deveremos complementar a ressecção radical do tumor com radioterapia

externa e/ou com I131

• Diferenciação, idade do doente, rediferenciação com retinoides

23 de Abril 2015 IPOFG / JRS 14

Ressecção Traqueal Segmentar(Permite a ressecção até ao máximo de sete

anéis traqueais)

• Anastomose laringo-traqueal ou traqueal com

abaixamento da laringe por libertação do osso hioide

(Técnica de Dedo)

• Libertação da paredes anterior e laterais da traqueia

cervical e torácica

• Anastomose com Prolene 000 com pontos separados.

IPOFG / JRS 1523 de Abril 2015

IPOFG / JRS

IPOFG / JRS 1723 de Abril 2015

23 de Abril 2015 IPOFG / JRS 18

Preservaçãqo da condução de pelo menos um nervorecorrente laringeo

23 de Abril 2015 IPOFG / JRS 19

Grillo stich

IPOFG / JRS 2023 de Abril 2015

Invasão da Laringe e da Faringe

23 de Abril 2015 IPOFG / JRS 21

Laringectomia Parcial

• Laringectomia fronto-lateral• Hemilaringectomia• Laringectomia “Near Total”• Ressecção parcial da cricoide

IPOFG / JRS 2223 de Abril 2015

IPOFG / JRS 2323 de Abril 2015

23 de Abril 2015 IPOFG / JRS 24

Invasão do Esófago

• Ressecção simples da muscular

• Ressecção e sutura simples

• Retalho mio-cutâneo

• Transplante livre de jejuno / Retalho livre antebraquial

• “Pull up” digestivo

IPOFG / JRS 2523 de Abril 2015

23 de Abril 2015 IPOFG / JRS 26

Invasão do Nervo Recorrente

•Um nervo funcionante não deverá ser

sacrificado

•Se no entanto existe uma paralisia prévia

não se deverá preservar o nervo.

IPOFG / JRS 2723 de Abril 2015

(A)Algorithm for preoperative recurrent laryngeal nerve (RLN) paralysis. (B) Algorithm for RLN infiltration found at surgery. G. W. Randolph, editor. Surgery of the thyroid and parathyroid glands. 2nd ed. Philadelphia, PA: Elsevier–Saunders, 2012.

CASO 1

• 51 anos, sexo masculino

• Carcinoma papilar bem diferenciado com invasão traqueal

• Inscrito em 15/03/2012

• Operado em 20/04/2012

• Tiroidectomia total+esvaziamento ganglionar bilateral+

ressecção de 3 anéis traqueais

• Radioterapia externa complementar

• Terapêutica com I131

3 anos de operado sem evidencia imagiológica ou Laboratorial de doença

• Sexo feminino, 78 anos

• Inscrita 11/04/06

• Operada 19/04/2006

• Tiroidectomia total + celulectomia bilateral +

laringectomia total

• RT complementar

CASO 2

CASO 2

• Fulguração com laser CO2 em 2013• Observada a ultima vez em Novembro 2014, bom

estado geral, 86 anos com 9 anos de sobrevida

CASO 3

• 68 anos, sexo masculino

• Operado em Março de 2007

• Tiroidectomia total+esvaziamento compartimento central+ressecção circunferencial da traqueia

• Radioterapia externa complementar

• Vivo com 8 anos com evidencia laboratorial de doença

CASO 4

IPOFG / JRS 46

• Fulguração com laser CO2 da componente de tumor vegetante da traqueia (lúmen a 40%)

• Tiroidectomia total+esvaziamento ganglionar cervical esquerdo+ressecção segmentar da traqueia

• Traqueostomia• Descanulado ao 10º dia

23 de Abril 2015

IPOFG / JRS 4723 de Abril 2015

IPOFG / JRS 4823 de Abril 2015