Paul Frake, MD The George Washington UniversityDivision of Otolaryngology – Head & Neck Surgery pfrake@gmail.com

Objectives: - To report a recent case of locally invasive thyroid cancer with intralumenal involvement of the esophagus.- To review the literature with respect to presentation, diagnosis, and surgical treatment of locally invasive thyroid cancer.

Study Design: Case report and literature review.

Methods: Medline was queried for thyroid neoplasms, papillary carcinoma, neoplasm invasiveness, thyroidectomy, esophageal neoplasms, and reconstructive surgical procedures. The results were reviewed and articles were correlated with the topic under discussion.

Results: A 68 year old female presented for evaluation of mild dysphagia. Barium esophagogram showed no abnormalities and CT scan of the neck showed a 4.7 x 2.7cm left thyroid mass that displaced the esophagus and trachea. The patient was taken for thyroidectomy and the thyroid enlargement was found to be invasive papillary carcinoma adherent to the trachea, encasing the recurrent laryngeal nerve, and penetrating into the lumen of the esophagus. The tumor was resected and a staged gastric pull-through esophagectomy was performed.

Conclusions:Invasive papillary carcinoma of the thyroid is a rare variant of a common cancer, invasion into the lumen of the esophagus is even more uncommon. It is important for the surgeon to be versed in the reconstructive options for locally invasive thyroid cancers. In the case of transmural invasion into the esophagus, there is no single best reconstructive procedure. Individualized anatomic and physiologic conditions should dictate which reconstructive procedure is used. Options include end to end reanastamosis, gastric pull through, right colon interposition, and jejunal, anterolateral thigh or radial forearm free flaps.

Transmural Invasion of the Esophagus by Locally Invasive Papillary Thyroid Cancer: a case report and review of reconstructive options.

Paul Frake, MD1; Alexandra Schopf, BA2; Joseph Goodman, MD1; Jeremy White, MD1; Nader Sadeghi, MD11The George Washington University Medical Center, Division of Otolaryngology – Head & Neck Surgery

2The George Washington University School of Medicine

Upon surgery, the thyroid tissue was found to be grossly adherent to the trachea, fully encasing the recurrent laryngeal nerve, and frankly invading the anterior and lateral wall of theesophagus. The border between the esophagus and tumor began to tear with gentle manipulation and the lumen of the esophagus became exposed. A sample of the mass was sent to pathology and found to be papillary thyroid cancer.

The tumor was unable to be separated from the left recurrent laryngeal nerve, therefore the nerve was sacrificed due to gross invasion. Tumor was shaved off of the trachea without entering the lumen of the airway. The tumor was observed to grossly involve the entire thickness of the esophagus and penetrate into its lumen. The involved portions of the esophagus were resected leaving defect that was 5cm long and greater than 50% of the circumference. The remaining esophagus was evaluated for mobility, but primary closure of the remaining esophageal edges was not possible. A16 French T-tube was used for diversion of saliva pending staged definitive treatment of the esophageal defect. The patient did well postoperatively and 10 days later returned to the operating room for esophageal reconstruction by gastric pull-up.

At four month follow up the patient reported speaking and swallowing reasonably well. Flexible nasolaryngoscopic exam revealed a paralyzed left vocal cord with excellent compensation from the right cord and good glottic closure. The patient was also scheduled for additional treatment of the papillary cancer with radiotherapy.

A 68 year old woman, with a medical history of hemithyroidectomy for goiter, presented for evaluation of dysphagia. She had dysphagia, mainly with solids and some with liquids. Mild dysphonia was noted as well.

On physical exam, the patient had an enlargement of the left lobe of the thyroid, which was firm. Her trachea was deviated to the right side. Her oral cavity, nasal exam, ears, and salivary glands were within normal limits.

She had stroboscopic examination of the larynx that showed full symmetric movement of both true vocal folds with mild Reinke’s edema. A barium swallow study revealed extrinsic compression on the proximal part of the esophagus with no abnormalities of intralumenal contrast flow. A CT scan of the neck revealed a left-sided thyroid mass wrapping around the trachea and compressing the esophagus dorsally. The right side showed a remnant of thyroid that was not enlarged. The patient was treated with proton pump inhibitors for laryngopharyngeal reflux and Reinke’s edema, and was scheduled for completion thyroidectomy for apparent recurrent goiter.

When treating patients with thyroid cancer, otolaryngologists and head and neck surgeons may encounter the scenario of an esophageal defect as described in our case. There are many options for the management of esophageal defects, and the option utilized will depend on the nature of the defect, patient factors, surgeon experience, and the resources available at a given institution. Recent studies have demonstrated that both gastrointestinal and fasciocutaneous grafts are safe and effective options for esophageal reconstruction in the hands of an experienced surgical team.

INTRODUCTION

Case

1) Patel KN, Shaha AR. Locally advanced thyroid cancer. Current Opinion in Otolaryngology & Head and Neck Surgery 2005;13:112-116.2) Bayles SW, Kingdom TT, Carlson GW. Management of thyroid carcinoma invading the

aerodigestive tract. Laryngoscope 1998;108:1402-1407.3) McCaffrey JC. Evaluation and treatment of aerodigestive tract invasion by well-differentiated

thyroid carcinoma. Cancer Control 2000;7:246-252.4) McCaffrey JC. Aerodigestive tract invasion by well-differentiated thyroid carcinoma: diagnosis,

management, prognosis, and biology. Laryngoscope 2006;116:1-11.5) Gillenwater AM, Goepfert H. Surgical management of laryngotracheal and esophageal

involvement by locally advanced thyroid cancer. Seminars in Surgical Oncology 1999;16:19-29.6) Archibald S, Young JE, Thoma A. Pharyngo-cervical esophageal reconstruction. Clin Plastic Surg

2005;32:339-346.7) Ferahkose Z, Bedirli A, Kerem M, Azili C, Sozuer EM, Akin M. Comparison of free jejuna graft with

gastric pull-up reconstruction after resection of hypopharyngeal and cervical esophageal carcinoma. Diseases of the Esophagus 2008;21:340-345.8) Stile FL, Sud V, Zhang F, Angel M, Anand V, Lineaweaver WC. Reconstruction of long cervical

esophageal defects with the radial forearm flap. Journal of Craniofacial Surgery 2006;17:382-387.9) Yu P, Lewin JS, Reece G, Robb GL. Comparison of clinical and functional outcomes and hospital

costs following pharyngoesophageal reconstruction with the anteriolateral thigh free flap versus the jejunal flap. Plastic and Reconstructive Surgery 2006;117:968-974.

CONCLUSIONS

DISCUSSION REFERENCES

Figures 1 & 2: CT scan of the neck demonstrating the left thyroid mass.

Figure 5: Invasion of papillary tumor into the recurrent laryngeal nerve.

ABSTRACT

CONTACT

Well differentiated thyroid cancers occasionally spread to local non-lymphatic structures in the neck. When they do they can involve any combination of the larynx, trachea, recurrent laryngeal nerve, or esophagus. Invasion of these structures frequently leads to associated symptoms including dyspnea, stridor, hemoptysis, hoarseness, dysphonia, or dysphagia. We will present a case of papillary thyroid cancer that was locally invasive, involving the trachea, recurrent laryngeal nerve, and the full thickness of the esophagus. This patient’s preoperative symptoms were dysphagia and mild dysphonia. The patient had a history of hemithyroidectomy for pathologically proven benign goiter. Following preoperative workup and fiberoptic laryngoscopy, CT scan, and barium esophagogram, the diagnosis of recurrent goiter was presumed. After discovering the extent of the disease intraoperatively an oncologic resection was performed. We will discuss the preoperative evaluation, intraoperative management, and decision making with particular focus on the management of esophageal defects secondary to thyroid tumor resection.

In the majority of known cases of invasive papillary thyroidcancer invading the esophagus, there is only partial invasion of the esophageal musculature, and shave excision is recommended.1,3-5 However, in this case of intraluminal involvement of the tumor, full-thickness resection of the esophagus was necessary.

The first option for reconstruction of an esophageal defect is reapproximation and anastamosis of the remaining esophageal segments. When this is not possible, an autologous graft may be employed. The grafts used to reconstruct esophageal defects include intestinal flap (jejunum or colon), gastic pull-up, and fasciocutaneous free flaps (radial forearm and anterior thigh).6-9

The jejunal free flap has been a mainstay in esophageal reconstruction due to its size and tissue characteristics and low rates of fistula formation.6,7 However, the disadvantages of this flap include a postoperative “wet voice” and an abdominal surgery with potential for bowel obstruction or ileus. With respect to the gastric pull-up operation, Ferahkose and colleagues, showed that it had a similar survival and morbidity profile to jejunal free flap, and that both were safe and effective options for esophageal reconstruction. Free jejunal transfer is more commonly used for defects of the pharynx and hypopharynx, and gastric pull-up is better suited for defects of the cervical and thoracic esophagus. A potential advantage of gastric pull-up is that, in one study, it had a lower stricture rate than the jejunal free flap. Also, the gastric pull-up is not a free tissue transfer, so it does not involve any microvascular anastamoses.7

The radial forearm flap is a fasciocutaneous free flap used to reconstruct esophageal defects. This flap has a long vascular pedicle and has been reported to have better postoperative speech characteristics than jejunum. However, when compared to jejunum the radial forearm flap may have a higher rate of fistula formation.6,8 Another fasciocutaneous reconstruction option is the anteriolateral thigh flap. This flap has been shown to have comparable success and morbidity to the jejunal flap. But, advantages of the anteriolateral thigh include better voice and swallow function, and a peripheral donor site (which eliminates the need for an abdominal surgery and its associated morbidities). 9

Figure 4: Papillary architecture and “Orphan Annie” nuclei..

Figure 3: Photograph of the papillary thyroid cancer eroding through the esophageal mucosa in to its lumen.

Fig. 1

Fig. 2

Invasion of papillary thyroid cancer into the aerodigestivetract is estimated to occur in approximately 3-16% of cases.1-5

A fraction of those invade the esophagus and even fewer will penetrate into the lumen of this organ. Dysphagia is a less common presentation of this disease after hoarseness, stridor, and no symptoms.3,5 Benign goiter, on the other hand, commonly causes dysphagia. The most likely diagnosis given this patient’s presentation was goiter.