Estratégia terapêutica nas
formas localmente
invasivas das VADS por
CPT
Alternativas à resignação
Jorge Rosa Santos
Serviço de Cirurgia de Cabeça e Pescoço
Instituto Português de Oncologia
Lisboa
23 de Abril 2015
Sem conflito de interesses
Apesar da quase benignidade da
evolução tumoral do carcinoma
diferenciado da tiroideia
• 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.
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Formas comuns de progressão tumoral,
nos casos de invasão laringo-traqueal
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Czaja and McCaffrey
Arch Otol. Head and
4 Neck
Surgery - May 1997
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
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Langenbecks Arch Surg. 2014 Feb;399(2):209-16.
Classification of aerodigestive tract invasion from thyroid cancer.
Brauckhoff M1.
II
Tratamento Paliativo
vs.
Ressecção radical
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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.
CONCLUSIONS
Only 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.
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.no
Abstract
Extrathyroidal 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 welldifferentiated 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.
Abstract
BACKGROUND:
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.
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.
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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.edu
RESULTS:
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.
TRATAMENTO CIRURGICO DAS FORMAS
INVASIVAS DE CARCINOMA DIFERENCIADO DA
TIROIDEIA
1990-2011
RESSECÇÕES LARINGO-TRAQUEAIS
Sobrevida média - 31,5 mêses
Mortalidade op. – (3/35) 8,6%
COMPLICAÇÕES
Paralisia bilateral dos recorrentes
Estenose
Fistula
Deiscência da anastomose traqueal
Mediastinite e complicações pulmonares
Deiscência dos retalhos
Supuração da ferida operatória
Hemorragia
IRA e MOF (Multiple Organ Failure)
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
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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.
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Preservaçãqo da condução de pelo menos um nervo
recorrente laringeo
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Grillo stich
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Invasão da Laringe e da Faringe
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Laringectomia Parcial
•
•
•
•
Laringectomia fronto-lateral
Hemilaringectomia
Laringectomia “Near Total”
Ressecção parcial da cricoide
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Invasão do Esófago
• Ressecção simples da muscular
• Ressecção e sutura simples
• Retalho mio-cutâneo
• Transplante livre de jejuno / Retalho livre antebraquial
• “Pull up” digestivo
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Invasão do Nervo Recorrente
•Um nervo funcionante não deverá ser
sacrificado
•Se no entanto existe uma paralisia prévia
não se deverá preservar o nervo.
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(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.
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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
CASO 2
• Sexo feminino, 78 anos
• Inscrita 11/04/06
• Operada 19/04/2006
• Tiroidectomia total + celulectomia bilateral +
laringectomia total
• RT complementar
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
• 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
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