Surgical Management of Invasive Differentiated Thyroid Cancer: An Evidence-Based Review

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Paper:
    • “Surgical Management of Invasive Differentiated Thyroid Cancer: An Evidence-Based Review”:
      • Published in: Thyroid, 2016; Vol 26(9): 1156–1166
        [DOI: 10.1089/thy.2015.0567]
  • Objective:
    • To provide an evidence-based review on the frequency, clinical implications, and management strategies of invasive differentiated thyroid cancer (DTC) involving adjacent structures of the neck.
  • Key Findings:
    • Frequency of Invasion (based on pooled data and institutional experience):
      • Recurrent Laryngeal Nerve (RLN): ~ 47% of locally advanced cases
      • Strap Muscles: ~ 40%
      • Trachea: ~ 21%
      • Esophagus: ~ 12%
      • Larynx: ~ 3%
      • Carotid Artery: ~ 2%
    • RLN and strap muscle invasion were:
      • The most common sites of local extension.
    • Surgical Management Recommendations:
      • Recurrent Laryngeal Nerve (RLN):
        • If functional and partially encased:
          • Consider nerve preservation via shaving
        • If non-functional or fully invaded:
          • Resection is advised with or without reinnervation techniques
        • Postoperative vocal cord assessment is mandatory
        • American Head and Neck Society (AHNS) Consensus Statement:
          • Statement 2-A:
            • RLN encased, ipsilateral vocal cord (VC) paresis / paralysis:
              • Resection is indicated (consensus)
          • Statement 2-B:
            • RLN encased, ipsilateral bilateral normal VC function:
              • Tumor may be shaved off to spare the RLN, as long as all gross disease is removed (consensus)
          • Statement 2-C:
            • RLN encased, contralateral VC paretic / paralyzed:
              • Tumor may be shaved off so that the RLN is spared (consensus)
          • Reference:
            • Shindo ML et al. Management of invasive well-differentiated thyroid cancer: An American Head and Neck Society Consensus Statement: AHNS Consensus Statement. Head Neck 2014 36: 1379-1390.
        • If the nerve is sacrified RLN reconstruction is advisable or thyroplasty or cord injection.
  • Surgical Management Recommendations:
    • Trachea:
      • Shaving of superficial invasion is acceptable
      • Full-thickness invasion may require window or segmental resection (e.g., tracheal reconstruction):
        • Multi-disciplinary planning often needed
      • Main methods of management:
        • Shave:
          • Used when tumor invades perichondrium or cartilage only:
            • Tangential excision with minimal invasion leaving mucosa intact
          • Preserves tracheal framework
          • Disadvantages:
            • Confirming negative margins intraoperatively
            • Lack of continuous plane underneath the external perichondrium
            • Tumor spread into the tracheal lumen via lymphatics that communicate in the intercartilaginous space
          • Local control:
            • Around 95% if tumor does not penetrate beyond the perichondrium
          • Window Resection:
            • Limited by the length and circumference of the trachea to mantain stability:
              • Need to resect < 1/3 of the circumference
              • Partial resection of < 3 rings
            • Often for McCaffrey Stage II to III
            • Primary closure rarely possible
            • Needs to be reconstructed with muscle flap or patch graft
          • Sleeve / Segmental Resection:
            • En bloc removal of ≥ 2 tracheal rings:
              • Up to 5 cm to 6 cm or 5 to 7 rings
            • End-to-end primary anastomosis under neck flexion
            • May include cricotracheal or laryngotracheal resection if involvement is proximal
            • Technical Considerations:
              • Maximum safe length for tension-free anastomosis: ~4.5 to 6 cm (5 to 7 rings)
              • Requires preoperative anesthesia planning for airway control
              • Neck flexion with chin-to-chest sutures post-op
              • Close monitoring for anastomotic dehiscence, tracheomalacia, or RLN injury
            • Outcomes:
              • 5-year disease-specific survival:
                • ~ 60% to 75% after R0 sleeve resection
              • Morbidity:
                • Risk of vocal cord paralysis, anastomotic leak, or stenosis
              • Local control better with segmental vs shave resection in deeply invasive tumors
          • Cricotracheal Resection
    • Esophagus:
      • Esophageal invasion occurs in approximately 5% to 15% of patients with locally advanced differentiated thyroid cancer (DTC) or poorly differentiated thyroid cancer:
        • Particularly with posterior capsular extension from the thyroid gland:
          • It is most often associated with invasion of the cervical esophagus and less frequently with thoracic extension
      • Assessment and Staging:
        • Preoperative Workup:
          • CT scan with contrast:
            • Assess loss of fat plane and wall thickening
          • Endoscopic ultrasound (EUS) or esophagoscopy:
            • Assess mucosal involvement
          • Barium swallow:
            • Functional and structural assessment
          • Flexible laryngoscopy:
            • Assess vocal cord function
        • McCaffrey Staging System (modified for posterior invasion):
          • Stage I to II:
            • Abutment or superficial muscular invasion
          • Stage III:
            • Transmural involvement with mucosal breach
          • Stage IV:
            • Extensive circumferential or thoracic invasion
      • Surgical Management:
        • Shave Excision:
          • For superficial invasion of muscularis layer only:
            • Avoids full-thickness resection
          • Low morbidity, but risk of residual disease if not adequately evaluated
        • Partial Thickness Resection:
          • Involves resection of outer muscular layer with cautery or cold dissection
          • Often with sternohyoid or SCM flap reinforcement
        • Full-Thickness Resection (Segmental Esophagectomy):
          • Reserved for mucosal or transmural involvement
          • Requires primary closure or flap reconstruction:
            • For example radial forearm, pectoralis major, or free jejunal flap
          • May require temporary nasogastric / PEG feeding or tracheostomy
        • Cervical Esophagectomy with Reconstruction:
          • Rare; indicated in extensive disease
          • High morbidity, reserved for selected cases with curative intent
      • Postoperative Considerations:
        • Leak test (methylene blue or contrast swallow) on POD 5 to 7 if full-thickness resection
        • Monitor for:
          • Dysphagia
          • Fistula
          • Stricture formation
          • Consider gastrostomy or jejunostomy in high-risk cases
      • Adjuvant Therapy:
        • Radioactive Iodine (RAI):
          • If iodine-avid disease and residual / recurrent disease
        • External Beam Radiation (EBRT)::
          • Gross residual disease
          • Positive margins
          • Non-RAI-avid disease
      • Prognosis:
        • Complete resection (R0) improves local control and survival
        • Positive margins or incomplete resection associated with:
          • Higher recurrence rates
          • Lower disease-specific survival
        • Five-year survival can still exceed 60% to 70% with aggressive, multidisciplinary management
    • Key References:
      • McCaffrey TV. Surgical management of invasion into the aerodigestive tract by well-differentiated thyroid carcinoma. Arch Otolaryngol Head Neck Surg. 1999;125(4):401–405.
      • Shaha AR. Airway and esophageal involvement in thyroid cancer. World J Surg. 2007;31(5):904–911.
      • Nixon IJ et al. Locally advanced thyroid cancer: Surgical management. Thyroid. 2016;26(9):1156–1166.
      • Gaissert HA et al. Surgical treatment of invasive thyroid cancer. Ann Thorac Surg. 2007;83(6):1950–1955.
      • Haugen BR et al. ATA Guidelines. Thyroid. 2016;26(1):1–133.
      • Kim JW et al. Optimal surgical approach to locally invasive DTC. J Surg Oncol. 2017;116(2):229–234.
      • McCaffrey TV. Surgical management of laryngotracheal invasion by well-differentiated thyroid cancer. Arch Otolaryngol Head Neck Surg. 1999;125(4):401–405.
      • Gaissert HA et al. Segmental tracheal resection for invasive thyroid carcinoma. Ann Thorac Surg. 2007;83(6):1950–1955.
      • Kim JW et al. Optimal surgical extent for locally invasive thyroid cancer. J Surg Oncol. 2017;116(2):229–234.
      • Shaha AR. Airway management in thyroid cancer. World J Surg. 2007;31(5): 903–908.
  • Strap Muscles:
    • Often resected without morbidity
      • Invasion here does not necessarily confer worse prognosis
    • The strap muscles (sternohyoid, sternothyroid, omohyoid, thyrohyoid):
      • Lie anterior and lateral to the thyroid gland and are often the first structures invaded in locally advanced disease
    • Seen in up to 40% to 50% of cases with extrathyroidal extension (ETE):
      • Classified by AJCC 8th edition as:
        • Minimal ETE:
          • Invasion into perithyroidal soft tissue:
            • Not included in T staging
        • Gross ETE to strap muscles: 
          • T3b disease
      • According to Nixon IJ et al., strap muscle is the most frequently invaded adjacent structure in locally advanced DTC
    • Diagnosis:
      • Clinical and Imaging Features:
        • May present as firm fixation of the gland to strap muscles
        • On ultrasound CT:
          • Loss of fat plane
          • Muscle effacement
        • Intraoperative findings often determine true invasion
    • Surgical Management:
      • Recommended Approach:
        • En bloc resection of involved strap muscles with the thyroid gland
        • Usually limited to sternohyoid and sternothyroid
        • No need for reconstruction unless deep muscle loss impairs swallowing or airway support
      • Not Recommended:
        • Piecemeal shaving or curettage:
          • May lead to positive margins
        • Avoid unnecessarily wide resections if invasion is not gross
      • Pathologic confirmation of muscle invasion is essential for staging (T3b)
    • Oncologic Impact:
      • Survival & Recurrence:
        • Strap muscle invasion alone does not significantly affect disease-specific survival
        • Prognosis more dependent on:
          • Nodal status
          • Margin status
          • Multifocality or vascular invasion
      • Kim et al., J Surg Oncol 2017 – strap muscle invasion was not an independent predictor of recurrence or mortality
    • Adjuvant Therapy:
      • RAI therapy based on full risk stratification (not just muscle invasion)
      • No EBRT indicated for strap-only invasion with negative margins
      • ATA 2015 Guidelines:
        • Strap invasion alone may not upstage to high-risk unless other features are present
  • Larynx and Carotid Artery:
    • Invasion is rare but serious
    • Laryngectomy or carotid resection is only considered in select patients with curative intent
    • Prognosis and Outcomes:
      • Gross extrathyroidal extension (T4 disease) is associated with worse disease-specific survival
      • However, microscopic invasion alone does not significantly impact survival
      • Complete surgical resection remains the most important prognostic factor
    • Conclusions:
      • Adjacent structure invasion is relatively common in advanced DTC, especially involving the RLN and strap muscles
      • Tailored surgical approaches balancing oncologic control and functional preservation are critical
      • Multidisciplinary care and evidence-guided surgical decision-making optimize outcomes.
McCaffrey Classification
Window Resection of the Trachea
Sleeve / Segemental Resection
We use #3-0 Vicryl to bring the segments together. We perform this in conjunction with thoracic surgery.
Cricotracheal Resection
Cricotracheal Resection
Temporoparietal free flap (TPFF) with buccal mucosa inner graft with thryoid cartilage as a construct.
Esphageal Invasion
  • Conclusion:
    • Surgery is the KEY component for survival in patients with poorly differentiated / invasive thyroid cancer
    • Not common:
      • Consider centers of excellence / high volume
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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