Alternativas à resignação 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. 23 de Abril 2015 IPOFG / JRS

23 de Abril 2015 IPOFG / JRS

Formas comuns de progressão tumoral, nos casos de invasão laringo-traqueal Czaja and McCaffrey Arch Otol. Head and Neck Surgery - May 1997 23 de Abril 2015 IPOFG / JRS

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 Langenbecks Arch Surg. 2014 Feb;399(2):209-16. Classification of aerodigestive tract invasion from thyroid cancer. Brauckhoff M1. 23 de Abril 2015

II Tratamento Paliativo vs. Ressecção radical 23 de Abril 2015 IPOFG / JRS

Head Neck. 2014 Oct;36(10):1379-90. doi: 10. 1002/hed. 23619 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 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. 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. 23 de Abril 2015 IPOFG / JRS

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.

RESSECÇÕES LARINGO-TRAQUEAIS 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% 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) COMPLICAÇÕES

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

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. 23 de Abril 2015 IPOFG / JRS

23 de Abril 2015 IPOFG / JRS

IPOFG / JRS

23 de Abril 2015 IPOFG / JRS

Preservaçãqo da condução de pelo menos um nervo recorrente laringeo 23 de Abril 2015 IPOFG / JRS

Grillo stich 23 de Abril 2015 IPOFG / JRS

Invasão da Laringe e da Faringe 23 de Abril 2015 IPOFG / JRS

Laringectomia Parcial Laringectomia fronto-lateral Hemilaringectomia Laringectomia “Near Total” Ressecção parcial da cricoide 23 de Abril 2015 IPOFG / JRS

23 de Abril 2015 IPOFG / JRS

23 de Abril 2015 IPOFG / JRS

Invasão do Esófago Ressecção simples da muscular Ressecção e sutura simples Retalho mio-cutâneo Transplante livre de jejuno / Retalho livre antebraquial “Pull up” digestivo 23 de Abril 2015 IPOFG / JRS

23 de Abril 2015 IPOFG / JRS

Invasão do Nervo Recorrente Um nervo funcionante não deverá ser sacrificado Se no entanto existe uma paralisia prévia não se deverá preservar o nervo. 23 de Abril 2015 IPOFG / JRS

(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. 23 de Abril 2015 IPOFG / JRS

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

Laboratorial de doença 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 23 de Abril 2015 IPOFG / JRS

23 de Abril 2015 IPOFG / JRS

23 de Abril 2015 IPOFG / JRS