F Georgiades, G Vasiliou, E Kyrodimos… - World, 2016
... Resections of the upper aerodigestive tract for locally invasive thyroid cancer. Am J Surg 1994;
168: 636639 [PMID: 7978010 DOI: 10.1016/S00029610(05)801369] 4 Moritani S. Surgical
Management of Cricotracheal Invasion by Papillary Thyroid Carcinoma. ...
Fanourios Georgiades, George Vasiliou, Efthimios Kyrodimos, Giannis Thrasyvoulou
Fanourios Georgiades, St George’s, University of London at the
University of Nicosia, 2408 Nicosia, Cyprus
George Vasiliou, Giannis Thrasyvoulou, ENT Department,
Nicosia General Hospital, 2029 Nicosia, Cyprus
Efthimios Kyrodimos, ENT Department, Hippokration Hospital,
Athens Medical School, 11527 Athens, Greece
Author contributions: Georgiades F, Vasiliou G and Thrasyvoulou
G collected data and prepared figures; Kyrodimos E contributed
to the correction and review of the manuscript; Georgiades F and
Thrasyvoulou G wrote the manuscript.
Institutional review board statement: The above mentioned
study was reviewed and approved by the Nicosia General Hospital
Institutional Review Board.
Informed consent statement: The patient involved in this study
gave her written informed consent authorizing use and disclosure of
her protected health information.
Conflict-of-interest statement: All authors declare no known
conflict of interests.
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
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the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
Manuscript source: Invited manuscript
Correspondence to: Fanourios Georgiades, BSc(Hons),
MSc, MBBS, St George’s, University of London at the University
of Nicosia, Medical School, 93, Agiou Nikolaou Street, Engomi,
2408 Nicosia, Cyprus. georgiades.f@live.sgul.ac.cy
Telephone: +357-99-769696
Fax: +357-25-350061
Received: February 29, 2016
Peer-review started: February 29, 2016
First decision: April 15, 2016
Revised: April 28, 2016
Accepted: May 17, 2016
Article in press: May 27, 2016
Published online: July 16, 2016
Abstract
Papillary carcinoma of the thyroid is the commonest
type of thyroid cancer. Laryngeal infiltration from
papillary thyroid carcinoma is extremely rare, with
only a few cases of partial invasion described in the
literature. We present a very unusual case of complete
infiltration of both thyroid and cricoid cartilages from a
neglected papillary thyroid carcinoma in a 59-year-old
male. This sequel resulted from refusal of the patient
to undergo treatment when initially diagnosed. An
invasion to such an extent has not been described in
the literature before, and in this case warranted a total
laryngectomy followed by radioactive iodine. Prompt
management of papillary carcinomas is crucial for
avoiding such complications. Future guidelines should
include management options for the patients who deny
treatment initially.
Key words: Papillary thyroid carcinoma; Laryngeal
infiltration; Cricoid cartilage; Management; Complications
© The Author(s) 2016. Published by Baishideng Publishing
Group Inc. All rights reserved.
Core tip: Aerodigestive tract invasion from a differentiated
thyroid cancer is a very rare complication. This is
the first case in the literature describing an infiltration
to the thyroid and cricoid cartilages to such an extent,
requiring a total laryngectomy followed by radioactive
iodine treatment. Future guidelines should include
management options for patients who refuse treatment
CASE REPORT
WJCC|www.wjgnet.com 187 July 16, 2016|Volume 4|Issue 7|
Extensive laryngeal infiltration from a neglected papillary
thyroid carcinoma: A case report
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DOI: 10.12998/wjcc.v4.i7.187
World J Clin Cases 2016 July 16; 4(7): 187-190
ISSN 2307-8960 (online)
© 2016 Baishideng Publishing Group Inc. All rights reserved.
World Journal of W J C C Clinical Cases
Georgiades F et al. Neglected thyroid carcinoma progression
during the initial stages of the disease.
Georgiades F, Vasiliou G, Kyrodimos E, Thrasyvoulou G.
Extensive laryngeal infiltration from a neglected papillary thyroid
carcinoma: A case report. World J Clin Cases 2016; 4(7): 187-190
Available from: URL: http://www.wjgnet.com/2307-8960/full/
v4/i7/187.htm DOI: http://dx.doi.org/10.12998/wjcc.v4.i7.187
INTRODUCTION
To date laryngeal infiltration and specifically infiltration
of the cricoid cartilage from papillary thyroid carcinoma
is extremely rare[1]. Here we present an unusual case
with complete infiltration of both thyroid and cricoid
cartilages from a neglected papillary thyroid carcinoma.
A few cases have been described in the literature[2-4],
but never before to such extent.
CASE REPORT
A 59-year-old man presented to our outpatient clinic
with a midline neck mass, stridor, dyspnoea, hoarseness
and dysphagia. These symptoms developed gradually
within the past year, with dyspnoea being his main
concern. Fine needle aspiration of a thyroid nodule a
year before revealed papillary carcinoma; however,
due to serious health issues concerning his son and
subsequent development of depression, he refused
treatment at that time.
His past medical history included diabetes mellitus,
hypertension, hypercholesterolaemia, depression, stage
3 chronic kidney disease and two acute myocardial
infarctions, in 1992 and in 2010. In 1994, he had undergone
coronary artery bypass graft surgery. He had a 40
pack-years smoking history and was consuming about
35 alcohol units per week for several years.
On examination he was tachypnoeic, with a breathy
biphasic stridor and low oxygen saturations. The
palpable midline neck mass was a non-tender, immobile,
hard mass with irregular borders, extending below
the anterior borders of the sternocleidomastoid muscle,
without displacement of the trachea. Cervical lymph
nodes were palpable bilaterally at levels II-IV and at
level VI, with none in the posterior triangle. Flexible
laryngoscopy demonstrated right vocal cord fixation and
diffuse laryngeal oedema.
A neck computed tomography scan revealed a 5.5
cm × 2.5 cm irregular soft tissue mass at the level
of the thyroid cartilage. Bilateral thyroid and cricoid
cartilage infiltration was evident, more on the left
thyroid cartilage lamina than the right (Figure 1). The
mass had infiltrated the lumen of the larynx, decreasing
the diameter of the airway to approximately 0.5 cm,
with associated lymph nodes detectable bilaterally.
The patient underwent emergency tracheostomy,
to secure the airway. Biopsies taken from the neck
mass itself, a lymph node at level VI on the left side and
from the first tracheal cartilage, confirmed the mass to
be thyroid papillary carcinoma with metastatic lymph
nodes at level VI. The multidisciplinary team meeting
decided to proceed with a total laryngectomy, a total
thyroidectomy and a selective bilateral neck dissection
of levels II-IV and VI. The oncologists suggested an
ablative dose of radioactive iodine post-operatively.
A wide-field total laryngectomy approach was
followed. The infiltration was readily visible intraoperatively
(Figure 2A). A tracheo-oesophageal puncture
was made with primary placement of a voice
prosthesis. Histology, from the completely excised
mass and larynx (Figure 2B), further established the
well-differentiated papillary thyroid carcinoma that was
infiltrating thyroid and cricoid cartilages of the larynx,
the true and false vocal cords bilaterally with level II
lymph nodes metastases on the left side and an area
with dermal metastasis. The surgical limits and lymph
nodes, at levels III and IV on the left side, levels II-IV on
the right side and centrally, were clear of metastases.
At 13 mo post-op, the patient had completed his
radioactive iodine treatment course, without any signs
of relapse. He had weekly sessions with the speech and
language therapists and was using his speech valve to
communicate.
DISCUSSION
To date, laryngeal infiltration and specifically infiltration
WJCC|www.wjgnet.com 188 July 16, 2016|Volume 4|Issue 7|
A
B
Figure 1 Axial computed tomography imaging revealed the thyroid mass
has infiltrated both thyroid and cricoid cartilages (A and B). The thyroid
cartilage on the left side and the left lateral side of the cricoid cartilage were
completely infiltrated with the right side showing extensive infiltration.
of the cricoid cartilage from papillary thyroid carcinoma
are extremely rare[1,3]. The literature is very limited on
laryngeal invasion from papillary thyroid carcinomas
and their management with a few case reports[2] or
retrospective cohort studies[3,4]. However, a laryngeal
infiltration to such an extent has never been described
in the literature until now.
The incidence of thyroid carcinomas invading the
aerodigestive tract ranges from 1%-8%, with the
majority of these being anaplastic thyroid carcinomas[1].
This broad category includes invasion of other structures
other than the larynx, such as the trachea, hypopharynx
and the oesophagus, which makes laryngeal invasion
from thyroid cancers a very rare complication. For
invasions of the aerodigestive tract from thyroid cancers
a classification proposed by Dralle et al[5] exists; describing
six types of laryngotracheal invasion and their
proposed operative management. According to this
classification, total laryngectomy is indicated with
bilateral larynx invasion or vertical tracheal invasion
of more than 5-6 cm[1]. Moreover, the vast majority of
these cases are treated promptly before invasion to
surrounding structures occurs.
According to the most recent tumour site, node metastases,
distant metastases classification for differentiated
thyroid cancer, invasion beyond the thyroid capsule is
considered as T4[6]. The radiological and histopathology
findings in the above described case placed the patient
to a T4aN1bM0 classification and Stage IVA, which has
a 10-year relative survival rate of 75.9%[6].
Current guidelines[6] focus mostly on the secondary
and tertiary care management of patients with thyroid
malignancies, with lack of management options for
patients who refuse treatment, despite medical advice.
In our case, the patient was fully informed about his
condition and treatment options, but refused to be
treated, when initially presented with a thyroid nodule.
At the time of his initial presentation, his son had serious
health problems, requiring 24 h support at home,
especially from his father. Our patient was reluctant
to pursue any sort of treatment, as that would have
rendered him unable to take care of his family. This
situation raises many medico-legal and ethical issues,
as by respecting this particular patient’s autonomy,
the patient ended up with a permanent tracheostomy,
compromising both his quality of life and life expectancy[7].
Does the liability remain with the patient or with
the medical team?
A multidisciplinary approach is needed for the
management of such advanced cases, as recommended
by current guidelines[6]. However, the lack of management
options from the guidelines, created an uncertainty
into the actual management of this patient; due to
the difficult social circumstances, as described above.
Therefore, we recommend an imperative role of primary
care physicians (e.g., general practitioners), community
nursing services and/or healthcare visitors assisting in
the management of such patients in the community;
with prompt referral to secondary care services, prior
to development of haemodynamic abnormalities, as
seen in this case. Moreover, this case has allowed us to
observe the natural progression of a well-differentiated
papillary carcinoma, from a nodule to a large mass
invading the aerodigestive tract in just 12 mo.
The above case highlights the importance of early
active management of thyroid carcinomas, as extensive
laryngeal infiltration could be one of the possible
outcomes. An infiltration to such an extent warrants
a total laryngectomy followed by radioactive iodine
treatment for any residual malignant cells. However,
further follow-up is required to assess the efficacy of
such management plan.
ACKNOWLEDGMENTS
The authors would like to thank the patient for agreeing
to share this information about his condition.
COMMENTS
Case characteristics
A patient presented with a midline neck mass, stridor, dyspnoea, hoarseness and
dysphagia.
Clinical diagnosis
Upper airway obstruction from a large midline neck mass with associated
lymphadenopathy.
Differential diagnosis
Any type of thyroid malignancy, lymphoma, benign thyroid disease, sarcomas,
infections.
WJCC|www.wjgnet.com 189 July 16, 2016|Volume 4|Issue 7|
Figure 2 Intra-operative image showing the extent of the thyroid
mass with absence of the thyroid cartilage (white arrow) (A) and
posterior view of the excised larynx held by the clamps from the
epiglottis (†) showed complete absence of the thyroid cartilage
on the left (black arrow) some remnants of the thyroid cartilage
on the right (‡) and posterior infiltration of the cricoid cartilage
(arrow heads) (B).
A B
COMMENTS
Georgiades F et al. Neglected thyroid carcinoma progression
Laboratory diagnosis
Initial blood tests revealed a hypochromic, normocytic anaemia, elevated glucose
and serum cholesterol levels.
Imaging diagnosis
Computed tomography scan of the neck revealed a large mass infiltrating both
the thyroid and cricoid cartilages.
Pathological diagnosis
Histology revealed a papillary thyroid carcinoma invading the thyroid and cricoid
cartilage.
Treatment
Total laryngectomy followed by radioactive iodine treatment.
Related reports
Patient had a thyroid nodule 1 year prior to his presentation to us, which
was investigate by fine-needle aspiration (FNA) to reveal a papillary thyroid
carcinoma. Patient was reluctant to undergo any treatment due to specific social
circumstances and refused follow-up. A year later he presented with advanced
disease and symptoms warranting treatment.
Term explanation
FNA refers to fine needle aspiration. Laryngectomy involves removing the whole
of the larynx and part of the proximal trachea, leaving an opening of the trachea
superior to the sternal notch.
Experience and lessons
Patients who refuse treatment in the initial stages of the disease should be
followed up in the community and referred to secondary care in a timely manner.
Peer-review
The authors described a case of extensive laryngeal infiltration from a neglected
papillary thyroid carcinoma, which was managed with total laryngectomy and
thyroidectomy, and selective neck dissection. The manuscript is interesting and
well-written.
REFERENCES
1 Brauckhoff M. Classification of aerodigestive tract invasion from
thyroid cancer. Langenbecks Arch Surg 2014; 399: 209-216 [PMID:
24271275 DOI: 10.1007/s00423-013-1142-x]
2 Ozturk K, Akyildiz S, Makay O. Partial laryngectomy with cricoid
reconstruction: thyroid carcinoma invading the larynx. Case
Rep Otolaryngol 2014; 2014: 671902 [PMID: 24660082 DOI:
10.1155/2014/671902]
3 Ballantyne AJ. Resections of the upper aerodigestive tract for
locally invasive thyroid cancer. Am J Surg 1994; 168: 636-639
[PMID: 7978010 DOI: 10.1016/S0002-9610(05)80136-9]
4 Moritani S. Surgical Management of Cricotracheal Invasion by
Papillary Thyroid Carcinoma. Ann Surg Oncol 2015; 22: 4002-4007
[PMID: 25786744 DOI: 10.1245/s10434-015-4492-5]
5 Dralle H, Brauckhoff M, Machens A, Gimm O. Surgical
management of advanced thyroid cancer invading the aerodigestive
tract. In: Clark OH, Duh QY, Kebebew E, ed. Textbook on
endocrine surgery. 2nd ed. Philadelphia: Elsevier Saunders, 2005:
318-333
6 Perros P, Boelaert K, Colley S, Evans C, Evans RM, Gerrard Ba
G, Gilbert J, Harrison B, Johnson SJ, Giles TE, Moss L, Lewington
V, Newbold K, Taylor J, Thakker RV, Watkinson J, Williams GR.
Guidelines for the management of thyroid cancer. Clin Endocrinol
(Oxf) 2014; 81 Suppl 1: 1-122 [PMID: 24989897 DOI: 10.1111/
cen.12515]
7 Verburg FA, Mäder U, Tanase K, Thies ED, Diessl S, Buck AK,
Luster M, Reiners C. Life expectancy is reduced in differentiated
thyroid cancer patients ≥ 45 years old with extensive local tumor
invasion, lateral lymph node, or distant metastases at diagnosis and
normal in all other DTC patients. J Clin Endocrinol Metab 2013;
98: 172-180 [PMID: 23150687 DOI: 10.1210/jc.2012-2458]
P- Reviewer: Ghosh M, Li XL, Vlastarakos PV, Wax MK
S- Editor: Ji FF L- Editor: A E- Editor: Wu HL
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Georgiades F et al. Neglected thyroid carcinoma progression
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