Anaplastic thyroid carcinoma is a highly aggressive tumor with very poor survival. Despite chemotherapy and radiation, survival is only a matter of months. Recurrence with tumor invasion of vital cervical structures and airway obstruction leads to death.
A 53 year old gentleman with history of benign thyroid goiter confirmed by thyroid scan about 20 years ago. He noted a rather rapid increase in his goiter about 4 years ago. An incisional biopsy revealed anaplastic thyroid carcinoma (spindle cell). Patient underwent tumor debulking 3 months after diagnosis. He had a prophylactic Tracheostomy done prior to receiving chemotherapy and radiation. He had a complete remission and was decannulated. Patient had moderate tracheal stenosis secondary to tracheostomy and extensive mediastinal fibrosis at the site of radiation causing chronic stridor in the past 4 years. Initially paient was followed by CT scan but he stopped follow up for the past 2 years. Four weeks prior to the current admission, he developed severe dyspnea on exertion. CT scans revealed no distant metastases, but a flow volume loop showed fixed obstruction and the patient underwent flexible bronchoscopy. Bronchoscopy revealed a 7 mm subglottic endotracheal mass approximately 10 mm below the vocal cords (see photo) and a subglottic stenosis (5 mm lumen) below the mass at the level of the previous tracheostomy. Virtual bronchoscopy was performed and the patient underwent several surgical evaluations and was deemed inoperable secondary to the extent of tumor invasion. The patient agreed to rigid bronchoscopy with Laser ablation of endotracheal tumor, with capability for emergent cardiopulmonary bypass if necessary. ND:Yag LASER coagulation was performed of the endotracheal lesion which was highly friable and bled easily. A coagulating snare was then introduced for further debulking. Pathologic evaluation revealed fibrovascular tumor with no malignant cells. The patient had immediate relief of symptoms post-operatively with and improvement of FEV1 from 53% to 79% predicted.
Anaplastic thyroid carcinoma is a lethal tumor with a 14% survival rate at 10 years, and a mean survival of six months. The tumor causes external compression or with endotracheal growth, obstruction with asphyxiation. Options for treating advanced disease are limited. Radiation, while initially leads to regression of tumor, can also stimulate future recurrence. Indium ablation, external-beam or intraoperative radiation therapy can be useful in controlling symptoms related to local tumor recurrences. Tracheal resection and re-anastomosis is a technically difficult or virtually impossible undertaking due to local tissue invasion. The patients usually die of respiratoy obstruction or local invasion of the tumor. LASER has been used to remove central airway obstruction and improve survival. This case is unique because the patient did not have recurrence of the Anaplastic tumor or distant metastases. The discovery of a tumor in his trachea was suggestive of recurrence of the Anaplastic Thyroid Ca. Surgery was not an option due to post radiation changes. When tumors are causing airway obstruction LASER ablation is the treatment of choice. We were able to not only relieve his symptoms, but also diagnose a benign lesion. There are reports of malignant tumor recurrences after radiation therapy of Thyroid tumors, but there is no report of a benign fibrovascular tumor in the literature.
The benefits of LASER(NdYAG) ablation include the fact that it is minimally invasive, can be repeated if tumor regrows, reduces hospital stay and cost. This patient has lived up to 44 months since diagnosis of Anaplastic thyroid cancer and seven months since intervention without any recurrence of airway symptoms.
Abdur Shad, None.