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Pulmonology Procedures |

Metastatic Papillary Thyroid Carcinoma With Tracheal Obstruction

Steven Khov*, MD; Michael Reed, MD; Jennifer Toth, MD
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Penn State Milton S. Hershey Medical Center, Hershey, PA


Chest. 2012;142(4_MeetingAbstracts):899A. doi:10.1378/chest.1387209
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Abstract

SESSION TYPE: Bronchology Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Despite its location, well-differentiated thyroid carcinoma rarely invades local structures. Prognosis worsens with tracheal invasion. Nearly one-half of deaths from papillary carcinoma stem from tracheal obstruction. Management of airway obstruction can be life saving.

METHODS: A 71 year-old male experienced dyspnea and hemoptysis for one month. CT revealed a soft tissue mass arising from the thyroid and invading the tracheal lumen. In addition, there was a soft tissue mass on the right anterior first rib with sclerotic margins and areas of cortical breakthrough and cervical lymphadenopathy. Flexible bronchoscopy demonstrated a near-obstructing tracheal mass 2 cm in length located 3 cm below the cricoid. Rigid bronchoscopy allowed endoluminal resection followed by argon plasma coagulation (APC).

RESULTS: The dyspnea and stridor improved significantly. He was discharged. The pathology was papillary adenocarcinoma. Thyroglobulin was 708 ng/ml with absent thyroglobulin antibody. Thyroid Stimulating Hormone and Free T4 were within reference laboratory values. PET-CT revealed FDG-avidity in both lobes of the thyroid with tracheal and esophageal invasion, and FDG-avidity in cervical lymph nodes, the right anterior first rib, and left adrenal gland, indicating T4aN1b staging. He underwent external beam radiation therapy then total thyroidectomy and bilateral neck dissections along with tracheostomy. The final pathology was papillary thyroid carcinoma with tracheal invasion, involved margins, and lymphovascular invasion. 14 out of 61 lymph nodes were positive. Follow-up thyroglobulin level was undetectable. Radioactive iodine treatment followed.

CONCLUSIONS: Nearly one half of mortality related to papillary thyroid carcinoma is due to airway obstruction. Thus, even with tracheal invasion, intervention is indicated. Depth of tracheal invasion, longitudinal extent of disease, and involvement of local structures impact therapy. Surgical options range from limited “shave” excision of the trachea to en bloc resection and tracheal reconstruction. Patients with locally invasive papillary carcinoma require treatment with radioiodine therapy and TSH suppression following total or near-total thyroidectomy.

CLINICAL IMPLICATIONS: With symptomatic tracheal obstruction from papillary thyroid carcinoma, bronchoscopic intervention can achieve a stable airway, thus facilitating subsequent safe surgical resection.

DISCLOSURE: The following authors have nothing to disclose: Steven Khov, Michael Reed, Jennifer Toth

No Product/Research Disclosure Information

Penn State Milton S. Hershey Medical Center, Hershey, PA

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