Surgical Management

Surgical Management

Clinical Outline

Educational Clips from TIROxMDS

1. Prognostic Factors for Stage IVa ATC

2. The Role of Surgery

3. Role of Tracheostomy

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Management Recommendations

The JAES developed a prognostic scoring for all Stage IVa patients. A score < 1 would benefit from surgical intervention, whereas patients > 2 would be considered for systemic therapy.

1. Prognostic Factors for Stage IVa ATC

• Acute exacerbation of symptoms.
• Tumor larger than 5 cm.
• Distant metastases.
• WBC > 10,000.
• T4b – gross extrathyroidal extension.
• Age > 70.

Surgical resection should be performed in highly selected patients with ATCs that are limited, (Stage IVA/IVB) and in whom an R0/R1 resection appears to be possible.^​1–4​

Multidisciplinary consultation should help to guide the extent of surgery that is contemplated. In general, it is not advisable to perform radical surgery that involves:

• A laryngectomy, 
• Tracheal resection, 
• Esophageal resection, and 
• Major vascular or mediastinal resections.

The poor prognosis of ATC makes radical surgery ill-advised except in very select circumstances and considering the potential role of targeted therapy when specific actionable mutations are identified.^​1–4​

2. The Role of Surgery

The surgical management of patients with confirmed or suspected ATC is based on the following overarching principles:

1. Determining whether the disease is staged as IVA or IVB by ruling out the presence of distant metastases.
2. Accurate determination of the extent of locoregional disease by defining visceral, neurologic, vascular and osseous involvement. 
3. Surgical management should only be undertaken if the surgeon believes that an R0 or an R1 resection can be achieved.
4. Debulking resections (R2) do not generally provide value to the patient and should not be undertaken.
5. Surgical resections that cause significant morbidity and require extensive time for wound healing prior to instituting radiation and chemotherapy should, in general, not be undertaken
6. The surgical plan should be in keeping with the patient’s expressed goals of care. 
7. Patients with systemic disease may be considered for surgical resection for palliative reasons to address or prevent airway compromise and /or esophageal obstruction due to local disease progression. 
8. In select circumstances, surgical exploration may be undertaken in order to determine the resectability of the disease. 
9. While total thyroidectomy is warranted in most instances due to the common coexistence of DTC with ATC, there are select circumstances where a unilateral lobectomy is warranted when ultrasound shows no evidence of disease in the contralateral lobe and/or the recurrent laryngeal nerve on one side is compromised preoperatively or during surgical resection.
10. Radical surgery may be considered in select individualized circumstances based on thorough multidisciplinary discussion and when the necessary ablative and reconstructive surgical expertise is available. In addition, the anticipated morbidity of the planned surgery must be consistent with the patient’s wishes and informed consent. 
11. Due to the rapid progression of ATC, the initiation of adjuvant therapy should take place within 2 to 3 weeks of surgery. The ability to achieve this important timing must be considered in determining the extent of planned surgery and reconstruction. 
12. It is recognized that the determination of resectability may vary from surgeon to surgeon based on their individual experience and level of comfort in addressing specific visceral or vascular structures. 
13. Neoadjuvant therapy should be considered in patients with unresectable tumors that express BRAF^V600E mutations in an effort to reduce the extent of the tumor such that surgical resection can be considered. This is true for patients who achieve a partial or a complete response to neoadjuvant therapy. 

3. Role of Tracheostomy

In patients without impending airway compromise, we advise against preemptive tracheostomy placement.^​1​ Prophylactic tracheostomy is, in most cases, not advisable unless there is an imminent risk of airway compromise.^​1,2​

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