Ann Thorac Surg 2001;72:1906-1908
© 2001 The Society of Thoracic Surgeons
Original article: general thoracic
Thoracic metastasectomy in thyroid malignancies
Aristotle D. Protopapas, FRCSa,
Andrew G. Nicholson, DMb,
Louiza Vini, FRCRc,
Clive L. Harmer, FRCRc,
Peter Goldstraw, FRCS*a
a Department of Thoracic Surgery, Royal Brompton Hospital, London, England, United Kingdom
b Department of Histopathology, Royal Brompton Hospital, London, England, United Kingdom
c Thyroid Unit, Royal Marsden Hospital, London, England, United Kingdom
Accepted for publication June 27, 2001.
* Address reprint requests to Dr Goldstraw, Department of Thoracic Surgery, Royal Brompton and Harefield NHS Trust, Sydney St, London, England SW3 6NP, United Kingdom
e-mail: p.goldstraw{at}rbh.nthames.nhs.uk
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Abstract
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Background. Relatively little evidence exists to guide the decision pathway regarding thoracic metastasectomy for thyroid malignancy.
Methods. Single-institution 10-year review.
Results. Sixteen patients had surgical treatment for intrathoracic metastatic thyroid malignancy: 12 men and 4 women, mean age 43.7 years (range 19 to 77). Histopathologic type was papillary in 6 cases, follicular in 4, Hürthle cell in 3, and medullary in 3. Indication was either "bulky" disease (8 patients) or poor response to radiotherapy (8 patients). We performed 11 sternotomies and five thoracotomies. Operative mortality was 6.25%. Operative morbidity was 6.25%. Mean survival was 39.5 months (0 to 144). Nine patients died during follow-up (mean survival of 41.2 months). Six patients survived, 4 free of disease (mean survival 70 months) and 2 with further relapse (mean survival 17 months). Five-year survival was 32.5%.
Conclusions. The cohort studied is one of the largest in the literature on the topic. Surgical treatment achieved a reasonable survival in a small subgroup of patients where radiotherapy had failed or was deemed inappropriate because of the size or location of the tumor. Further follow-up and more observations will be required for evaluating these preliminary findings.
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Introduction
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Radioactive iodine is the treatment of choice affording good outcomes in metastatic thyroid cancer [1]. It seems to fail only in particularly bulky lesions and tumors that do not concentrate iodine [2]. Surgical treatment has occasionally been considered as a substitute to radiotherapy [3–5], in an attempt to apply the lessons of pulmonary metastasectomy for commoner tumors [6]. Relatively little evidence exists to guide the decision pathway. We have retrospectively studied the cohort that underwent surgery for metastatic thyroid malignancy in the Royal Brompton Hospital between 1988 and 1998.
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Material and methods
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We identified the cohort in our database and collected data from the medical records.
Demographics
Sixteen patients were thus identified; 12 of them were male, 4 were female. Age range was 19 to 77 years (mean 46.6, median 47).
Pathology
The site of the metastasis was noted. The histopathology slides were reviewed and classified according to current terminology for thyroid malignancies.
Clinical and surgical data
The following were noted: principal presenting finding, indication for operation, and details for each identified procedure.
Follow-up
Postoperative follow-up was conducted by telephone interviews with the patients or their general practitioners, as well as consulting the medical records.
Statistical analysis
Survival (in calendar months) was calculated and statistical analysis of mean values was performed with the Prism statistical package. (Prism Version 2.0, Graphpad, San Diego, CA). Nonparametric estimates of survival were obtained by the method of Kaplan and Meier [7].
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Results
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Pathology
Histopathologic type was papillary (6), follicular (4), Hürthle cell (3), and medullary (3). Site of intrathoracic disease was the mediastinum (10) or the lungs (6): 4 on the right, 1 on the left lung, and 1 on both lungs. Principal presenting finding was a lesion on computed tomography surveillance (9 patients), dyspnea due to intrathoracic airway compression (6 patients) or elevated serum calcitonin (1 patient).
Indications for surgical treatment
Indications were put by the referring radiotherapists in close collaboration with the surgical team. The indication was therefore either absence of uptake of iodine (8 patients), or bulky intrathoracic disease inappropriate for radiotherapy (8 patients).
Surgical treatment
Each patient underwent a single thoracic operation with curative intent, namely, 11 sternotomies: 7 consisted of radical mediastinal exenteration (simultaneous thyroidectomies were performed in 2 cases); 3 entailed limited metastasectomy; lastly, 1 was for bilateral pulmonary metastasectomy; and 5 thoracotomies: 4 on the right (2 upper, 1 middle lobectomy, 1 multiple wedge metastasectomy) and 1 on the left (upper lobectomy).
Surgical complications
Operative mortality was 6.25% (1 in 16). A 65-year-old woman presented with dyspnea at rest due to multiple bilateral pulmonary metastases from follicular carcinoma. Following sternotomy and bilateral metastasectomies, she succumbed to acute respiratory distress syndrome on the 3rd postoperative day. Morbidity was also 6.25% (1 in 16). A 77-year-old man suffered bilateral vocal cord paresis following mediastinal and cervical metastasectomy for follicular carcinoma refractory to radiotherapy. He required emergency reintubation and mechanical ventilation for 2 weeks. He recovered fully and was discharged the 23rd postoperative day.
Follow-up survival in months
Mean survival was 42.7, range 0 to 144, median 33.1. (see Table 1). Nine patients were found to be dead on follow-up, 1 as an operative fatality, 9 from distant recurrences of the thyroid malignancy (postoperative survival 0 to 78, mean survival 37.1, and median 33.1). Six individuals were found alive on follow-up (range 9 to 144, mean 52.1, and median 38). Four of them were found alive and free of disease on follow-up (postoperative survival 12 to 144). Lastly, 2 patients (12.5%) were found alive with further recurrence on follow-up (mean survival 17). The survival estimates (Kaplan–Meier) are depicted in Figure 1. Five-year survival was 32.5%.
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Fig 1. Survival of patients that underwent radical surgery for intrathoracic relapse of thyroid cancer, 1988–1998.
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Comment
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Due to lack of randomized trials, the role of the thoracic surgeon in the management of patients with thyroid carcinoma is still controversial. Our cohort of 16 individuals is one of the largest to appear in the English literature. The limited number and heterogeneity do not allow stratification into prognostic groups. We note that the gender of the patients and the frequency of tumor types in this cohort differ from the general pattern seen in thyroid cancer. In our experience of selected patients, intrathoracic metastasis occurred mostly in males with follicular carcinoma (4 of 16; 25%) being equally distributed between the lungs and mediastinum. In contrast, the metastases from papillary carcinoma were mostly located in the mediastinum (5 of 6; 83.3%). However, when these data are assessed in terms of site of metastatic disease, the majority of those limited to the lung were either Hürthle cell or follicular in type (4 of 5 cases). Those with mediastinal disease showed greater variation in tumor type, with papillary, follicular, and medullary variants all represented. However, within such a heterogeneous study group, a common denominator has emerged: anticipated or proven lack of response to radiotherapy, the usual treatment of choice. All of our patients underwent surgery because, in their selected cases, the latter was not appropriate.
We conclude that surgery should be considered for patients with metastases unlikely to benefit from radioactive iodine therapy because of their size or lack of concentration of isotope. In view of the prolonged indolent course of the disease, further follow-up is required to provide conclusive evidence.
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References
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Schlumberger M., Challeton C., De Vathaire F., et al. Radioactive iodine treatment and external radiotherapy for lung and bone metastases from thyroid carcinoma. J Nucl Med 1996;37:598-608.[Abstract/Free Full Text]
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Khan J.H., McElhinney D.B., Rahman S.B., et al. Pulmonary metastases of endocrine origin: the role of surgery. Chest 1998;114:526-534.[Abstract/Free Full Text]
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Ozaki O., Ito K., Manabe Y., et al. Clinical studies on pulmonary metastases from differentiated thyroid carcinoma—characteristics of patients with pulmonary metastases which appear before thyroid operation or afterwards. Nippon Geka Gakkai Zasshi 1986;87:79-83.[Medline]
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Kaplan E.L., Meier P. Nonparameteric estimation from incomplete observations. J Am Stat Assoc 1958;53:457-481.
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Abstract
Introduction
