Letter to the editor regarding: Management of invasive well‐differentiated thyroid cancer: An American Head and Neck Society Consensus Statement

To the Editor: We applaud the efforts of the American Head and Neck Society for creating this consensus statement from the work product of such an experienced and distinguished group of head and neck endocrine surgeons. This document will no doubt make a significant impact on patient care by providing a consistent guideline for surgeons managing this group of patients. We would, however, offer an alternative to the recommendation of circumferential sleeve resection for all cases of intraluminal or significant tracheal invasion (statement 6b), that being complete tumor resection using anterior wedge resection with preservation of the posterior tracheal wall and primary tracheal closure. Unless the posterior wall of the trachea is involved with disease, resecting this portion only places the patient at greater risk for postoperative stenosis without benefit of improved disease control. A circumferential resection has inherently a greater risk of postoperative stenosis than a less than circumferential resection when performed for tracheostenosis. The statement that a complete circumferential sleeve resection should be done because of “circumferential cartilage invasion” is contrary to the known anatomic structure of the trachea (p1384), which is that the cartilaginous rings are incomplete and the trachea is only membranous posteriorly. The literature supports less than complete circumferential resection from an oncologic standpoint. McCaffrey demonstrated no advantage of circumferential resection compared to shave resection or window resection with primary closure or flap closure as long as all gross disease was resected. Anterior wedge resection is also a reported and accepted method of treatment of selected cases of tracheostenosis when the posterior wall is not involved. We have used the anterior resection technique with primary closure successfully in a series of patients (results not published) with extensive tracheal involvement from invasive papillary thyroid carcinoma in conjunction with either adjuvant radioactive iodine or external beam radiation and have had excellent results both from the standpoint of airway and disease control. Figures 1 to 4 show FIGURE 1. Preoperative CT scan showing extensive intraluminal involvement.