Abstract
We present a 60-year-old man with recurrent follicular thyroid cancer (initially staged pT4aN0M0) with multiple high-risk features including poorly differentiated histology with insular component, extrathyroidal extension with involvement of the cricoid, trachea and esophagus, and recurrence after prior radioactive iodine treatment. He underwent extensive surgical resection including total laryngectomy, bilateral neck dissection, tracheal shave resection, and cricopharyngeal myotomy. A tracheoesophageal puncture (TEP) was performed with placement of a voice prosthesis. He was treated with adjuvant external beam radiotherapy (EBRT) to the neck. Subsequent systemic therapies included the antiangiogenic multi-kinase inhibitors lenvatinib and pazopanib. Over time, he developed a tracheoesophageal fistula requiring multiple surgical interventions, enteral feeding, and therapy changes. In this case report, we discuss risk factors for fistularization including TEP prosthesis, adjuvant EBRT, and antiangiogenic therapy, and we discuss strategies to minimize and manage treatment-related toxicities.
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References
Romesser PB, et al. External beam radiotherapy with or without concurrent chemotherapy in advanced or recurrent non-anaplastic non-medullary thyroid cancer. J Surg Oncol. 2014;110:375–82. https://doi.org/10.1002/jso.23656.
Chow S-M, et al. Papillary thyroid carcinoma: prognostic factors and the role of radioiodine and external radiotherapy. Int J Radiat Oncol Biol Phys. 2002;52:784–95.
Terezakis SA, et al. Role of external beam radiotherapy in patients with advanced or recurrent nonanaplastic thyroid cancer: Memorial Sloan-Kettering Cancer Center experience. Int J Radiat Oncol Biol Phys. 2009;73:795–801.
Schwartz DL, et al. Postoperative external beam radiotherapy for differentiated thyroid cancer: outcomes and morbidity with conformal treatment. Int J Radiat Oncol Biol Phys. 2009;74:1083–91.
Azrif M, Slevin NJ, Sykes AJ, Swindell R, Yap BK. Patterns of relapse following radiotherapy for differentiated thyroid cancer: implication for target volume delineation. Radiother Oncol. 2008;89:105–13.
Keum KC, et al. The role of postoperative external-beam radiotherapy in the management of patients with papillary thyroid cancer invading the trachea. Int J Radiat Oncol Biol Phys. 2006;65:474–80.
Chow S-M, Yau S, Kwan C-K, Poon PCM, Law SCK. Local and regional control in patients with papillary thyroid carcinoma: specific indications of external radiotherapy and radioactive iodine according to T and N categories in AJCC 6th edition. Endocr Relat Cancer. 2006;13:1159. https://doi.org/10.1677/erc.1.01320.
Cooper DS, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association (ATA) guidelines taskforce on thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19:1167–214.
Kiess AP, et al. External-beam radiotherapy for differentiated thyroid cancer locoregional control: a statement of the American Head and Neck Society. Head Neck. 2016;38:493–8.
Bentzen SM. Preventing or reducing late side effects of radiation therapy: radiobiology meets molecular pathology. Nat Rev Cancer. 2006;6:702–13.
Fleckenstein K, et al. Temporal onset of hypoxia and oxidative stress after pulmonary irradiation. Int J Radiat Oncol Biol Phys. 2007;68:196–204.
Brierley JD, Giuliani ME. Practical management of thyroid cancer. Cham: Springer; 2018. p. 147–52.
Rosenbluth BD, et al. Intensity-modulated radiation therapy for the treatment of nonanaplastic thyroid cancer. Int J Radiat Oncol Biol Phys. 2005;63:1419–26.
Beckham TH, et al. Intensity-modulated radiation therapy with or without concurrent chemotherapy in nonanaplastic thyroid cancer with unresectable or gross residual disease. Thyroid. 2018;28:1180–9.
Brierley JD, Tsang RW. External beam radiation therapy for thyroid cancer. Endocrinol Metab Clin North Am. 2008;37:497–509, xi. https://doi.org/10.1016/j.ecl.2008.02.001.
Capdevila J, et al. Optimisation of treatment with lenvatinib in radioactive iodine-refractory differentiated thyroid cancer. Cancer Treat Rev. 2018;69:164–76.
Schmidt A, Iglesias L, Klain M, Pitoia F, Schlumberger MJ. Radioactive iodine-refractory differentiated thyroid cancer: an uncommon but challenging situation. Arch Endocrinol Metabol. 2017;61:81–9.
Schlumberger M, et al. Definition and management of radioactive iodine-refractory differentiated thyroid cancer. Lancet Diabet Endocrinol. 2014;2:356–8.
Kim SY, et al. Safety of tyrosine kinase inhibitors in patients with differentiated thyroid cancer: real-world use of lenvatinib and sorafenib in Korea. Front Endocrinol. 2019;10:384.
Schlumberger M, et al. A phase 3, multicenter, double-blind, placebo-controlled trial of lenvatinib (E7080) in patients with 131I-refractory differentiated thyroid cancer. 2014. https://ascopubs.org/doi/abs/10.1200/jco.2014.32.18_suppl.lba6008.
Qi WX, Shen Z, Tang LN, Yao Y. Congestive heart failure risk in cancer patients treated with vascular endothelial growth factor tyrosine kinase inhibitors: a systematic review and meta-analysis of 36 clinical trials. Br J Clin Pharmacol. 2014;78:748–62.
Steingart RM, et al. Management of cardiac toxicity in patients receiving vascular endothelial growth factor signaling pathway inhibitors. Am Heart J. 2012;163:156–63.
Blevins DP, et al. Aerodigestive fistula formation as a rare side effect of antiangiogenic tyrosine kinase inhibitor therapy for thyroid cancer. Thyroid. 2014;24:918–22. https://doi.org/10.1089/thy.2012.0598.
Dewey EH, et al. Reconstruction of expanding tracheoesophageal fistulae in post-radiation therapy patients who undergo total laryngectomy with a bipaddled radial forearm free flap: report of 8 cases. Head Neck. 2016;38:E172–8. https://doi.org/10.1002/hed.23966.
Pawar P, Sayed S, Kazi R, Jagade M. Current status and future prospects in prosthetic voice rehabilitation following laryngectomy. J Cancer Res Ther. 2008;4:186–91. https://doi.org/10.4103/0973-1482.44289.
Cavalot AL, et al. Pharyngocutaneous fistula as a complication of total laryngectomy: review of the literature and analysis of case records. Otolaryngol Head Neck Surg. 2000;123:587–92. https://doi.org/10.1067/mhn.2000.110617.
Iyer PC, et al. Salvage pembrolizumab added to kinase inhibitor therapy for the treatment of anaplastic thyroid carcinoma. J Immunother Cancer. 2018;6:68. https://doi.org/10.1186/s40425-018-0378-y.
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Kut, C., Liang, A., Kiess, A.P. (2021). A Case of Fistula After Adjuvant External Beam Radiotherapy and Lenvatinib for High-Risk Follicular Thyroid Cancer. In: Grani, G., Cooper, D.S., Durante, C. (eds) Thyroid Cancer. Springer, Cham. https://doi.org/10.1007/978-3-030-61919-0_28
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