Abstract
Medullary thyroid cancer (MTC) represents less than 1% of all thyroid cancers. Complete surgical resection remains the mainstay of treatment for locoregional disease. Unfortunately, patients with recurrence may present with metastasis to challenging anatomic locations. We describe the first case of a recurrent MTC metastatic to the parapharyngeal space (PPS) that was managed using a combined transoral robotic surgery (TORS) and transcervical (TC) approach. We review the presentation, natural history, diagnosis and management of recurrent MTC, and describe a novel combined TORS–TC surgical approach for the treatment of PPS metastasis. A 66-year-old male with history of MTC treated with total thyroidectomy in 2000 and a liver resection in 2011 for metastatic MTC was referred to our Head and Neck Surgery Clinic in October 2016 due to increased calcitonin and CEA levels. Exam was significant for mild right tonsillar/pharyngeal bulging and induration. Imaging with PET–CT and MRI showed an enlarging ovoid mass centered within the right PPS without the presence of another systemic metastasis. FNA was consistent with MTC. The patient was taken to the operating room for a combined TORS–TC approach. Final pathology was consistent with metastatic MTC. Until recently, PPS tumors have been managed using highly morbid and cosmetically disfiguring open surgical approach. TORS provides a safe and effective alternative.
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs11701-019-00930-5/MediaObjects/11701_2019_930_Fig1_HTML.jpg)
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs11701-019-00930-5/MediaObjects/11701_2019_930_Fig2_HTML.png)
Similar content being viewed by others
References
Wells SA Jr, Asa SL, Dralle H, Elisei R, Evans DB, Gagel RF, Lee N, Machens A, Moley JF, Pacini F, Raue F, Frank-Raue K, Robinson B, Rosenthal MS, Santoro M, Schlumberger M, Shah M, Waguespack SG (2015) American Thyroid Association Guidelines Task Force on Medullary Thyroid Carcinoma. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid 25(6):567–610
Kebebew E, Ituarte PH, Siperstein AE, Duh QY, Clark OH (2000) Medullary thyroid carcinoma: clinical characteristics, treatment, prognostic factors, and a comparison of staging systems. Cancer 88(5):1139–1148
Saad MF, Ordonez NG, Rashid RK, Guido JJ, Hill CS Jr, Hickey RC, Samaan NA (1984) Medullary carcinoma of the thyroid. A study of the clinical features and prognostic factors in 161 patients. Medicine 63(6):319–342
Rufini V, Salvatori M, Garganese MC, Di Giuda D, Lodovica Maussier M, Troncone L (2000) Role of nuclear medicine in the diagnosis and therapy of medullary thyroid carcinoma. Rays 25(2):273–282
Khafif A, Segev Y, Kaplan DM, Gil Z, Fliss DM (2005) Surgical management of parapharyngeal space tumors: a 10-year review. Otolaryngol Head Neck Surg 132(3):401–406. https://doi.org/10.1016/j.otohns.2004.09.062
Lombardi D, Nicolai P, Antonelli AR, Maroldi R, Farina D, Shaha AR (2004) Parapharyngeal lymph node metastasis: an unusual presentation of papillary thyroid carcinoma. Head neck 26(2):190–196. https://doi.org/10.1002/hed.10341
Ducci M, Bozza F, Pezzuto RW, Palma L (2001) Papillary thyroid carcinoma metastatic to the parapharyngeal space. J Exp Clin Cancer Res CR 20:439–441
Ahmad F, Waqar-uddin, Khan MY, Khawar A, Bangush W, Aslam J (2006) Management of parapharyngeal space tumours. J Coll Phys Surg Pak 16:7–10
Duek I, Amit M, Sviri GE, Gil Z (2017) Combined endoscopic transcervical-transoral robotic approach for resection of parapharyngeal space tumors. Head Neck 39(4):786–790. https://doi.org/10.1002/hed.24685
Goodwin WJ Jr, Chandler JR (1988) Transoral excision of lateral parapharyngeal space tumors presenting intraorally. The Laryngoscope 98(3):266–269. https://doi.org/10.1288/00005537-198803000-00005
Boyce BJ, Curry JM, Luginbuhl A, Cognetti DM (2016) Transoral robotic approach to parapharyngeal space tumors: case series and technical limitations. The Laryngoscope 126(8):1776–1782. https://doi.org/10.1002/lary.25929
Chu F, Tagliabue M, Giugliano G, Calabrese L, Preda L, Ansarin M (2017) From transmandibular to transoral robotic approach for parapharyngeal space tumors. Am J Otolaryngol 38(4):375–379. https://doi.org/10.1016/j.amjoto.2017.03.004
O’Malley BW Jr, Quon H, Leonhardt FD, Chalian AA, Weinstein GS (2010) Transoral robotic surgery for parapharyngeal space tumors. ORL J Otorhinolaryngol Relat Spec 72(6):332–336. https://doi.org/10.1159/000320596. (Epub 2010 Oct 1. PubMed PMID: 20924206)
Maglione MG, Guida A, Pavone E, Longo F, Aversa C, Villano S, Ionna F (2018) Transoral robotic surgery of parapharyngeal space tumours: a series of four cases. Int J Oral Maxillofac Surg 47(8):971–975. https://doi.org/10.1016/j.ijom.2018.01.008
Chabrillac E, Morinière S, Jegoux F, Blanchard D, Choussy O, Hans S, Vergez S (2018) Transoral robotic resection of benign tumors of the upper aerodigestive tract: experience of the French group of GETTEC. Head Neck. https://doi.org/10.1002/hed.25197. (Epub ahead of print] PubMed PMID: 29697873)
Acknowledgements
We would like to thank Amarilys Irizarry Hernandez, Graphic Designer, Information and Technology Center, University of Puerto Rico School of Medicine, for the illustration of the transoral robotic surgical approach to the parapharyngeal space.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors of this manuscript: Shayanne A. Lajud, Jaime A. Aponte-Ortiz, Miguel Garraton, and Laureano Giraldez, have no financial conflicts of interest and nothing to disclose.
Ethical approval
Consent section: The procedure performed was in accordance with the ethical standards of the institution and with the 1964 Helsinki declaration and its later amendments.
Informed consent
Informed consent was obtained from the patient included in the study and additional written informed consent was obtained from the patient for publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Rights and permissions
About this article
Cite this article
Lajud, S.A., Aponte-Ortiz, J.A., Garraton, M. et al. A novel combined transoral and transcervical surgical approach for recurrent metastatic medullary thyroid cancer to the parapharyngeal space. J Robotic Surg 14, 233–236 (2020). https://doi.org/10.1007/s11701-019-00930-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11701-019-00930-5