This article reminds readers of how often invasive thyroid disease can appear, as the symptomatology is minimal. Noticeable airway symptoms appear after 50% of the airway is involved and surgeons can often fall in the unsuspecting trap of discovering locally invasive disease at the time of definitive surgery. To avoid this an intensified examination of all patients to include a direct laryngoscopy/oesophagoscopy, complemented by cross sectional imaging (CT/MRI), is suggested. Decisions regarding optimal management are complicated by the paucity of evidence, the likelihood that invasion has followed previous treatment failures, and that it occurs in a more elderly population. Despite the lack of research, it is commonly felt that invasive disease is best treated surgically, with the American Association suggesting that this is in conjunction with radioactive iodine or external beam radiotherapy. The authors then describe specific circumstances that the surgeon may encounter, including involvement of the RLN, larynx/trachea, vascular structures or oesophagus. These are supported with intraoperative photographs and imaging for the reader’s benefit.
They highlight the pros and cons of performing differing types of surgical procedures for each type of invasion. They also remind surgeons not to rely on the effects of radio-iodine following surgery as the histological type for invasive disease is often iodine-resistant – tall cell, insular and sclerosing papillary.
Despite the resistant nature of some invasive tumours, the authors do remind the reader that this may still be an option in some cases, as well as IMRT. Clearly these decisions should be made in a multi-disciplinary setting with expertise in advanced thyroid disease, most importantly including the patient and their family in the discussion too. A succinct and useful synopsis of the problem.