EP83 – A Novel Combined Transoral and Transcervical Surgical Approach for Recurrent Metastatic Medullary Thyroid Cancer to the Parapharyngeal Space

      Lajud, Shayanne A1; Aponte, Jaime A.1; Garraton, Miguel1; Giraldez, Laureano1 1 Otolaryngology – Head and neck Surgery, University of Puerto Rico School of Medicine, San Juan, Puerto Rico   Background/purpose: Medullary thyroid cancer (MTC) represent less than one percent 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. Here we describe the first case of a recurrent MTC metastatic to the parapharyngeal space (PPS) and its management using a combined transoral robotic surgery (TORS) and transcervical (TC) approach. Objectives: To review the presentation, natural history, diagnosis and management of Recurrent MTC, and to describe a novel combined TORS-TC surgical approach for the treatment of PPS metastasis. Methods: Case report and literature review. Results: A 66 year-old male with history of MTC status-post total thyroidectomy in the year 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. FNA was consistent with MTC. The patient was taken to the operating room for a combined TORS-TC approach. The hypoglossal, glossopharyngeal and lingual nerves were preserved. Final pathology was consistent with metastatic MTC measuring 4.0 x 3.0 x 1.0cm. Discussion & Conclusion: Until recently, PPS tumors have been managed using highly-morbid and cosmetically-disfiguring open surgical approach. TORS provides a safe and effective alternative. To our knowledge, this is the first reported recurrent MTC to PPS treated with a combined TORS-TC.   References:
    1. Duek I, Amit M, Sviri GE, Gil Z. Combined endoscopic transcervical-transoral robotic approach for resection of parapharyngeal space tumors. Head Neck. 2017
    2. Benet A, Plata Bello J, El-Sayed I. Combined Endonasal-Transcervical Approach to a Metastatic Parapharyngeal Space Papillary Thyroid Carcinoma. Cureus. 2015
    3. Asimakopoulos P, Nixon IJ, Shaha AR. Differentiated and Medullary Thyroid Cancer: Surgical Management of Cervical Lymph Nodes. Clin Oncol (R Coll Radiol). 2017
    4. Bozza F, Vigili MG, Ruscito P, Marzetti A, Marzetti F. Surgical management of parapharyngeal space tumours: results of 10-year follow-up. Acta Otorhinolaryngol Ital. 2009


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