Table 5.

Airway Evaluation, Inclusion and Exclusion Criteria for Resectability Before or During Surgical Intervention

Immediate Airway Evaluation

Does the patient have stridor?

Is immediate tracheostomy required?

Prerequisites/Inclusion Criteria for Surgery

Detailed surgical aerodigestive evaluation:

Fiberoptic evaluation including vocal cord status: laryngeal, subglottic, and upper tracheal regions need to be examined

Contrast-enhanced imaging of neck and upper mediastinum (CT or MRI preferred over ultrasound)

Consider: Endoscopic visualization of esophagus to assess invasion

Consider: Bronchoscopic visualization to assess tracheal invasion

Is R0/R1a resection expected?

R0/R1 resection anticipated without extensive visceral/vascular resection (laryngectomy, arterial/tracheal resection, permanent tracheostomy not anticipated)

Assembled surgical team optimally poised for the planned surgery

Undertake systematic evaluation (experienced surgeon, endocrinologist, pathologist, radiation oncology, medical oncology, radiology, nuclear medicine, and palliative care and ethics consultations)

• Assure correct pathologic diagnosis

FNA and core, negative calcitonin, expert pathology review including immunohistochemical marker assessment; send sample for genomic interrogation (especially BRAFV600E mutation assessment)

• Completed radiographic evaluation/clinical staging (Table 3):

Define global clinical stage (IVA, IVB, IVC)

Brain imaging (MR preferred, else contrast-enhanced CT)

• Patient comorbidities and psychosocial fitness for surgery assessed—and acceptable to proceed based upon global patient condition

• Patient competent in terms of decision-making capacity and meeting the U-ARE criteria and with sufficient understanding to make thoughtful decisions (see Table 4 and consider involvement of surrogate decision makers as needed)

• Patient goals of care, preferences, code (DNR/DNI) status, advanced directives, and surrogate/proxy decision makers defined

• Consensus achieved with patient and team on initial therapeutic plan and go/no-go for surgery

Exclusionary Conditions Before or at Time of ATC Surgery

Patient condition, goals of care, or decision-making capacity unsuitable for surgery

High-volume ATC metastasesb

Anticipated prohibitive morbidity from required surgical procedure?

Unacceptably high risk of extensive laryngeal, tracheal, bilateral nerve, esophageal, and/or vascular resection required to achieve R0/R1 resection

Anticipated time of postoperative recovery prohibitive in the context of anticipated need for additional superimposed therapies (e.g., chemoradiotherapy)

^aR0, negative microscopic and gross margin resection; R1, negative gross margin resection.

^bHigh-volume metastatic disease should preclude surgery, but coexistent metastatic DTC or oligometastatic/low-volume metastatic ATC should not necessarily preclude surgery.

DNI, do not intubate; DNR, do not resuscitate; FNA, fine needle aspiration.