26
Treatment
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/R1
a
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 patholog y review including
immunohistochemical marker assessment; send sample for genomic interrogation
(especially BRAF
V600E
mutation assessment)
• Completed radiographic evaluation/clinical staging (see Table 3):
▶ Define global clinical stage (IVA, IVB, IVC)
▶ Brain imaging (MR preferred, else contrast-enhanced CT)
• Patient co-morbidities and psychosocial fitness for surgery assessed — and acceptable
to proceed based upon global patient condition
• Patient competent in terms of decision-making capacity, 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
