Endocrine Abstracts

Lenvatinib is a tyrosine kinase inhibitor (TKI), approved for the management of locally recurrent or metastatic, progressive, radioactive iodine–refractory differentiated thyroid cancer (DTC). A side effect of this drug is the tracheoesophageal fistula, described in 14.7% of patients. When this side effect is present, the interruption/withdrawn of the TKI is required and in this case no valid therapeutic options are described. We present the case of a 63-year-old woman patient with thyroid follicular carcinoma (FTC) with lung metastases, treated with Lenvatinib, stable for ten years. For the appearance of dysphagia, odynophagia and chronic cough, the patient performed a whole-body computed tomography (CT) which confirmed a locoregional recurrence, in retrotracheal space, with the presence of air bubbles. Bronchoscopy and radiography of the esophagus with contrast medium documented saliva leakage into the trachea, confirming the tracheoesophageal fistula. For these reasons, Lenvatinib was interrupted, and an enteral nutrition by nasogastric tube was started. Four months later the suspension of Lenvatinib, the patient had a progression on local disease and lung metastases with concomitant increase of the serum Thyroglobulin levels (TG) (4042.91 mg/l vs 1882.25) and, despite enteral nutrition, the patient had a weight loss (10 kg). Since a significant PD occurred in the neck and since the patient complained a strong discomfort due to the presence of naso-gastric tube and to the weight loss, after a multidisciplinary evaluation, she underwent to the surgery of pharyngo-laryngo-esophagectomy, gastric anastomosis and definitive tracheostomy. The patient gradually resumed to feed orally, with a referred by patient improvement of her quality of life. One month later the surgery, in consideration of the stability of the clinical conditions, the patient restarted Lenvatinib. Eight months later the surgery and seven from TKI beginning, the CT showed remission of loco-regional disease and a partial response of lung disease with a reduction of TG (1,424 mg/l vs 2.927). Although the TKI therapy, the patient had a weight increase (5 kg). This was the first case of DTC with tracheoesophageal fistula treated with surgery. The surgical treatment allowed not only the local control of the disease but also the possibility to start again systemic treatment with Lenvatinib. The present case also demonstrates that local treatment, despite highly invasive, could improve the subjective perception of quality of life.