Surgical management of substernal goitres at a tertiary referral centre: A retrospective cohort study of 2,104 patients

Surgical Management of 48 Patients with Retrosternal Goiter and Tracheal Stenosis: A Retrospective Clinical Study from a Single Surgical Center

Background

Benign retrosternal thyroid goiters can become large enough to compress the trachea and result in tracheomalacia and stenosis. This retrospective study from a single surgical center aimed to study the surgical management of 48 patients with retrosternal goiter and tracheal stenosis diagnosed and treated from January 2017 to December 2021.

Material/Methods

All preoperative contrast-enhanced CT scans showed retrosternal goiter and tracheal stenosis. RG was classified into type I in 28 patients, type II in 12 patients, and type III in 8 patients. TS was classified into grade I in 31 patients, grade II in 11 patients, and grade III in 6 patients. All patients were referred for surgery. Clinicopathologic features and surgical outcomes were recorded.

Results

All operations were successfully performed. There were 41 patients with transcervical incision, 4 with cervical incision+sternotomy, 2 with cervical incision and thoracoscopic surgery, and 1 with cervical incision and surgery via the subxiphoid approach. Two patients presented recurrent laryngeal nerve injury. One patient showed short-term hand and foot numbness. The patients were pathologically diagnosed as simple nodular goiter (n=27), nodular goiter combined with cystic change (n=6), adenomatous nodular goiter (n=10), and thyroid adenoma (n=5). There was no prominent tumor recurrence or gradual TS remission.

Conclusions

This study has highlighted that patients with retrosternal goiter and tracheal stenosis may have comorbidities and require a multidisciplinary approach to management. The choice of anesthesia, surgical approach, and maintenance of the airway during and after surgery should be individualized.

A Monster in the Chest: A Tale of a Goiter

Substernal goiter is usually presented in elderly patients and is mostly asymptomatic. A large substernal goiter is surgically challenging and can be managed through a transcervical incision and sternotomy. This case report is about a large substernal goiter extending into the anterior mediastinum and causing superior vena cava syndrome that was resected via a transcervical and full sternotomy approach. The patient was a 47-year-old male, who visited our hospital for surgical treatment of substernal goiter. The computed tomography (CT) of the neck and thorax revealed a large substernal goiter extending into the mediastinum causing tracheal compression, vessel compression, and development of collateral vessels. Total thyroidectomy was performed via a full sternotomy and transcervical approaches. Postoperatively, the patient recovered well with no nerve palsy. Histopathological examination revealed the lesion as an adenomatous goiter. Substernal goiters are usually managed by transcervical approach, but a full sternotomy is required in cases of large substernal goiter with extension up to the pericardium and the presence of superior vena cava syndrome. A multidisciplinary team approach is necessary and can help reduce the risk of complications, such as nerve injury, major vessel injury, tracheal injury, and morbidity of the surgery.

A large intrathoracic goiter with tracheal stenosis: Complete resection using a robot-assisted thoracoscopic approach

Growing intrathoracic goiters may compress surrounding organs and deteriorate the cardiopulmonary function. Treating such cases requires carefully considering how to maintain oxygenation and resect the tumor with minimal invasiveness without complications. We herein report a surgically resected case of a large intrathoracic goiter‐compressed trachea extending from the right lower pole of the thyroid gland to the carina. We secured the airway by intubation preparing for extracorporeal membrane oxygenation and successfully performed surgical complete resection using a robot‐assisted thoracoscopic and cervical approach. Intrathoracic goiter is a tumor with abundant neovascularity, and the right vagus nerve is displaced in the thoracic cavity, but a robot‐assisted thoracoscopic approach using CO₂ insufflation improved visualization at the narrow apex area of the thoracic cavity. Robot‐assisted thoracoscopic surgery is a useful surgical procedure enabling safe and minimally invasive surgery without recurrent laryngeal nerve palsy or tracheal injury for intrathoracic giant goiters extending into the thoracic cavity.

Retrosternal Goitre: Anatomical Aspects and Technical Notes

Background and Objectives: surgery for substernal goitre is still debated in the literature, due to the wide range of surgical options. This article outlines the findings of our extensive experiences, which include 264 cases of patients with “goitre plongeant“, and compares postoperative complications, despite surgical approaches. Material and Methods: preoperative planning and anatomical landmarks are described to determine the potential need of a combined approach. The surgical procedure is described, along with some stratagems, to ensure that the operation is completed safely. A statistical analysis of complications and the length of stay, with a comparison of cervicotomy and combined access, was performed using the Pearson chi-square significance test. Results: 264 patients underwent thyroid surgery for substernal goitre. The Kocher incision was the surgical approach chosen in 256 patients (96.6%), while an accessory incision was performed in 8 patients (3.4%). The necessity to use a two-fold surgical access was linked to a higher rate of postoperative complications (p-value < 0.01). The average length of stay (LOS) for cervicotomy was 2 days (1−3 days), while the average LOS was 5 days (4−7 days) (p-value = n.s.) for combined access. Conclusions: cervicotomy should be the gold standard technique for exploring intrathoracic goitre with a digital dissection, which, in almost all cases, enables the externalization of the mediastinal portion associated. Sternotomy is related to a higher rate of complications, so it should be performed only in selected cases. Management in large-volume centres may be more appropriate.

Clinicopathologic Characteristics and Outcomes of Massive Multinodular Goiter: A Retrospective Cohort Study

BACKGROUND

Thyroidectomy for massive goiters is challenging because of the increased risk of tracheomalacia, combined sternotomy, postoperative morbidity, and mortality, whereas studies investigating the clinicopathologic characteristics, postoperative morbidities, and surgical outcomes of massive goiters are limited.

METHODS

Patients with goiters undergoing thyroid surgery between 2009 and 2019 were retrospectively reviewed. A total of 227 patients were enrolled and divided into massive goiter group and large goiter group according to the weight of the goiter. Clinicopathologic characteristics, postoperative morbidities, and surgical outcomes were compared between the two groups.

RESULTS

Seventy-four patients (32.6%) had a goiter weighing more than 250 g and 153 patients (67.4%) were categorized in the large goiter group. Compared to large goiter patients, massive goiter patients had higher rates of retrosternal extension (82.4% vs. 30.7%), combined sternotomy (12.2% vs. 1.3%), intensive care unit admission (25.7% vs. 7.2%), transient hypoparathyroidism (41.9% vs. 25.5%), and transient recurrent laryngeal nerve palsy (10.8% vs. 3.3%) as well as prolonged length of hospital stay (P < 0.05).

CONCLUSIONS

Massive goiter patients were at increased risk of combined sternotomy, intensive care unit admission, postoperative morbidities as well as prolonged length of hospital stay after thyroidectomy compared to large goiter patients, but most of them can be treated through a cervical approach with a favorable outcome.

Management of a huge intrathoracic goitre in a rural specialist hospital in Nigeria-Case report and review of literature

Retrosternal goiter is expectedly a common presentation in rural African communities due to long periods of neglect. The treatment of choice is surgical - commonly via a trans-cervical incision. A few require an extra-cervical surgical approach and multidisciplinary management as reported in this case performed in a rural specialist hospital in Nigeria.

Substernal goitre presenting with upper and lower extremity oedema

Substernal goitre is characterised by compressive symptoms of the airway and oesophagus. Chronic, progressive symptoms usually result in surgical removal. We report a rare presentation of substernal goitre in a male in his early 70s who suffered from severe bilateral lower extremity (LE) lymphoedema, resulting in immobility and nursing home placement, and left upper extremity lymphoedema. Our initial assessment led to a filariasis work-up, which was negative, due to the patient's prior 2-year residence in India and service overseas. Chest CT scan revealed an incidental substernal goitre extending posterior to the left innominate vein and aortic arch to the level of the left mainstem bronchus. The patient underwent a left hemithyroidectomy via cervical excision and sternotomy and had an uneventful recovery with resolution of lymphoedema and mobility. Despite extensive literature regarding clinical presentations of substernal goitre, severe lymphoedema of the LE is not a well-established association.

An overview of retrosternal goiter

Goiters tend to grow slowly and steadily over many years, occasionally reaching the mediastinum and extending through the thoracic inlet into the visceral compartment. In most cases, retrosternal goiters originate from the cervical portion of the thyroid. The incidence of retrosternal goiters varies considerably, ranging from 0.2 to 45% of all thyroidectomies, depending on the criteria used to define this type of goiter. Symptoms are generally related to the compressive nature of the mass on the adjacent structures, and most patients report some form of respiratory manifestation associated with the goiter. A diagnostic assessment usually includes an evaluation of thyroid function, chest radiography, and computed tomography. Fine-needle aspiration biopsy should be avoided in substernal areas of the goiter due to limited visibility and location of vital structures in this region. Treatment of retrosternal goiters is surgical, as medical therapy is generally unsuccessful in these cases.

Cardiopulmonary Arrest Caused by Large Substernal Goiter-Treatment with Combined Cervical Approach and Median Mini-Sternotomy: Report of a Case

INTRODUCTION

Substernal goiter is usually defined as a goiter that extends below the thoracic inlet or a goiter with more than 50% of its mass lying below the thoracic inlet. Substernal goiters may compress adjacent anatomical structures causing a variety of symptoms.

CASE REPORT

Here we report a rare case of a 75-year-old woman presenting with cardiac arrest caused by acute respiratory failure due to tracheal compression by a substernal goiter.

DISCUSSION

Substernal goiters can be classified as primary or secondary depending on their site of origin. Symptoms are diverse and include a palpable neck mass, mild dyspnea to asphyxia, dysphagia, dysphonia, and superior vena cava syndrome. Diagnosis of substernal goiter is largely based on computed tomography imaging, which will show the location of the goiter and its extension in the thoracic cavity. Surgery is the treatment of choice for symptomatic patients with substernal goiter. The majority of substernal goiters are resected through a cervical approach. However, in approximately 5% of patients, a thoracic approach is required. The most important factor determining whether a thoracic approach should be used is the depth of the extension to the tracheal bifurcation on CT imaging.

CONCLUSION

Cardiac arrest appearing as the first symptom of a substernal goiter is a very rare condition and should be treated by emergency thyroidectomy via a cervical or thoracic approach depending on the CT imaging findings.

Surgery for retrosternal goiter: cervical approach

BACKGROUND

Retrosternal goiter refers to when the thyroid gland extends from the neck to the substernal portion, descending below the thoracic inlet into the mediastinum. It is typically accompanied by compressive symptoms, and most patients need to undergo surgery. This retrospective study set out to analyze the surgical approach to retrosternal goiter and to evaluate perioperative complications, with the aim of recommending best surgical technique.

METHODS

We carried out retrospective analysis of 115 patients with retrosternal goiter treated at our center between May 4, 2011 and March 19, 2019. We analyzed patient characteristics, surgical methods, and perioperative complications using SPSS.

RESULTS

Of the 115 patients in our study, 112 underwent thyroidectomy by cervical approach, with only 3 requiring an extracervical approach. The median age of the patients was 52.3 years, and the majority were female (81.74%). Most of the patients (73.91%) experienced no symptoms but were diagnosed with tracheal compression during surgery or preoperative imaging examination. Ninety-eight (85.22%) of our patients underwent preoperative evaluation of their condition by CT imaging. No obvious surgical contraindications were found before thyroid function tests. The mean operation time was 115.11 min, and the average amount of bleeding during surgery was 54.43 mL. The mean postoperative hospital stay was 5.38 days. In 109 cases (94.78%), the goiter was found to be benign, and malignancy was diagnosed in 6 patients (5.22%). Of the 112 patients who were treated with the cervical approach, 7 (6.25%) experienced recurrent laryngeal nerve palsy; 6 of these cases were transitory and 1 was permanent. The number of patients treated by cervical and extracervical approach who experienced transient hypocalcaemia was 23 (20.54%) and 2, respectively. Transient hypoparathyroidism affected 16 patients (14.29%) treated by cervical approach. Two patients had tracheomalacia phenomenon and one patient had pleural effusion after surgery. No cases experienced permanent hypocalcemia, permanent hypoparathyroidism, postoperative hematoma, tracheostomy, or death.

CONCLUSIONS

Retrosternal goiter surgery is challenging for surgeons. The best surgical approach for the patient should be based on CT scan evaluation. In our study, based on preoperative CT imaging and in-operation evaluation, 50% of the tumor volume was located below the thoracic inlet and 50% of the tumor volume was located above the thoracic inlet in almost all of the patients. Both sections could be successfully removed via a cervical incision, and no obvious complications were observed during the perioperative period. With careful planning and execution before surgery and meticulous operation during surgery, most retrosternal goiters can be safely treated by cervical approach.

Ultrasound-Guided Percutaneous Microwave Ablation for Substernal Goiter: Initial Experience

OBJECTIVES

To preliminarily evaluate the safety, effectiveness, and feasibility of microwave ablation (MWA) for substernal goiter (SSG) in select patients and to provide a relevant treatment reference for further studies.

METHODS

From April 2017 to December 2017, 10 patients with SSG were treated by MWA. All patients were followed for at least 3 months to observe the therapeutic effects and complications. Therapeutic effects were assessed at follow-up for the relief of patients' symptoms, resolution of the cosmetic grade, and volume reduction rate (VRR) of SSG. Possibly related factors for the 3-month VRR of the nodules were analyzed.

RESULTS

The study included 9 female patients and 1 male patient with a mean age ± SD of 56.8 ± 10.1 years (range, 34-70 years). The mean volume of the nodules was 52.9 ± 27.9 mL (range, 23.7-122.6 mL). The nodule volume was significantly reduced at the 3-month follow-up (17.5 ± 9.5 mL; P < .05). The mean 3-month VRR of the index nodule was 66.7% ± 7.1%. A higher ablated portion-to-nodule ratio 1 day after MWA predicted a higher 3-month VRR (Spearman r = 0.646; P = .044). The mean symptom score (from 4.5 ± 1.7 to 1.5 ± 1.0; P = .005) and cosmetic grade (from 3.3 ± 0.5 to 2.2 ± 0.4; P = .004) declined significantly 3 months after the procedure. No complications or unexpected side effects were observed.

CONCLUSIONS

Our preliminary results support the effectiveness and safety of MWA for local control of SSG. This technology can be applied in select patients with SSG who are ineligible for surgery.

A Large Substernal Goiter that Extended to Both Sides of the Thorax

Most substernal goiters can be managed through the transcervical approach, but a sternotomy is required in some cases. This report is about a large substernal goiter, which was resected via a transcervical and full sternotomy approach. The patient was a 57-year-old female, who visited our hospital for surgical treatment for a large substernal goiter. Computed tomography of the neck and chest revealed that the substernal goiter extended to both sides of the thorax and had compressed the trachea. We performed total thyroidectomy safely via a transcervical and full sternotomy approach. No postoperative complications occurred, except transient hypocalcemia. A histopathological examination did not reveal any malignancy, and the lesion was diagnosed as an adenomatous goiter. Most substernal goiters can be managed through the transcervical approach, but a full sternotomy is required when a substernal goiter extends to both sides of the thorax and/or has a larger diameter than the thoracic inlet or airway constriction is revealed. A full sternotomy provides excellent exposure and can help reduce the risk of complications, such as recurrent laryngeal nerve palsy and injuries to major blood vessels.

Can Thyroid Ultrasonography Predict Substernal Extension or Tracheal Compression in Goiters?

PURPOSE

To determine whether an ultrasonography (US)-defined thyroid volume can accurately predict substernal extension or tracheal narrowing.

METHODS

After research ethics approval, we identified patients with thyroid nodules investigated with both US and computed tomography (CT). Reviewers assigned scores for both substernal extension and tracheal compression on CT using pre-established classification systems. Statistical analysis with receiver operating characteristic curve analysis was performed to find the US-determined thyroid volume thresholds that correlated with each substernal extension and tracheal compression.

RESULTS

This study included 120 patients (mean age 63.4 years; SD ± 15.9; 67% female). Thirty-five patients (29%) had substernal extension. The mean US total thyroid gland volume in patients with and without substernal extension were 92.4 and 37.6 cm³, respectively (P < .001). 86% of patients with substernal extension had tracheal narrowing vs. 27% of patients without substernal extension (P < .0001). A cutoff dominant gland volume of ≥37.5 cm³ showed 83% sensitivity and 79% specificity for substernal extension (area under the curve [AUC] = 0.84). A total thyroid gland volume threshold of ≥37.8 cm³ showed 89% sensitivity and 87% specificity for any degree of tracheal narrowing (AUC = 0.90).

CONCLUSIONS

This study suggests that US volumes may be used as a predictor to identify those patients with thyroid enlargement who are most at risk of substernal extension and tracheal compression and who may benefit from preoperative CT imaging for optimal surgical and anesthetic planning.

Resection of mediastinal goiter extending to the carina with use of artificial pneumothorax, two-lung ventilation, and thoracoscopy, with the patient in a prone position

A 67-year-old woman was presented with a mediastinal tumor extending from the left lobe of the thyroid and passing through the posterior trachea, causing displacement of the esophagus to the left side of the patient and then descending into the right side of the mediastinum to below the carina. Surgery was performed under two-lung ventilation with the patient in a prone position; general anesthesia was performed with a single-lumen tube combined with artificial pneumothorax. In thoracoscopic surgery, we were able to confirm and preserve anatomical structures. After detachment of the tumor at the level of the left and right subclavian arteries, the patient was placed supine, a cervical incision was added, and the tumor was extracted. The tumor was diagnosed as a nonmalignant mediastinal goiter (MG). No such surgical report was found in the literature, and one would be useful for this new approach to MG removal.

Retrosternal goitre: the role of the thoracic surgeon

Purpose of this Mini-Review is to evaluate the role of a thoracic surgeon in the surgical management of retrosternal goitre. A cervical approach is sufficient in the majority of the cases. On the other hand, there are cases where a cervical approach is combined with sternotomy or thoracotomy, depending on the position of the goitre, in the anterior or posterior mediastinum. On top of that, different minimally invasive approaches including video-assisted thoracoscopic surgery (VATS) and robotic-assisted surgery (RATS) have been introduced, providing faster recovery, superior manoeuvrability and better aesthetic results.