Complete excision of a giant thyroid goiter in posterior mediastinum

Isolated Posterior Mediastinal Thyroid Nodule Simulating Esophageal Pathology: A Multi-Modality Diagnosis

Posterior mediastinal goiter is not a common cause of dysphagia, and symptoms can simulate esophageal malignancy. This case report highlights two critical clinical aspects. First, the patient's symptoms of gradually worsening dysphagia to solids and liquids, odynophagia, and hoarseness of voice secondary to retrosternal thyroid nodule extension can simulate esophageal malignancy. Second, a barium swallow study can effectively rule out esophageal pathology even though more advanced studies, like High-resolution computed tomography (HRCT), are inconclusive. We present a unique case of isolated posterior mediastinal exophytic thyroid nodule simulating the symptoms of esophageal pathology.

Clinical Characteristics and Predictors Related to the Progression of Multinodular Goiter Causing Tracheal Compression and Deviation: A Report of Two Cases and Review of the Literature

We describe the clinical course of two patients who developed tracheal compression and deviation by multinodular goiter (MNG). Case 1: A 66-year-old woman presented with thyroid swelling. Five years after the initial admission, she was diagnosed with hyperthyroidism by Graves' disease and increased bilateral thyroid lobes compressing the trachea. Thyroglobulin was elevated from 210 to 472 ng/mL. Case 2: A 52-year-old woman presented with thyroid swelling. Five years after the initial admission, the increased right lobe deviated the trachea and compressed the right recurrent laryngeal nerve. Thyroglobulin was elevated from 122 to 392 ng/mL. Two cases and literature review indicated that MNG with >50 mm, solid components, and extension to the mediastinum or paralarynx were risk factors of tracheal compression and deviation. Monitoring thyroglobulin elevation can help predict the clinical course.

Efficacy and safety of single-session radiofrequency ablation for intrathoracic goiter: preliminary results and short-term evaluation

BACKGROUND

An intrathoracic goiter (ITG) is defined as a thyroid extension below the sternal notch. Compared to cervical goiters, surgery for ITG is more challenging, with a higher risk of an extracervical approach. Ultrasound (US)-guided radiofrequency ablation (RFA) is a minimally invasive treatment modality. The purpose of this study was to prospectively evaluate the safety and efficacy of RFA in patients with ITG.

METHODS

From a total of 324 patients who underwent thyroid RFA at a single medical center, 15 patients (mean age 52.2 years; 73.3% female) with 16 ITGs were included and classified into three grades and three types using the cross-section imaging CT system. Clinical features and demographics, degree of extension, RFA details, goiter volume, and complications were analyzed.

RESULTS

Mean pre- and post-RFA goiter volumes as measured by US were 106.62 ± 61.82 and 25.09 ± 14.22 mL respectively, with a volume reduction rate (VRR) of 75.5% (p < 0.001) at 6 months. The VRR as measured by CT/MRI was 57.0 ± 10.0% (p < 0.001) at 6 months. The intrathoracic length reduction rate at 6 months was 44.9 ± 39.2% (p = 0.001). In addition, 4 (25%) ITGs had total regression of the intrathoracic extension, with a downgrade from grade 1 to cervical goiter. Mean pre- and post-RFA symptom and cosmetic scores were 1.53 and 0.15 (p = 0.001), and 2.67 and 2.00 (p = 0.001), respectively. One patient had transient vocal cord palsy and another had perithyroidal and mediastinal hemorrhage.

CONCLUSION

US-guided RFA is an effective treatment for ITG in terms of both cervical and intrathoracic reductions with an acceptable complication rate.

Retrosternal goiter in thoracic surgical practice

OBJECTIVE

To evaluate and optimize surgical approaches to the management of retrosternal goiter.

MATERIAL AND METHODS

A cohort retrospective single-center study included 56 patients aged 68.3±9.8 years with retrosternal goiter who underwent surgery between 2004 and 2019. Right-sided goiter was diagnosed in 16 cases, left-sided goiter in 21 patients, bilateral goiter in 19 patients. Palpable neck mass was found in 17 (30.4%), stridor in 16 (28.6%), thyrotoxicosis in 4 (7.1%) and recurrent laryngeal nerve palsy in 2 (3.6%) cases. X-ray signs of tracheal compression were detected in 43 (76.8%) patients, deviation in 26 (46.4%) patients. Resection through cervical collar incision was performed in 40 (71.4%) patients. Additional sternotomy was required in 11 (19.6%) patients, 1 (1.8%) patient required collar incision and right anterior mediastinotomy. Right-sided posterolateral thoracotomy without collar incision was performed in 1 (1.8%) patient with a suspected mediastinal teratoma. Three patients underwent median sternotomy only because of preoperative diagnosis of teratoma in one and thymoma in two patients.

RESULTS

There was no perioperative mortality. Transient vocal changes occurred in 3 (5.4%) patients, recurrent laryngeal nerve palsy in 3 (5.4%), atrial fibrillation in 2 (3.6%), wound complications in 2 (3.6%), left phrenic nerve palsy in 1 (1.8%), transient hypocalcaemia in 1 (1.8%) and persistent hypothyroidism in 1 (1.8%) patient. Hospital-stay ranged from 2 to 12 (5.5±2.0) days. Multinodular goiter was found in 53 (94.6%) patients, diffuse goiter in 1 (1.8%), ectopic thyroid in 1 (1.8%) and oncocytic tumor in 1 (1.8%) patient. One (1.8%) patient underwent simultaneous resection of RSG via a collar incision and right-sided VATS upper lobectomy for primary lung cancer. One (1.8%) patient also underwent simultaneous resection of RSG via collar incision and right-sided VATS subcarinal lymph node biopsy for coexistent lymphoma. Mean vertical length of goiter in the collar incision group was 7.6 cm compared to 10.6 cm in the sternotomy group. Mean weight of specimens was 162.3 g in patients with collar incisions and 312.5 g in the sternotomy group. Sternotomy was required in 14 (25%) patients.

CONCLUSION

Resection of retrosternal goiter is more commonly performed via cervical collar incision with mandatory availability of sternotomy. Radiological measurement of craniocaudal length may predict the need for sternotomy. Surgical outcomes are not affected by surgical approach. Simultaneous thoracic interventions for a coexistent pathology in patients with RSG may be considered. Further research of minimally invasive interventions for RSG resection is required.

Surgical Treatment of Retrosternal Goitre

This study aims to evaluate surgical approaches to the management of retrosternal goitre. Between 2004 and 2014, 35 patients (eight males; mean age 67.4 ± 10.9 years) with retrosternal goitre (mainly right-sided in 9, left-sided in 14 and bilateral in 12) underwent surgery. A palpable neck mass was found in 11 (31.4%), stridor in 10 (28.6%) and thyrotoxicosis in 4 (11.4%) cases. 4 (11.4%) patients were asymptomatic. Tracheal compression was detected radiologically in 27 (77.2%) patients with deviation in 18 (51.4%). A collar incision was performed in 34 patients, 6 (17.1%) of whom required additional sternotomy, 1 (2.9%) was assisted by an anterior mediastinotomy. 1 (2.9%) had a right lateral thoracotomy. There was no operative mortality. Transient vocal changes occurred in 3 (8.6%) patients, recurrent laryngeal nerve palsy in 3, atrial fibrillation in 2, and wound complications in 2 (5.7%). Hospital stay ranged from 2 to 12 days (5.5 ± 2.0). Multinodular goitre was found in 33 patients, diffuse goitre in 1 and ectopic thyroid in 1. The average vertical length of goitres in the collar incision group was 7.6 cm compared to 10.6 cm in the sternotomy group. The average weight of specimens was 156.3 g in patients with collar incisions and 307.5 g in the sternotomy group. Removal of retrosternal goitre is more commonly performed via a cervical collar incision with mandatory availability of sternotomy. Radiological measurement of craniocaudal length may predict the risk of sternotomy. Surgical outcomes are not affected by surgical approach.

Imaging Evaluation of Mediastinal Masses in Children and Adults: Practical Diagnostic Approach Based on A New Classification System

A compartmental approach to the diagnosis of the mediastinal masses in children and adults has been widely used to facilitate the diagnosis and planning of diagnostic interventions and surgical treatment for many years. Recently, a new computed tomography-based mediastinal division scheme, approved by the International Thymic Malignancy Interest Group, has received considerable attention as a potential new standard. In this review article, this new computed tomography-based mediastinal division scheme is described and illustrated. In addition, currently used imaging modalities and techniques, practical imaging algorithm of evaluating mediastinal masses, and characteristic imaging findings of various mediastinal masses that occur in children and adults are discussed. Such up-to-date knowledge has the potential to facilitate better understanding of mediastinal masses in both pediatric and adult populations.

Demographics, disparities, and outcomes in substernal goiters in the United States

BACKGROUND

Disparities distinguishing patients with substernal goiters from nonsubsternal goiters have not been thoroughly described.

METHODS

The National Inpatient Sample database was used to compare patients who underwent substernal thyroidectomy years 2000 to 2010 with those who underwent thyroidectomy for nonsubsternal goiter.

RESULTS

A total of 110,889 patients underwent thyroidectomy for goiter (5,525 substernal and 105,364 nonsubsternal). Substernal thyroidectomy patients were older, more likely to be Black or Hispanic and to have Medicare insurance. They had a higher comorbidity index, were more likely to be admitted emergently and to have postoperative complications such as hemorrhage/hematoma, pneumothorax, pulmonary embolism, and hypocalcemia/hypoparathyroidism. Furthermore, substernal thyroidectomy patients had 73% increased odds of death during admission than nonsubsternal thyroidectomy patients.

CONCLUSIONS

Substernal goiters present a distinct type of goiter with identifiable patient-level characteristics and an increased risk of postoperative complications and death. Earlier identification and treatment of goiters may allow earlier interventions at a stage when risks are reduced.

Surgical approach to mediastinal goiter: An update based on a retrospective cohort study

AIM

Surgery for mediastinal goiters (MG) is indicated for compression symptoms and risk of malignancy. Total thyroidectomy by cervicotomy is universally considered the standard surgical approach to MG. In selected cases sternotomy or a thoracotomy are used. Options of the operative technique and practical surgical problems are analysed.

METHODS

A retrospective analysis of twenty-eight-years on 1767 cases of MG in a referral centre for endocrine surgery was carried out. All patients underwent standard preoperative study and CT based surgical planning. Surgery was performed by an experienced surgical team with standard technique via cervical approach or in selected case via sternotomy or thoracotomy. Clinical records were examined.

RESULTS

Total thyroidectomy was performed in all cases. A cervical approach was used in almost 99% of patients. Significant shorter surgical time was observed for surgery via the cervical approach vs sternotomy and thoracotomy. Benign struma was observed in 1503 patients and a carcinoma in 264. We observed postoperative bleeding in 0.5% of cases, permanent monolateral recurrent laryngeal nerve palsy occurred in 1.3%, bilateral palsy in 0.6%, transient and permanent hypoparathyroidism in 14% and 4.1% respectively.

CONCLUSION

MG may be approached by a cervicotomic access only with a clear knowledge of potential risk and complications of the surgical manoeuvres. Sternotomy or of a thoracotomy are indicated only in selected cases but their inapplicability may be really dangerous in those MG not otherwise resectable. MG should be referred only to specialized centre.

Surgical management of cervico-mediastinal goiters: Our experience and review of the literature

AIM

We analyze and discuss the clinical presentation, the diagnostic procedures and the surgical technique in relation to post-operative complications and results in cervico-mediastinal thyroid masses admitted in Thoracic Surgery Unit of AOU Second University of Naples from 1991 to 2006 and in Thoracic Surgery Unit of AOU "S. Giovanni di Dio & Ruggi D'Aragona" of Salerno over a period of 3 years (2011-2014).

METHODS

We reviewed 97 patients who underwent surgical treatment for cervico-mediastinal goiters. 47 patients (49.2%) had cervico-mediastinal goiter, 40 patients (40%) had mediastino-cervical goiter and 10 patients (10.8%) had mediastinal goiter. 73 cases were prevascular goiters and 24 were retrovascular goiters. We performed total thyroidectomy in 40 patients, subtotal thyroidectomy in 46 patients and in 11 cases the resection of residual goiter. In 75 patients we used only a cervical approach, in 21 patients the cervical incision was combined with median sternotomy and in 1 patient with transverse sternotomy.

RESULTS

Three patients (3.1%) died in the postoperative period (2 cardio-respiratory failure and 1 pulmonary embolism). The histologic study revelead 8 (7.7%) carcinomas. Postoperative complications were: dyspnea in 9 cases (10.7%), transient vocal cord paralysis in 6 patients (9.2%), temporary hypoparathyroidism in 9 patients (9.2%) and kidney failure in 1 case (0.9%).

CONCLUSIONS

The presence of a cervico-mediastinal thyroid mass with or without respiratory distress requires a surgical excision as the only treatment option. Thyroid masses extending to the mediastinum can be excised successfully by cervical incision. Bipolar approach (cervical incision and sternotomy) has an excellent outcome, achieving a safe resection, especially in large thyroid masses extending to the mediastinum with close relations to mediastinal structures and in some limited cases (carcinoma, thyroiditis, retrovascular goiter, ectopic goiter). Postoperative mortality and morbidity is very low, independent of surgical techniques. Other surgical approaches for excision of a Posterior Mediastinal Thyroid Goiter reported in literature are: VATS techniques to remove an ectopic intrathoracic goiter, robot-assisted technique for the removal of a substernal thyroid goiter, with extension into the posterior mediastinum.

Surgical management of mediastinal goiter in the elderly

AIM

Mediastinal goiter (MG) is characterized by compression symptoms such choking, dyspnea, sleeping apnea and dysphagia. It is significantly observed in elderly patients who due to comorbidity are associated to increased surgical risk. Total thyroidectomy is indicated to treat tracheal compression. Cervicotomy is the most used surgical access. AIM of the study was the evaluation of the role of surgery in the treatment of MG in the elderly.

METHODS

A retrospective analysis of twenty-eight-years on 1721 (390 over 80-years-old) cases of MG in a referral center for endocrine surgery was carried out. CT was used as a standard in the preoperative study. Surgery was performed by an experienced surgical team with standard technique via cervical approach or in selected cases via sternotomy or thoracotomy. Clinical records were examined.

RESULTS

Patients were divided into two groups: older and younger than 80-years-old. Total thyroidectomy was performed in all cases and via a cervical approach in almost 99% of patients. Tracheal dislocation and tracheomalacia were prevalent in elderly patients and were treated conservatively. Benign struma was observed in 1463 patients and a carcinoma in 258. Larger thyroid weight was observed in the elderly. The rate of complications was similar between groups.

CONCLUSION

Total thyroidectomy via cervical approach is the treatment of choice for MG in the elderly. It should be treated only in referral centers with adequate caution for elderly patients to achieve complete cure with limited complications.