Differences in surgical outcomes between cervical goiter and retrosternal goiter: an international, multicentric evaluation

Prevalence and Clinical Risk Factors of Thyroid Cancer in Retrosternal Goiter: A Retrospective Comparative Study with Cervical Multinodular Goiter

Background: Surgical intervention in asymptomatic retrosternal goiter (RSG) is debated in the absence of suspicious cytology, while performing fine-needle aspiration (FNA) is challenging in thyroids with mediastinal extension. The rate of unexpected thyroid cancers found at the time of thyroidectomy varies widely, while the notion of increased cancer incidence in RSG with respect to cervical goiters is still controversial. Methods: We retrospectively reviewed 411 patients with a preoperative diagnosis of multinodular goiter (MNG) (114 retrosternal, 297 cervical) who underwent thyroidectomy at an academic endocrine surgery referral center between January 2019 and October 2022. Rates of cancer detected on the final pathology examination, overall and not anticipated by preoperative workup, were compared between cervical MNG (cMNG) and RSG. Results: Patients with RSG were older (58.2% vs. 50.6%; p < 0.001) and more likely to be men (34.2% vs. 23%; p = 0.014). Overall, thyroid cancer was found in 49.5% of cMNG specimens and in 35.1% of RSGs (p = 0.02), and cancer > 1 cm was found in 37.4% of cMNG and 17.4% of RSG (p = 0.003). Prevalence of unexpected thyroid cancer was not significantly different between cMNGs (29.8%) and RSGs (28.8%). Unexpected carcinomas > 1 cm impacted 11% of all RSGs. Conclusions: In this study, the prevalence of unexpected thyroid cancer in RSG was similar to cMNG and significant from a clinical standpoint, with 1 in every 10 RSG diagnosed with differentiated cancer > 1 cm. Findings may be partially attributed to the difficulty in performing FNA in the mediastinum. Surgeons should counsel patients preoperatively regarding the risk of unexpected thyroid cancer to set appropriate expectations of outcome.

Outcomes of Total Thyroidectomy in Large Goiters With Retrosternal Extension and Tracheal Compression: A Multivariate Analysis

INTRODUCTION

Large retrosternal goiters often cause tracheal compression and deviation, leading to respiratory symptoms and complicating surgical treatment. Total thyroidectomy is the treatment of choice though it carries a risk of complications due to the altered anatomy and its proximity to vital structures. This study examines the outcomes of total thyroidectomy in patients with retrosternal goiters and assesses the impact of tracheal compression on clinical results.

METHODS

This retrospective study included 32 patients treated with total thyroidectomy for retrosternal goiter between January 2018 and June 2024. Patient records were analyzed for clinical presentation, tracheal status, extent of retrosternal extension, intubation details, surgery performed, intraoperative findings, and postoperative complications. Tracheal compression and deviation were noted by preoperative imaging and flexible fiberoptic bronchoscopy. A correlation between difficult intubation and tracheal status was attempted. Complications such as hypocalcemia, recurrent laryngeal nerve palsy, and tracheomalacia were assessed alongside surgical variables.

RESULTS

Among the 32 patients, tracheal deviation was noted in 62.5% (n=20), and tracheal compression occurred in 43.8% (n=14). Complications included hypocalcemia in 43.8% (n=14) of cases, recurrent laryngeal nerve palsy in 6.25% (n=2), and tracheomalacia in 15.6% (n=5). Advanced airway management techniques such as flexible fiberoptic-assisted intubation were often required, particularly in cases with significant tracheal compression. Malignant goiters showed a higher incidence of tracheal deviation and postoperative complications but overall complication rates were comparable to benign cases.

CONCLUSION

Large retrosternal goiters carry the risk of airway compromise and surgical complications, particularly in the presence of tracheal compression. Hence, preoperative assessment of tracheal involvement and tailored surgical approaches are essential to manage airway complications and improve postoperative outcomes. A multidisciplinary approach is recommended for the management of these cases to enhance patient outcomes.