Substernal goiter: when is a sternotomy required?

Isolated Mediastinal Goitre: A Case Report

Retrosternal goitre is not an uncommon entity owing to various reasons - ignorance, fear, lack of access to safe surgical technique, incomplete thyroid surgery. Retrosternal goitre could have varied presentations, especially in cases with prior thyroid surgery. Fifty-three-year-old female with history of thyroid surgery 20 years back presented with a large neglected anterior neck swelling. Computed tomography imaging revealed the rare entity of an isolated mediastinal goitre type 3 with no communication with the cervical thyroid gland. Careful evaluation of computed tomography and pathology indicated the need for extra - cervical approach. Patient underwent total thyroidectomy and mediastinal goitre excision via cervical and median sternotomy approach. Post operative histopathology revealed benign adenomatous goitre. CT imaging of retrosternal goitre is of primary importance along with appropriate CT grading. Mediastinal seeding of thyroid goitre could occur in cases with prior thyroid surgery. Extra cervical approaches for primary mediastinal goitre are recommended.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04663-2.

Long-term outcomes of radiofrequency ablation for intrathoracic goiter up to 5 years: evaluated by computed tomography/magnetic resonance imaging and ultrasound

OBJECTIVES

This study evaluated the long-term efficacy and safety of radiofrequency ablation (RFA) for intrathoracic goiter (ITG) over a follow-up period exceeding six months.

METHODS

From 2017 to 2022, 22 patients (6 males, 16 females) with 24 ITGs treated with RFA at a single medical center were evaluated. All patients underwent ultrasonography (US), computed tomography (CT), or magnetic resonance imaging (MRI) before RFA. Follow-up CT/MRI was performed six months after the initial RFA and then every 6-12 months. The primary outcomes measured were the degree of extension, goiter volume, volume reduction rate (VRR), tracheal deviation, and tracheal lumen. Additionally, we assessed the outcomes of single-session RFA (n = 16) vs. multiple sessions (n = 8) on goiters and explored the correlation between ITG volume measurements obtained using ultrasonography and CT/MRI.

RESULTS

The median follow-up period was 12 months (interquartile range: 6-36.8 months). At the last follow-up, the nodule volume measured by CT/MRI had significantly decreased (76.2 vs. 24.6 mL; p < 0.05), with a VRR of 64.6%. Patients who underwent multiple RFA sessions showed a significantly higher VRR than the single-session patients (63.8 vs. 80.1%, p < 0.05). The intraclass correlation between goiter volumes measured using US and CT/MRI was moderate.

CONCLUSION

This study affirms the long-term efficacy and safety of RFA for ITG, providing an alternative treatment for nonsurgical candidates. Multiple RFA sessions may be beneficial for achieving better volume reduction. Sole reliance on ultrasonography is inadequate; therefore, integrating CT/MRI is essential for accurate pre-RFA and follow-up assessments.

Surgical management of anterior mediastinal tumors of thyroid origin: a comprehensive analysis of approaches, techniques, and outcomes

BACKGROUND

This manuscript aims to describe the symptoms, demographics, surgical approaches and techniques, the volume of surgical interventions, histological results, intra- and postoperative complications, and postoperative results in patients with anterior mediastinal tumors of thyroid origin (AMTTO).

METHODS

Twenty patients with AMTTO were operated between 2017 and 2021. Fifteen were women and 5 were men. The mean age was 66.8 years.

RESULTS

The most common histology was nodular micro- and macrofollicular goiter (15/20, 75%). Kocher cervicotomy (65%) was the preferred approach. Total thyroidectomy was performed in 95% of patients. Intraoperative complications were identified in 25% (5/20), and in 2 patients a tracheostomy was required. Early postoperative complications were established in 65% and the most common was unilateral transient recurrent nerve paresis or paralysis and dysphonia (25%).

CONCLUSIONS

Commonly resection of AMTTO is a challenge due to its complexities associated with high-risk cases, emphasizing the need for experienced centers in managing such cases.

Personalized Management of Malignant and Non-Malignant Ectopic Mediastinal Thyroid: A Proposed 10-Item Algorithm Approach

We aimed to analyze the management of the ectopic mediastinal thyroid (EMT) with respect to EMT-related cancer and non-malignant findings related to the pathological report, clinical presentation, imaging traits, endocrine profile, connective tissue to the cervical (eutopic) thyroid gland, biopsy or fine needle aspiration (FNA) results, surgical techniques and post-operatory outcome. This was a comprehensive review based on revising any type of freely PubMed-accessible English, full-length original papers including the keywords "ectopic thyroid" and "mediastinum" from inception until March 2024. We included 89 original articles that specified EMTs data. We classified them into four main groups: (I) studies/case series (n = 10; N = 36 EMT patients); (II) malignant EMTs (N = 22 subjects; except for one newborn with immature teratoma in the EMT, only adults were reported; mean age of 62.94 years; ranges: 34 to 90 years; female to male ratio of 0.9). Histological analysis in adults showed the following: papillary (N = 11/21); follicular variant of the papillary type (N = 2/21); Hürthle cell thyroid follicular malignancy (N = 1/21); poorly differentiated (N = 1/21); anaplastic (N = 2/21); medullary (N = 1/21); lymphoma (N = 2/21); and MALT (mucosa-associated lymphoid tissue) (N = 1/21); (III) benign EMTs with no thyroid anomalies (N = 37 subjects; mean age of 56.32 years; ranges: 30 to 80 years; female to male ratio of 1.8); (IV) benign EMTs with thyroid anomalies (N = 23; female to male ratio of 5.6; average age of 52.1 years). This panel involved clinical/subclinical hypothyroidism (iatrogenic, congenital, thyroiditis-induced, and transitory type upon EMT removal); thyrotoxicosis (including autonomous activity in EMTs that suppressed eutopic gland); autoimmune thyroiditis/Graves's disease; nodules/multinodular goiter and cancer in eutopic thyroid or prior thyroidectomy (before EMT detection). We propose a 10-item algorithm that might help navigate through the EMT domain. To conclude, across this focused-sample analysis (to our knowledge, the largest of its kind) of EMTs, the EMT clinical index of suspicion remains low; a higher rate of cancer is reported than prior data (18.8%), incident imagery-based detection was found in 10-14% of the EMTs; surgery offered an overall good outcome. A wide range of imagery, biopsy/FNA and surgical procedures is part of an otherwise complex personalized management.

Surgical Management of Substernal Thyroid Goiters

Substernal thyroid goiters can present with progressive symptoms involving compression of vital structures such as the esophagus, trachea, or large vessels. A multidisciplinary approach is critical when diagnosing and treating these patients. This article discusses patient presentation, workup, and management options for patients with substernal goiter as well as surgical pearls to minimize risk of complications.

Evaluation of thoracic inlet view plain radiograph in the management of patients with goitre

Background

Thoracic inlet view radiograph is an investigation for assessing patients with goitre in many centres in the sub-Saharan-region. However, there is paucity of information on its usefulness in the diagnosis of retrosternal goitre (RSG) and in planning for thyroidectomy.

Method

A review of patients with goitre managed in the Division of Endocrine Surgery, University College Hospital, Ibadan, Nigeria, between 2002 and 2014 was done. Data were obtained from Operating Theatre Log and electronic data archive of the Division. Clinical RSG (CRSG) was taken as a gland that the examining fingers could not get below its lower margin and Radiological RSG (RRSG) on thoracic inlet view was any extension of the thyroid gland beyond the thoracic inlet. Intra-operatively, if any part of the gland extends beyond the thoracic inlet it was considered as an RSG.

Results

221 (96.5%) of the 229 patients who had thoracic inlet plain radiograph were included in this study. The Male to Female ratio was 1:5.5. WHO grade III goitre was seen in 56.1% of the patients and 43.9% had grade II goitre. The CRSG, RRSG and Intra-operative RSG were seen in 7.7%, 16.7% and 17.6% respectively. The specificity and sensitivity of clinical examination in determining RSG was 88.7% and 94.1% and that of Thoracic inlet radiograph was 97.8% and 94.6% respectively.

Conclusion

It is a useful study for screening patients with goitre for retrosternal extension, however it could not be used to determine the need for extra-cervical surgical access during thyroidectomy.

Utility of Novel Clavicle-lifting Technique in Mediastinal Thyroid Surgery: A Case Series Study

BACKGROUND/AIM

Symptomatic mediastinal goitre requires surgery and is usually resectable using the cervical approach alone; however, sternotomy is occasionally required. Sternotomy is a highly invasive procedure, and its complications, including mediastinitis and osteomyelitis, can be critical. To date, there have been no reports of non-invasive techniques to avoid sternotomy for mediastinal thyroid tumours. We investigated the safety and efficacy of thyroidectomy using the clavicle lifting technique with a paediatric Kent hook.

PATIENTS AND METHODS

This was a retrospective study of 8 patients who underwent thyroidectomy with a clavicle lifting technique between November 2014 and July 2021 at the Department of Surgery, International University of Health and Welfare Hospital. The primary endpoint was sternotomy avoidance rate and R0 resection rate. An extension retractor used in paediatric surgery was used for the clavicle lifting technique.

RESULTS

Sternotomy avoidance rate and R0 resection rate were 100%. The mean operative time was 161±53.5 min, and the mean blood loss was 125.6±125.8 ml. There were no intraoperative or postoperative complications related to the clavicle lifting technique.

CONCLUSION

Thyroidectomy with a clavicle lifting technique for mediastinal goitre and thyroid cancer is safe and useful because it avoids sternotomy without causing massive intraoperative bleeding or damage to other organs.

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.

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.

Split Sternotomy in Retrosternal Thyroid and Mediastinal Parathyroid Pathologies

Objectives

Although cervical incisions are usually sufficient in mediastinal located thyroid and parathyroid pathologies, sometimes mediastinal approaches are required. In recent years, less invasive methods have been used instead of median sternotomy. In this study, the adequacy of the incision and morbidity in patients who underwent split sternotomy due to retrosternal goiter (RG) and mediastinal parathyroid pathology in our clinic were investigated.

Methods

The files of patients who underwent split sternotomy in addition to cervical incision or split sternotomy extending from the sternal notch to the third intercostal space with a separate vertical incision due to retrosternal thyroid pathology or mediastinal ectopic parathyroid adenoma between January 2010 and January 2021 were retrospectively reviewed. Operative success, exposure provided by split sternotomy, and complication rates were investigated.

Results

Twelve patients who underwent split sternotomy were included in the study. The mean age of the patients was 57.25±12.62 (44-83) years. Eight (66.7%) of the patients were female and 4 (33.3%) were male. The indication for surgery was multinodular goiter (MNG) in 3 (25%) patients, recurrent MNG in 3 (25%) patients, hyperparathyroidism in 3 (25%) patients, and thyroid cancer in 3 (25%) patients. Transient hypocalcemia in 6 (50%) patients and unilateral vocal cord paralysis in 1 (8.3%) patient developed postoperatively, and all complications resolved spontaneously in an average of 3 weeks. Median sternotomy was not required for any of the patients.

Conclusion

Split sternotomy is an adequate and applicable method for the success of the surgery in RG and mediastinal parathyroid pathologies that cannot be excised with the cervical approach.

Imaging of the Thyroid: Practical Approach

Imaging evaluation of the thyroid gland spans a plethora of modalities, including ultrasound imaging, cross-sectional studies, and nuclear medicine techniques. The overlapping of clinical and imaging findings of benign and malignant thyroid disease can make interpretation a complex undertaking. We aim to review and simplify the vast current literature and provide a practical approach to the imaging of thyroid disease for application in daily practice. Our approach highlights the keys to differentiating and diagnosing common benign and malignant disease affecting the thyroid gland.

Surgical Considerations in Thyroid Cancer: What the Radiologist Needs to Know

Management of thyroid cancer requires a multidisciplinary approach including head and neck/endocrine surgeons, endocrinologists, oncologists, and radiologists. The radiographic evaluation of thyroid cancer is critical for complete and precise staging and affects the surgical approach to address these cancers. The purpose of this article is to briefly review the common thyroid cancer pathologies and surgical considerations in thyroid cancer, focusing on the extent of surgery and the influence of preoperative imaging on surgical decision-making. This article assumes that a diagnosis of thyroid cancer has been made and does not discuss the workup or surveillance of thyroid nodules.

A rare case of ectopic retrosternal goiter

It is important for the clinician to be familiar with interpreting a variety of radiological modalities that provide vital information that will aid in the preoperative planning, counseling, and subsequent management of patients with retrosternal goiter.

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.

Sutureless Total Thyroidectomy for Substernal Goiter: Amending Versus Unnecessary

Substernal goiter is an enlarged thyroid gland, harboring a component extending into the mediastinum. Surgical management requires genuine and rigorous preoperative planning as physicians could encounter the prospect of the gland coming into close quarters with the vital intrathoracic structures. The neck and chest multiplanar cross-sectional imaging provide essentialness of an extracervical approach for the procedure. In the present study, a 57-year-old female who admitted with the intermittent dyspnea and dysphagia with a huge goiter is reported. The labs were reported within the normal limits and the video laryngoscopy displayed no pathologic finding. Her neck sonography revealed the multiple nodules within the gland, without determining the most proximal border of the left lobe. The neck and chest computed tomography depicted a substernal goiter harboring the left lobe, extending till the left innominate vein and a sutureless total thyroidectomy by the collar incision without a median sternotomy was performed. We would recommend sutureless thyroidectomy for substernal goiter just considering to divide meticulously the superior thyroid arteries and veins separately and exploring the fibrous Ligament of Berry, that is, the true Ligament of Berry, with its safe relationship to the recurrent laryngeal nerve in Thyroidology.

Clinical Presentation and Surgical Treatment of Retrosternal Goiter: A Case Series Study

Background: The retrosternal goiter (RSG) is a slow-growing mass often benign in nature; thyroidectomy remains the preferred standard curative treatment. This study aimed to explore the local experience of RSG with respect to the clinical presentation, classifications, management, and outcomes. Method: A retrospective chart review was conducted to include all cases diagnosed with RSG and underwent thyroidectomy between January 1998 and December 2013. Results: A total of 1210 patients underwent thyroidectomy; of which 30 (2.5%) patients were diagnosed to have RSG. The commonly reported symptoms were dyspnea (40%), pain and discomfort (30%), dysphagia (26.7%), and hoarseness (20%). Thirteen patients (43.3%) were completely asymptomatic. The fine-needle aspiration cytology was performed in 22 (73.3%) patients, of whom the majority was benign (77.3%). The grading classification showed that grade 1 is the most frequent (73.3%). Total bilateral thyroidectomy was the most prevailing procedure in 57% cases followed by partial thyroidectomy. All patients underwent retrosternal thyroidectomy through a cervical incision except for one case. Postoperative histopathology showed frequent benign multinodular goiter (83.3%), followed by papillary thyroid cancer (10%) and thyroiditis (6.7%). The most common complication after thyroidectomy was tracheomalacia (13.4%), transient hypocalcemia (10%), and hypoparathyroidism (6.7%). There was no intraoperative or perioperative mortality. Conclusion: RSG is a rare entity often presented with pressure symptoms, mostly involving anterior mediastinum and had a challenging surgical procedure. A large multicenter study is needed to include more cases in order to have a consensus on the definition and classification system for such important clinical goiter presentation.

Thyroiditis process as a predictive factor of sternotomy in the treatment of cervico-mediastinal goiter

Background

About 10% of cervico-mediastinal goiter need to associate cervicotomy with a total or partial sternotomy to allow a safe removal of the goiter.

Aim of this study is to identify preoperative predictors of sternotomy for mediastinal goiter.

Methods

Between January 2008 and December 2015, 586 patients were submitted to total thyroidectomy at Surgical Clinic of Brescia, Italy.

Among these, patients with cervico-mediastinal goiter have been divided in two groups based on the necessity of an associated sternotomy in the operating field: Group 1 (n = 40 patients) did not need sternotomy and Group 2 (n = 4 patients) underwent cervicotomy associated with sternotomy.

Clinical and pathological characteristics of patients were retrospectivelly recorded.

Results

Among study group, 44 patients had cervico-mediastinal goiter. Thoracic CT was performed in all patients: an extension above aortic arch was found in 41 patients (93.18%) while an extention below aortic arch was found in 3 patients (6.82%).

The extension of the goiter below the aortic arch resulted as a predictive value in the choice of surgical treatment (p = 0.0001).

The thyroiditis process was found to be a significant predictive of the extention to a sternotomic approach (p = 0.029).

The years of goiter’s presence were on average 8.40 years in Group 1 and 14.75 years in Group 2.

These parameters proved to be predictive when choosing a cervicotomy with sternotomy.

Conclusions: Our study, despite limitations posed by small sample and its retrospective analisys, highlights the role of goiter’s extention (below the aortic arch), disease length (for more than 14.75 years) and flogistic process (positivity of Tg Ab and anti-TPO-Ab) in the choice of combined (cervicotomic and sternotomic) approach to goiter’s removal.

Predictors of the need for an extracervical approach to intrathoracic goitre

Background

Sternotomy and lateral thoracotomy are required infrequently to remove an intrathoracic goitre (ITG). As few studies have explored the need for an extracervical approach (ECA), the aim of this study was to examine this in a large cohort of patients.

Methods

A prospective database of all patients who had surgery for ITG between 2004 and 2016 was interrogated. Patient demographics, preoperative characteristics and type of operation were analysed to identify factors associated with an ECA.

Results

Of 237 patients who had surgery for ITG, 29 (12·2 per cent) required an ECA. ITGs below the aortic arch (odds ratio (OR) 10·84; P = 0·004), those with an iceberg shape (OR 59·30; P < 0·001) and revisional surgery (OR 4·83; P = 0·022) were significant preoperative predictors of an ECA.

Conclusion

The extent of intrathoracic extension in relation to the aortic arch, iceberg goitre shape and revisional surgery were independent risk factors for ECA. Careful preoperative assessment should take these factors into consideration when determining the optimal surgical approach to ITG.

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.

A case report of a concomitant total thyroidectomy and carotid body tumor resection in a 43 year old female

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Carotid body tumors (CBT) are rare neoplasms with malignant potential.

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The concomitant presentation of a CBT with goiter has been only reported in one case in 1950.

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The extended Kocher incision for resection of both tumors was performed succesfully.

Introduction

Carotid body tumors (CBT) are rare neoplasms with relatively; due to their malignant potential, the indicated treatment is surgical resection. There have been described some associations of carotid body tumors with other neoplasms, however, the concomitant presentation of CBT with multinodular goiter is rarely encountered.

Presentation of case

We herein present the case of a 43-year old woman with the aforementioned association. As a part of the diagnostic evaluation, an ultrasound was performed, revealing both conditions simultaneously. The surgery took place with the aim of resecting both lesions during the same intervention. The patient was discharged without complications.

Discussion

The concomitant presentation of goiter and carotid body tumor is rarely reported but an extended Kocher incision could be enough to an adequate exposure and same surgical procedure resection.

Conclusion

This case reinforce the concomitant assessment in two different pathologies. Although there is one case reported before, this case lead to improvement in the treatment of these patients.

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.

Surgical approach to the intrathoracic goiter

Objective

In a retrospective study, the authors analyzed the surgical approach to the intrathoracic goiter to avoid sternotomy or thoracotomy.

Methods

We selected 70 intrathoracic cases of multinodular goiter out of 988 cases of thyroidectomy and compared them with cervical goiter cases. Surgical technique, results, and postsurgical complications were assessed.

Results

The analyzed cases presented the retrosternal goiter (n = 53; 75.7%), the retrotracheal goiter (n = 9; 12.8%), and the retroesophageal goiter (n = 8; 11.4%). Complaining of chest pressure or discomfort was specific for intrathoracic cases (50%; 35 of 70). All goiters except one were removed via cervical incision. The surgeons used head reclination and isthmus dissection when removing sizable goiters. Mean weight of goiters was 180 g. The recurrent laryngeal nerve was more often temporarily damaged in intrathoracic cases in comparison with cervical cases (4.3% vs. 2.8%, P = .04), but the difference in permanent injury was less significant (P = .09). The incidence of temporary hypoparathyroidism was significantly higher in intrathoracic cases (P = .01).

Conclusion

In cases of multinodular goiter the goiters of various extensions can be successfully removed via the cervical incision in most of the cases even if they occupy the retrosternal, retrotracheal, or retroesophageal position. The transthoracic approaches and sternotomy might be justified in malignant cases.

Level of Evidence

4.

Substernal Goiter: Correlation between Grade and Surgical Approach

Substernal goiter is defined as a thyroid growth beyond the thoracic inlet. Using the cross-section imaging CT system, it can be classified into three grades. The aim of the study was to validate the surgical approach and the occurrence of postoperative complications with substernal goiter extension in our patient population. From a total of 1145 patients who underwent thyroid surgery at our institution in a 15-year period, 60 patients with substernal goiter were included. Clinical features and demographics, degree of extension, surgical details, and complications were analyzed. Mean ± SD age of the patients was 58 ± 14.7 years and 88 per cent were females. According to the cross-section imaging CT system 61.7 per cent were grade I,23.3 per cent grade II, and 15 per cent grade III. Total thyroidectomy was performed in 78.3 per cent of the patients, subtotal thyroidectomy in 18.3 per cent, and lobectomy in 3.3 per cent. The cervical approach was sufficient to perform 96.7 per cent of the thyroidectomies, requiring partial sternotomy in only two patients with grade III substernal goiter. Patients with grade III substernal goiter had a higher risk for postoperative dysphonia (OR = 14.29, IC95% 1.14-178.9, P = 0.03), which occurred in three patients (two transient and one permanent). Transitory hypoparathyroidism was present in 20 patients (33.3%) and did not correlate with goiter extension. Most substernal goiters can be resected through a cervical approach, with relatively low morbidity. Postoperative dysphonia was directly related to the extension of the goiter. Few cases with grade III goiters require a partial sternotomy.

An investigation into symptoms, diagnosis, treatment, and treatment complications in patients with retrosternal goiter

Introduction:

Retrosternal goiter refers to any thyroid enlargement in which over 50% of the thyroid permanently located under the thoracic inlet or the lower pole of thyroid is not palpable with the neck in hyperextended position. Due to the increasing number of surgical procedures of retrosternal goiter, the present study was carried out to examine the symptoms, diagnosis, treatment, and treatment complications in retrosternal goiter patients.

Materials and Methods:

Data related to demographic data (age and gender), clinical symptoms (dyspnea, dysphagia, dysphonia, lumps in neck, and hoarseness), methods of diagnosis (computed tomography [CT], chest X-ray [CXR], ultrasonography, and magnetic resonance imaging), and postoperative complications (bleeding, early and late dysphonia, early and late dyspnea, transient and permanent hypocalcemia, transient, and permanent recurrent laryngeal nerve paralysis) were collected.

Results:

According to the results 71.4% of patients were women and most of the participants (67.1%) aged 45–60 years. Mass in the neck was the most frequent symptoms before surgery (88.6%). The most common incision for thyroidectomy (95/7%) was neck Collar incision. Diagnosis method in 82.9% and 17.1% of cases was, respectively, based on CT scans with CXR and CT scans with CXR and ultrasound. According to the postoperative pathologic findings, 58.5% of the cases were multinodular goiter, 22.9% were papillary cell carcinoma, 7.1% were medullary carcinoma, 5.7% were anaplastic carcinoma, 5.7% were thyroid lymphoma, and only 1.4% were thyroid adenoma. Postoperative complications occurred in 47.14% of patients. Most common complication was early transient dysphonia.

Conclusion:

This study recommends that retrosternal goiter should be operated early under suitable conditions, and the best diagnosis tool and best surgery methods are CT scan and surgery with collar incision, respectively.

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.

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.

Patient-tailored management of an asymptomatic massive substernal goiter presenting as brachiocephalic vein occlusion. Report of a case and review of sternotomy indications

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Substernal goiter definition is controversial, while they are generally defined as goiters which at least 50% of the thyroid mass extends bellow the thoracic inlet.

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Our patient had a massive substernal multinodular goiter, the left lobe of which caused compression of the braciocephalic vein with symptoms from his left upper extremity.

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The massive size of the gland along with the strict adhesion of the isthmus and left thyroid lobe to the brachiocephalic vein led to the decision of performing a median sternotomy.

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Despite the extensive procedure, patient recovery was uneventful.

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The lack of a uniform definition on substernal goiter and the diversity of thoracotomy indications, lead to a patient-tailored surgical approach. Still the execution of thoracotomy is considered safe in the hands of an experienced surgeon.

Introduction

Substernal goiters are characterized by the protrusion of at least 50% of the thyroid mass below the level of the thoracic inlet. Still their definition is controversial.

Case presentation

The case refers to a 44 year old male who presented to our department due to swelling and a feeling of ‘heaviness’ of his left upper extremity for the past 6 months. CT scan revealed a massive substernal goiter extending to the great vessels. Intraoperatively, a median sternotomy was performed due to the size of the gland and the close adhesion of the isthmus and lower left thyroid lobe to the brachiocephalic vein. Resection of the gland revealed the vein to have a cord-like shape, leading to reduced venous return and upper extremity symptoms. Recovery was uneventful for the patient who was discharged on the 7th postoperative day.

Discussion

While most substernal goiters can be surgically managed through a cervical incision, there are cases in which a median sternotomy is indicated. Those cases include excessive gland size, thoracic pain, ectopic thyroid tissue and the extent of the goiter to the aortic arch. Median sternotomy is associated with a number of intra and postoperative complications, although when performed by an experienced surgeon, mortality and morbidity rates along with long-term recovery are not affected.

Conclussion

The lack of a uniform definition and variety of indications, lead to a patient-tailored approach regarding the execution of sternotomy during surgical management of massive substernal goiters.

Anatomical approach to surgery for intrathoracic goiter

The anatomical approach to the intrathoracic goiter (ITG) was used to understand its etiology and to rationalize surgical technique of thyroidectomy. For a retrospective chart review, we selected cases of multinodular goiter with totally ITGs (n = 69; M 29, F 40), while 916 cases with cervical goiter were used for comparison. The topography of the thyroid gland was assessed against the tracheal rings and against the vertebrae. The regional anatomy of the thoracic inlet was assessed by its bony margins and the relations of structures traversing the area. Average tracheal-diameter-to-thoracic-inlet ratio was calculated. The ITG group consisted of 52 cases of retrosternal goiter (75.4 %), nine cases of retrotracheal goiter (13 %), and eight cases of retroesophageal goiter (11.6 %). In all but one analyzed cases, the goiters were removed via cervical incision. Mean weight of goiters was 183 g. The area of thoracic inlet in the cases of ITG had no difference in comparison with the cases of cervical goiter (F/M p = 0.11/0.15), but the tracheal-diameter-to-thoracic-inlet ratio was significantly smaller (F/M p = 0.06/0.04). In the ITG cases, the position of the upper edge of the isthmus of the thyroid was about 1.5 tracheal rings lower than in healthy individuals (p = 0.03). The area of the thoracic inlet, the neck size, and the anteroposterior diameter of the inlet do not affect the development of the ITG. The smaller tracheal-diameter-to-thoracic-inlet ratio and the lower position of the thyroid gland are the main indicators for the development of the ITG.

Retrosternal Goiter

Objective

Retrosternal goiters pose a significant challenge in determining the indications and appropriate approach for surgical removal while limiting postoperative morbidity and mortality. The objective of this study is to use the National Surgical Quality Improvement Program (NSQIP) database to compare outcomes of transcervical and transthoracic approaches for retrosternal goiter removal and to review the literature regarding the varying indications for the 2 surgical approaches.

Study Design

Administrative database analysis.

Setting

NSQIP database.

Subjects and Methods

The NSQIP database was queried for all cases of retrosternal thyroid: 2716 patients were included, which represents one of the largest data reviews of patients with retrosternal thyroid pathology who underwent surgery. Data were analyzed to examine morbidity and mortality of the cervical and transthoracic approaches.

Results

Patient demographics and preoperative comorbidities were similar between groups. Patients undergoing a transthoracic approach experienced increased rates of unplanned intubations and need for transfusion and length of stay postoperatively.

Conclusions

A transthoracic approach is associated with increased rates of several critical postoperative morbidities, and the data indicate the potential of increased overall mortality. Given equivalent retrosternal extension, a transcervical approach should be attempted whenever anatomically possible, regardless of pathology.

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.