[Assessment and surgical treatment for 58 substernal goiter].

Objective: To investigate the diagnosis and treatment of substernal goiter. Methods: A total of 58 cases with substernal goiters undergoing surgery between January 2005 and December 2015 were analysed retrospectively. There were 10 males and 48 females and their age ranged from 38 to 82 years with a median age of 58 years. According to enhanced CT and clinical signs of substernal goiters, there were 40 cases for typeⅠ, 17 cases for type Ⅱ, and 1 case for type Ⅲ. Results: Patients with typeⅠand Ⅱ substernal goiters (8 cases of papillary carcinoma) underwent low neck and collar-type incision, and patients with type Ⅲ substernal goiters received carotid chest surgery. The use of harmonic scalpel in sternal goiter surgery provided with clearer surgical field, less bleeding. All the operations were successful, and recurrent laryngeal nerve was visually identified in all patients. Postoperative complications included trachyphonia (2 cases), without difficult breathing and tracheal stenosis. Conclusions: Enhanced CT is the best means of preoperatively assessment of substernal goiter. It is feasible to treat patients with typeⅠand Ⅱ substernal goiters by lower neck and collar-type incision. Use of harmonic scalpel in substernal goiter surgery can reduce operation time and bleeding.

Proposal for a new mediastinal compartment classification of transverse plane images according to the Japanese Association for Research on the Thymus (JART) General Rules for the Study of Mediastinal Tumors.

There is no existing worldwide published method for mediastinum compartment classification based on transverse section images for the differential diagnosis of mediastinal tumors. Herein, we describe a new method for anatomic mediastinal compartment classification using transverse section computed tomography (CT) images and the use of this method to classify mediastinal lesions, and thus evaluate whether the method is sufficiently user-friendly and useful. In a publication of the Japanese Association for Research on the Thymus (JART), we proposed the following four mediastinal compartments based on transverse CT images: superior portion of mediastinum, anterior mediastinum (prevascular zone), middle mediastinum (peri-tracheoesophageal zone), and posterior mediastinum (paravertebral zone). In the present study, we retrospectively analyzed 445 pathologically proven mediastinal mass lesions, and categorized them into the proposed four compartments by consensus reading. Mass lesions were classified into compartments based on the location of the lesion centroid, and each lesion was satisfactorily categorized into a compartment. Almost all thymic epithelial tumors (99%, 244/246), all 24 thymic malignant lymphomas and a majority of germ cell neoplasms (93%, 54/58) were classified as being in the anterior mediastinum compartment. The majority of intrathoracic goiters (82%, 14/17) were categorized as being in the superior portion of the mediastinum compartment. Approximately two-thirds of mass lesions in the middle mediastinum were cysts, including foregut and pericardial cysts. Approximately 80% of 37 mass lesions in the posterior mediastinum were neurogenic tumors. Correspondingly, 29 of the 49 neurogenic tumors (60%) were categorized as being in the posterior mediastinum, while 10 (20%) were in the superior portion of the mediastinum, 4 (8%) in the anterior mediastinum, and 6 (12%) in the middle mediastinum. Our findings showed that the newly proposed mediastinal compartment classification using transverse images appears to be user-friendly enough for practical clinical application and may be helpful in differential diagnoses.

CT cross-sectional imaging classification system for substernal goiter based on risk factors for an extracervical surgical approach.

BACKGROUND: The purpose of this study was to identify risk factors for surgical extracervical approach in patients with substernal goiter. We used a novel classification system based on CT scan cross-sectional imaging (CSI) reconstruction. METHODS: Medical records of 4297 patients with thyroid disease operated on at our department were reviewed. A CSI classification system defined substernal goiter in the cranio-caudal dimension as: grade 1 (above aortic arch), grade 2 (level of aortic arch), and grade 3 (below aortic arch); in the anteroposterior dimension as type A (prevascular), type B (retrovascular-paratracheal), and type C (retrotracheal); in the latero-lateral dimension as: monolateral or bilateral. RESULTS: The prevalence of substernal goiter was 222 of 4297 cases (5.1%). Fifteen of 222 cases (6.7%) required an extracervical approach due to grade ≥2 and/or type C substernal goiter (14 of 15 cases). Ten of 15 patients had malignancy. CONCLUSION: The CT-CSI classification system allows us to identify risk factors for extracervical surgical approach in substernal goiter. They are grade ≥2, type C substernal goiter, and malignancy.

Cervicothoracic goitre: an anatomical or radiological definition? Report of 223 surgical cases.

OBJECTIVES: To analyse and compare chest radiographs and cervicothoracic computed tomography scans taken prior to thyroid surgery, in order to locate and predict thoracic extension of substernal goitres. METHOD: This eight-year, retrospective study included 223 patients who had undergone total thyroidectomy for benign, substernal, multinodular goitres. Chest radiographs and computed tomography scans were reviewed by two physicians (a senior ENT surgeon and a senior radiologist). RESULTS: The most frequent mode of extension was anterior or prevascular, seen in 76 per cent of cases, especially on the left side. Fifty-nine per cent of goitres did not reach the aortic arch and 11 per cent extended beyond the aortic arch. A cervical surgical approach was performed in approximately 99 per cent of cases. DISCUSSION: Thorough examination of computed tomography scans is essential in order to identify and classify substernal goitres and to decide the best surgical procedure. A cervical surgical procedure is almost always sufficient and safe for the surgical management of substernal goitres. CONCLUSION: Computed tomography appears to be the best imaging modality for identifying and characterising substernal goitres. Surgical management is almost always via a cervical approach and does not differ from that used for benign cervical goitres. In the future, magnetic resonance imaging may be used; its results would need to be compared with those of computed tomography.

[Intrathoracic goiter]. / Intratoraksne strume.

AIM: A goiter, situated partly or on completely in the thoracic cavity is usually referred to as intrathoracic goiter (ITG). However, inadequate definition of intrathoracic malpositions of thyroid gland caused usage of different classifications. This produced different and, often unclear criteria for the grouping of intrathoracic thyroid malpositions and, consequently, very different results and difficulties in any attempt of parallel review or analysis. The aim of this research was to analyze the ITG that include goiters with more than 80% of tissue in the thoracic cavity and intrathoracic thyroid choristomas, and to point out the diagnostic problems and surgical dilemmas. METHODS: Source of the used data were the studies published in the last 50 years in English, French, Italian, German and Russian language. Data have been integrated and combined for the detailed analysis, while quantitative synthesis was achieved by statistical analysis. RESULTS: ITG was represented in 1% of operatively treated thyroid diseases. One third of patients were asymptomatic. Commonly observed symptoms were dyspnea, stridor and dysphagia, and there was no significant difference in appearance of these symptoms between the two groups of ITG. Chest roentgenography and CT scan could provide the maximal information with no need for expensive procedures. Accuracy of scintigraphy in revealing and discerning of ITG is 70%, averagely. In 20% of patients correct preoperative diagnosis was not established. Therapy of choice in the treatment of ITG was surgical, even in asymptomatic cases. Thoracic approach was used in 95% of cases and there was no significant difference between the two groups of ITG. Total thyroidectomy or total lobectomy was definitely obligatory with contralateral subtotal lobectomy. There was no significant difference in the frequency of operative complications between ITG and non-ITG, and between the two groups of ITG. CONCLUSIONS: ITG is rare, but might present a difficult diagnostic and complex surgical problem. Common clinical presentation and identical surgical approach in operative treatment justify the common review of the two groups of ITG. With timely and adequately performed surgical approach, in specialized institutions, frequency of complications in operative treatment of ITG was not higher if compared to operative treatment of non-ITG.

[Dystopic goiter--aspects of definition and surgical therapy]. / Dystope Struma--Aspekte der Definition und chirurgischen Therapie.

The incidence in the literature of dystopic goiter depends on classification of the false endothoracic goiter ("substernal goiter") as dystopic and varies from 2 to 20%. From November 1989 through April 1993 we operated on 530 patients with benign nodular goiters. In 84 patients (15.8%) the operation proved a dystopic goiter. We showed that difficulties in comparing our data with published series were due to misnomers of the dystopic goiter. The dystopic goiter comprises the true endothoracic goiters (alliata vera and isolata vera) as well as the false endothoracic goiters (substernal goiter). The precise classification of the dystopic goiter is crucial to an optimal operative strategy reducing postoperative morbidity.

Bocio cervicotorácico: experiencias y consideraciones sobre 57 casos / Cervicothoracic goiter: considerations and experiences of 57 cases

Se considera la experiencia sobre 57 casos de bocio cervicotorácico. Analizamos las clasificaciones de esta patología y se adopta la que consideramos más apropiada; se realiza el estudio clínico y métodos complementarios, destacándose la importancia de la T.A.C., como elemento de diagnóstico y orientador de la táctica quirúrgica a seguir. Damos las pautas de la técnica quirúrgica empleada; se analizan las complicaciones encontradas y advertimos de los riesgos de esta cirugía. Hacemos notar que con una cervicotomía amplia, prolija disección, individualizados los elementos nobles que se nos presentan, llegamos por esta vía a un final satisfactorio, en la casi totalidad de los casos. Destacamos las escasas complicaciones surgidas como consecuencia de un acto realizado con minuciosidad

[Substernal goiters]. / Les goîtres plongeants.

In a series of 363 patients operated for goiter, 60 were retrosternal (16.5%). The female incidence although less than in cervical goiters remains predominant (2,5:1). Most patients are in older age group, 68% being above 40 years. The majority of goiters are multinodular and of long duration. Bilateral (37%) and left sided location (43%) were common. The incidence of cancer was 7%, thyrotoxicosis was noted in 5 patients (8%). Most patients were symptomatic (97%). Diagnosis is easily done by physical examination, chest X-Ray and thyroid scintigraphy. Computed tomography might be helpful. Retrosternal goiter is an indication to surgery except in high risk patients. The cervical approach has been used in 98% of cases. There were no post-operative death and no major complications (compressive hematoma, laryngeal nerve paralysis, hypocalcemia).