Extended cervical approach for retrosternal multinodular goiter.

Objective: Partial or total sternotomy is required for 10% of retrosternal goiter. This study reviewed our experience with an extended cervicotomic approach as an alternative surgical solution for retrosternal goiter. Methods: A retrospective study was performed on patients who underwent partial or total thyroidectomy for retrosternal goiter between 2014 and 2019 at a tertiary medical centre. Data on clinical, radiologic, and pathologic factors were analysed. Peri- and postoperative outcomes were compared between extended and standard cervical approaches to predict the need for an extended cervical approach. Results: The cohort included 265 patients, of whom 245 (92.4%) were treated by standard thyroidectomy. In 17 (6.4%), the standard approach proved insufficient, and the horizontal incision was extended to a T-shape to improve access. The remaining 3 patients required a sternotomy. Use of the extended cervical approach was significantly associated with clinical features such as male gender, diabetes, high body mass index and postoperative hypocalcaemia. Conclusions: The extended cervicotomic approach is an alternative surgical solution for retrosternal goiter, with no increased risk of significant post-operative complications.

Toxic intrathoracic goiter and mediastinal lymphadenopathy: an unusual presentation of systemic primary AL amyloidosis.

Mediastinal lymphadenopathy and goiter have been associated with primary amyloidosis, although not in the same patient. One previous case report described the association of an amyloid goiter and hyperthyroidism (due to Graves' disease) with primary amyloidosis. Till now no case reports of patients presenting simultaneously with mediastinal lymphadenopathy, intrathoracic amyloid goiter and hyperthyroidism as the first manifestation of systemic primary (idiopathic) amyloidosis have been described. The present case report describes the clinical, biological radiological and histological features in such a male patient.

[A case of complete mediastinal goiter located in the retrotracheal region: review on reported cases from 1986 to 1997 in Japan].

A 66-year-old man was admitted to our hospital as a result of an abnormal shadow which was observed on his chest X-ray. A chest CT scan and chest MRI revealed an upper mediastinal tumor. The tumor was located in the retrotracheal region and resected completely following a thoracotomy. Histological examination of the tumor revealed follicular adenoma of the thyroid gland. Complete mediastinal goiter is a relatively rare lesion, with only 59 cases (including our case) in Japan prior to 1997. Only two cases were reviewed, in which the tumors were located in the retrotracheal region, out of the 59 cases in Japan.

[A case of mediastinal goiter with hyperthyroidisms].

A 65-years-old woman admitted to the hospital in order to treat of the mediastinal tumor, but she suffered from palpitation, slight fever, sweating, uneasiness, sleeplessness and weightloss. On the physical examination, she was experiencing tachycardia, fevering (37.2 approximately 37.6 degrees C). Skin was moist but had no exophtalmos or neck tumor. Chest X-ray showed an abnormal shadow in the upper mediastinum. On chest CT, a tumor mass (9 x 5 x 4 cm) with cystic regions and scattered calcifications occupied from anterior to posterior mediastinum. The tumor compressed trachea to the left and right brachiocephalic vein and SVC to the right. Lower portion of the tumor intruded into behind of the trachea. Lymph node swelling of mediastinum was also detected. Results of general laboratory examination were within normal limits. Thyroid function test revealed hyperthyroidism; T3U 58%, free T3 24.4 pg/ml, free T4 6.0 ng/dl and thyroglobulin 967 mg/dl, but TSH was < 0.01 microIU/ml. After daily administration of methimazole (300 mg/day) for 4 weeks, thyroid function became to normal level and symptoms of hyperthyroidism was disappeared. The tumor was completely extirpated with right hemithyroidectomy and lymph node dissection under neck colla incision and median sternotomy. Pathological finding of the tumor showed follicular-fetal adenoma of thyroid with hyaloid degeneration and cystic change. There was no finding suspected of Graves' disease. She is well without any complications for 8 months after operation. Some discussion of the literature was mentioned.

Substernal goiter.

The management of a substernal goiter is a problem which has challenged surgeons since its first description in 1749. While the overall incidence in the United States has decreased with the routine use of iodized salt, the development of large multinodular substernal goiters in the rest of the world is still common. In addition, even in those regions where they are less common, knowledge of their treatment is important as they can represent up to 7% of mediastinal tumors. Certainly, the majority are large, benign masses found in the superior and anterior mediastinum, although from 3 to 15% can be malignant in nature. The presenting symptoms generally relate to the compressive nature of the mass on nearby structures. Up to 90% of patients report some form of respiratory symptoms in association with these masses. Diagnostic evaluation should include chest x-ray and computed tomographic (CT) scan. Needle aspiration biopsy should be avoided due to its dangerous substernal location. The treatment is surgical, as medical therapy is generally unsuccessful. Perioperative management should include careful evaluation of the airway as the extent of compression and deviation caused by the mass can lead to a difficult intubation. The vast majority of substernal goiters can be removed via a cervical incision; occasionally sternotomy or thoracotomy is necessary. Although rare, tracheomalacia secondary to prolonged compression of the trachea by the mass needs to be watched for postoperatively. Overall, the results of surgical treatment are excellent, as morbidity and mortality are minimal and patients can expect full relief of symptoms secondary to these mediastinal masses.

Management of patients with substernal goiters.

The presence of a substernal goiter is an indication for thyroidectomy, even in asymptomatic patients, because there is no other effective method of preventing growth of the goiter. Both primary and secondary substernal goiters usually exhibit slow but steady growth, which leads to tracheal, esophageal, vascular, and neurologic compression syndromes. Airway obstruction, which poses a life-threatening situation, may be suddenly precipitated by spontaneous or traumatically induced bleeding into the substernal goiter, as well as by tracheal infections. Substernal goiters can also produce symptoms of thyrotoxicosis. In addition, substernal goiters are known to have a relatively high incidence of malignancy. CT scans permit proper distinction between primary and secondary goiters and allow for sound preoperative planning. Advances in anesthetic techniques and the use of small-caliber endotracheal tubes facilitate proper perioperative management, even for patients with significant respiratory compression symptoms. A tracheostomy is rarely necessary. Aggressive surgical therapy for substernal goiters avoids life-threatening situations and results in minimal morbidity and practically zero mortality when performed by a surgeon experienced in managing such patients. Resection of substernal goiters generally can be accomplished through a transcervical approach, either by digital mobilization alone or with the addition of a spoon technique. Morcellization or fragmentation of the goiter is less desirable because of the possibility of dissemination of potential malignancies within the goiter. Primary intrathoracic goiters, recurrent goiters, and malignant goiters often require a median sternotomy for safe removal. The recurrence rate of goiters after surgical removal is low.

Goiter with severe respiratory compromise: evaluation and treatment.

Goiter with major respiratory compromise is uncommon but troublesome. Evaluation and treatment of this condition are controversial. Of a total of 2,908 goiters operated on over a 17-year period, 58 cases with this particular complication were studied retrospectively to define optimal management. Twenty-two patients had severe or acute dyspnea, and four of them required immediate tracheal intubation. Thirty-six patients had chronic dyspnea without cyanosis. Carcinoma was present in these two groups in 50% and 11% of patients, respectively. Results of our retrospective study are as follows: long-standing tolerance of goiter did not preclude the possibility of compressive respiratory distress or carcinoma. Optimal management of goiter with respiratory compression was obtained when surgery was delayed until satisfactory operating room conditions and adequate possibilities of interpretation of pathologic conditions were united. In case of respiratory distress, tracheal intubation allowed to abide without risks. In other patients preoperative investigations were kept to a minimum. Technical artifices facilitated the extraction of the goiter via cervicotomy without sternotomy in 92% of patients with minimal morbidity. Whenever necessary, endotracheal intubation obviated the need for tracheostomy. These data suggest preventive removal of all large or substernal goiters.

[Autonomous intrathoracic goiter. Apropos of 2 new cases]. / Goitre endothoracique autonome. A propos de 2 nouveaux cas.

An autonomous intrathoracic goiter (AIG) is a thyroid gland formation located in the thorax or, more precisely, the mediastinum. It is not a metastasis of thyroid cancer, and it has no parenchymatous or vascular connections with the cervical thyroid gland. It is fed by thoracic vessels and is observed in the absence of previous thyroidectomy. Its multiple appellations, and the fact that clinical reports often lack precision and detail, complicate investigations concerning AIG, a rare variety of mediastinal goitre (slightly more than 100 cases published). AIG is essentially caused by an abnormal embryonic development of the thyroid gland. It must be distinguished from migratory goitres partially resected and forgotten in the thorax after cervicotomy. This fully mediastinal tumour is usually removed by the thoracic approach.

Substernal goiter.

The literature on substernal goiter from the seventeenth century to the present is reviewed. Substernal goiter may be defined as any thyroid enlargement that has its greater mass inferior to the thoracic inlet. Truly ectopic mediastinal goiters are rare, and most substernal goiters arise from and maintain some attachment to the cervical thyroid gland. Patients are generally in the fifth decade of life, and women predominate. Most patients experience dyspnea, stridor, or dysphagia, but 15 to 50% are asymptomatic; symptoms are often positional, and acute stridor may occur. Ten to twenty percent have no cervical mass or tracheal deviation on examination, and virtually all patients are euthyroid. Standard chest roentgenograms are often diagnostic, but computed tomographic or radioactive iodine scans may be helpful. The presence of a substernal goiter in all but the highest-risk patients is an indication for resection, usually through a cervical collar incision; an occasional patient will require sternotomy or thoracotomy. Death or major complications should be rare postoperatively. Substernal goiters are adenomatous and benign, but carcinoma occurs in 2 to 3% and may be occult. Patients should be followed closely, as these goiters may recur.