Les goitres plongeants : particularites cliniques; radiologiques et therapeutiques

Introduction: Les goitres plongeants; devenus rares de nos jours; posent des problemes diagnostiques et chirurgicaux particuliers. Leur prise en charge est facilitee par l'apport de la tomodensitometrie permettant de planifier l'attitude therapeutique.Le but de ce travail est de preciser les modalites d'exploration et de prise en charge chirurgicale des goitres plongeants. Materiels et methodes : Nous rapportons une etude retrospective portant sur42 cas de goitre plongeant colliges sur une periode de 11 ans entre 2001 et 2011. Resultats : L'age moyen de nos patients etait de 56;9 ans (36-86 ans). Le sex-ratio etait de 0;13. La tumefaction basi-cervicale etait le motif de consultation le plus frequent; rapportee dans 74 des cas associee a des signes de compression oesotracheale dans 45 des cas.Une paralysie recurrentielle unilaterale a ete objectivee dans 3 cas.Une radiographie de thorax a montre un elargissement mediastinal dans 23 des cas avec deviation tracheale chez 63 des malades. Une TDM cervico-thoracique pratiquee dans 85 des cas a confirme le diagnostic. Le traitement chirurgical etait mene par voie cervicale exclusive chez tous les patients. Une paralysie recurentielle a ete observee dans 3 cas. Aucune hypoparathyroidie definitive n'a ete rapportee avec un reculmoyen de 24mois. Conclusion : Les goitres plongeants devenus rares du fait de la prise en charge plus precoce des nodules thyroidiens. Ils posent actuellement moins de difficultes therapeutiques. L'indication chirurgicale est toujours formelle devant le risque vital qu'ils posent

[Management of thyroid goiters invading mediastinum and thoracic cavity].

OBJECTIVE: To investigate the diagnosis and treatments of thyroid goiters invading mediastinum and thoracic cavity. METHODS: Seventy-eight cases of thyroid goiters invading mediastinum and thoracic cavity and undergoing surgery from 1995 to 2005 were reviewed. There were 22 males and 56 females and their age ranged from 45 years to 78 years with a median age of 59 years. According to the classification of intrathoracic thyroid goiters, there were 50 cases in Class I, 20 cases in Class II and 8 cases in Class III. In these patients, 38 cases suffered from dyspnea at degree I and 20 cases at degree II. Of the patients, 71 underwent thyroidectomy through neck approach and 7 underwent thyroidectomy by a combined approach of neck incision plus sternotomy or lateral thoracotomy. Tracheal defects in 4 cases and esophageal defects in 3 cases were repaired. Postoperative residual diseases were found in tracheoesophageal wall (5 cases) and mediastinum (6 cases). Eleven patients received postoperative radiotherapy and 18 underwent (131)I treatment. No case died of operation and no case with wound infection. RESULTS: The time of follow-up was 60 - 180 months with a median of 110 months. Three patients lost follow-up. Dyspnea in 58 cases were improved after operation. Three of 49 patients with nodular goiters died from cardiocerebrovascular diseases. Of 29 patients with thyroid papillary carcinoma, 2 died from lung metastasis and 3 died from neck relapse. Five-year survival rate was 75.0% in the patients with thyroid cancer. CONCLUSIONS: Most of thyroid goiters invading mediastinum and thoracic cavity can be completely resected via neck approach, but a combined approach of neck incision plus sternotomy or lateral thoracotomy may be used in some cases with malignant goiters to dissect the diseases completely. Postoperative external beam radiotherapy are required for the residual diseases. (131)I may be considered in high-risk differentiated thyroid carcinoma cases.

Bocio intratorácico. Revisión de la literatura médica / Intrathoracic goitre: A literature review

El bocio intratorácico se define como aquel bocio que se encuentra parcial o totalmente en el mediastino y que puede localizarse en el mediastino anterior o posterior; su incidencia está en relación con el bocio multinodular. El diagnóstico se realiza con cierta facilidad, en su mayoría con pruebas de imagen, y el tratamiento es variado, pero de elección se recomienda la cirugía. Con este artículo se pretende realizar una revisión de la literatura médica tanto del diagnóstico como del tratamiento de esta enfermedad (AU)

Intrathoracic goitre is defined as that goitre which is partially or totally found in the anterior or posterior mediastinum, and its incidence is associated with multinodular goitre. The diagnosis is relatively easy, mainly with imaging tests, and treatment varies, but of choice, surgical treatment is recommended. This article attempts to present a review of the literature on the diagnosis and management of this disease (AU)

[Intrathoracic goitre: a literature review]. / Bocio intratorácico. Revisión de la literatura médica.

Intrathoracic goitre is defined as that goitre which is partially or totally found in the anterior or posterior mediastinum, and its incidence is associated with multinodular goitre. The diagnosis is relatively easy, mainly with imaging tests, and treatment varies, but of choice, surgical treatment is recommended. This article attempts to present a review of the literature on the diagnosis and management of this disease.

Adenoma paratiroideo intratorácico: diagnóstico y terapéutica / Intrathoracic parathyroid adenoma: diagnosis and treatment

El hiperparatiroidismo primario es una entidad rara vez provocada por Adenomas Paratiroideos Intratorácicos (19-6,8 por ciento), requiriendo en menos del 2 por ciento un abordaje mediastinal transesternal. El objetivo de la presente comunicación analiza 1 paciente con HPTP, cuyos estudios preoperatorios localizan una tumoración funcionalmente hipercaptante en mediastino anterior e inferior y que necesitó una esternotomía mediana completa para su terapéutica(AU)

Manejo diagnóstico e terapêutico do bócio mergulhante / Diagnostic and therapeutic management of substernal goiter

As condutas clínicas e cirúrgicas no bócio mergulhante ainda são controversas, não havendo um consenso na literatura sobre qual o momento ideal para intervir cirurgicamente nos pacientes com esta enfermidade. É preciso conhecer as indicações, conseqüências e complicações do tratamento cirúrgico do bócio mergulhante. Este trabalho resulta de uma revisão de publicações sobre tratamento do bócio mergulhante no período de 1995 a 2000. As bases de dados utilizadas foram Medline e Lillacs. Objetiva-se atualizar, orientar e esclarecer dúvidas dos profissionais a respeito desses fatores. Discutem-se os métodos diagnósticos e as condutas terapêuticas em casos de bócio mergulhante...

There is no unanimity regarding clinical or surgical procedures in treatment of substernal goiter. Indications, consequences, and complications of substernal goiter surgery must be carefully evaluated. A review of the literaturc based on Medline and Lillacs regarding surgery of substernal goiter from 1995 to 2000 is made and discussed.

[Diagnosis and therapy of patients with euthyroid goiter]. / Diagnostiek en therapie bij patiënten met euthyreotisch struma.

Nontoxic goitre is common, even in areas where iodine intake is sufficient. The most important symptoms and signs of nontoxic goitre are caused by compression of vital structures in the neck or upper thoracic cavity. In any patient with goitre the serum concentration of thyroid-stimulating hormone (TSH) should be measured to detect or exclude clinically inapparent (subclinical) hyper- or hypothyroidism. CT and MRI are expensive but very sensitive methods to identify tracheal compression and to determine intrathoracic extension. Thyroid ultrasonography and scintigraphy are not routinely indicated. Fine-needle aspiration biopsy is indicated in patients with fast-growing nodules and nodules that have a firmer consistency than other nodules within the gland. Thyroidectomy is standard therapy for young and otherwise healthy patients, especially when prompt decompression of vital structures is required. Radioiodine therapy is an attractive alternative to surgery in older patients, in those with cardiopulmonary disease, and in those with recurrent goitre. Thyroxin therapy may be tried in young patients with small, diffuse goitres who have normal serum TSH concentrations.

Tratamiento del bocio cervicomediastínico / Management of cervicomediastinal goiter

Introducción. Los bocios cervicomediastínicos son una enfermedad infrecuente, con un crecimiento lento y en su evolución pueden ocasionar clínica compresiva de estructuras vecinas. Es importante resaltar su asociación a neoplasias (3-15 por ciento). Actualmente persiste la controversia en el manejo terapéutico del mismo. Pacientes y método. En un estudio retrospectivo de los últimos 7 años se han intervenido 26 bocios endotorácicos. Se estudiaron la edad, sexo, antecedentes personales, sintomatología, diagnóstico, vía de abordaje y tipo de cirugía, histopatología, estancia hospitalaria, evolución y control de los casos. Resultados. Fueron 26 los bocios cervicomediastínicos, 18 en mujeres y 8 en varones. La sintomatología fue variada, solapándose varios síntomas; en el 35 por ciento de los casos fue asintomático. La forma de presentación más frecuente fue la subaguda o crónica. La localización del bocio fue predominante en el lado izquierdo. La exploración que mejor reveló el diagnóstico y la topografía fue la TAC. La vía de abordaje empleada fue en 21 casos la cervicotomía y en tres se asoció una esternotomía. En dos casos se realizó una mediastinotomía diagnóstica. Se practicaron 17 lobectomías, 7 tiroidectomías subtotales, una biopsia y una exéresis de restos tiroideos mediastínicos. La estancia media postoperatoria fue de 4,72 días. Entre las complicaciones destaca una hemorragia muscular y 2 disfonías.Conclusiones. El bocio endotorácico posee un crecimiento lento, se presenta en una edad avanzada, aumenta la incidencia de cáncer y en su evolución puede desarrollar complicaciones. El abordaje, por vía cervical, puede realizarse en la mayoría de los casos. Por todo esto opinamos que ante el bocio cervicomediastínico se debe indicar su tratamiento quirúrgico, dada la nula mortalidad y la escasa morbilidad (AU)

Use of a Foley catheter in the removal of a substernal goiter.

Substernal goiters present a technical challenge to the surgeon. Most substernal goiters may be removed through a cervical incision; however, a median sternotomy may be required in 1% to 2% of patients. To avoid a median sternotomy, many techniques have been described in the literature to facilitate extraction. Special spoons and clamps have been described, and techniques, such as morcellation, the drawer technique, and piecemeal extraction, have been popularized. We describe a method whereby a Foley catheter is used to deliver a large substernal goiter through a cervical incision. It consists of steady traction on the inflated balloon of a Foley catheter placed beyond the substernal component of the goiter. This method has been used successfully and safely on 2 patients and may obviate the need for a sternotomy.

[Substernal goiter: new diagnostic methods and treatment]. / Il gozzo immerso: attualità terapeutiche sulla base dei nuovi mezzi diagnostici.

The authors report 47 cases of substernal goiters operated between 1971 and 1990. Forty-five patients had mediastinal-cervical-goiters (g.c.m.) and 2 had ectopic goiter (g.e.). Cervicotomy was performed in the 45 g.c.m., in 3 cases associated with sternal "split". The g.e. were treated with thoracotomy. Computed Tomography (TC) has been performed since 1984 in 26 patients; Magnetic Resonance (RM) since 1987 in 6 patients. The diagnostic accuracy for TC was 84.6% and 100% for MR on anatomical-topographic-definition, and 80.8% and 83.3% for presumptive diagnosis of nature, respectively. Considering the high diagnostic accuracy, the possibility to reconstruct the images in sagittal and coronal planes, the RM seems to be the elective diagnostic procedure for all substernal goiters.

[Tracheal injury caused by intubation for compressive endothoracic goiter]. / Plaie trachéale à l'intubation pour goître endothoracique compressif.

The tube cannot pass along the marked curve of the trachea, which is displaced by a large goiter extending into the posterior mediastinum. The trachea is perforated in a low thoracic location. Tracheal suture and exeresis of the goiter are performed through sternotomia. This serious accident seems to be exceptional. Can it be predicted?

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.