Evidence-based surgical management of substernal goiter

Beyond the Neck: When Is Thoracic Operation Needed for Thyroidectomy?

BACKGROUND

Although most patients with intrathoracic thyroid glands can undergo thyroidectomy via a cervical incision, some cases necessitate intraoperative thoracic surgery assistance. This study aimed to identify CT findings that predict the need for thoracic surgery assistance during thyroidectomy.

STUDY DESIGN

We reviewed administrative data at our institution (2012 to 2023), encompassing 7,370 thyroidectomies, to identify patients who underwent thyroidectomy for intrathoracic thyroid glands, defined as thyroid glands that extended below the sternal notch. Detailed CT analysis was conducted, including measurements of intrathoracic thyroid dimensions, shape, extension to posterior mediastinum, and relation to thoracic inlet. Receiver operating characteristic curve analysis and multivariable regression analysis were performed to identify the most accurate independent predictors of the need for intraoperative thoracic surgery assistance.

RESULTS

Among 255 patients with intrathoracic thyroid glands, 34 (13.3%) required intraoperative thoracic surgery assistance. Patients needing thoracic assistance had significantly larger intrathoracic thyroid glands in anteroposterior, craniocaudal, and horizontal dimensions compared with those without. Additionally, their thyroid glands were more likely to enlarge below the sternal notch or extend into the posterior mediastinum receiver operating characteristic curve indicated that distance from inferior border of thyroid gland to sternal notch (area under curve [AUC] = 0.94) is a better predictor than distance to aortic arch (AUC = 0.91) or sternal angle (AUC = 0.91). Thresholds of distance to sternal notch 5.3 cm or more, anteroposterior dimension 5.2 cm or more, and horizontal dimension 5.3 cm or more provided 80% sensitivity and 70% or more specificity for predicting the need for thoracic assistance. Multivariable regression analysis identified thyroid increasing in size below sternal notch, distance to sternal notch 5.3 cm or more, and horizontal dimension 5.3 cm or more as independent predictors for intraoperative thoracic assistance.

CONCLUSIONS

Thyroid glands extending 5.3 cm or more below sternal notch, enlarging below sternal notch, or having a horizontal dimension 5.3 cm or more warrant preoperative thoracic surgery consultation for potential intraoperative assistance.

Incidental Thyroid Goiter with Large Posterior Mediastinal Extension: A Case Report

Mediastinal goiters represent descent of thyroid tissue from the neck to the intra thoracic cavity most commonly in the anterior mediastinal compartment. Posterior mediastinal extension is uncommon, comprising only 10-15% of all mediastinal goiters. Thyroid masses within mediastinum may present with range of symptoms from being asymptomatic to severe compressive symptoms according to size and location. Surgical excision is treatment of choice in most cases. Although cervical approach is sufficient for most anterior mediastinal goiters, additional extra cervical approaches may be required for posterior mediastinal goiters. We report a case of 48-year-old female patient with an incidental finding of a thyroid goiter having large extension in right posterior mediastinum found on CT scan. It was excised using combination of cervical and Video Assisted Thoracoscopic Surgery and posterolateral thoracotomy approach with uneventful post-operative period. Histopathology revealed it to be benign multinodular goiter.

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.

[Extracervical approach for retrosternal goiter]

OBJECTIVE

To analyze treatment outcomes in patients with retrosternal goiter.

MATERIAL AND METHODS

There were 13 patients aged 32-77 years with retrosternal goiter between 2016 and 2024. The ratio of men and women was 2:11.

RESULTS

Twelve patients underwent thyroidectomy, one patient - video-assisted thoracoscopic thymectomy with resection of aberrant goiter. Among 12 patients, thyroidectomy through collotomy was performed in 6 patients, sternotomy was performed in 5 patients. Aberrant goiter was removed through thoracotomy in one patient with recurrent retrosternal goiter. Complicated postoperative period was observed in 4 patients. Two patients underwent postoperative tracheostomy (prevention of respiratory failure following high risk of bilateral paresis of recurrent laryngeal nerves in one case and laryngeal edema in the second case). There were no deaths in long-term period.

CONCLUSION

Preoperative planning should include CT-based analysis of intrathoracic component of thyroid gland and volume of chest cavity. This is valuable to plan the optimal surgical approach and reduces the risk of intraoperative complications.

Three-Leaf-Clover Thyroid and Minimally Invasive Trans-Cervical Synchronous Thyroidectomy and Ectopic Mediastinal Thyroid Tissue Removal: Does the Age of the Patient Count amid a Multifaceted Strategy?

Background: Ectopic organ-associated conditions belong to the larger panel of developmental ailments, and among this challenging medical and surgical chapter, ectopic endocrine glands-related picture is mostly focused on the presence of the ectopic parathyroid and thyroid. Ectopic thyroid tissue within mediastinum (ETTM) stands for a less common ETT site; while, globally, less than 1% of the mediastinum masses are ETTM. Objective: We aim to introduce a rare case of ETTM in a senior lady to whom one-time synchronous thyroidectomy with ETT removal was successfully performed via a minimally invasive modern procedure upon cervicotomy and intra-operatory use of the Cooper thymectomy retractor. Results: The panel of pros and cons with respect to providing endocrine thoracic surgery for ETTM resection in a 73-year-old subject is discussed amid a PubMed search of original English-language original reports from January 2000 until 15 August 2024 in order to identify similar distinct cases (individuals of 70 years or older who underwent surgery for ETTM). Conclusions: 1. We propose the term "three-leaf-clover thyroid" to capture the imaging essence of having an enlargement of both (eutopic) thyroid lobes and ETTM. 2. The modern surgical approach under these circumstances provided a rapid patient recovery with a low rate of complications and a minimum hospital stay. Hence, the procedure may be expanded to older patients after a careful consideration of their co-morbidities and of the need to releasing connected complaints (e.g., a 7-month history of intermittent dyspneea was found in this case with post-operatory remission). 3. The management remains a matter of individualised decision, and age may not be a limiting factor. 4. At the present time, this case adds to the very limited number of similar published cases in the mentioned age group that we could identify (seven patients, aged between 72 and 84; male-to-female ratio of 5 to 2; the rate of malignant ETTM was 3/7); of these cases, not all were reported to have a trans-cervical approach, and none reported the use of the Cooper thymectomy retractor to help the overall surgical procedure. This innovative surgical procedure offers the advantage of avoiding a sternotomy incision which has clear functional and aesthetic implications, while the video-assisted approach allows optimal visualization of the mediastinal anatomy and safe vascular sealing under visual control, without the risk of a major hemorrhage.

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.

Combined Transcervical and Median Sternotomy Approach for a Massive Substernal Goiter

Herein, we describe a combined transcervical and median sternotomy approach for a massive substernal goiter causing tracheal stenosis. A goiter of this size, specifically weighing 630 g, is rare. We advocate for a multidisciplinary approach for airway management and for consideration of awake fiberoptic intubation with tracheosomy avoidance for similar patients.

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.

Gasless transoral endoscopic thyroidectomy in a primary substernal goitre patient: First case

ABSTRACT

For most primary substernal goitre (SG) surgeries, sternotomy is required because the blood supply vessels of tumours come from the mediastinum. However, sternal dehiscence may lead to several surgical complications. We reported an older patient who underwent simultaneous removal of a primary SG and parathyroid adenoma through a gasless transoral endoscopic approach. The patient recovered well with no hoarseness, post-operative bleeding or other complications after the operation. To the best of our knowledge, this is the first reported case of gasless transoral endoscopic parathyroid adenoma and primary SG resection in the real world. We found that gasless transoral endoscopic surgery is feasible in patients with small primary SG and parathyroid adenoma.

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.

Extracervical Approaches to Substernal Thyroid Goiter Resection: A Systematic Review and Meta-Analysis

Objective

To evaluate the prevalence of extracervical approaches (ECAs) for substernal goiter (SSG) excision.

Data Sources

Search strategies created in collaboration with a medical librarian were implemented using PubMed, Cochrane, Scopus, Web of Science, and Google Scholar from inception to July 2021.

Review Methods

Participants included adults ages >18 years undergoing SSG excision. The primary outcome was rate of ECA via sternotomy or thoracotomy. Studies were categorized into the 3 most common distinct definitions: goiter descending below the plane of the thoracic inlet (definition 1), ≥50% of thyroid mass extending below the sternal notch (definition 2), and goiter extending ≥3 cm below the suprasternal notch when the neck is hyperextended (definition 3). Two reviewers independently extracted data for analysis and performed a quality assessment using the Methodological Index for Non-Randomized Studies criteria.

Results

Of the 551 studies identified, 69 studies were included for analysis. Definition 1 included 3441 patients from 31 studies; definition 2 included 2957 patients from 26 studies; and definition 3 included 2921 patients from 12 studies. A random-effect model estimating the pooled prevalence of ECA using definition 1 resulted in prevalence of 6.12% (95% confidence interval: 3.48-9.34, I 2 = 90.72%).

Conclusion

Extension below the thoracic inlet is the most widely used definition of SSG. Approximately 6% of patients with a SSG undergo an ECA. Patients with SSG undergoing surgery should be counseled on the prevalence, risks, and morbidity of an ECA in the rare occurrence it is needed.

The Use of a Surgical Spoon in the Removal of Substernal Goiter

Goiter with substernal extension is common, with a reported incidence of up to 20% in patients undergoing thyroidectomy. It has been shown that the vast majority of substernal goiters can be removed through a cervical incision. However, if this is not possible, a sternotomy is usually required, which could add significant morbidity to an otherwise routine operation. During substernal mobilization, the surgeon's finger is typically placed under the strap muscles and against the thyroid capsule, hooking around the inferior aspect of the gland to facilitate separation of the gland from its mediastinal attachments. In cases where the length required for successful substernal mobilization is beyond the reach of a surgeon's fingers, the use of an alternative strategy may be required. A surgical spoon is a blunt, curved instrument that can allow safe substernal mobilization while providing the added length needed when digital mobilization is inadequate. Here, we describe the use of a surgical spoon for the safe and successful removal of a goiter with substernal extension unable to be removed with digital manipulation.

Surgical Resection of Retrosternal Goitre: The Four-Finger Technique

Retrosternal goitre (RSG) is a thyroid gland with more than 50% of its mass located below the thoracic inlet. Pre-operative Computed Tomography can visualise the anatomical relations between the RSG and each mediastinal component, and the level of extension. Most cases of RSG can be resected via the cervical approach, as the thoracic approach carries a greater risk of complications. We describe a four finger technique for total thyroidectomy in five cases of RSG through a neck incision, without the need for a sternotomy. The recurrent laryngeal nerve (RLN) was identified early in the Baehr's triangle. The thyroid was mobilised in the neck by ligation of the feeding vessels and separated from the tracheal attachments. The retrosternal portion was then delivered into the neck by blunt dissection, keeping two fingers of each hand close to the thyroid gland. The RLN and parathyroids were identified early in the surgery to avoid the complications of hoarseness and hypoalcemia, respectively.

Management of surgical diseases of thyroid gland indications of the United Italian Society of Endocrine Surgery (SIUEC)

A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in thyroid surgery published in 2016, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 13 members of the SIUEC highly trained and experienced in thyroid surgery. The main topics concern clinical evaluation and preoperative workup, patient preparation for surgery, surgical treatment, non-surgical options, postoperative management, prevention and management of major complications, outpatient care and follow-up.

Management of Retrosternal Goiter in Resource-Limited Settings: Outcomes From 28 Cases Using Cervical Approach

Background Despite thyroidectomy being the preferred approach for retrosternal goiter (RSG), controversies surround its rationale in asymptomatic cases. This study aimed to investigate the treatment of RSG in resource-limited settings. Methods A retrospective study conducted between April 2010 and June 2022 included 28 RSG cases who underwent thyroidectomy using the cervical approach at Al-Nasar Hospital, Ibb, Yemen. A bivariate analysis was performed to investigate the risk factors for postoperative complications. Results The main age was 49.4±9.9 years, and most of them (60.7%) were females. The main symptoms were cervical mass appearance and breathing difficulty in 75 %, and 32.1%, respectively. Twenty-four (86%) cases were classified as Grade 1 (above aortic arch) and four (14%) cases were classified as Grade 2 (aortic arch to the pericardium). All patients underwent total thyroidectomy through the cervical approach without needing sternotomy. The mean operative time was 121.9±26.7min (99-200 min) and the mean intraoperative bleeding was 321.2±137.4 mL. Postoperatively, the malignant entity was histopathologically proven in seven patients (25%). The postoperative complications (14%) were transient hypocalcemia in two (7.1%) and hematoma in two (7.1%). Older age, bigger thyroid mass, extension below the aortic arch (Grade 2), longer operative time and bleeding, intensive care unit admission, and malignant features are associated with postoperative complications (all p < 0.05). Conclusion Cervical approach for patients with RSG in our experience is an optimum, feasible, and less invasive surgical approach, in a resource-limited setting. Older age, bigger thyroid, extension below the aortic arch, longer operative time and bleeding, intensive care unit admission, and malignant features are associated with postoperative complications.

Ultrasound-guided microwave ablation combined with ethanol injection for the treatment of solitary nodular retrosternal goiter: a prospective study of 72 patients

OBJECTIVES

We prospectively evaluated the efficacy and safety of microwave ablation (MWA) combined with ethanol injection (EI) in solitary nodular retrosternal goiters (RSGs).

METHODS

From November 2018 to November 2020, 72 patients diagnosed with solitary nodular RSG were treated by ultrasound-guided MWA with EI. Patients were followed up at 1, 3, 6, and 12 months and every 6-12 months thereafter by ultrasound and contrast-enhanced ultrasound (CEUS). The nodule volume, volume reduction ratio (VRR), neck circumference, symptom score, and cosmetic grading score were recorded to evaluate the treatment efficacy.

RESULTS

All patients successfully underwent treatment. The mean initial nodule volume was 71.25 mL ± 61.61 mL, which decreased significantly to 7.47 mL ± 9.19 mL at a mean follow-up time of 23.89 months ± 7.66 months (range 15-39 months) with a mean VRR of 90.99% ± 7.52%. The neck circumference, symptom score, and cosmetic grading score significantly decreased from 36.94 cm ± 3.04 cm to 35.06 cm ± 2.84 cm, from 3.78 ± 1.19 to 0.36 ± 0.63, and from 3.42 ± 0.76 to 1.13 ± 0.37, at the 12 months after treatment, respectively (all 7 p < 0.001). Of all the nodules, eight (11.1%) received a second ablation. No major complications occurred.

CONCLUSION

Ultrasound-guided MWA combined with EI is an effective and safe treatment for solitary nodular RSG and may be a potential alternative to surgery in selected patients, especially for those who are ineligible or unwilling to receive surgical treatment.

KEY POINTS

• MWA combined with EI is an effective and safe approach for the treatment of solitary nodular RSG. • This treatment should be conducted by experienced physicians. • It provides a potential alternative to surgery for solitary nodular RSG in patients who are ineligible or unwilling to receive surgical treatment.

Depth of mediastinal extension can predict sternotomy need for substernal thyroid goiters

BACKGROUND

Surgical excision of substernal thyroid goiters is usually achieved through a conventional transcervical approach, and transthoracic excision is rarely necessary. Currently, there are no clear guidelines for substernal thyroid goiters that may require a transthoracic approach. This study examined what preoperative factors were significantly associated with transthoracic surgical excision for substernal thyroid goiters.

METHODS

A retrospective review of prospectively collected data of 109 patients with substernal thyroid goiters from a single institution was performed. The patients were stratified by transcervical and transthoracic approaches for substernal thyroid goiters. The factors possibly predictive of a transthoracic approach, including substernal extension beyond the thoracic inlet, patient-reported symptoms, tracheal deviation, and malignancy, were analyzed. Demographics including age, sex, and race, among others, were also studied.

RESULTS

Of 1,080 patients who underwent surgical resection for multinodular goiter, there were 109 (10%) patients with substernal thyroid goiters. Of the substernal thyroid goiter group, 11 (10%) patients underwent partial sternotomy, whereas 6 (5.5%) underwent total sternotomy. On logistic regression, only substernal component of the thyroid goiter extending beyond the sternal notch into the mediastinum was statistically significant in predicting sternotomy (odds ratio 3.43, confidence interval 1.65-6.41, P < .001). Substernal thyroid goiters with mediastinal extension of ≥5 cm beyond the sternal notch showed a sensitivity of 94% and specificity of 86.5% to predict need of sternotomy.

CONCLUSION

Patients with substernal thyroid goiters who exhibit progressive enlargement and/or compressive symptoms should undergo surgical excision. Although most are removed through the conventional transcervical approach, substernal thyroid goiters with a depth of mediastinal extension ≥5 cm have a high likelihood of requiring sternotomy.

Difficult airway management and emergency tracheostomy in a patient with giant goiter presenting with respiratory arrest: A case report

Giant goiter is commonly asymptomatic or progresses with nonspecific symptoms, such as pain, hoarseness and dysphagia. In rare cases, enlargement of the thyroid may cause compression of the trachea and lead to life-threatening complications. As a result of iodization programs implemented throughout the world to address iodine deficiency disorders, giant goiter is rare today. Although not common, the disease may result in a difficult airway in cases of tracheal compression. The present study shares our experience of a giant retrosternal goiter in a patient presenting with respiratory arrest who underwent emergency tracheostomy after multiple attempts at orotracheal intubation and then thyroidectomy during an intensive care stay due to the development of tracheomalacia.

Retro-sternal Goitre: an Overview

Retro-sternal goitres are slow growing in nature. Dyspnoea on exertion is the most common presenting symptom due to the pressure effect of goitre on trachea. Due to the increased use of radiological investigations, retrosternal goitres are often diagnosed incidentally without any symptoms. Surgical resection is considered the gold standard management in all symptomatic patients and most of asymptomatic patients. However, "wait and watch" approach is an option, in selected asymptomatic patients, with the evolution of alternative treatment methods. So, the management of retrosternal goitre continues to be a surgical controversy. This article aims at reviewing the evidence-based practice of management of retrosternal goitres including challenges of surgery and postoperative complications.

Retrosternal Goitre: Anatomical Aspects and Technical Notes

Background and Objectives: surgery for substernal goitre is still debated in the literature, due to the wide range of surgical options. This article outlines the findings of our extensive experiences, which include 264 cases of patients with “goitre plongeant“, and compares postoperative complications, despite surgical approaches. Material and Methods: preoperative planning and anatomical landmarks are described to determine the potential need of a combined approach. The surgical procedure is described, along with some stratagems, to ensure that the operation is completed safely. A statistical analysis of complications and the length of stay, with a comparison of cervicotomy and combined access, was performed using the Pearson chi-square significance test. Results: 264 patients underwent thyroid surgery for substernal goitre. The Kocher incision was the surgical approach chosen in 256 patients (96.6%), while an accessory incision was performed in 8 patients (3.4%). The necessity to use a two-fold surgical access was linked to a higher rate of postoperative complications (p-value < 0.01). The average length of stay (LOS) for cervicotomy was 2 days (1−3 days), while the average LOS was 5 days (4−7 days) (p-value = n.s.) for combined access. Conclusions: cervicotomy should be the gold standard technique for exploring intrathoracic goitre with a digital dissection, which, in almost all cases, enables the externalization of the mediastinal portion associated. Sternotomy is related to a higher rate of complications, so it should be performed only in selected cases. Management in large-volume centres may be more appropriate.

[Mediastinal Tumors]

If mediastinal tumours cause symptoms these are related to their anatomical localization or a paraneoplastic syndrome. The differential diagnosis is based on the clinical situation with finding the lesion, and, furthermore, taking into account the age and sex of the patient, and the mediastinal compartment where the lesion is located. Cross-sectional radiographic diagnostic is essential for defining the therapeutic strategy. The anterior mediastinum is dominated by thymic tumours, mediastinal lymphomas, germ cell tumours and ectopic mediastinal poiters. The middle mediastinal compartment is the most frequent place of mediastinal cystic tumours, whereas the posterior mediastinum is the domain of neurogenic tumours. For selected cases a tissue biopsy is required. Surgery is the mainstay for most mediastinal tumours. Median sternotomy is the most frequent conventional surgical technique while minimally invasive surgery with thoracoscopic and above all robot assisted operation techniques are increasingly frequent. Combined chemotherapy and modern radiotherapy are essential components of the comprehensive treatment for mediastinal tumours.

Clinicopathologic Characteristics and Outcomes of Massive Multinodular Goiter: A Retrospective Cohort Study

BACKGROUND

Thyroidectomy for massive goiters is challenging because of the increased risk of tracheomalacia, combined sternotomy, postoperative morbidity, and mortality, whereas studies investigating the clinicopathologic characteristics, postoperative morbidities, and surgical outcomes of massive goiters are limited.

METHODS

Patients with goiters undergoing thyroid surgery between 2009 and 2019 were retrospectively reviewed. A total of 227 patients were enrolled and divided into massive goiter group and large goiter group according to the weight of the goiter. Clinicopathologic characteristics, postoperative morbidities, and surgical outcomes were compared between the two groups.

RESULTS

Seventy-four patients (32.6%) had a goiter weighing more than 250 g and 153 patients (67.4%) were categorized in the large goiter group. Compared to large goiter patients, massive goiter patients had higher rates of retrosternal extension (82.4% vs. 30.7%), combined sternotomy (12.2% vs. 1.3%), intensive care unit admission (25.7% vs. 7.2%), transient hypoparathyroidism (41.9% vs. 25.5%), and transient recurrent laryngeal nerve palsy (10.8% vs. 3.3%) as well as prolonged length of hospital stay (P < 0.05).

CONCLUSIONS

Massive goiter patients were at increased risk of combined sternotomy, intensive care unit admission, postoperative morbidities as well as prolonged length of hospital stay after thyroidectomy compared to large goiter patients, but most of them can be treated through a cervical approach with a favorable outcome.

Hyperthyroidism secondary to a primary mediastinal goiter with normal functional cervical thyroid gland

Primary mediastinal goiter is extremely uncommon. The majority of primary mediastinal goiters were reported as incidental findings on chest imaging of asymptomatic patients. Symptoms related to compression of adjacent structures or hyperthyroidism were rarely described. Herein we report a case of hyperthyroidism secondary to a primary mediastinal goiter.

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.

An overview of retrosternal goiter

Goiters tend to grow slowly and steadily over many years, occasionally reaching the mediastinum and extending through the thoracic inlet into the visceral compartment. In most cases, retrosternal goiters originate from the cervical portion of the thyroid. The incidence of retrosternal goiters varies considerably, ranging from 0.2 to 45% of all thyroidectomies, depending on the criteria used to define this type of goiter. Symptoms are generally related to the compressive nature of the mass on the adjacent structures, and most patients report some form of respiratory manifestation associated with the goiter. A diagnostic assessment usually includes an evaluation of thyroid function, chest radiography, and computed tomography. Fine-needle aspiration biopsy should be avoided in substernal areas of the goiter due to limited visibility and location of vital structures in this region. Treatment of retrosternal goiters is surgical, as medical therapy is generally unsuccessful in these cases.

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.

Combined cervicosternotomy and cervicotomy for true retrosternal goiters: a surgical cohort study

Objective

Intrathoracic goiters are a heterogeneous group characterized by limited or extensive substernal extension. Whereas the former can be treated through cervicotomy, the latter sometimes requires a cervicosternotomy. Whether cervicosternotomy leads to more morbidity remains unclear.

This study aimed to compare intra- and postoperative morbidity in patients treated by cervicotomy or cervicosternotomy for intrathoracic goiters and standard thyroidectomy.

Methods

In a prospectively gathered cohort undergoing thyroid surgery (2010–2019) intra- and postoperative morbidity of cervicotomy (N = 80) and cervicosternotomy (N = 15) for intrathoracic goiters was compared to each other and to a ‘standard’ thyroidectomy (N = 1500).

Results

An intrathoracic extension prior to surgery was found in 95 (6%) of all thyroidectomies. Eighty patients (84%) were operated by cervicotomy and 15 (16%) by cervicosternotomy. The risk of temporary recurrent laryngeal nerve palsy was much higher in the cervicosternotomy group (21%) compared to cervicotomy (4%) and standard thyroidectomy (3%). The risk of temporary hypocalcemia after cervicotomy (28%) was comparable to a standard thyroidectomy (32%) but higher after cervicosternotomy (20%). No cases of permanent hypocalcemia or laryngeal nerve palsy were observed in both groups with substernal extension. The need for surgical reintervention was significantly higher in the cervicotomy group (6%) compared to cervicosternotomy (0%) and standard thyroidectomy (3%).

Conclusion

In patients undergoing thyroid surgery for an intrathoracic goiter, cervicosternotomy was associated with more temporary laryngeal nerve palsy, but none of the interventions resulted in higher risks of permanent nerve damage, permanent hypocalcemia, or reintervention for bleeding. Reintervention was even more common after cervicotomy compared to cervicosternotomy.

Level of evidence

IV

Supplementary Information

The online version contains supplementary material available at 10.1007/s13304-021-01027-1.

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.

Cervical approach to cervico-mediastinal goiters: Experience of a Moroccan ENT tertiary center - Case series

Background

The purpose of the study was to analyze and discuss the demographic, clinical, radiological, therapeutic and postoperative findings of the Cervico-mediastinal goiters (CMG) treated through a cervical approach admitted in the ENT department of Ibn Rochd university hospital, Casablanca, Morocco between January 2014 and January 2020.

Materiels and methods

Over a period of 6 years, 116 patients underwent surgical treatment for CMG. It was defined as a goiter extending below the plane of superior thoracic aperture on CT scan. All our patients had clinical, biological and radiological assessment before surgery. A nasofibroscopy was carried out pre and postoperatively. All the CMG have been extracted trough a cervical approach by an experimented ENT surgeon.

Results

84,48% of the CMG was diving into the anterior mediastinum and 15.52% into the posterior. The CMGs extended above, at, and below the level of the aortic arch respectively in 76.72%, 18.10% and 5.17% of the patients. All of 116 goiters were successfully removed through a cervical approach. No patient required a sternotomy. Postoperatively, vocal cord paralysis was transient in 3 patients (2.58%) and permanent in 2 patients (1.72%). Hypocalcemia was transient in 10 patients (8.62%) and permanent in 2 patients (1.72%). Final histology found 106 benign multinodular goiters (91.37%), 7 papillary carcinomas (6.03%) and 3 vesicular carcinomas (2.58%). No death was noted.

Conclusions

With expertise in thyroid surgery, cervical approach for CMGs is safe and sufficient in the majority of the cases with low morbidity rate and no mortality.

•

In the literature, there is no consensus on the definition of cervico-mediastinal goiters.

•

CMG is a challenging disease that needs proper clinical, biological and radiological assessment.

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Malignancy in a CMG is not higher than that of the cervical goiters and most of the foci in CMG were in the intrathoracic region.

•

With expertise in thyroid surgery, cervical approach for CMGs is safe and sufficient in the majority of the cases.

To explore the risk factors and preventive measures affecting the treatment of retrosternal goiter: An observational study

The definition of substernal goiter (SG) is based on variable criteria, leading to considerable variations in the reported incidence (from 0.2% to 45%). The peri- and postoperative complications are higher in total thyroidectomy (TT) for SG than that for cervical goiter. This study aimed to evaluate the preoperative risk factors associated with postoperative complications.From 2002 to 2014, 142 (8.5%; 98 women and 44 men) of the 1690 patients who underwent TT had a SG. We retrospectively evaluated the following parameters: sex, age, histology, pre- and retro-vascular position, recurrence, and extension beyond the carina. These parameters were then related to the postoperative complications: seroma/hematoma, transient and permanent hypocalcemia, transient and permanent laryngeal nerve palsy, and the length of surgery. The results were further compared with a control group of 120 patients operated on in the same period with TT for cervical goiter (CG).Statistical analysis (Student t test and Fisher exact test) indicated an association between recurrence and extension beyond the carina with all postoperative complications. The group that underwent TT of SG showed a statistically significant higher risk for transient hypocalcemia (relative risk = 1.767 with 95% confidence interval: 1.131-2.7605, P = .0124, and need to treat = 7.1) and a trend toward significance for transient recurrent laryngeal nerve palsy (relative risk = 6.7806 with 95% confidence interval: 0.8577-53.2898, P = .0696, and need to treat = 20.8) compared with the group that underwent TT of cervical goiter. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina.TT is the procedure to perform in SG even if the incidence of complications is higher than cervical goiters. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

"Tracheomalacia after Thyroidectomy," Does it Truly Exist?

Aim:

Tracheomalacia is a potentially life-threatening, but a rare complication of thyroidectomy. In previous studies, the incidence rate was very different. Considering the relatively high prevalence of goiter and thyroidectomy in the West Azerbaijan region, we designed this study to determine the tracheomalacia incidence in patients who underwent thyroidectomy within a 10-year interval.

Materials and Methods:

This retrospective study was done in Urmia Imam Khomeini Hospital in West Azarbayjan Province. Demographic characteristics including the age and sex of patients who underwent thyroidectomy between 2007 and 2017 and also the incidence of tracheomalacia after surgery were recorded.

Results:

From 2007 to 2017, total 1236 thyroidectomy were performed. The patients’ age ranged from 15 to 83-year-old with a mean age of patients was 44.5 ± 13.81 years old. Two hundred and twenty-nine patients (19%) were male and 1007 (81%) were female. We did not find any cases of tracheomalacia after thyroidectomy in our study population.

Conclusion:

Based on the results of this study, it seems that with the necessary precautions, the incidence of tracheomalacia can reach zero.

Giant Intrathoracic Goiter of Atypical Presentation: A Case Report

BACKGROUND

The term goiter is used to describe any abnormal growth of the thyroid gland, which can be diffuse or nodular, and can be associated with normal, diminished, or increased thyroid function. Multinodular goiter is a common disease whose prevalence increases at age 50. Clinical manifestations can be due to thyroid function impairment or related to size and location of the gland with compressive symptoms. Intrathoracic location is less frequent, can be mistaken with pulmonary lesions and usually implies a difficult surgical approach.

CASE PRESENTATION

A 66-year-old woman with a history of subtotal thyroidectomy presented with 7-month dyspnea, dry cough. There was no evidence of neck masses, or jugular engorgement. Physical examination was normal. Chest x-ray showed an 11 cm mass in the upper right hemithorax. Computed tomography (CT)-scan, showed calcifications, and compression of the superior vena cava without infiltration, the right subclavian vein and left displacement of the trachea. Distinction between intrapulmonary or mediastinal location was not clear. Biopsy showed thyroid origin, and bilateral thoracotomy was performed with confirmation of a giant multinodular goiter.

CONCLUSIONS

Intrathoracic goiter should undergo surgical or ablative management if compressive symptoms of the airway and cervical or thoracic vessels are present. The large size of the tumor along with the presentation after thyroidectomy and the seeming location in the right upper lobe made this particular case striking. Specially in the elderly, multidisciplinary perioperative management is key for a successful recovery.

Surgical management of intrathoracic goitres

BACKGROUND

Intrathoracic goitres (ITG) often present with compressive symptoms and require specialised care by experienced surgical teams. Most ITG can be accessed by a transcervical approach (TCA) and only between 1 and 15% will require an extracervical approach (ECA). Many controversies exist regarding the clinical presentation, evaluation, selection of cases for ECA, surgical technique and outcomes. This paper reviews the recent literature on the management, outcomes and evidence-based treatment strategies of ITG.

METHODS

We conducted a review of the literature on the evaluation, management and outcomes of surgery for ITGs.

RESULTS

The incidence of cancer in the ITGs ranges between 4 and 20%. Multiplanar CT scanning offers the best preoperative evaluation and aids to determine the approach. Most ITG can be accessed by TCA and ECA are only needed in maximum 15% of cases. In experienced hands, the outcome of these surgeries is comparable to thyroid surgery for non-ITG.

CONCLUSIONS

Surgery for ITG is challenging. The experienced surgeon however, with few exceptions can address ITG via TCA, with outcomes comparable to those of uncomplicated thyroid surgery.

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.

Can Thyroid Ultrasonography Predict Substernal Extension or Tracheal Compression in Goiters?

PURPOSE

To determine whether an ultrasonography (US)-defined thyroid volume can accurately predict substernal extension or tracheal narrowing.

METHODS

After research ethics approval, we identified patients with thyroid nodules investigated with both US and computed tomography (CT). Reviewers assigned scores for both substernal extension and tracheal compression on CT using pre-established classification systems. Statistical analysis with receiver operating characteristic curve analysis was performed to find the US-determined thyroid volume thresholds that correlated with each substernal extension and tracheal compression.

RESULTS

This study included 120 patients (mean age 63.4 years; SD ± 15.9; 67% female). Thirty-five patients (29%) had substernal extension. The mean US total thyroid gland volume in patients with and without substernal extension were 92.4 and 37.6 cm³, respectively (P < .001). 86% of patients with substernal extension had tracheal narrowing vs. 27% of patients without substernal extension (P < .0001). A cutoff dominant gland volume of ≥37.5 cm³ showed 83% sensitivity and 79% specificity for substernal extension (area under the curve [AUC] = 0.84). A total thyroid gland volume threshold of ≥37.8 cm³ showed 89% sensitivity and 87% specificity for any degree of tracheal narrowing (AUC = 0.90).

CONCLUSIONS

This study suggests that US volumes may be used as a predictor to identify those patients with thyroid enlargement who are most at risk of substernal extension and tracheal compression and who may benefit from preoperative CT imaging for optimal surgical and anesthetic planning.

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.

•

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.

Substernal goiter: Treatment and challenges. Twenty-two years of experience in diagnosis and management of substernal goiters

OBJECTIVE

Descending goiter has been a focus of controversy in thyroid surgery until nowadays. This study aims to investigate the diagnosis and treatment options of thyroid goiters extending into the mediastinum and the thoracic cavity.

METHODS AND MATERIALS

A retrospective study was conducted assessing all cases of substernal goiter managed in a tertiary care referral center within 22 years. Demographics, clinical, operative, anatomical, and pathological data of the patients were recorded and analyzed.

RESULTS

Among 3.028 total thyroidectomies, 212 procedures for substernal goiters were studied. All cases underwent total thyroidectomy. The surgical approach was cervical in all but two cases. A very low rate of complications and zero mortality were noted. Incidence of malignancy on permanent histology was 16%.

CONCLUSION

Descending goiter constitutes a major indication for thyroid surgery. The overwhelming majority of descending goiters may be managed surgically through a neck incision. In experienced hands good results with low morbidity should be expected. Such cases should be considered as challenging, however, and therefore management in a referral center may be necessary in order to ensure optimal results.

An unusual cause of hoarseness and recurrent laryngeal nerve palsy

Recurrent laryngeal nerve palsy and thyroid disease suggest locally invasive thyroid malignancy. In contrast, recurrent laryngeal nerve palsy caused by benign multinodular goiters or ectopic thyroid tissue accounts for only 1% of cases. This article describes an unusual case of recurrent laryngeal nerve palsy secondary to a benign ectopic retrosternal thyroid tissue mass. Recurrent laryngeal nerve palsy should be considered in the differential diagnosis of patients presenting with progressive voice weakness and hoarseness.

Medial Approach for the Resection of Goiters with Suprahyoid, Retropharyngeal, or Substernal Extension

BACKGROUND

Resection of massive goiters with suprahyoid, retropharyngeal, and substernal extension may not be amenable to standard approaches. This study evaluates a surgical approach allowing resection of massive goiters with minimal substernal and deep neck dissection.

METHODS

Cases of thyroidectomy for goiters with substernal, retropharyngeal, or suprahyoid extension at a single institution from 2006 to 2017 were reviewed. The technique involves initial complete division of the medial thyroid tracheal attachments after identification of the RLN medial-inferiorly or superiorly. Deep components are then delivered into the superficial paratracheal region of the neck.

RESULTS

Sixty patients were included, 46 of which had substernal and 14 had only suprahyoid or retropharyngeal extension. Mean substernal extension was 3.7 cm (range 1.5-7.5 cm). The medial approach was successful in identifying the RLN in 70 (83%) of 84 goiter sides (71% medial-inferiorly and 29% superiorly). Standard inferior/lateral approaches were used in 12 (14%) nerves or not found until after goiter removal in 2 (2.5%). No patients required sternotomy or tracheotomy. Complications included postoperative seroma/hematoma (n = 9, 15%) with one re-exploration, transient RLN injury (n = 4, 4% of all lobectomies), transient hypocalcemia (n = 6, 16% of total thyroidectomies), permanent hypocalcemia (n = 2, 5% of total thyroidectomies), and permanent RLN paralysis (n = 1, 1% of all lobectomies).

CONCLUSION

Large suprahyoid, retropharyngeal, and substernal goiters were resected transcervically with low morbidity. Early complete division of Berry's ligament after medial-inferior RLN identification was achieved in a high proportion of patients, facilitating goiter delivery with minimal mediastinal and deep neck dissection.

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.

The Value of Preoperative Volumetric Analysis by Computerised Tomography of Retrosternal Goiter to Predict the Need for an Extra-Cervical Approach

Background:

A thyroidectomy can be performed via a cervical incision in most patients with retrosternal goiter.

Aims:

To investigate the correlation between the volume of the mediastinal portion of the thyroid gland and the need for an extra-cervical approach for retrosternal goiter.

Study Design:

Diagnostic accuracy study.

Methods:

The measurement of craniocaudal length and the volume of the mediastinal component of the thyroid gland on computerised tomography images was performed in 47 patients with retrosternal goiter. Of these 47 patients, 8 (17%) required an extra-cervical approach and were classified as group 1, and 39 (83%) patients that required a cervical incision were classified as group 2. Receiver operating characteristic analysis was performed to determine the cut-off value for the craniocaudal length and the volume of the mediastinal thyroid mass, which significantly correlated with an extra-cervical approach for retrosternal goiter.

Results:

Reoperative surgery was significantly more frequent in group 1 than in group 2 (50% vs 13%; p=0.03). The craniocaudal length of the mediastinal thyroid gland was significantly longer in group 1 than in group 2 (77±11 mm vs 31±21 mm, respectively; p=0.0001). The volume of the mediastinal component was significantly larger in group 1 compared to group 2 (264±106 cm³ vs 40±41 cm³, respectively; p=0.0001). The receiver operating characteristic curve of craniocaudal length and the volume of the mediastinal component identified ≥66 mm and ≥162 cm³ as the cut-off values with the maximum accuracy, respectively. The craniocaudal length of the thyroid mass below the thoracic inlet ≥66 mm or a volume of the mediastinal portion ≥162 cm³ were significantly associated with an extra-cervical approach (p=0.0001). For predicting an extra-cervical approach, the sensitivity, positive predictive value and negative predictive value of the cut-off value for craniocaudal length was 87.5%, 64% and 97%, respectively. For predicting an extra-cervical approach, the sensitivity, positive predictive value and negative predictive value of the cut-off values for the mediastinal volume were 100%, 89% and 100%, respectively.

Conclusion:

A thyroid volume of ≥162 cm³ extending below the thoracic inlet was a significant determining factor for an extra-cervical approach, with a negative predictive value for the extra-cervical approach of 100% for retrosternal goiter with smaller volumes. Further studies with an increased number of patients are needed to determine the value of volumetric analysis of retrosternal goiter to predict the need for an extra-cervical approach in retrosternal goiter.

Cancer Frequency in Retrosternal Goiter

Retrosternal goiter prevalence is 5 to 40 per cent according to classifications in goiter series. Goiters with mediastinal extension were reported to be related with higher cancer rates. In our study, we aimed to investigate whether cancer incidence increased in retrosternal goiters compared with the cervical ones. Three hundred and ninety consecutive patients, who had surgery because of retrosternal goiter in Istanbul University Medical Faculty Department of General Surgery between 2005 and 2015 were included in the study (Group 1). Control group included 880 patients who had surgery because of nontoxic multinodular goiter in the same period (Group 2). Preoperative ultrasonography (USG) was performed to each patient. Fine-needle aspiration biopsy was performed in suspicious nodules and results were recorded. Carcinomas in histopathological examination were classified as intrathorasic and extrathorasic. Diagnostic rates of USG results were compared with histopathologic cancer results. Papillary carcinoma was diagnosed in 76 patients with retrosternal goiter (19%) and in 200 patients in the control group (22%). No statistically significant difference was detected between groups regarding the tumor rates (P > 0.05). One hundred and forty-four tumoral foci were detected in 76 patients with papillary carcinoma in retrosternal goiter patients. Three hundred and seventy tumoral foci were detected in 200 patients with papillary carcinoma in the control group. In the retrosternal goiter group, 104 carcinoma lesions of 144 papillary carcinomas were intrathorasic (72%). No statistically significant difference was detected between intrathorasic (2.1 ± 1 cm) and extrathorasic regiones (1.9 ± 0.8 cm) regarding the tumor size P > 0.05. When patients with and without cancer in the retrosternal goiter group were compared regarding familial thyroid cancer history, radiation to the neck, and cervical adenopathy, no statistically significant difference was detected. Cancer incidence of retrosternal goiters was not higher than that of the cervical ones. Yet, cancer foci of retrosternal goiters were commonly located in the intrathorasic area and were not detected with USG. Depending on these findings, we suggest that all retrosternal goiters should be surgically treated.