Transcervical Approach for Mediastinal Mass Originated from Thyroid Gland: An Alternative Surgical Option Using Ballooning Catheter

PURPOSE: The aims of this study were to introduce an alternative surgical technique using a ballooning catheter and assess the outcomes of its use in patients with an upper mediastinal mass originated from the thyroid gland. METHODS: Between May 2001 and April 2004, 8 patients undewent an operation via a cervical approach using a ballooning catheter were enrolled in this study. The study group was reviewed by their clinical characteristics, diagnostic methods, postoperative results, histopathological findings and prognosis. Instead of a sternotomy, a ballooning catheter technique was used to assist in the transcervical delivery and extraction of these huge or deep mediastinal masses. The ballooning catheter was placed at the base of the mediastinal mass via a narrow plane which could not be reached by the surgeon's fingers. When the mediastinal mass was freed up by careful dissection with traction using an inflated ballooning catheter, could the mass was able to be delivered without injury to the surrounding tissues. RESULTS: There were 3, 2 and 3 cases of substernal goiters, substernal goiters combined with a papillary microcarcinoma and metastatic papillary carcinoma from thyroid cancer, respectively. The mean operation time and period of hospitalization were 121 minutes, (ranging from 70 to 195 minutes), and 6 days, (ranging from 3 to 10 days), respectively. In the 5 cases with a substernal goiter, the average size of the resected specimen was 9.9 cm, (ranging from 5.5 to 17.6 cm), with an average weight of 100.2 g, (ranging from 45 to 172.2 g). In the 3 cases of metastatic mediastinal lymph nodes, the postoperative 131I scan and serum thyroglobulin level showed no evidence of remnant metastatic tissue or cancer spillage. The median follow up duration was 24.8 months (ranging from 13 to 42 months). No major complications were documented, and no evidence of recurrence was encountered. CONCLUSION: The use of the ballooning catheter was found to be helpful in the transcervical removal of an upper mediastinal mass, and useful for substernal goiters. Furthermore, for mediastinal lymph node metastasis, this technique can be adopted as an alternative method in carefully selected cases.

Graves' Disease Presenting Concurrently with Thyroid Cancer

PURPOSE: Graves' disease presenting concurrently with thyroid cancer is a rare condition. The clinical behaviors and the extent of surgery in this condition is still controversial. This study examined the prognostic factors influencing the long-term outcomes as well as the appropriate treatment modalities in patients with Graves' disease presenting concurrently with thyroid cancer. METHODS: Forty nine patients who underwent surgery for thyroid cancer with Graves' disease were enrolled in this study. The outcomes of various types of surgical treatments as well as the factors associated with the long-term outcome were retrospectively analyzed. RESULTS: There were 42 women and 7 men with a median age 39 years (15~70 years). The surgical procedures included a bilateral subtotal thyroidectomy (n=17), a bilateral total thyroidectomy (n=16), and a total and contralateral subtotal thyroidectomy (n=16). The mean follow-up period was 83 months (4~218 months) after surgery. Disease-free survival at 5 and 10 years were 97.6% and 88.9%, respectively. Univariate log-rank survival analyses revealed that the age at diagnosis, the size of the thyroid cancer, capsular invasion, multiplicity, lymph node involvement, and clinical cancer to be poor prognostic factors. However, the extent of the surgical treatment was not significant for survival. CONCLUSION: The prognosis is expected to be poor when thyroid cancer presenting concurrently with Graves' disease is clinically apparent or has invaded the thyroid capsule. Patients with Graves' disease should be screened with ultrasonography to detect thyroid cancer. A total thyroidectomy or completion total thyroidectomy is not necessary in patients who do not have any of the poor prognostic factors, such as incidentally detected microcarcinoma postoperatively.

Infected Urachal Remnants with Symtoms of the Acute Abdomen: The Differential Diagnosis & Proper Management

PURPOSE: Urachal anomalies are rare, but often give rise to a number of problems, such as infection, rupture, sepsis and malignant change. The abdominal manifestation of urachal remnants often prompts referral to general or urologic surgeons. Herein, our clinical experiences were analyzed and guide lines for the preoperative diagnosis and proper management of complicated urachal anomalies suggested. METHODS: Twelve cases of urachal cyst, who visited the surgery department of Pochon CHA university hospital between April 1, 1995 and December 10, 2002, were studied. Clinical data, including clinical manifestations, diagnostic modalities and treatment methods were reviewed. RESULTS: Of the twelve cases reviewed, nine were males and three were females with a mean age of 33.6 years. The most common clinical manifestation was abdominal pain (58%), followed by a palpable mass (25%). The accuracies of the diagnostic modalities were 60 and 37% for abdominopelvic computed tomography and abdominal ultrasonography, respectively. The preoperative diagnosis rate was 50%, with one case not even diagnosed during surgery. CONCLUSION: Persistent urachal remnants can present at any age, with a variety of clinical manifestations. Abdominal computed tomography is a reliable diagnostic tool, and additional diagnostic studies are not generally warranted. The early surgical treatment seems to be the best solution prior to the onset of complications that would expose patients to difficult surgical operations and protract hospitalization.