Substernal Goiter: a case to remember

SUMMARY Goiter is a localized or generalized thyroid hypertrophy. It can remain within the cervical region or grow down until it invades the mediastinum. The signs and symptoms depend on the size and location of the goiter. Although drugs and radioactive iodine are often used to treat thyroid disease, the presence of symptomatic substernal goiter is a clear indication for surgery. Death or postoperative complications rarely occur. We present a case of a 71-year-old man with recurrent thyroid pathology in the form of substernal goiter and hyperthyroidism even after partial thyroidectomy. The importance of this relates to the clinical evolution, volume, and location of the goiter as well as the surgical and pharmacological approach.

RESUMO O bócio é a hipertrofia da glândula tiroide localizada ou generalizada. Esta pode localizar-se na região cervical ou crescer através do mediastino. Os sinais e sintomas dependem do tamanho e da localização do bócio. Embora os fármacos e o iodo radioativo sejam frequentemente usados para tratar doenças tireoidianas, a presença do bócio subesternal sintomático é uma clara indicação para a cirurgia. A morte ou complicações pós-operatórias são raras. Apresentamos o caso de um homem de 71 anos com recorrência de patologia tireoidiana sob a forma de bócio subesternal e hipertireoidismo após tireoidectomia parcial. A importância desse caso relaciona-se com a evolução clínica, o volume e a localização do bócio e a abordagem cirúrgica e farmacológica desse tipo de patologia.

Assessment and surgical treatment for 58 substernal goiter / 中华耳鼻咽喉头颈外科杂志

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

Bocio endotorácico. Presentación de dos casos / Endothoracic goiter. Presentation of two cases

Un bocio se considera intratorácico cuando más de un 50 % de la glándula tiroides está en el mediastino, o sea, por debajo del nivel del estrecho torácico superior. Es una enfermedad poco frecuente, que representa alrededor del 10 % del total de las masas mediastínicas. Se presentan dos casos de pacientes operadas de bocio endotorácico en el hospital Dr. Gustavo Aldereguía Lima de Cienfuegos. El tratamiento quirúrgico aplicado fue la hemitiroidectomía derecha, con istmectomía y resección de la prolongación mediastínica del tumor. Se trata de una entidad poco frecuente, por lo que se considera de interés su publicación.

A goiter is considered thoracic when more than 50% of the thyroid gland is in the mediastinum, under the level of the upper thoracic inlet. It is an infrequent disease, which represents about 10% of the mediastinal masses. Two cases are presented of patients who underwent endothoracic goiter surgery in the Hospital Dr. Gustavo Aldereguía Lima of Cienfuegos. The surgical treatment applied was right hemithyroidectomy, with isthmectomy and resection of the mediastinic tumor extension. It is an infrequent entity, reason for which it is considered a publication of interest.

Necessity of Bone Wax Stanching Bleeding at Sternal Edge in Patients With Cardiac Surgery by Median Sternotomy / 中国循环杂志

Objective: To explore the necessity for application of bone wax stanching bleeding at sternal edge in cardiac surgery by median sternotomy. Methods: A total of 445 patients who receive cardiac surgery by the same surgeon performing median sternotomy in our hospital from 2011-01 to 2014-12 were studied. According to application of bone wax stanching bleeding, the patients were divided into 2 groups: Bone wax group,n=210 and Non-bone wax group,n=235. Re-thoracotomy for hemostasis, 12 h, 24 h and total draining volume after the operation and time of closing incision were compared between 2 groups. Results: There were 2 patients and 1 patient received re-thoracotomy for hemostasis in Bone wax group and Non-bone wax group respectively, which was not related to bone marrow cavity bleeding. In Bone wax group and Non-bone wax group, the draining volume at 12 h post-operation were (451 ± 240) ml vs (483 ± 238) ml, at 24 h post-operation were (615 ± 304) ml vs (639 ± 285) ml and the total volume were (842 ± 467) ml vs (842 ± 364) ml, allP>0.05; the time of closing incision were (68.0 ± 23.0 ) min vs (66.0 ± 19.0 ) min,P>0.05; the total transfusion rates were 21% vs 19%,P>0.05. Conclusion: Application of bone wax at sternum edge could neither affecting the drainage nor the speed of closing incision in cardiac surgery and therefore, it might be given up.

Percutaneous microwave ablation of type I substernal goiter under ultrasonic guidance / 中华超声影像学杂志

Objective To investigate the feasibility and clinical effect for percutaneous microwave ablation of type I substernal goiter under the guidance of ultrasound . Methods Thirteen patients with type I substernal goiter were selected . All patients underwent percutaneous microwave ablation treatment under the guidance of ultrasound . Thirteen patients with 47 medals nodules were performed ultrasound guided percutaneous microwave ablation . Intraoperative heat blocking blood flow was used to prevent severe hemorrhage .Liquid isolation belt and leverage from methods were used to effectively prevent surrounding important structures against heat damage .Small amount of residual method was used to avoid tracheal collapse . All patients were followed up post‐operative 1 ,3 ,6 ,12 months by monitoring of thyroid nodule volume change , adverse reactions , and postoperative complications . Results Thirteen patients with 47 medals nodules were successfully performed percutaneous microwave ablation guided by ultrasound . Among them ,2 patients performed the second treatment for too large volume of goiter ,tracheal displacement and poor physical tolerance of older . The postoperative ultrasound contrast and color Doppler showed that the lesions were completely inactivated . No obvious complications occurred in all 13 patients , and no permanent hoarseness occured . The symptoms of cervical oppression and discomfort disappeared for all patients within 1-4 months after surgery . Thirteen patients were followed up for 12 months after the operation . The thyroid function was normal and the volume reduction rate of thyroid nodules was (85 ± 31)% . Conclusions Percutaneous microwave ablation of type I substernal goiter under ultrasonic guidance is a safe and effective method to reduce the thyroid nodules with no serious complications . It is worth to be popularized in clinical practice .

Surgical treatment of substernal goiter : analysis of 102 patients / 中华普通外科杂志

Objective To summarize surgical experience for the treatment of substernal goiter.Methods 102 cases of substernal goiter underwent surgical resection,in 74 by low collar incision,12 cases by larger low collar incision and pillowing the shoulder pad about 20 degrees for neck hyperextension,8 cases by unilateral or bilateral infrahyoid muscles transection,8 cases by low collar and up-mid-sternal incision plus horizontal sawing in 2 and 3 ribs.Results Resection was performed successfully in all cases.Hoarseness occurred in 7 cases,4 cases recovered after one month,3 cases did not improve because of tumor invasion of laryngeal recurrent nerve.Postoperative transient hypocalcemia in 9 cases recovered after 2 to 3 months.102 patients were followed up for 1 to 3 years without recurrence.Conclusions Substernal goiter can be resected successfully through a transcervical approach or mid-sternal incision.CT scanning and chest X radiograph are decisive for the surgical approach.

Experience of managing substernal goiter by totally endoscopic procedure / 北京大学学报(医学版)

SUMMARY To summarize the experience of managing substernal goiter by totally endoscopic procedure and evaluate the curative effect , we analysed eight patients diagnosed as substernal goiter type Ⅰ and treated with totally endoscopic technique via central routing approach during March 2011 to June 2013 in Beijing Shijitan Hospital retrospectively .The feasibility , safety and curative effect of this surgical tech-nique were estimated .All the cases were successfully operated with the totally endoscopic procedure , and the pathological result showed that 6 were goiter and the other 2 were minimal papillary carcinoma .None of the patients suffered from any complication , and the median follow up time was 6 months ( 1 -28 months) .The totally endoscopic technique is a feasible , safe and cosmic one for managing substernal goiter type Ⅰ.

Caracterización y resultados inmediatos en pacientes con tratamiento quirúrgico de bocio intratorácico / Characterization and immediate results in patients with surgical treatment of intrathoracic goiter

Objectives: To describe characteristics and immediate results of surgical treatment of patients with intrathoracic goiter (ITG). Methods: Retrospective review. Period: October 2003 - March 2010. We describe general characteristics, morbidity and mortality. Results: 33 patients, 23 women, mean age 59.1 +/- 14.3 years. Preoperative thyroid function: 32 euthyroid and 1 hyperthyroid. Asymptomatic 10 patients. ITG rate: 31 cervico-mediastinal and 2 mediastinal. Approach: 24 cervicotomy, 7 cervicotomy and sternotomy and 2 sternotomy. Type of resection: 19 total thyroidectomy and 14 subtotal thyroidectomy. Histology: 29 benign and 4 malignant neoplasms. Postoperative stay: median of 4.5 days. Complications in 12 patients: 10 hypo-parathyroidism (9 transient and 1 permanent), 2 dysphonia, 2 cervical hematoma (one redo), 1 wound infection and 1 ventilator associated pneumonia. One patient died (pneumonia). Conclusions: The ITG is more common in women, most are euthyroid and may be asymptomatic. Most can be resected by cervicotomy. The histology is benign in most but may represent malignancies. The surgery is not free of morbidity and mortality.

Objetivos: Describir características y resultados inmediatos del tratamiento quirúrgico de pacientes con Bocio Intratorácico (BIT). Material y Método: Revisión retrospectiva. Período: octubre de 2003 - marzo de 2010. Se describen características generales y morbi-mortalidad. Resultados: 33 pacientes, 23 mujeres, edad promedio 59,1 +/- 14,3 años. Comorbilidades: 12 hipertensos y 1 diabético. Función tiroidea preoperatoria: 32 eutiroideos y 1 hipertiroideo. Asintomáticos 10 pacientes. Tipo BIT: 31 cérvico-mediastínicos y 2 mediastínicos. Abordaje: 24 cervicotomía, 7 cervicotomía más esternotomía y 2 esternotomía. Tipo de resección: 19 tiroidectomía total y 14 tiroidectomía subtotal. Histología: 29 benignos y 4 neoplasias malignas. Estadía postoperatoria: mediana de 4,5 días. Complicaciones en 12 pacientes: 10 hipoparatiroidismos (9 transitorios y 1 permanente), 2 disfonías, 2 hematomas cervicales (uno se reexploró), 1 infección herida operatoria y 1 neumonía asociada a ventilación mecánica. Fallece un paciente (neumonía). Conclusiones: El BIT es más frecuente en mujeres, la mayoría son eutiroideos y pueden ser asintomáticos. La mayoría pueden ser resecados por cervicotomía. La histología es benigna en la mayoría aunque pueden corresponder a neoplasias malignas. La cirugía no está exenta de morbi-mortalidad.

Diagnosis and surgical therapy of substernal goiter / 中华普通外科杂志

Objective To study the presentation,sensitivity of different diagnostic methods,snrgical modalities and pathological findings for patients of substemal goiter. Methods The clinical data of fifty nine cases of substernal goiter surgically treated were retrospectively analyzed. Results The main symptoms of substernal goiter patients were asymptomatic cervical mass(39/59),airway obstruction (13/59),hyperthyroidism(4/59),hoarseness(3/59)and choke(3/59).The sensitivity of chest X-ray,ultrasonography,CT and scintigraphy was 62.8%,15.8%,85.7%,and 50.0%respectively,and the specificity Was 99.4%,99.8%,99.5%and 99.0%,respectively.Standard cervical approach was successful for thyroidectomy operations in 57 cases.One patient underwent thyroidectomy by sternotomic approach,and another one by combined cervici-sternotomic approach.No major complications or perioperative deaths occurred.Pathology revealed nodular goiter in 48 cases.Grave's disease in one,thyroid adenoma in 2,and carcinoma in 8. Conclusions CT and chest X-ray are sensitive diagnostic techniques for substerual goiter.Cervical approach is appropriate for most substernal goiter.