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.

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.

Substernal goiter and laryngopharyngeal reflux

ABSTRACT Objective This study aims to compare the prevalence of laryngopharyngeal reflux signs between two groups of patients undergoing thyroidectomy for voluminous goiter: substernal goiters and voluminous cervical goiter without thoracic extension. Subjects and methods A retrospective case-control study was performed with data retrieved of the charts of the patients submitted to thyroidectomies occurred at a tertiary care center (Head and Neck Surgery Department, University of São Paulo Medical School) between 2010 and 2014. The selected thyroidectomies were allocated in two groups for study: patients with substernal goiters and patients with voluminous cervical goiter without thoracic extension. Cervical goiters were selected by ultrasonography mensuration. Clinical criterion was used to define substernal goiter. Results The average thyroid volume in patients with substernal goiter was significantly greater than the average volume in patients with only cervical goiter (p < 0.001). The prevalence of signs of reflux laryngitis at laryngoscopy was significantly greater in substernal goiter patients (p = 0.036). Moreover, substernal goiter was considered as the unique independent variable for high reflux laryngitis signs at laryngoscopy (OR = 2.75; CI95%: 1.05-7.20; p = 0.039) when compared to only cervical goiter patients. Conclusion This study shows a significant association between substernal goiters and signs of laryngopharyngeal reflux at preoperative laryngoscopy. Therefore, when compared with voluminous cervical goiters, the substernal goiters increase the chance of reflux laryngitis signs in patients.

Substernal goiter and laryngopharyngeal reflux.

OBJECTIVE: This study aims to compare the prevalence of laryngopharyngeal reflux signs between two groups of patients undergoing thyroidectomy for voluminous goiter: substernal goiters and voluminous cervical goiter without thoracic extension. SUBJECTS AND METHODS: A retrospective case-control study was performed with data retrieved of the charts of the patients submitted to thyroidectomies occurred at a tertiary care center (Head and Neck Surgery Department, University of São Paulo Medical School) between 2010 and 2014. The selected thyroidectomies were allocated in two groups for study: patients with substernal goiters and patients with voluminous cervical goiter without thoracic extension. Cervical goiters were selected by ultrasonography mensuration. Clinical criterion was used to define substernal goiter. RESULTS: The average thyroid volume in patients with substernal goiter was significantly greater than the average volume in patients with only cervical goiter (p < 0.001). The prevalence of signs of reflux laryngitis at laryngoscopy was significantly greater in substernal goiter patients (p = 0.036). Moreover, substernal goiter was considered as the unique independent variable for high reflux laryngitis signs at laryngoscopy (OR = 2.75; CI95%: 1.05-7.20; p = 0.039) when compared to only cervical goiter patients. CONCLUSION: This study shows a significant association between substernal goiters and signs of laryngopharyngeal reflux at preoperative laryngoscopy. Therefore, when compared with voluminous cervical goiters, the substernal goiters increase the chance of reflux laryngitis signs in patients.

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.

Substernal goiter: Experience with 50 cases.

INTRODUCTION: Goiter is localized or generalized thyroid hypertrophy. It is usually cervical, but may show intra-thoracic development beyond the thoracic inlet and down to the mediastinum: i.e., substernal goiter. The purpose of this study was to analyze the epidemiological, clinical and paraclinical profile of substernal goiter and the difficulties of management. MATERIAL AND METHODS: A retrospective study included 50 cases from our ENT department. RESULTS: Mean age was 47 years, with a sex ratio of 0.06. Clinical symptomatology was dominated by medial anterior cervical swelling. Compression signs were observed in 26 patients, and cervical lymph nodes in 3. Mean time to consultation was 7 years. Fiberoptic endoscopy found vocal cord palsy in 3 patients. Cervical ultrasonography was the first-line diagnostic test. Cervical-thoracic CT scan was requested in 45 patients to study thoracic extension and the relation of the thyroid mass with the supra-aortic vascular axes. Treatment systematically comprised total thyroidectomy on a cervical approach. There were 6 cases of malignancy. DISCUSSION-CONCLUSION: Substernal goitre is fairly frequent. Despite particularities, an exclusively cervical approach is sufficient in a large majority of cases. The substernal nature of the goitre did not have major impact on postoperative complications.

Video assisted thoracoscopic thyroidectomy for retrosternal goitre.

INTRODUCTION: Thyroidectomy for retrosternal goitre is usually carried out through a cervical incision. Around 4-12% of patients, however, require an extracervical approach, usually by sternotomy. Anatomically, the thyroid extends deep behind the great vessels in the pretracheal fascia. A sternotomy is therefore not only a substantial incision but this anterior approach is also not ideal for exposure. We report the use of video assisted thoracoscopic surgery (VATS) instead of a sternotomy or thoracotomy in conjunction with a transverse cervical incision for these patients. METHODS: A retrospective descriptive study was carried out of seven patients with retrosternal goitre who underwent a VATS thyroidectomy. RESULTS: Twenty-one patients with retrosternal goitre were referred to our institution for surgical excision with the anticipation of requiring an extracervical incision. Of these, seven (median age: 68 years, range: 58-73 years) underwent a VATS thyroidectomy. The median operating time was 218 minutes (range: 120-240 minutes). The median diameter of the retrosternal goitre was 70 mm (range: 40-145 mm). Only one patient required conversion to a manubriotomy to deliver the bulky thyroid and one patient suffered a transient right recurrent laryngeal nerve palsy. The median postoperative pain scores for days 0 and 1 were 1 (range: 0-5) and 0 (range: 0-3) respectively. The median length of stay was 5 days (range: 3-7 days). CONCLUSIONS: The use of VATS in thyroidectomy for retrosternal goitre offers a minimally invasive approach resulting in less morbidity while affording excellent exposure.

Retrosternal goiters.

UNLABELLED: The term of retrosternal or substernal goiter means that more than 50% of thyroid gland descends in the thorax. MATERIAL AND METHODS: There is a retrospective study on retrosternal and substernal goiter and its patological features among 2482 patients who underwent thyroidectomy between 2000 and 2010 in the First Surgery Clinic of Iasi. Retrosternal goiter was identified 54 patients (2.17%). All patients were refered to surgery from the Clinic of Endocrinology. RESULTS: Mean age at diagnosis was 55.3 +/- 3.58 years, and most cases were found in women (83.3%). The clinical pictures of retrosternal goiter was dominated by compressive disorders. Thyroid function abormalities were identified by hormonal assays performed on Endocrinology Clinic lasi in 15 cases (27.7%). The diagnosis of retrosternal goiter was suggested by clinical examination and confirmed by imagery: thorax X ray, ultrasonography, CT scan. The cervical approach was being safely performed. Only in 8 cases (14,8%), sternotomy was necessary. There was no mortality and morbidity was 5.5% (3 cases). The length of stay in the hospital was 4.3 days. We compared our recent data with a previous report on retrosternal and thoracic goiter treated in First Surgery Clinic of lasi during 1950 to 1979 and published in the journal "Chirurgia" in 1981. CONCLUSIONS: Retrosternal goiter is a particular form of thyroid surgical pathology presentation with declining incidence. Diagnosis and treatment of retrosternal goiter involve a multidisciplinary team. The endocrinologist has an important role in diagnosis and postoperative follow-up. Surgery is the treatment of choice for substernal goiters, but there are still some controversies on surgical approach, and complication rate. The cervical approach can be safely performed in almost all cases but when required, sternotomy should be performed without hesitation.

[The plunging goiter : about 43 cases]. / Les goîtres plongeants : à propos de 43 cas.

BACKGROUND: The plunging goiter consists in a goiter whose lower limit is not palpable in surgical position. AIM: To study the epidemiologic characteristics, the circumstances of discovery, the clinical signs, and the management of this disease. METHODS: A retrospective study about 43 cases of plunging goiters operated during a period of 14 years in the ENT department of the hospital The Rabta Tunis. RESULTS: The average age of our patients was 59.3 years. On physical examination, goiter was palpable in 41 patients (95.3%). The plunging character of the goiter was noted, at echography, in 26 patients. A cervico-thoracic scanner was performed in 41 patients (95.3%). It helped to confirm the plunging goiter in all patients. These goiters were most frequently pre vascular (73.2%) compared to the innomined venous trunk. The lower limits of the intrathoracic extensions were on the level of the superior vena cava in 4 cases (9.7%), on the level of the left brachio-cephalic venous trunk in 16 cases (39%) and on the level of the aortic arch in 15 cases (36,5%). The cervical incision was sufficient in 39 cases (97.5%) and we used a combined sternotomy in one patient (2.5%). CONCLUSION: The plunging goiter is a thyroid tumour cervical originally descended, then developed, in the mediastinum. A good clinical examination and paraclinical can reach a definite diagnosis and to achieve better surgical.

Substernal goiters: incidence, surgical approach, and complications in a tertiary care referral center.

BACKGROUND: Surgery is the treatment of choice for substernal goiters, but there are still some controversies on their definition, the surgical approach, and the complications rate. We analyzed our experience in a tertiary care referral center. METHODS: Among a series of 2263 patients who underwent thyroidectomy between 2004 and 2008, 355 patients with substernal goiter were identified. A control group of 355 patients with cervical goiters operated on during the same period was selected. The operative and pathological characteristics and the complications rate of the 2 groups were compared. RESULTS: Only 2 patients (0.6%) required an extracervical approach (1 primary intrathoracic goiter and 1 recurrent carcinoma). No significant difference was found in terms of complications between the 2 groups. CONCLUSION: The cervical approach can be safely performed in almost all the patients with substernal goiters. An extracervical procedure has very limited indications. Substernal goiter is not associated with increased complications rate.

Primary intrathoracic goiter: a rare and potentially serious entity.

BACKGROUND: Here we review primary intrathoracic goiter (P-ITG), a rare but potentially serious congenital entity that is distinct from the much more common secondary intrathoracic goiter. The latter is an extension of cervical thyroid that descends within the mediastinum. In contrast, P-ITGs lack a connection with the cervical thyroid and their blood supply comes from intrathoracic vessels. SUMMARY: P-ITGs can coexist with a normal or goitrous thyroid gland. When they coexist, either or both may be independently affected by neoplastic, infectious, or infiltrative processes. P-ITGs are mainly located in the anterosuperior mediastinum. Location in posterior or middle mediastinum is observed in 15% of cases, making the diagnosis challenging. Although P-ITGs are rare, they are important because they may reach large dimensions with serious consequences. Compression of the trachea is the most common clinical finding, but compression of other mediastinal organs is also observed. Computerized axial tomography (CT) and radionuclide imaging can suggest or make the diagnosis in most cases. The differential diagnosis includes other mediastinal tumors that show high attenuation on unenhanced CT. The treatment of choice is surgical resection of the goiter through a thoracic approach. Thoracic surgery for resection of a small primary mediastinal goiter is considered to be a relatively safe procedure. Long-standing P-ITGs may cause pressure on the trachea, however, resulting in tracheomalacia. This development is serious in its own right and complicates thoracic surgery. CONCLUSIONS: Resection through a thoracic approach is the appropriate treatment for a P-ITG. Surgical intervention is usually indicated without delay upon the establishment of the diagnosis because these goiters exhibit progressive growth. When P-ITGs are small, this approach should prevent the development of tracheomalacia and other serious complications.

Substernal goiters and sternotomy.

OBJECTIVE: To determine what factors predispose patients with retrosternal goiters to median sternotomy. STUDY DESIGN: Retrospective review. METHODS: Analysis of a single surgeon experience with 113 substernal goiters operated upon during a 10-year period. RESULTS: 108 goiters were successfully removed through a cervical approach. Four patients required sternotomy, and it was concluded that one patient who did not receive sternotomy might have been better managed with sternotomy. Factors that led to sternotomy were malignancy, involvement of the posterior mediastinum, extensive substernal extension, and the presence of an ectopic nodule. The latter two were the most important factors. Revision surgery and tracheal compression did not influence the need for sternotomy. CONCLUSIONS: On the basis of preoperative imaging, it is possible to predict which patients with retrosternal goiters are likely to require median sternotomy. These factors are malignancy, extension into the posterior mediastinum, substernal extension inferior to the level of the aortic arch, and the lack of a solid attachment between the cervical and mediastinal components of the thyroid gland. Although previously reported, the latter factor has not received sufficient recognition in the management of retrosternal goiter.

Increasing incidence of thyroid cancer is due to increased pathologic detection.

BACKGROUND: There has been a marked increase in the incidence of thyroid cancer worldwide over recent decades. Patients with retrosternal goiter (RSG) are not picked up generally by common surveillance techniques such as ultrasound. The aim of this project was to study the incidence of thyroid cancer in patients with RSG. METHODS: This is a retrospective cohort study. Documented were patient demographics as well as the size, type, and numbers of thyroid cancers. The number of routine histologic blocks examined for multinodular goiter in the different time periods was also examined. RESULTS: Within a cohort of 13,793 thyroidectomies performed over 40 years, there were 2,260 patients (14%) who underwent surgery for RSG. The percentage of patients with RSG containing thyroid cancer increased from 3.6 to 7.5% (P < .05); however, once papillary microcarcinomas (PMC) (

[Clinical signs and correlation with radiological extent in a series of 117 retrosternal goitre]. / Signes cliniques et corrélations radiocliniques dans une série de 117 goitres cervico-thoraciques.

OBJECTIVES: To report, compare the clinical signs and the radiological signs of retrosternal goitre (cervico-thoracic goitre) and try to establish a correlation between clinical signs and radiological extent. PATIENTS AND METHOD: One hundred and seventeen patients with a goitre beyond the sub-clavian vessels in cervico-thoracic CT-scan and with a benign histopathology examination after thyroid surgery in the head and neck department, University Hospital, Amiens, France between February 1997 and January 2004 were included in this retrospective study. The initial clinical assessment includes the respiratory and swallowing functional signs, palpable mass and mobility of the vocal cords. A correlation is analyzed between the extent of the goitre, the anatomic relations with the trachea and oesophagus and clinical signs. RESULTS: Dyspnea is the commonest of the functional signs (39.3%) for young subjects (p < 0.05), due to tracheal compression regardless of the side of extension of the goitre. Dysphagia (16.2%) is not correlated with the extent of the goitre in this series. A cervical palpable mass is present in 69.2% of cases. CONCLUSION: The cervico-thoracic CT-scan is the key examination of the assessment of a retrosternal goitre making it possible to appreciate its features, its anatomic relations and its tracheal involvement sometimes announced by respiratory disorders, the presence of a dysphagia should alert to the possibility of posterior extension which can not be felt during the cervical palpation.

Substernal goiters.

BACKGROUND: Substernal goiter, also said cervico-mediastinic goiter, is a thyroid formation with cervical departure that goes beyond, with stretched neck, the superior thoracic strait for at least 3 cm and that preserves, generally, the parenchimal or fibrous connections between the cervical and thoracic portion, maintaining a direct vascularization supplied by the thyroid arteries. The prevalence of this pathology is very variable and fluctuates between 1.7% and 30% of all thyroid damages. The actual classification is provided by the radiologic examination of the chest and, above all, by the new techniques of imaging. METHODS: In the period between January 1998 and December 2003, 332 patients with thyroid pathology have been treated surgically. Forthy-five (13.5%) of these were afflicted with a cervico-mediastinic goiter. In 32/45 (71.1%) cases a total thyroidectomy has been performed by collar carving in accordance with Kocher; in 11/45 (24.5%) cases an hemithyroidectomy has been performed by collar incision; in 2/45 (4.4%) cases, already submitted to surgical intervention of isthmus-lobectomy a totalization has been performed. RESULTS: The surgical technique foresees always an anterior collar neck incision. This way of access is to prefer in the substernal goiters, both for the presence of a cervical vascularization easy to control and for the possibility, nearly always realizable, to dislocate the goiter by that way. As for what concerns the results of the histological examination, in 2/45 (4.5%) cases it has been set a diagnosis of follicular carcinoma (one of them surely invading and the other, leastly invading), in 3/45 (6.6%) cases papillary carcinoma, in 4/45 (8.8%) cases colloido-cystic goiter, in 33/45 (73.5%) cases micro-macrofollicular hyperplasia (in one of which contemporarily compromise from lymphoma of Hodgkin); in 3/45 (6.6%) cases of adenomatous hyperplasia of the thyroid. DISCUSSION: The surgical approach has been in all cases the collar neck incision in accordance to Kocher, and it has never been necessary to associate a sternotomy or thoracotomy. After the intervention, in all the patients the symptomatology tied to the mediastinal compression has disappeared. The goiter showed signs of neoplastic degeneration in 11.1% of the cases, with prevalence of the papillary carcinoma in the 6.6% and, in the remaining 4.5%, of follicular carcinoma. These data are superimposable to the data gathered in other surveys. All the patients passed the post-operating hospitalization in optimal conditions and have been discharged during the fourth post-operating day with the prescription of increasing levothyroxine doses according to the body weigh.

Pattern of intrathoracic goiter in Ibadan, Nigeria.

This study is to review the pattern of intrathoracic goiter in a large black population. In a retrospective review, the cardiothoracic unit managed ninety-eight primary mediastinal masses of which sixteen patients with intrathoracic goiters were treated during the same period. This constitutes 1.3% of treated goiters and 16.3% of primary mediastinal masses. Seventy-five per cent of the intrathoracic goiters were in association with cervical goiters. Twelve of the intrathoratic goiters were located in the anterosuperior mediastinum, and two in the middle mediastinum. There were three goiters in the posterior mediastinum. Six patients had cervical exploration and median sternotomy, three had cervical exploration and thoractomy, 3 had only thoractomy, two had only median sternotomy for excision. Thirteen patients (81.3%) had either simple colloid or multinodular intrathoracic goiter, one had follicular adenoma, and 2 patients had malignant goiters. One patient had recurrent cervical goiter. The endemicity of thyroid disease does not seem to increase the frequency of intrathoracic goiter.

Substernal goiter: a clinical review.

Thyroid disease is a very common problem, but indications for surgery are few. We have seen a large number of patients with multinodular goiter. The main indications for surgery in thyroid disease include fear of malignancy, tracheo-esophageal compression, and cosmetic reasons. Tracheo-esophageal compression is most commonly noted in patients with mediastinal goiters. Substernal goiter is defined as those situations in which at least 50% of the gland is in the mediastinal location. Although its incidence has decreased, it remains prevalent in almost every country in the world today. SSG is best diagnosed by a thorough history and physical examination, complemented by airway films, fiberoptic laryngoscopy, and computerized tomography. The most common presenting symptoms are those produced secondary to compression effects. SSG show a poor response to medical treatment. Moreover, given their propensity to cause acute airway symptoms, surgical treatment should be considered in most cases. Extirpation of the gland is best performed through a collar incision, with the addition of a median sternotomy in select few and difficult cases. Median sternotomy is necessary in only 1% to 2% of cases. Operative mortality is negligible, and the incidence of complication is minimized by following strict surgical principles.

[Surgery in goiter with a primary mediastinal manifestation]. / Cirugía en el bocio con manifestación primaria mediastínica.

Eight patients with mediastinal masses and occupational syndrome were presented. Seven were diagnosed prior to surgery, allowing the staff to plan the procedure. The cervical route is advisable. It provides the best exposure that provides the safest surgery, but the incision must often be enlarged for the patient's safety. Results of surgery are excellent, with immediate relief of compressive symptoms. Postoperative infection of the wound is a possible complication. Results of medium- and long-term follow-up lead us to advise concomitant medical treatment along with surgery, given the risk of recurring goiter.

Management of substernal goitre.

Goitres of the thyroid gland whose major component resides substernally would appear to have a different presentation and management protocol than those goitres that reside mainly in the neck. These goitres, as opposed to their supraclavicular counterparts, usually present with symptoms referrable to compression of the trachea or esophagus. Even in those patients who are asymptomatic, a precise history may elicit pertinent findings. Furthermore, these goitres do not respond to suppression and require surgical removal. The trans-cervical approach is the most desirable, but the surgeon must be willing to enter the chest on that rare occasion. We reviewed the charts of 938 patients undergoing thyroid surgery who were registered in the Head and Neck Tumour Registry of the University of Toronto. Approximately 2.4% of patients had substernal goitres. Their history, pathology and ultimate surgical management will be discussed.