Cirugía robótica endotorácica en la patología de tiroides y paratiroides / Robotic thoracic surgery in thyroid and parathyroid pathology

Introducción y objetivo: Durante la última década se ha producido una amplia difusión de los abordajes torácicos mínimamente invasivos para el tratamiento de enfermedades pulmonares y mediastínicas. Clásicamente, la patología quirúrgica torácica derivada de afecciones de tiroides y paratiroides ha sido tratada mediante abordajes abiertos como la esternotomía, la cervicoesternotomía y la toracotomía. Sin embargo, en los últimos años, la cirugía robótica ha surgido como una nueva vía de abordaje mínimamente invasiva que aporta resultados similares y ventajas significativas sobre otros abordajes mínimamente invasivos como la laparoscopia y la videotoracoscopia. Su aplicabilidad en el tratamiento quirúrgico de lesiones mediastínicas ha quedado ampliamente demostrada en la literatura. El objetivo del presente artículo es describir las indicaciones de la cirugía robótica torácica en la patología tiroidea y paratiroidea, así como comentar los principales aspectos técnicos relacionados con estos procedimientos.Síntesis: La cirugía robótica torácica está indicada especialmente en casos de “bocios olvidados” y de bocios ectópicos. En casos de bocios cérvico-mediastínicos el abordaje combinado cervical y torácico robótico ha demostrado ser una opción factible y segura. Por lo que respecta a las.paratiroides ectópicas de localización mediastínica, el abordaje robótico ofrece ventajas significativas como la visión en 3D y la optimización de la maniobrabilidad de instrumentos que facilitan la visualización y disección de la glándula.Conclusiones: La cirugía robótica constituye un abordaje mínimamente invasivo eficaz y seguro para el tratamiento de la patología tiroidea y paratiroidea de localización mediastínica y podría constituir el abordaje de elección en pacientes con bocios olvidados, bocios ectópicos y adenomas paratiroideos de localización mediastínica. (AU)

Introduction and objective: During the last decade there has been a wide spread of minimally invasive thoracic approaches for the treatment of pulmonary and mediastinal diseases. Classi-cally, thoracic surgical pathology derived from thyroid and parathyroid diseases has been treated by open approaches such as sternotomy, cervicoesternotomy and thoracotomy. However, in recent years, robotic surgery has emerged as a new route of minimally invasive approach that provides similar results and significant advantages over other minimally invasive approaches such as laparoscopy and videothoracos-copy. Its applicability in the surgical treatment of mediastinal lesions has been amply demonstrated in the literature. The aim of this article is to describe the indications of thoracic robotic surgery in thyroid and parathyroid pathology, as well as to comment on the main technical aspects related to these procedures. Synthesis: Robotic thoracic surgery is especially indicated in cases of «forgotten goiters» and ectopic goiters. In cases of cervical-mediastinal goiters, the combined cervical and thoracic robotic approach has been shown to be a feasible and safe option. With regard to mediastinal ectopic parathyroids, the robotic approach offers significant advantages such as 3D vision and the optimization of the maneuverability of instruments that facilitate the visualization and dissection of the gland. Conclusions: Robotic surgery is an effective and safe minimally invasive approach for the treatment of thyroid and parathyroid pathology of mediastinal location and could constitute the approach of choice in patients with forgotten goiters, ectopic goiters and mediastinal parathyroid adenomas. (AU)

Incidental Primary Intrathoracic Goiter: Dual-Isotope Scintigraphy and Early-MIBI SPECT/CT.

Primary intrathoracic goiter is an uncommon congenital entity resulting from over decent ectopic thyroid tissue. As compared with secondary intrathoracic goiter, primary entities are discrete from orthotopic thyroid tissue and may lead to potentially serious complications such as malignancy and shortness of breath. Intrathoracic goiters have been described as showing mild or absent uptake of 99m Tc-pertechnetate on planar scintigraphy. We present an incidental primary intrathoracic goiter found in a patient undergoing evaluation with multimodal scintigraphy and early 99m Tc-sestamibi single-photon emission computed tomography/computed tomography (SPECT/CT) for localization of parathyroid adenomas. The mass was inconspicuous on TcO 4- scintigraphy but methoxyisobutylisonitrile-avid on early planar and SPECT/CT.

A large intrathoracic goiter with tracheal stenosis: Complete resection using a robot-assisted thoracoscopic approach.

Growing intrathoracic goiters may compress surrounding organs and deteriorate the cardiopulmonary function. Treating such cases requires carefully considering how to maintain oxygenation and resect the tumor with minimal invasiveness without complications. We herein report a surgically resected case of a large intrathoracic goiter-compressed trachea extending from the right lower pole of the thyroid gland to the carina. We secured the airway by intubation preparing for extracorporeal membrane oxygenation and successfully performed surgical complete resection using a robot-assisted thoracoscopic and cervical approach. Intrathoracic goiter is a tumor with abundant neovascularity, and the right vagus nerve is displaced in the thoracic cavity, but a robot-assisted thoracoscopic approach using CO2 insufflation improved visualization at the narrow apex area of the thoracic cavity. Robot-assisted thoracoscopic surgery is a useful surgical procedure enabling safe and minimally invasive surgery without recurrent laryngeal nerve palsy or tracheal injury for intrathoracic giant goiters extending into the thoracic cavity.

A case of cervico-mediastinal paraganglioma mimicking an ectopic goiter.

INTRODUCTION AND IMPORTANCE: Mediastinal paragangliomas are rare neuroendocrine tumors that originate from extra-adrenal paraganglia, occasionally secreting catecholamines. Nonfunctional mediastinal paragangliomas present nonspecific clinical and radiological features and represent a diagnostic challenge. CASE PRESENTATION: A 53-year old woman presented with cough and dyspnea increasing over time. CT-scan and ultrasonography showed a large vascularized cervico-mediastinal mass, consistent with an intrathoracic ectopic goiter. Preoperative angiography showed a blood supply from neck vessels. The lesion was completely removed through a cervical approach. The diagnosis of paraganglioma was a histological surprise. The patient is alive without recurrence 30 months after surgery. CLINICAL DISCUSSION: When preoperatively diagnosed, the treatment of choice of a mediastinal paraganglioma is surgical excision. However, a preoperative diagnosis of mediastinal paraganglioma is difficult to obtain, especially in cases of nonfunctional lesions. Distinction between an intrathoracic goiter and a nonfunctional paraganglioma can be extremely difficult and, given the rarity of the latter, an ectopic goiter is suspected in first instance. CT-scan and ultrasonography are of little use in the differential diagnosis. However, scintigraphy with 123I-metaiodobenzylguanidine can be an useful diagnostic tool when a paraganglioma is suspected. In case of vascularized cervico-mediastinal mass, such as paragangliomas or intrathoracic goiter, preoperative angiography should be performed to study the blood supply and orient the surgical approach. CONCLUSION: Although uncommon, paragangliomas should be considered in the differential diagnosis of mediastinal masses, especially when an ectopic goiter is suspected.

Efficacy and safety of single-session radiofrequency ablation for intrathoracic goiter: preliminary results and short-term evaluation.

BACKGROUND: An intrathoracic goiter (ITG) is defined as a thyroid extension below the sternal notch. Compared to cervical goiters, surgery for ITG is more challenging, with a higher risk of an extracervical approach. Ultrasound (US)-guided radiofrequency ablation (RFA) is a minimally invasive treatment modality. The purpose of this study was to prospectively evaluate the safety and efficacy of RFA in patients with ITG. METHODS: From a total of 324 patients who underwent thyroid RFA at a single medical center, 15 patients (mean age 52.2 years; 73.3% female) with 16 ITGs were included and classified into three grades and three types using the cross-section imaging CT system. Clinical features and demographics, degree of extension, RFA details, goiter volume, and complications were analyzed. RESULTS: Mean pre- and post-RFA goiter volumes as measured by US were 106.62 ± 61.82 and 25.09 ± 14.22 mL respectively, with a volume reduction rate (VRR) of 75.5% (p < 0.001) at 6 months. The VRR as measured by CT/MRI was 57.0 ± 10.0% (p < 0.001) at 6 months. The intrathoracic length reduction rate at 6 months was 44.9 ± 39.2% (p = 0.001). In addition, 4 (25%) ITGs had total regression of the intrathoracic extension, with a downgrade from grade 1 to cervical goiter. Mean pre- and post-RFA symptom and cosmetic scores were 1.53 and 0.15 (p = 0.001), and 2.67 and 2.00 (p = 0.001), respectively. One patient had transient vocal cord palsy and another had perithyroidal and mediastinal hemorrhage. CONCLUSION: US-guided RFA is an effective treatment for ITG in terms of both cervical and intrathoracic reductions with an acceptable complication rate.

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.

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.

Enlargement of Intrathoracic Goiter with Unilateral Phrenic Nerve Paralysis Leading to Cardiopulmonary Arrest.

As an intrathoracic goiter expands, it causes airway stenosis and phrenic nerve paralysis, and slight respiratory stimuli can trigger sudden life-threatening hypoventilation. A 78-year-old obese woman with a large intrathoracic goiter was found unconscious with agonal breathing in her room early in the morning. Cardiopulmonary resuscitation restored spontaneous circulation. She underwent surgical removal of the goiter; however, she required long-term mechanical ventilation because of atelectasis due to phrenic nerve paralysis. In patients with large intrathoracic goiters, difficulty breathing on exertion and diaphragm elevation on chest X-ray may be significant findings predicting future respiratory failure.

Bocio Intratorácico / Intrathoracic goiter

El bocio intratorácico se define como aquel bocio que se encuentra parcial o totalmente en el mediastino; su incidencia está en relación con el bocio multinodular. Es asintomático entre el 20­30%. Su diagnóstico se hace por pruebas de imagen; su Gold estándar es la tomografía axial computarizada. El tratamiento más efectivo y recomendado es la cirugía, sobre todo para pacientes con síntomas opresivos o con sospecha de malignidad y bocios hiperfuncionantes en quienes el tratamiento farmacológico no fue exitoso. Se detalla el caso de una paciente de 59 años de edad, quien, con síntomas opresivos esternales, a quien se le diagnostica masa mediastínica, la cual se resuelve con indicación quirúrgica, siendo resolutiva para la paciente, con mejoras en la sintomatología y diagnostico de benignidad. (AU)

Intrathoracic goiter is defined as partially or totally in the mediastinum; its incidence is related to multinodular goiter. It is asymptomatic in 20-30%. Its diagnosis is made by imaging tests; the gold standard is computerized axial tomography. Treatment can be pharmacological with risk of recurrence; the most effective and recommended is surgery, especially for patients with oppressive symptoms or with suspected malignancy. We present the case of a 59-year-old patient with sternal oppressive symptoms, who is diagnosed with a mediastinal mass, which resolved by surgery, with improvements in symptoms and a diagnosis of benignity. (AU)

Intrapericardial goiter.

Intrapericardial goiter cases are only a few in the literature. We present a 53-year-old woman who was operated for 8-cm anterior mediastinal mass located completely intrapericardial and histopathological examination revealed an ectopic goiter. It may be difficult to distinguish between mediastinal masses within or outside the pericardium. Thoracoscopy may be needed in such cases.

Surgical approach to the intrathoracic goiter.

OBJECTIVE: In a retrospective study, the authors analyzed the surgical approach to the intrathoracic goiter to avoid sternotomy or thoracotomy. METHODS: We selected 70 intrathoracic cases of multinodular goiter out of 988 cases of thyroidectomy and compared them with cervical goiter cases. Surgical technique, results, and postsurgical complications were assessed. RESULTS: The analyzed cases presented the retrosternal goiter (n = 53; 75.7%), the retrotracheal goiter (n = 9; 12.8%), and the retroesophageal goiter (n = 8; 11.4%). Complaining of chest pressure or discomfort was specific for intrathoracic cases (50%; 35 of 70). All goiters except one were removed via cervical incision. The surgeons used head reclination and isthmus dissection when removing sizable goiters. Mean weight of goiters was 180 g. The recurrent laryngeal nerve was more often temporarily damaged in intrathoracic cases in comparison with cervical cases (4.3% vs. 2.8%, P = .04), but the difference in permanent injury was less significant (P = .09). The incidence of temporary hypoparathyroidism was significantly higher in intrathoracic cases (P = .01). CONCLUSION: In cases of multinodular goiter the goiters of various extensions can be successfully removed via the cervical incision in most of the cases even if they occupy the retrosternal, retrotracheal, or retroesophageal position. The transthoracic approaches and sternotomy might be justified in malignant cases. LEVEL OF EVIDENCE: 4.

Chylothorax Associated with Substernal Goiter in Graves' Disease Treated with Radioactive Iodine.

INTRODUCTION: We present a rare case of chylothorax associated with an intrathoracic goiter in Graves' disease that was treated with radioactive iodine. CASE REPORT: A 23-year-old woman with Graves' disease was referred to our clinic with a pleural effusion, dyspnea, characteristic bilateral proptosis, and a diffuse goiter. The pleural fluid biochemistry was consistent with chylothorax. However, the chylothorax did not decrease with conservative therapy. Therefore, RAI was administered. Subsequently, the chylothorax and goiter improved more quickly than expected. CONCLUSIONS: This case illustrates that chylothorax associated with a substernal goiter in Graves' disease can be treated successfully with radioactive iodine instead of surgery.

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.

Surgical treatment of substernal goiter: An analysis of 44 cases.

OBJECTIVE: Substernal goiters are classified as primary or secondary intrathoracic goiters. Here, we report the diagnosis, symptoms, treatment, and postoperative complications of 44 substernal goiters (2 primary mediastinal goiter and 42 secondary mediastinal goiters). METHODS: A retrospective chart review of 351 patients undergoing thyroidectomy at the Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center. Between 2009 and 2015, 44 patients underwent surgery for substernal goiter. RESULTS: The frequency of primary and secondary mediastinal goiters was 0.5% and 11.9%, respectively. The preoperative symptoms were neck mass, dyspnea, and dysphagia. Eight patients were asymptomatic. Thirty-nine patients had benign masses and 5 patients had malignant masses. Most patients were operated on for adenomatous goiters (52.2%). In ten cases beyond the aortic arch, the tumors were benign and there were eight cases of adenomatous goiter. All patients underwent a successful transcervical incision without sternotomy. Even the primary intrathoracic goiters were extracted after total thyroidectomy via the cervical approach without complications. Although one case showed unilateral recurrent nerve paralysis as a postoperative complication, phonetic function improved in 6 postoperative months. No instances of postoperative bleeding or definitive hypoparathyroidism occurred, and tracheostomy was not performed in any of the cases. CONCLUSION: The cervical approach was safely performed in almost all substernal goiters without an extracervical procedure. Selected cases of primary mediastinal goiter may be excised via the cervical approach.

Anatomical approach to surgery for intrathoracic goiter.

The anatomical approach to the intrathoracic goiter (ITG) was used to understand its etiology and to rationalize surgical technique of thyroidectomy. For a retrospective chart review, we selected cases of multinodular goiter with totally ITGs (n = 69; M 29, F 40), while 916 cases with cervical goiter were used for comparison. The topography of the thyroid gland was assessed against the tracheal rings and against the vertebrae. The regional anatomy of the thoracic inlet was assessed by its bony margins and the relations of structures traversing the area. Average tracheal-diameter-to-thoracic-inlet ratio was calculated. The ITG group consisted of 52 cases of retrosternal goiter (75.4 %), nine cases of retrotracheal goiter (13 %), and eight cases of retroesophageal goiter (11.6 %). In all but one analyzed cases, the goiters were removed via cervical incision. Mean weight of goiters was 183 g. The area of thoracic inlet in the cases of ITG had no difference in comparison with the cases of cervical goiter (F/M p = 0.11/0.15), but the tracheal-diameter-to-thoracic-inlet ratio was significantly smaller (F/M p = 0.06/0.04). In the ITG cases, the position of the upper edge of the isthmus of the thyroid was about 1.5 tracheal rings lower than in healthy individuals (p = 0.03). The area of the thoracic inlet, the neck size, and the anteroposterior diameter of the inlet do not affect the development of the ITG. The smaller tracheal-diameter-to-thoracic-inlet ratio and the lower position of the thyroid gland are the main indicators for the development of the ITG.

EMERGENCY SURGICAL TRACHEAL DECOMPRESSION IN A HUGE RETROSTERNAL GOITER.

INTRODUCTION: Over the past decades, several definitions and classifications of cervico-mediastinal goiters have been proposed. We analyzed and discussed the clinical presentation, the diagnostic procedures and the surgical technique in relation to post-operative complications and long-term results in a case of a sixty-six years old obese, hypertensive female admitted in the Thoracic Surgery Department with respiratory distress (inspiratory dyspnea, stridor) progressively aggravating during the latest month. METHODS: Cervico-thoracic CT scan revealed the existence of a cervico-mediastinal huge goiter which developed mostly intrathoracic (2/ 3 of the goiter). It determined a tracheal compression, reducing its caliber by two thirds, and its displacement to the right side. The proposed surgical procedure was total thyroidectomy and it involved a bipolar approach (transcervical and transsternal) through a partial upper cervico-sternotomy. RESULTS: The complete removal of the goiter and the decompression of the trachea have been achieved. Postoperative results were very satisfactory, with the absence of the respiratory distress. The histological examination revealed a multinodular goiter with epithelium hyperplasia. CONCLUSION: The presence of a complicated cervico-mediastinal goiter with severe respiratory distress required a surgical excision as the main and immediate treatment option. The surgical procedure represented a milestone for both the anesthesiologist (difficult intubation, with a thin tracheal tube in the absence of the jet ventilation technology) and for the surgeon. The goiter's excision from the visceral mediastinum was very difficult because of its huge dimensions and close relations with trachea and great vessels (anterior) and esophagus, erector spinal muscles and the spine (posterior).

Tumor fibroso solitario de la glándula tiroides con extensión intratorácica / Solitary fibrous tumor of the thyroid gland with intrathoracic extension

El tumor fibroso solitario (TFS) es una neoplasia mesenquimal de células fusiformes infrecuente descrita inicialmente en la pleura pero con localización reconocida en otros sitios. El TFS de la glándula tiroides (TFST) es aun más raro. Se describe el caso de una mujer de 65 años de edad, con masa cervical de crecimiento progresivo, a tal punto que ya la masa se hacía notable en parte inferior de su cuello, siendo este el único síntoma narrado. La paciente presentaba una gran masa tiroidea en el lóbulo derecho con extensión intratorácica. Se practicó hemitiroidectomia derecha (paciente tenia historia previa de resección del lóbulo tiroideo izquierdo por lesión benigna) Total, además de toracotomía endoscópica por la extensión de la masa la cual en la tomografía contrastada, se originaba en el lóbulo tiroideo derecho y descendía paralelo a la columna dorsal desplazando a la tráquea y el esófago. La patología reportó un tumor de 15 centímetros, con células fusiformes y patrón de crecimiento hemangiopericítico sin pleomorfismo, atipia, mitosis o necrosis. Luego de practicar diferentes estudios y marcadores tumorales, de todos estudios fueron positivos CD34, Bcl2, CD99 y vimentina. Se diagnosticó tumor fibroso solitario de glándula tiroides. El nervio vago derecho fue lesionado en la cirugía, actualmente está en terapia de voz. Al momento actual casi seis meses luego de su cirugía, no se documenta recidiva tumoral.

Solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm initially described as spindle cells in the pleura but recognized location elsewhere. The TFS thyroid gland (TFST) even infrequent. A case of a 65 years old woman with progressive growth of a right cervical mass without associated symptoms described other than cosmesis is described . The patient had a thyroid mass in the right lobe with intrathoracic extension. A right Hemi thyroidectomy and thoracotomy for the extent of the mass was performed. Pathology reported a 15 cm tumor with spindle cell and growth pattern hemangiopericitic without pleomorphism, atypia, mitosis or necrosis. Immunohistochemistry was positive for CD34, Bcl-2, CD99 and vimentin, making the diagnosis of solitary fibrous tumor of thyroid gland. The patient's right Vagus nerve was injured intraoperatively and she is currently under voice therapy. Currently now, almost six months after her surgery she is free of disease.

Bocio del mediastino posterior - abordaje mínimamente invasivo: videotoracoscopia derecha más cervicotomía / Intrathoracic goiter resection by combined surgical approach: resection by right videothoracoscopy and cervicotomy

Resumen La cirugía es el manejo recomendado para el bocio intratorácico y cerca de un 90 % de ellos pueden resecarse mediante cervicotomía. El bocio en el mediastino posterior ha sido manejado satisfactoriamente empleando diversos abordajes cervicotorácicos, existiendo poca información en la literatura acerca del uso de la videotoracoscopia como parte de estas técnicas combinadas. Presentamos el caso de un paciente con un bocio intratorácico con extensión a mediastino posterior, en quien, dadas las características de la masa y su localización, sumado a las ventajas ampliamente conocidas de la cirugía mínimamente invasiva, se decide remplazar la toracotomía y la esternotomía por la videotoracoscopia, permitiendo una buena exposición y disección segura del mediastino. Consideramos que la videotoracoscopia es una técnica segura y efectiva en casos seleccionados de pacientes con bocio con extensión a mediastino posterior.

Abstract Surgery is the recommended treatment for intrathoracic goiter. About 90 % of the lessons can be resected by cervicotomy. The posterior mediastinal goiter was been successfully managed using different cervico-thoracic approaches; however, there is little available information in the literature about the use of videothoracoscopy as part of these combined techniques. We present a case of a patient with a intrathoracic goiter extended to the posterior mediastinum, in which, given the characteristics of the mass and its location added to the widely known benefits of minimally invasive surgery, it was decided to replace thoracotomy and sternotomy with videothoracoscopy allowing good exposure and safe dissection of the mediastinum. We consider that videothoracoscopy is a safe and effective technique in selected cases of patients with goiter extending into the posterior mediastinum.

Intrathoracic toxic thyroid nodule causing hyperthyroidism with a multinodular normal functional cervical thyroid gland.

Radionuclide scintigraphy with I-131 and Tc-99m pertechnetate ((99)mTc04) has been widely used in detecting toxic nodules. Intrathoracic goiter usually presents as an anterior mediastinal mass. Mostly the connection between intrathoracic mass and the cervical thyroid gland is clearly and easily identified occurring as a result of inferior extension of thyroid tissue in the neck, which is called as secondary intrathoracic goiter. Completely separated, aberrant or in other words primary intrathoracic goiters arise as a result of abnormal embryologic migration of ectopic thyroid closely associated with aortic sac and descend into the mediastinum. Intrathoracic goiters are generally nontoxic nodules existing with mass effect without causing hyperthyroidism. However, mostly reported cases had enlarged thyroid glands in the neck. This report demonstrates the usefulness of I-131 and (99)mTc04 scintigraphy for detecting intrathoracic goiter causing hyperthyroidism with a normal functioned cervical thyroid gland.

Complete transthoracic resection of giant posterior mediastinal goiter: case report and review of surgical strategies.

Intrathoracic goiters generally occupy anterior mediastinum, rarely involving the posterior mediastinal space. Reported herein is a 54-year-old female with a giant posterior mediastinal mass that was successfully resected via right posterolateral thoracotomy. The final pathologic diagnosis was giant posterior mediastinal goiter. This patient has done well postoperatively, with no evidence of local recurrence at 12-month follow-up. Related surgical strategies in past publications are summarized.