Abstract
Background: Retrosternal goiters (RG) are those lesions extending to occupy the thoracic cavity. They carry a surgical risk due to distorted anatomy, the minimal access, and the potential for great vessels or pleural injury. No other effective therapeutic alternative to surgery exists. Cervicotomy is still the surgical approach of choice, although a form of sternotomy may always be necessary for field extension and safe gland delivery. Materials and Methods: This is a single institution combined retrospective & prospective study including retrospective analysis of all cases presenting to the NCI, Cairo University with RG candidate for surgery between Jan. 2008 until the end of Dec. 2012, and a prospective study of all cases with the same presentation presenting to the NCI between Jan. 2013 until the end of Dec. 2015. Data was collected from archive of patients at the statistical department. Aims: To study the clinico-pathological characteristics, the presentation, work-up, surgical approaches and postoperative complications of RG. Results: 42 patients were included & were divided into benign (34 patients, 80.9%) and malignant groups (8 cases, 19.1%). All patients (100%) were adults ranging (19 to 73 years) with mean 53.1 years. There was a female predominance (36 female, 85.7%) versus (6 males, 14.3%). Median duration of symptomatology was 23 months ranging (6 - 53 months). 23 patients (54.7%) were symptomatic while 19 cases (45.3%) accidently discovered. Mean tumor size was 9.97 cm in the benign group and 11.1 cm in the malignant group. 31 patients (73.8%) were euthyroid, 9 (21.4%) were thyrotoxic and 2 (4.7%) were hypothyroid. All patients (100%) underwent total thyroidectomy. The commonest approach was cervicotomy (33 cases, 78.6%), while a type of sternotomy was done in 9 cases (21.4%). 2 cases (4.7%) received postoperative radiation therapy & 4 cases (9.5%) received postoperative radioactive iodine. No perioperative mortality occurred & the overall morbidity was 6 cases (14.2%) in the benign group and 2 cases (4.7%) in the malignant group (4.7%). The median follow up period was 17.5 months. The median overall survival (OS) was 39.4 months and the median disease free survival (DFS) was 9.8 months for the malignant group. Conclusion: Cervicotomy is a safe favorable approach to remove a RG. Intraoperative field extension up to a form of sternotomy may be necessary for gland delivery with increasing operating time, hospital stay and morbidity. Postoperative morbidity is mainly due to the respiratory, recurrent laryngeal nerve palsy and hypoparathyroidism which is mainly increased when sternotomy is performed.
Highlights
Goiter is a term derived from the Latin word tumidum gutter, meaning swollen throat, and is defined as a thyroid that is twice the normal size or over 40 g
They usually remain asymptomatic for long time, they have the potential for sudden enlargement secondary to hemorrhage, cystic degeneration or malignant change resulting in air way compromise that can be life threatening [2]
A Retrosternal goiters (RG) is diagnosed when the retrosternal extension exceeds 2 cm below the manubrium on CT scanning of the neck and chest. The majority of these goiters are resected safely through a cervical incision in 1% - 15% of patients, a form of sternotomy is needed to allow a safe exposure for goiter delivery [3]
Summary
Goiter is a term derived from the Latin word tumidum gutter, meaning swollen throat, and is defined as a thyroid that is twice the normal size or over 40 g. RGs are those goiters extending beyond the thoracic inlet It was first described in 1749 by Albrecht von Haller who considered these thyroid enlargements as a surgical challenge [1]. They usually remain asymptomatic for long time, they have the potential for sudden enlargement secondary to hemorrhage, cystic degeneration or malignant change resulting in air way compromise that can be life threatening [2]. A RG is diagnosed when the retrosternal extension exceeds 2 cm below the manubrium on CT scanning of the neck and chest The majority of these goiters are resected safely through a cervical incision in 1% - 15% of patients, a form of sternotomy is needed to allow a safe exposure for goiter delivery [3]. The median overall survival (OS) was 39.4 months and
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