Cervical Goiter Research Articles

Should asymptomatic retrosternal goitre be left untreated? A prospective single-centre study.

Retrosternal goiter may cause symptoms of airway obstruction and dysphagia, but often it is asymptomatic and is increasingly detected incidentally with imaging investigations. Consensus has been reached that sternotomy is not necessary in most cases, as a collar incision normally suffices. Yet, surgery for retrosternal goiter is associated with more complications than cervical goiter. There is controversy over whether patients with asymptomatic retrosternal goiter should be operated. Proponents argue that retrosternal goiter may be a risk for thyroid cancer and may progress to later cause symptoms, although clear evidence is missing. Between 1984 and 2012, 132 patients underwent surgery for benign retrosternal goiter. Preoperatively, the benign nature was clinically apparent and confirmed by fine needle cytology in most cases. Sternotomy was required in only 4 of the 132 operations. Three patients died in the postoperative period. The risk of morbidity and mortality was 16.7% in 60 patients with compression symptoms and 13.9% in 72 patients without compression symptoms (P = 0.808). Histology revealed no case of unsuspected cancer. Surgery for retrosternal goiters involves a higher risk for complications than do cervical goiters, and the risk does not differ between patients with and without symptoms. This, and the fact that no patient in this study had unsuspected cancer, calls into question the rationale for surgery in patients with asymptomatic retrosternal goiter without suspected cancer.

Acute respiratory failure in a rapidly-enlarging benign cervical goiter

Acute respiratory failure in a rapidly-enlarging benign cervical goiter

Intrathoracic Goiter in Elderly Patients

There are few encounters with massive thyromegaly and intrathoracic extension as a result of the general usage of iodized salt and bread, which was an early therapeutic intervention for thyroid disorders. However, cervical goiter enlargement over time may extend into the thoracic space, causing respiratory distress, dysphagia, and vascular compression. Hence, even though it may be asymptomatic, there is potential for sudden enlargement (secondary to hemorrhage), cystic degeneration, or malignant change that can be life threatening and may require surgery. Patients who underwent surgery with curative intent for intrathoracic goiter from January 1970 to July 2002 were included in this retrospective study at the thoracic surgical division of Taipei Veteran General Hospital in Taipei, Taiwan. Data were compared between patients ≥65 years of age (elderly group) and patients <65 years of age (younger group). Patient characteristics, hospital course, surgical mortality, morbidity, and survival were compared between patients in these two age groups. Total surgical treatment was given in 153 patients (men, 85; women, 68) with a mean age of 66.9 years (range, 41–86 years) who were enrolled in our study. A total of 95 (62.1%) patients were at least 65 years of age (mean age, 74.2 years) and 58 (37.9%) patients were younger than 65 years of age (mean age, 55 years; p < 0.001). Mean hospitalization was 9.5 days (range, 4–115 days), and the mean follow-up period was 4.5 years (range, 4 months–14 years). The elderly group had a significantly higher risk of respiratory syndromes (63.2% versus 34.5%, p < 0.001) and were predominantly men (63.2% versus 43.1%, p < 0.001). However, the elderly group had a significantly lower incidence of malignancy (0% versus 12.1%, p < 0.001). The pathology was generally found to be benign in elderly patients, but seven (12.1%) patients presented with carcinoma in the younger group. The mortality and complications were observed in 1.3% and 10.5% of the all patients. The results of this study suggest that curative surgery for intrathoracic goiter in elderly patients may result in high risks of acute airway compression compared with younger patients. Our data suggest that an age of 65 years or older should not be contraindicated for curative surgery in intrathoracic goiter patients. Surgical resection is recommended for all intrathoracic goiters due to high risks of acute airway compression and occult malignancy.

Resection of a giant bilateral retrovascular intrathoracic goiter causing severe upper airway obstruction, 2 years after subtotal thyroidectomy: a case report and review of the literature.

The intrathoracic (or substernal) goiter is more often benign; but it can be malignant in 2-22% of patients. There is history of prior thyroid surgery in 10% to more than 30% of patients. Intrathoracic goiters cause adjacent structure compression more frequently than the cervical goiters, due to the limited space of the thoracic cage. Compression of trachea, oesophagus, vascular and neural structures may cause dyspnoea, dysphagia, superior vena cava syndrome, subclavian vein thrombosis, hoarseness, and Horner's syndrome. There is usually progressive deterioration, but acute exacerbation may occur. The presence of a thoracic goiter (>50% of the mass below the thoracic inlet) is per se an indication for resection. Tracheal compression by (cervical or thoracic) goiter is also an indication for resection; early tracheal decompression is recommended particularly in symptomatic patients. In severe respiratory distress, intubation and semi-urgent operation may be required. With early intervention, most intrathoracic goiters can be removed through a cervical approach, while tracheomalacia is avoided. We hereby present successful and uncomplicated total thyroidectomy, through a median sternotomy, of a benign, gigantic, bilateral, retrovascular, posterior mediastinal, intrathoracic goiter, encircling the trachea, and causing severe respiratory distress in a 63 year old man with history of previous subtotal thyroidectomy.

Does Mediastinal Extension of the Goiter Increase Morbidity of Total Thyroidectomy? A Multicenter Study of 19,662 Patients

To compare the outcome in patients with cervical goiters and cervicomediastinal goiters (CMGs) undergoing total thyroidectomy using the cervical or extracervical approach. This was a retrospective study conducted at six academic departments of general surgery and one endocrine-surgical unit in Italy. The study population consisted of 19,662 patients undergoing total thyroidectomy between 1999 and 2008, of whom 18,607 had cervical goiter (group A) and 1055 had CMG treated using a cervical approach (group B, n = 986) or manubriotomy (group C, n = 69). The main parameters of interest were symptoms, gender, age, operative time, duration of drain, length of hospital stay, malignancy and outcome. A split-sternal approach was required in 6.5% of cases of CMG. Malignancy was significantly more frequent in group B (22.4%) and group C (36.2%) versus group A (10.4%; both P < .001), and in group C versus group B (P = .009). Overall morbidity was significantly higher in groups B + C (35%), B (34.4%) and C (53.5%) versus group A (23.7%; P < .001). Statistically significant increases for group B + C versus group A were observed for transient hypocalcemia, permanent hypocalcemia, transient recurrent laryngeal nerve (RLN) palsies, permanent RLN palsies, phrenic nerve palsy, seroma/hematoma, and complications classified as other. With the exception of transient bilateral RLN palsy, all of these significant differences between group B + C versus group A were also observed for group B versus group A. Symptoms, malignancy, overall morbidity, hypoparathyroidism, RLN palsy and hematoma are increased in cases of substernal goiter.

The surgical management of goiter: Part II. Surgical treatment and results

Surgery for goiter embodies a unique challenge. Our objective is to provide a comprehensive analysis of cervical and substernal goiter data in two paired articles. This second article focuses on surgical management. The following null hypotheses regarding goiter excision have been tested: 1) there are no goiter-associated risk factors for difficult intubation; 2) there are no predictive risk factors for recurrent laryngeal nerve injury (RLN) or postoperative hypocalcemia; 3) there is no difference in RLN injury with neural monitoring versus without. A retrospective review of 200 consecutive thyroidectomies meeting inclusion/exclusion criteria for cervical or substernal goiter. Temporary RLN paralysis occurred in 1.8% of nerves at risk and was significantly lower with recurrent laryngeal nerve monitoring than without. Permanent hypoparathyroidism occurred in 3% overall. Bilateral cervical goiter emerged as a definitive risk factor for difficult intubation (P = .05, univariate), recurrent laryngeal nerve injury (P = .002), and postoperative hypocalcemia (P = .001). Female patients (P = .04) or patients with positive family history (P = .01) were more likely to need repeat surgery. There were no cases of tracheomalacia, and sternotomy was required in 1%. In this series of patients with extensive goiter, primary and revision surgery were associated with low rate of complications. Surgical complications were associated with bilateral and large goiters suggesting increased caution in these patients.

Approach to Management of the Patient with Primary or Secondary Intrathoracic Goiter

Intrathoracic (substernal) goiter, depending on definition, is seen in up to 45% of all patients operated for goiter. It can either be primary (ectopic thyroid tissue detached from a cervical thyroid mass), which is very rare (1%), or (more commonly) secondary, where a portion of the goiter extends retrosternally. There is no consensus on diagnostic or therapeutic management, partly because many are asymptomatic. Classification involves functional characterization with serum TSH and morphological characterization with diagnostic imaging and cytology to rule out malignancy, which is not more common than in cervical goiters. Pulmonary function is often affected in asymptomatic individuals also. Therefore, but also because natural history is continuous growth and evolution from euthyroidism to hyperthyroidism, most experts recommend therapy. In primary as well as secondary intrathoracic goiter, the therapy of choice is total/near-total thyroidectomy and subsequent levothyroxine substitution. Data suggest that complications are only slightly more prevalent than in cervical goiters. Although levothyroxine is not recommended for goiter shrinkage, there is increasing focus on radioactive iodine as an alternative to surgery in secondary intrathoracic goiters. Here it can reduce thyroid size by on average 40% after 1 yr and improve respiratory function and quality of life. Recent studies show that recombinant human TSH, currently used off-label, can augment the radioiodine-related goiter shrinkage by 30-50%. With currently used doses of recombinant human TSH, the side effects, besides hypothyroidism, are rare and mild. Future studies should also explore the use of radioiodine in primary intrathoracic goiter and compare surgery and radioiodine, head to head.

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

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. 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. 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. 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.

An Unusual Recurrent Intrathoracic Goiter: Case Report

Most intrathoracic goiters are located in the anterior mediastinum, frontal to the recurrent laryngeal nerve and anterolateral to the trachea. Posterior mediastinal goiters account for only 10 to 15% of all intrathoracic goiters and arise from the posterolateral portion of the thyroid gland. We present a case involving a 59-year-old man with history of gradual-onset dyspnea who was referred to us for evaluation of a large mediastinal mass. He had undergone bilateral thyroid lobectomy for a cervical goiter 10 years previously, with no subsequent complications. Contrast-enhanced computed tomography demonstrated a large, well-circumscribed mass extending paratracheally from the thoracic inlet to the posterior mediastinum. The mass was removed via a transcervical and transthoracic approach.

Benign cervical multi-nodular goiter presenting with acute airway obstruction: a case report

IntroductionBenign cervical goiters rarely cause acute airway obstruction.Case presentationWe report the case of a 64-year-old woman of African descent who presented with acute shortness of breath. She required immediate intubation and later a total thyroidectomy for a benign cervical multi-nodular goiter with no retrosternal tracheal compression.ConclusionBenign multi-nodular goiters are commonly left untreated once euthyroid. Peak inspiratory flow rates should be measured via spirometry in all goiters to assess the degree of tracheal compression. Once tracheal compression is identified, an elective total thyroidectomy should be performed to prevent morbidity and mortality from acute airway obstruction.

Diagnosis and Surgical Treatment of Substernal Goiter

Objective To investigate the clinical characteristics diagnosis and surgical treatment of substemal goiter. Methods Clinical data of 29 cases of substernal goiter from Jan 1995 to Jan 2008 were retrospectively analyzed. Results The main symptoms of substernal goiter were asymptomatic cervical mass in 20 patients, airway obstruction in 3 ones,baffle when swallow in 3 ones respectively. There were 26 cases of descendingsubsternal goiter and 3 cases of truly intrathoracic thyroid. Pathology identified benignity in 28 cases and malignancy in 1. Operation were performed in 26 cases through low cervical incision ,in 2 ones with combined cervici-stenotomic approach,1 through cervical inter-ribs incision. Conclusion Substemal goiters often result from the descent of a cervical goiter, CT scanning of neck and thorax is valuable in the diagnosis of substemal goiters.Most substernal goiters can be removed through a transcervical approach, although combined cervici-stemotomic approach is occasionally required Key words: Goiter; Substernal; Diagnosis; Thyroidectomy

Falsa asma – A propósito de um caso clínico

Most mediastinal goiters are extensions of cervical goiters. Patients are generally female and only occasionally have symptoms4. Patients most commonly complain of a mass-like sensation, dyspnoea, dysphagia and cough1. The authors describe the case of a 67 year-old female who presented at the emergency room with dyspnoea, anterior cervical discomfort and tightness which had onset a few months prior but which had worsened in the last week. The patient cited a history of bronchial asthma, for which she was under medication, but the true diagnosis was mediastinal goiter.Rev Port Pneumol 2009; XV (6): 1205-1209

Mediastinal Extension of a Goiter

A 67-year-old woman presented with a 6-month history of dyspnea and dysphagia. Physical examination revealed a small cervical goiter, but the lower poles of the thyroid were not palpable.

Surgical management of mediastinal goiter: risk factors for sternotomy

Mediastinal goiter constitutes an indication for surgical management. The procedure can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The objective of the investigation was to analyze the prevalence and therapeutic results in patients with mediastinal goiter and to assess factors that affect the need of performing sternotomy in the course of mediastinal goiter surgery. In the years 1984-2004, i.e., over 21 years, 11,849 patients with various types of goiter were operated on in the department. Mediastinal goiter was detected in 88 (0.76%) individuals. The analyzed material included 64 (72.7%) females and 24 (27.3%) males. The age of the patients ranged between 19 to 81 years, with the mean age of 61 +/- 13 years of life. The material was statistically analyzed. Risk factors for sternotomy were assessed using the multidimensional logistic regression method. The highest percentage of mediastinal goiter was noted in patients operated on due to recurrent goiter (3.86%). Goiter situated in the anterior mediastinum was noted in 61 (69.3%) individuals, while 27 (30.7%) patients demonstrated goiter located in the posterior mediastinum; of the latter, nine were previsceral and 18 retrovisceral. In the majority of cases, these were primarily cervical goiters, which descended from the neck to the mediastinum (53 patients). Aberrant adenomas were diagnosed in 32 (36.4%) individuals. Four patients presented with the superior cava vein syndrome. Primary goiters evaluated intraoperatively with blood supply originating from the mediastinal vessels were observed in 12 (13.6%) cases. In 27 (30.7%) patients, sternotomies were necessary. In the majority of cases, these were individuals with goiters showing additional blood supply originating from the mediastinal vessels, patients with aberrant adenomas in the mediastinum, especially in recurrent goiters, or else subjects with goiters situated in the posterior mediastinum as compared to anterior mediastinal goiters. No postoperative mortality during stay in a hospital was noted. Surgical management of patients with mediastinal goiter is the therapeutic modality that requires considerable experience of the surgical team, performed in specialized centers, and appropriate preoperative diagnostic management. Statistically significant risk factors for sternotomy are as follows: recurrent goiter, primary mediastinal goiter, posterior mediastinal location of goiter, and the presence of an aberrant adenoma situated in the mediastinum.

Evidence‐Based Surgical Management of Substernal Goiter

A number of reports have been published concerning the surgical treatment of substernal goiters; however, there is yet to be a comprehensive review of this body of literature using evidence-based methodology. This article is a systematic review of the literature using evidence-based criteria and a review of unpublished data from our institution. Issue 1. Limited level III/IV data suggest that the incidence of cancer in substernal goiters is not higher than the incidence of cancer in cervical goiters. Risk factors for malignancy in substernal goiters may include a family history of thyroid pathology, a history of cervical radiation therapy, recurrent goiter, and the presence of cervical adenopathy (grade C recommendation). Issue 2. Prospective level V data suggest that, for most patients, expert endocrine surgeons utilize an extracervical approach approximately 2% of the time to remove a substernal goiter safely; a sternotomy or thoracotomy appears more likely in cases of a primary substernal goiter or a mass larger than the thoracic inlet (no recommendation). Issue 3. There may be a higher rate of permanent hypoparathyroidism and unintentional permanent recurrent laryngeal nerve injury when total thyroidectomy is performed for removal of a substernal goiter than for removal of a cervical goiter alone (grade C recommendation). Injury of the external branch of the superior laryngeal nerve was not specifically addressed and is almost certainly underreported. Issue 4. The presence of a substernal goiter, especially being present more than 5 years and causing significant tracheal compression, is likely a risk factor for tracheomalacia and tracheostomy (grade C recommendation). Tracheomalacia with substernal goiter is an infrequent occurrence, and many cases of tracheomalacia can be managed without tracheostomy (no recommendation). Issue 5. Prospective level V data suggest that about 5% to 10% of operations for substernal goiters are performed because of recurrent or persistent disease, although retrospective level V data report an even higher rate, up to 37%. The most common initial operations with recurrence or persistence appear to be subtotal or hemithyroidectomy (no recommendation). Evidence-based recommendations provide reliable information regarding the pathologic findings and operative management of substernal goiters in expert hands.

Robotic Resection of an Ectopic Goiter in the Mediastinum

We report the first robotic resection of an ectopic mediastinal thyroid adenoma in a 72-year-old woman. This intervention was part of staged management for excessive bilateral cervical goiter with intrathoracic dispersion. The robotic resection was found to be feasible and safe. The robotic operating system offers better visual control and operative accuracy than does conventional thoracoscopy.

Large mediastinal mass of heterotopic thyroid tissue: a case report and review of literature

Incidental detection of a mediastinal mass in a asymptomatic patient poses a not easy diagnostic problem. For solid masses or cysts, histology or cytology is often necessary. Although substernal extension of a cervical goiter is common, totally intrathoracic primary thyroidal mass is unusual. We describe a rare case of heterotopic accessory mediastinal thyroid in a patient completely asymptomatic both for signs of thyroid dysfunction and mechanical compression. Radiological and hormonal 6 and 12 months follow-up is reported.

Prospective study of postoperative complications after total thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery.

(1) To show that total thyroidectomy (TT) can be performed in multinodular goiter (MG) by surgeons with experience in endocrine surgery with a definitive complication rate of 1% or less; and (2) to analyze the risk factors for complications in these patients. There is current controversy over the role of TT in the treatment of MG; although there are potential benefits, high rates of complications are not acceptable in surgery for a benign pathology. A prospective study was conducted on 301 MGs meeting the following criteria: (1) bilateral MG; (2) no prior cervical surgery; (3) operation by surgeons with experience in endocrine surgery; (4) no associated parathyroid pathology; (5) no initial thoracic approach; and (6) minimum follow-up of 1 year. Age, sex, time of evolution, symptoms, cervical goiter grade, intrathoracic component, thyroid weight, and presence of associated carcinoma were analyzed as risk factors for complications. The chi test and a logistic regression analysis were applied. Complications were presented by 62 patients (21%), corresponding to 29 hypoparathyroidisms, 26 recurrent laryngeal nerve injuries, 4 lesions of the superior laryngeal nerve, 3 cervical hematomas, and 1 infection of the cervicotomy. The variables associated with the presence of these complications were hyperthyroidism (P = 0.0033), compressive symptoms (P = 0.0455), intrathoracic component (P = 0.0366), goiter grade (P = 0.0195), and weight of excised specimen (P = 0.0302); hyperthyroidism (relative risk [RR] 2.5) and intrathoracic component (RR 1.5) persisted as independent risk factors. Definitive complications appeared in 3 patients (1%), corresponding to 2 hypoparathyroidisms and 1 recurrent laryngeal nerve injury. Two cases corresponded to a toxic goiter, and the third to an intrathoracic goiter with compressive symptoms. In endocrine surgery units, TT can be performed for MG with a definitive complication rate of around 1%; the main independent risk factors for the development of complications are hyperthyroidism and goiter size.

Does radioiodine therapy have an equal effect on substernal and cervical goiter volumes? Evaluation by magnetic resonance imaging.

Most often thyroidectomy is recommended in patients with large goiters. However, high-dose (131)I therapy may be used in case of contraindications to surgery. Large goiters are often partially located in the mediastinum. The aim of this study was to evaluate the impact of (131)I therapy on the cervical and the substernal goiter volume, separately. Fourteen patients (median age, 69 years; range, 52-86 years) with a large multinodular goiter (three hyperthyroid) and with a substernal extension greater than 15 mL were included. T1-weighted magnetic resonance (MR) estimates of the thyroid volume in the cervical and substernal compartments were obtained before and 1 year after high-dose (131)I therapy. The total goiter volumes ranged from 182 to 685 mL. The median substernal volume was 66 mL (fraction of total volume, 17.6%; range, 8.0%-78.9%). One year after treatment, the median substernal goiter volume was reduced by 29.2% (range, -6.1%-59.4%, mean: 26.1% +/- 6.0%), and the cervical goiter volume by 30.3% (range, 6.0%-75.4%, mean, 35.6 +/- 5.6%) compared to baseline values; p = 0.25 for difference in a regional effect. The volume reduction was unrelated to initial substernal goiter size. Likewise, deterioration of the inspiratory capacity did not correlate with the magnitude of the substernal goiter extension. In conclusion, high-dose (131)I therapy seems as effective in reducing the substernal as the cervical goiter volume. However, because the overall effect is modest, this therapy should primarily be considered for the patient with a high surgical risk.

Tc-99m pertechnetate imaging and CT show bilateral huge cervical and intrathoracic goiter extending to the posterior mediastinum.

A patient with goiters had Tc-99m pertechnetate neck and chest images that showed enlargement of both thyroid lobes with mediastinal extension. The intensity of the large areas of diffuse uptake in the mediastinum was less than in the neck. CT imaging showed bilateral thyroid goiters with inferior extension to the posterior mediastinum. These findings corresponded with both a thyroid goiter and with intrathoracic extention into the posterior mediastinal by CT imaging. The patient underwent bilateral total thyroidectomy and right thoracotomy for the resection of the posterior mediastinal goiter. The removed posterior mediastinal goiter measured 7.5 x 5.4 x 4.1 cm and was confirmed to be a multinodular goiter. Although the intensity of radioactivity in the mediastinal goiter was less than that of the cervical goiter, the mediastinal portion of the goiter remained detectable by Tc-99m pertechnetate.