Cervico-mediastinal Goiter Research Articles

Selective Arterial Embolization for the Management of Large Multinodular Cervicomediastinal Goiter

In the surgical treatment of thyroid disease, surgery of cervicomediastinal goiters has always been a challenge, due to the high risk of intraoperative and postoperative complications, especially excessive bleeding. Case report Fifty-one-year-old female patient with multiple underlying diseases, presenting a large cervical mass resulting to be a large multinodular cervicomediastinal goiter. Underwent selective arterial embolization of vascular branches supplying irrigation to the mass and later a total thyroidectomy with minimum blood loss during the intraoperative time. Conclusion Even if preoperative selective artery embolization is far from being a routine technique in cervicomediastinal goiter surgery, in selected patients who have many underlying medical problems, very voluminous goiter, high bleeding risk or high intraoperative risk, it can be considered a useful and safe procedure.

Successful excision of a giant cervical mediastinal goiter by cervical collar incision and a thoracoscopic approach: a case report

BackgroundGiant cervicomediastinal goiter extending to the bifurcation of the trachea mostly requires median sternotomy in addition to a cervical collar incision for resection. Sternotomy provides a good operative field, although it is one of the most invasive thoracic approaches. We herein report a case of giant cervicomediastinal goiter resected by a less-invasive and highly effective method with a thoracoscopic and cervical approach.Case presentationA 71-year-old Japanese woman with giant cervicomediastinal goiter extending to the bifurcation of the trachea was introduced and admitted to our hospital with dyspnea. Chest computed tomography showed tumor-induced airway narrowing due to the giant goiter of the right side of the thyroid lobe. We safely performed resection of the giant goiter through a cervical collar incision and thoracoscopic approach, and this combined approach contributed to the early discharge of the patient from the hospital.ConclusionA combined approach of cervical collar incision and thoracoscopy is useful for resection of giant goiter.

Combined thoracoscopic and axillary subcutaneous endoscopic thyroidectomy: a novel approach for cervicomediastinal goiters.

After our group described the first remote-access thyroidectomy series in 2000, the procedure has been further developed. Although a thoracoscopic approach with a conventional open cervical incision for thyroid goiters with mediastinal extension has been performed at many institutions, remote-access thyroidectomy for cervicomediastinal goiters has not been established. We have performed combined thoracoscopic and axillary subcutaneous endoscopic thyroidectomies (axillo-thoracic endoscopic thyroidectomies). Here, we describe a novel technique for performing a remote-access thyroidectomy for a cervicomediastinal goiter (CMG). The patients with CMGs who agreed to an axillo-thoracic endoscopic thyroidectomy at one of two hospitals in Japan underwent a remote-access thyroidectomy. We performed the axillo-thoracic endoscopic right or left hemithyroidectomy successfully, but most of the patients did not require the thoracoscopic procedure. None of the patients had complications, and none was converted to an open thyroidectomy. Most thyroid goiters with substernal extension can be removed by the axillary approach, but some cases require a thoracoscopic approach. The novel approach described herein (axillo-thoracic endoscopic thyroidectomy) enables the safe excision of a CMG with high patient satisfaction for selected patients.

Peculiarities of surgical treatment of cervico-mediastinal goiter

Objective. To analyze a surgical tactics and a component of operative interventions, performed for goiter of cervico-mediastinal localization; to formulate the operative technique peculiarities, which give positive effect.
 Materials and methods. Into the investigation the materials of clinical work in 2005 - 2019 yrs were incorporated of Department of Surgery No 2 of the Second Municipal Clinical Hospital of Poltava City, which constitutes a base of the Department of Surgery No 1 of Ukrainian Medical Stomatological Academy. There were analyzed the results of surgical treatment of 530 patients, suffering various forms of goiter.
 Results. Basing on data of complex clinic-instrumental and cytological investigations several tactically different operative interventions were performed, the content of which was directly dependent on anatomic peculiarities present. In 155 patients a cervico-mediastinal goiter was present.
 Conclusion. In big mediastinal goiter a severe operative situation occurs, necessitating nonstandard surgical decisions making. That is why the neck surgical access of the authors own in accordance to Kocher method was proposed. Extrafascial procedures may prevent some iatrogenic complications.

Thyroiditis process as a predictive factor of sternotomy in the treatment of cervico-mediastinal goiter

BackgroundAbout 10% of cervico-mediastinal goiter need to associate cervicotomy with a total or partial sternotomy to allow a safe removal of the goiter.Aim of this study is to identify preoperative predictors of sternotomy for mediastinal goiter.MethodsBetween January 2008 and December 2015, 586 patients were submitted to total thyroidectomy at Surgical Clinic of Brescia, Italy.Among these, patients with cervico-mediastinal goiter have been divided in two groups based on the necessity of an associated sternotomy in the operating field: Group 1 (n = 40 patients) did not need sternotomy and Group 2 (n = 4 patients) underwent cervicotomy associated with sternotomy.Clinical and pathological characteristics of patients were retrospectivelly recorded.ResultsAmong study group, 44 patients had cervico-mediastinal goiter. Thoracic CT was performed in all patients: an extension above aortic arch was found in 41 patients (93.18%) while an extention below aortic arch was found in 3 patients (6.82%).The extension of the goiter below the aortic arch resulted as a predictive value in the choice of surgical treatment (p = 0.0001).The thyroiditis process was found to be a significant predictive of the extention to a sternotomic approach (p = 0.029).The years of goiter’s presence were on average 8.40 years in Group 1 and 14.75 years in Group 2.These parameters proved to be predictive when choosing a cervicotomy with sternotomy.Conclusions: Our study, despite limitations posed by small sample and its retrospective analisys, highlights the role of goiter’s extention (below the aortic arch), disease length (for more than 14.75 years) and flogistic process (positivity of Tg Ab and anti-TPO-Ab) in the choice of combined (cervicotomic and sternotomic) approach to goiter’s removal.

Assessment and management of cervico-mediastinal goiter

Cervico-mediastinal goiter is a particular entity from the point of view of thyroid surgery. Its volume, hardness and intrathoracic extension require the surgeon to adapt technique and perform a painstaking preoperative work-up, so as to draw up fully-fledged plan. CT is now indispensable, to anticipate risks and determine whether sternotomy is needed. Surgery seems to induce more postoperative complications than in conventional surgery, although they can be reduced by retrograde dissection of the inferior laryngeal nerve and downward dissection of the posterior side of the lobe to optimize control of adjacent structures. This surgery requires optimal teamwork between all of the specialties involved in patient management: medical, radiological, anesthesiological and surgical.

13. Neck hematoma after thyroidectomy. Do antiplatelet/anticoagulant drugs use or coagulopathies affect it? A case control study from a single center on 3150 patients

13. Neck hematoma after thyroidectomy. Do antiplatelet/anticoagulant drugs use or coagulopathies affect it? A case control study from a single center on 3150 patients

12. Forgotten goiter (FG). Lession learned from a multicentric experience

12. Forgotten goiter (FG). Lession learned from a multicentric experience

Early biomarkers of hypocalcemia following total thyroidectomy

Hypocalcemia is the most frequent major complication following total thyroidectomy (TT), delaying timely hospital demission. We prospectively evaluated the diagnostic utility of parathyroid hormone (PTH) measured one hour after TT and the delta (post-minus pre-surgery) PTH in order to determine which biomarker best predicted post-surgery hypocalcemia.Ninety-six consecutive patients, with either plurinodular goiter, Graves' disease or cervico-mediastinal goiter (22 (23%) men and 74 (77%) women, mean age 48.5 ± 15.2 and 47.9 ± 13.2 years, respectively), scheduled to undergo TT were enrolled. PTH was measured prior and one hour after surgery. Delta PTH was defined as one-hour post-surgery values minus pre-surgery PTH level. Hypocalcemia was defined as a calcemia under 8.0 mg/dL. Receiver operating characteristic (ROC) analysis was used to evaluate the Area Under Curve (AUC), sensibility and specificity of the two biomarkers for the occurrence of hypocalcemia. Forty-nine (51%) patients presented biochemical values under the cut-off but only 17 (18%) had clinical symptoms.Both variables yielded statistically significant AUC (PTH one-hour post surgery: 0.654; p = 0.0403; 95%CI: 0.519–0.773 and delta PTH: 0.659; p = 0.0263; 95%CI: 0.527–0.776). Although comparison of the two ROC curves did not yield significant differences, delta PTH yielded a better sensitivity and PTH one-hour post-TT yielded a marginally better specificity (sensitivity of 50% and 87% and specificity of 76% and 67% for cut-offs of <39.8 pg/dl and <54.5 pg/dl, respectively).Both biomarkers have similar diagnostic accuracy for hypocalcemia, and can be used to indicate when supplemental therapy should be implemented in order to favor a timely discharge.

Floating left innominate vein neoplastic thrombus: A rare case of mediastinal extension of follicular thyroid carcinoma

We report a case of advanced follicular thyroid cancer with innominate vein involvement. To our knowledge, this seems to be the first case treated in emergency surgery, reported in literature. A 59-year-old woman with a five-year history of a large and mainly right-sided cervical mass presented with dyspnea, unilateral arm swelling, facial flushing, and venous congestion. An emergency computed tomography scan revealed a thyroid mass extending into the upper mediastinum with displacement and compression of the right jugular vein and carotid artery and apparent adherence to the superior vena cava and left innominate vein. An emergency total thyroidectomy was performed by means of a sternotomy. The lower portion of the retrosternal goiter projected directly into the left innominate vein, with tumor floating in its lumen. Removal of the neoplastic thrombus was performed, through an incision in the vein, en bloc with the thyroid mass. Both goiter and thrombus were completely replaced by follicular carcinoma. Accurate preoperative assessment through contrast-enhanced computed tomography is strongly suggested in the presence of enlarged thyroid gland extending into the mediastinum whenever angioinvasion is suspected. This could prevent blinded maneuvers such as digital externalization of the thoracic component of the gland, which can be fatal in cases of cervico-mediastinal goiter extending into great cervical or mediastinal veins.

Malignant solitary fibrous tumor of the esophagus

Solitary fibrous tumor (SFT) of the esophagus has been very rarely reported in literature. Herein, we report a case of a successful surgically treated malignant solitary fibrous tumor of the esophagus. A 36-year-old woman was admitted at our hospital with an erroneous ultrasound-based diagnosis of cervico-mediastinal goiter. Surprisingly, the preoperative diagnostic work-up, including a computed tomographic chest scan, endoscopy, and endoscopic ultrasonography, revealed a pedunculated intraluminal mass in the esophagus. The tumor was radically removed through left antero-lateral cervicotomy. Pathologic and immunohistochemical examination was concluded for a malignant SFT, a rare variant not previously described in relation to the esophagus. The patient underwent adjuvant radiotherapy and is alive with no signs of tumor recurrence 32 months after surgery.

Cervico-mediastinal goiter: is telescopic exploration of the mediastinum (video mediastinoscopy) useful?☆

Surgeons are aware that most mediastinal goiters can be excised through a Kocher transverse collar incision, but in rare circumstances a partial-complete median sternotomy or a thoracotomy are mandatory. During an operation to remove a large cervico-mediastinal goiter (CMG) a profound, not massive, bleeding in the anterior mediastinum developed. Bleeding was unsuccessfully treated with packing. Instead, to perform an urgent sternotomy we used telescopic imaging to identify the source of hemorrhage, and a metallic clip was used to stop the bleeding. Since then we have prospectively used the telescope in the case of large CMG causing compression of an adjacent structure. This report is a preliminary communication demonstrating the technique. Telescopic exploration of the mediastinum was performed in seven patients. The goiters were located in the middle mediastinum in five patients and in the anterior and middle mediastinum in one, respectively. The use of a telescope can help the surgeon during the removal of a large mediastinal goiter. It facilitates a) the visualization of the intrathoracic tributaries reducing the risk of hemorrhage, b) the research of ectopic thyroid gland, and finally c) minimizes the risk of complications of a median sternotomy.

Multidetector Computed Tomography in the Preoperative Evaluation of Retrosternal Goiters: A Useful Procedure for Patients for Whom Magnetic Resonance Imaging Is Contraindicated

Diagnostic imaging provides useful anatomical and morphological information of cervico-mediastinal goiters. The aim of this study was to assess the usefulness of multidetector computed tomography (MDCT) with multiplanar reformatting and volume rendering reconstructions for the preoperative evaluation of retrosternal goiters in patients for whom magnetic resonance imaging is contraindicated. From March 2006 to January 2009, 34 patients (20 women and 14 men; mean age, 48 years; range, 42-74 years) with suspected cervico-mediastinal goiter were assessed by MDCT after intravenous injection of contrast material. The following parameters were evaluated: morphology, size, and enhancement of thyroid lobes; presence, location, and mediastinal extension of thyroid tissue; and relations with mediastinal vessels and organs. All patients underwent thyroidectomy. A reference group of 34 patients evaluated by single-detector computed tomography was created. The two groups of patients were compared searching for operative time (OT, in hours), hospital stay (HS, in days), and morbidity rate observed after thyroid surgery in all cases. In 29/34 patients, thyroid was enlarged with left mediastinal extension in 12 cases, right extension in 10 cases, and posterior extension in 7 cases. In 3/34 patients, a normal cervical thyroid connected to the mediastinal goiter through a thin parenchymal stripe was observed. In 2/34 patients, thyroid lobes were enlarged, without mediastinal extension. By comparing the two groups of patients for OT and HS values, a significant reduction to 3.7 +/- 0.1 hours and 4.3 +/- 0.1 days, respectively, was found in the group of MDCT patients, and also a trend to the reduction for morbidity rate (21%) could be recognized. MDCT represents a noninvasive tool in the evaluation of retrosternal goiters. High-quality multiplanar reformatting and volume rendering reconstructions allow an optimal analysis of the plunged gland and could reduce OT, HS, and probably the morbidity rate.

Preoperative Embolization of Thyroid Arteries in a Patient with a Large Cervicomediastinal Hyperfunctioning Goiter

We present the case of a 61-year-old male patient with chronic obstructive pulmonary disease and a large cervicomediastinal multinodular hyperfunctioning goiter that made thyroidectomy a daunting task, especially considering the risk of intraoperative bleeding. The preoperative computed tomographic (CT) scan showed the right thyroid lobe very deeply rooted in the mediastinum, below the horizontal plane passing through the aortic arch. The thyroid mass imprinted the arterious and venous innominate trunks. To avoid a median sternotomy and remove the enlarged thyroid through a cervical approach alone, we decided to reduce the goiter in volume preoperatively by embolizing the thyroid arteries. We embolized the superior and inferior left, and the inferior right thyroid arteries. We spared the superior right thyroid artery because its blood supply contributed little to thyroid perfusion. After embolization, the patient was treated with antithyroid agents and corticosteroid drug therapy. At the same time, severe leukocytosis developed, thyroid hormone values increased, and a CT scan obtained 7 days after embolization showed the thyroid unchanged in volume. We therefore discharged the patient and were waiting for his laboratory blood chemical findings to return to normal. Thirty days later the patient was readmitted to hospital, and a new CT scan showed that the thyroid mass had diminished to half its initial volume. We could therefore perform a total thyroidectomy through a cervical approach alone. The only problem arose in dissecting tight right inferior laryngeal nerve adhesions to the thyroid capsule, probably sequelae of postembolization thyroiditis. Even though preoperative thyroid-artery embolization cannot be considered a routine technique in cervicomediastinal goiter surgery, in a rare patient who presents with a voluminous goiter such as the one we describe here, it is a useful procedure.

Tratamiento quirúrgico del bocio cervicomediastínico

To review our experience with the surgical treatment of cervicomediastinal goiters. Charts of patients with cervicomediastinal goiters undergoing thyroidectomy within the last 10 years were reviewed. Data regarding previous disease, clinical features, diagnostic procedures, surgical intervention and postoperative evolution were recorded. Twenty-eight patients (19 female and 9 male) 62 +/- 2 years old underwent surgery to treat cervicomediastinal goiter during the period reviewed. Among patients with compressive manifestations (75.6%), dyspnea was the most common (36.6%) symptom, followed by dysphagia and superior vena cava syndrome. An extrathoracic obstruction pattern was found in 3 (11.2%) cases. Thyroid scintigraphy showed increased thyroid size in 25 patients, and in 9 of them a cold nodule was present as well. Fine needle aspiration of the thyroid gland was performed in 5 patients; malignancy was found only in 1 case. Fiberoptic bronchoscopy was performed in 15 patients; in 7 (25%) tracheal compression was found. In these patients there was no higher rate of postoperative complications. Cervicotomy was the surgical approach used in 23 (82.1%) patients. Cervicosternotomy was used in 4 (14%), and thoracotomy in 1 (3.6%). The surgical procedure was bilateral subtotal thyroidectomy in 15 (53.6%), total thyroidectomy in 3 (10.7%), right lobectomy in 6 (21.4%), and left lobectomy in 4 (14.3%). Colloid goiter was the most common histological type (42.8%), followed by nodular hyperplasia (35.8%), cancer (10.7%) and adenoma (10.7%). Three patients showed transient recurrent paralysis in the postoperative period, and another 3 patients presented major complications: 1 case of postoperative bleeding and 2 cases of tracheomalacia requiring tracheostomy. Cervicomediastinal goiter is a disease that may involve compressive symptoms. In our experience, most cases were resected through cervicotomy, colloid goiter and the nodular hyperplasia being the most common histological types. There was no relationship between surgical procedure and the incidence of complications.