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PubMed2004

Surgical management of substernal goiters: clinical experience of 170 cases.

PURPOSE: To discuss the presentation, diagnosis, treatment, histopathological findings, and complications of patients who underwent thyroidectomy for substernal goiter in our surgical clinic. METHODS: We retrospectively analyzed 170 patients with substernal goiters among 2650 patients undergoing surgical treatment for various thyroid diseases between 1990 and 2003. We evaluated the clinical data, preoperative diagnostic findings, surgical treatments, histopathological results, and postoperative complications. RESULTS: The most common symptoms were a cervical mass (88%) and dyspnea (35%), but 26% of the patients were asymptomatic. Chest radiography provided the first evidence of a substernal goiter in 77% of the patients. We performed total or near total thyroidectomy and operated through a cervical incision in all but 12 of the patients. There was no operative mortality but 12 (7%) patients suffered temporary hypoparathyroidism and 4 suffered transient vocal cord paralysis (2%). Malignancy was diagnosed by histopathological examination in 22 (13%) patients. CONCLUSION: We think that the diagnosis of a substernal goiter is an indication for thyroidectomy, which is associated with very low postoperative morbidity.

Adolescent↗
PubMed1999

Substernal goiter: clinical experience of 72 cases.

The aim of this work was to study the clinical management and surgical approach of substernal goiters. We studied the clinical data, preoperative evaluation, surgical treatment, histopathologic data, complications, and follow-up of 72 patients found to have substernal goiter over a period of 15 years, from a total of 780 patients with goiter who underwent surgery. In this group, 83% were women, and the mean age was 61 years. The most common symptoms were the existence of a palpable cervical mass (93% of cases) and dyspnea (40%). The most successful study to diagnose substernal goiter was computed tomography (100%), followed by chest radiography (75%), gammagraphy (19%), and ultrasound (15%). All but 7 patients received a Kocher cervicotomy, and 49% of the cases underwent a total thyroidectomy. The histologic study revealed 3 carcinomas (4%). There was 1 permanent unilateral recurrent laryngeal nerve injury (1.4%) and 1 instance of permanent hypoparathyroidism (1.4%). We regard surgery as the most successful treatment for patients with substernal goiter, even in those without compressive symptoms. We base our choice on the low morbidity and zero mortality obtained.

Adult↗
PubMed1995

Surgical management of substernal goiter: analysis of 237 patients.

Between 1968 and 1991, 237 patients underwent thyroidectomy for substernal goiter. Sixteen of them presented malignancies (6.8%). Mean age of the 159 women and 78 men was 57.7 years. Twenty-five patients had undergone previous thyroid surgery. The initial symptoms were cervical mass (72%), compression (16.2%), hyperthyroidism (13.1%), hypothyroidism (1.3%), and 5.5 per cent were asymptomatic. Most patients had long-standing goiter (mean duration: 12.9 yrs). All but eight operations were performed through a cervical incision. There were two postoperative deaths (0.8%), both in patients with advanced neoplasms. Early postoperative complications were hemorrhage (0.8%), dysphonia (4.6%), and transient hypocalcemia (2.9%). Five patients (2.1%) required tracheotomy. Complications were more frequent after total thyroidectomy than partial resection (P < 0.05), after surgery for malignancy than for benign disease (P < 0.05), and in complex than in simple forms (P < 0.05). One hundred ninety-four patients were followed after surgery; dyspnea was found in two patients (1.0%), dysphonia in seven (3.6%), and hypoparathyroidism in one. Analysis of our data indicates that 1) substernal goiter arose in elderly patients more than a decade later than cervical goiter; 2) goiters with a "complex" endothoracic development had an increased rate of short and long term complications; 3) cancer occurred in a significant number of patients, without any specific symptoms of malignancy; 4) the group of patients with hyperthyroidism was characterized by a significantly longer clinical history than euthyroid patients; 5) nearly all substernal goiters could be approached through a cervical collar incision; 6) the morbidity and mortality were low also after sternotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

Operative treatment of substernal goiters.

This report describes the operative experience in 72 patients with substernal goiters treated over the past 5.5 years. Even though the incidence of multinodular goiter has decreased in the United States due to the routine use of iodized salt, we continue to see a large number of patients with massive goiters, predominantly from Caribbean Islands. The diagnosis of substernal goiter was made on clinical examination augmented by such radiologic studies, as chest x-ray, barium esophagograms, airway films, and CT scans. Computed tomographic (CT) scanning was particularly helpful in evaluating the extent of substernal extension. Confirmation of the extent of disease was made at the time of operation. Ninety percent of the patients had tracheal deviation and 85% were symptomatic from airway compression. Esophageal compression was noted in 60% of the patients. All patients had a long history of goiter with recent onset of pressure symptoms. Flow-volume-loop studies were performed in 44% of the patients and were useful in the evaluation of pressure symptoms. However, the decision for operation was made primarily based on clinical evaluation of signs and symptoms. Sixteen patients in this group were admitted with acute airway distress requiring airway intubation or semi-emergency decompression. Only 1 patient required mediastinal splitting, while all others were operated by the cervical approach. The decision as to the extent of thyroidectomy was made at the time of operation. Drains were routinely used because of the large dead space. One patient developed a hematoma in the recovery room and required re-exploration.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1985

Substernal goiter. Analysis of 80 patients from Massachusetts General Hospital.

Eighty patients at the Massachusetts General Hospital underwent resection of substernal goiter in the years 1976 to 1982. Mean age of the 50 women and 30 men was 56 years, and 10 (19 percent) had undergone prior thyroid surgery. The most common symptoms were cervical mass (69 percent), dysphagia (33 percent), and dyspnea (28 percent); 13 percent were asymptomatic. On examination, cervical mass was present in most (90 percent) but not all patients, 51 percent were obese, and more than one third had tracheal deviation. Fifty-one of 52 patients tested were euthyroid and one was mildly hypothyroid. Chest radiographs showed tracheal deviation in 79 percent and soft tissue mass in 56 percent. Seventy-eight patients underwent resection through a cervical collar incision only; one had cervical incision plus upper partial sternotomy; and one required cervical incision plus full median sternotomy. Pathologic examination revealed multinodular goiter in 41 (51 percent), follicular adenoma in 35 (44 percent), and Hashimoto's thyroiditis in 4 (5 percent). Mean goiter weight was 104 g, and the mean greatest dimension was 9 cm. Occult papillary carcinoma was found in two patients. There were no deaths or major complications. Analysis of our data indicate the following: (1) Substernal goiter may exist in the absence of symptoms or signs. (2) Extensive radiologic evaluation and thyroid function testing are rarely required. (3) With rare exceptions, substernal goiter represents an extension of a cervical growth through the thoracic inlet and can be approached through a cervical collar incision. (4) Histologically, these are multinodular goiters or follicular adenomas, although Hashimoto's thyroiditis may occur. (5) Given the small but present risks of acute stridor or occult malignancy and the negligible surgical risk, operation should be recommended. (6) Patients should be followed since, with or without levothyroxine, goiters may recur.

Adult↗
PubMed2003

[Three dimensional spiral computed tomography imaging in preop diagnosis of substernal goiter (preliminary study)].

The aim of the study was the estimation of substernal goiter by use of three-dimensional spiral computed tomography (3-D sCT) with the contrast agent. The size and anatomy of goiter as well as its relation to surrounding tissues, particularly blood vessels was evaluated. The examination allowed good visualization of both inferior thyroid arteries. The use of 3-D sCT may have a great meaning in preoperative examination in particular in technically difficult cases of substernal goiter.

Arteries↗
PubMed1993

[Substernal goiter: new diagnostic methods and treatment].

The authors report 47 cases of substernal goiters operated between 1971 and 1990. Forty-five patients had mediastinal-cervical-goiters (g.c.m.) and 2 had ectopic goiter (g.e.). Cervicotomy was performed in the 45 g.c.m., in 3 cases associated with sternal "split". The g.e. were treated with thoracotomy. Computed Tomography (TC) has been performed since 1984 in 26 patients; Magnetic Resonance (RM) since 1987 in 6 patients. The diagnostic accuracy for TC was 84.6% and 100% for MR on anatomical-topographic-definition, and 80.8% and 83.3% for presumptive diagnosis of nature, respectively. Considering the high diagnostic accuracy, the possibility to reconstruct the images in sagittal and coronal planes, the RM seems to be the elective diagnostic procedure for all substernal goiters.

Adult↗
PubMedDate not supplied

[Substernal goiter: a diagnostic and therapeutic problem. (Report of 39 surgically treated cases)].

Substernal goiter is a rare pathology and its definition varied from author to author. We considered substernal the goiter that has the larger diameter below the thoracic inlet, in accord to definition of Valdoni (1957). The authors examined retrospectively 40 cases of endothoracic goiter, that represent 6.1% of patients operated on thyroid. Surgical access was in 35 cases a cervical collar incision; in 2 patients was necessary to associate a median superior sternotomy and in another patient a lateral thoracotomy. In 3 patients the access was a median sternotomy and in the last patient a posterolaterally thoracotomy. The authors carried out 12 total thyroidectomy (30.7%), 15 subtotal thyroidectomy (38.6%), 10 total lobectomy (25.6%), 2 subtotal lobectomy (5.1%). No mortality was observed. The morbility was represented by 5 monolateral temporary palsy of recurrent laringeal nerve, 6 transitory hypocalcemia, 1 tetanic syndrome, 1 transitory arrhythmy. The follow-up was managed on 35 patients (89.7%). We observed 1 definitive hypoparathyroidism, 1 paralysis of recurrent laringeal nerve, 1 mediastinic relapse. One patient was operated on total thyroidectomy 14 years after the first surgery for a differentiated carcinoma. In conclusion the treatment of substernal goiter is surgical. Debating point is the entity of exeresis. We think that the first choice operation is thyroidectomy, done through a cervical collar incision. Occasionally sternotomy or thoractomy are necessary.

Female↗
PubMed1996

[Specific morbidity of substernal goiters. A comparative study with a matched series of cervical goiters].

The operative morbidity rates in patients operated for substernal goiter (SG) vary from one series to another. The aim of this study was to reevaluate the morbidity using a matched technique. Each SG was matched to a cervical goiter for surgical technique, histology and thyroid function. There were 97 SG (75% of women), 43% with normal thyroid function, 28% with mild hyperthyroidism, 29% with hyperthyroidism. 87% of thyroidectomies were bilateral. Mean age was 66.5 +/- 11.5 years versus 55.8 +/- 11.9 years for cervical goiters (p < 0.001). The percentage of men was higher for SG than for cervical goiter (25% versus 10%, p < 0.01). Specimen weighed 166 +/- 109g versus 76 +/- 95g (p < 0.0001). Total volume of drainage was 164.0 +/- 68 ml versus 123.2 +/- 68 ml (p = 0.003). No operative death occurred. Early hypoparathyroidism rate was 3% versus 2% (p = 0.5), and late hypoparathyroidism was 1% versus 0% (p = 0.5). There was a 10 mg/l in serum calcium post-operative drop in both groups but no change in serum phosphate was noted (bilateral thyroidectomies). The early recurrent laryngeal nerve palsy rate was 4% versus 0% (p = 0.06) and 3% versus 0% one year later (p = 0.12). Early postoperative reoperation rate for hemostasis was 2% versus 1% respectively (p = 0.25). We conclude that there is no significant difference in surgical morbidity between thyroidectomies for SG and cervical goiters when patients are operated in specialized centers. Operative fears are not justified.

Aged↗
PubMedDate not supplied

Comparison between computed tomography and magnetic resonance data and pathologic findings in substernal goiters.

Computed Tomography (CT) and Magnetic Resonance (MR) permit the acquirement of important diagnostic elements for the anatomo-topographic staging of substernal goiters, and for their characterization. The authors compared data obtained by CT and MR with intraoperative anatomo-topographic findings and definitive histology in 28 patients with substernal goiters. CT was performed in all these patients while MR only in 9. The results obtained showed an accuracy of 85.7% for CT and 100% for MR regarding the anatomo-topographic correspondence with intraoperative findings, without a significant statistical difference between these two diagnostic procedures. MR is more accurate than CT in showing the vascular dislocations. CT and MR have an accuracy of 82.1% and 77.7% respectively comparing their findings with histologic results obtained in operative specimens, without a significant statistical difference. In conclusion MR has to be considered the more accurate diagnostic procedure and therefore recommended in the study of patients with substernal goiters, while CT can be performed only in selected patients.

Adult↗
PubMed1983

Rationale for the operative management of substernal goiters.

During the course of 872 thyroidectomies performed at the University of Michigan Medical Center between 1972 and 1982, 50 patients (5.7%) were found to have substernal goiters, 42 of which were benign and eight malignant (16%). Symptoms included airway compression (22 patients), dysphagia (13 patients), hoarseness (four patients), weight loss (three patients), and thyrotoxicosis (10 patients). Five patients with compression symptoms, four of whom had benign disease, had superior vena cava syndrome. Most patients were elderly (mean age 66 years), were women (3.2 women:1 man), and had long-standing goiters (mean duration 16 years). All but one operation was performed through a cervical incision. There were no intraoperative deaths. Complications were: pneumonia (one patient), wound hematoma (one patient), transient hypocalcemia (two patients), and atrial fibrillation (two patients). This series illustrates five reasons to support operative management. (1) There is no other treatment for long-standing large multinodular goiters. (2) Iodine 131, the alternative to operation for patients with large thyrotoxic goiters, can precipitate acute reactions in the elderly that can result in respiratory distress. (3) A long history of having a large multinodular goiter precluded neither malignancy, hyperfunction, nor complications such as tracheal or esophageal compression. (4) Malignancy occurs in a significant number of these lesions, which are inaccessible to needle biopsy. (5) Nearly all substernal goiters can be removed through a cervical incision. Presence of a substernal goiter is in itself an indication for operation.

Adult↗
PubMed1998

Management of substernal goiter.

OBJECTIVE: To analyze the presentation, evaluation and treatment of patients with large substernal goiters, with emphasis on the radiographic evaluation and the results of treatment. STUDY DESIGN: A retrospective chart review of 150 patients undergoing thyroidectomy at the Vanderbilt University Department of Otolaryngology-Head and Neck Surgery. METHODS: Charts of patients undergoing thyroidectomy were reviewed. Those with substernal goiter, defined as a major portion of the goiter within the mediastinum, were included in the study. When available, the radiographic studies were reviewed by a staff neuroradiologist. RESULTS: Twenty-three patients (15.3%) presented with substernal extension of the goiter. Characteristics of these patients included mean age of 59 years, 78% female, symptoms of compression such as dyspnea, choking, and dysphagia (65%), hoarseness (43%), and previous thyroid surgery (30%). Seventeen percent were asymptomatic. Preoperative radiographs demonstrated tracheal compression (73%), tracheal deviation (77%), esophageal compression (27%), and major vessel displacement (50%). Histology revealed multinodular goiter (16/23, 70%), thyroiditis (3/23, 13%), and malignancy (4/23, 17%). The average size of the resected specimen in greatest dimension was 8.0 cm (range, 3.0-14.0 cm) and weighed 148 g (range, 39-426 g). All were successfully approached through a transcervical incision without the need for sternotomy, and total thyroidectomy was performed in 83% of the cases. No major complications have been documented, and no evidence of tracheomalacia was encountered. CONCLUSION: Despite the large size of these goiters and the significant involvement of the major mediastinal structures, all were approached through the transcervical incision. Further, despite significant tracheal involvement, there were no cases of tracheomalacia or major complications. For intraoperative planning, the authors advocate the routine use of preoperative computed tomography scanning.

Adult↗
PubMed2001

[Surgery of substernal goiter].

OBJECTIVE: To study the surgical approaches and operative techniques for substernal goiter. METHOD: A retrospective study of 27 cases with substernal thyroid nodules was made in our hospital. RESULT: The operations on 27 patients with substernal nodules have been successfully carried out. Among them, 10 were goiters, 9 adenomas, 4 malignancy and 4 were thyroid cancer metastasizing to paratracheal or substernal nodes. Resection via cervical collar incision was adequate in 23 cases. Three thyroid cancers with paratracheal node metastasis were completely resected by sternotomy and only one thyroid cancer with paratracheal and substernal nodes metastasis was resected by combined thoracotomy and cervical collar incision. CONCLUSION: Resection via cervical collar incision for all retrosternal thyroid nodules were advised. The preliminary experience with this procedure suggests that it has some advantages in the management of substernal goiter, including: 1. ease of operation compared to both sternotomy and thoracotomy; 2. relatively low morbidity; 3. safe and reliable.

Adult↗