Intrathoracic mediastinal thyroid goiter: imaging manifestations.
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Intrathoracic goiter (more than 80% of tissue in the thoracic cavity) represents very rare clinical entity (less than 1% of total number of thyroid gland surgical procedures). Cancer incidence in these goiter is 0-5%. The aim of this article is to present a case report of intrathoracic thyroid papillary carcinoma with multiple compressive syndrome and review of compressive intrathoracic syndrome of thyroid etiology. In our patient we have found: tracheal and oesophageal deviation and compression, superior vena cava syndrome, downhill varices, chylothorax, pericardial effusion, compress of the left a. subclavia, unilateral lesion of recurrent and phrenic nerve, and brachial plexopathy. This was a unique case with multiple compressive syndrome between 3000 patients surgically treated for all kinds of thyroid diseases. Intrathoracic goiter can cause all the known symptoms and syndromes of intrathoracic compression with possibility of rapid deterioration and fatal end.
Primary mediastinal tumour or cyst was surgically treated in 129 patients (including 19 younger than 12 years) during a 16-year period. All histologic specimens and smears from fine-needle aspiration biopsy were reviewed. Intrathoracic goitre, neurogenic lesions and thymomas comprised 62% of all the tumours. Fifty lesions (39%) were found at routine radiographic examination and were asymptomatic. Eight of these 50 lesions were malignant. Chest pain, fatigue, weight loss and fever were significantly more common in malignant than in benign disease. Despite extensive investigations, the diagnosis was not established preoperatively in 32% of the cases. Chest radiography, CT-scanning and fine-needle aspiration biopsy usually provide satisfactory diagnostic information, thereby substantially reducing the need for other preoperative procedures. Early operative intervention is mandatory in these cases.
A rare case in tracheal invasion by a papillary carcinoma in an intrathoracic goiter is reported. Subtotal thyroidectomy and tracheoplasty were performed. Surgery should be considered as first-line treatment of intrathoracic goiter in order to avoid future compression of the respiratory tract and to remove possible concomitant malignant lesion.
A retrospective review is presented of 20 cases with resection of intrathoracic goitre between 1975 and 1993. The mean age of the 11 men and nine women was 53 years. The intrathoracic goitre was primary in seven cases and secondary in 13. The presenting clinical features and the pathology, surgical risks and optimal approaches are discussed. Primary intrathoracic goitre should be approached via a thoracotomy, because of the independent vascular supply. As secondary intrathoracic goitres are supplied by vascular pedicles arising from the inferior thyroid artery, a cervical collar incision is preferable. In the event of significant mediastinal bleeding, which is difficult to control from a cervical incision, a T-shaped incision for partial or full sternotomy can be performed, or even thoracotomy.
The schwannoma is thought to arise from the schwann cells of the nerve sheath. This tumor is usually solitary and may arise from any cranial or peripheral nerve. It is encapsulated and appears to arise focally on a nerve trunk so that the nerve itself is stretched over the tumor rather than running through it as in neurofibroma. This report is unusual as the tumor started as a cervical swelling which subsequently grew into the mediastinum simulating a retrosternal goiter. The patient, a 25 year-old female was referred to the University College Hospital, Ibadan, 24 hours after an attempted thyroidectomy at a private hospital. The history was of a painless anterior neck swelling of 4 years duration devoid of symptoms of hyperthyroidism with associated dysphagia and weakness of the left hand. Examination showed an asthenic young woman. Her voice was hoarse but there were no eye signs suggestive of thyrotoxicosis. On the anterior neck was a sutured skin-crease scar over a diffuse anterior neck swelling which one could not get below. The left hand showed wasting of the thenar and hypothenar eminences. Thyroid function test results were within normal limits, indirect laryngoscopy showed a left vocal cord paralysis, packed cell volume was 38%. Her chest x-ray showed a huge left retrosternal and apical soft tissue mass displacing the trachea to the right (figure 1). A fine needle aspiration cytology was reported as a chronic lymphocytic thyroiditis. A presumptive diagnosis of thyroid carcinoma with retrosternal extension was made. At surgery, manipulation of the mass was difficult as the tissue was soft, slimy and ruptured easily. Severe hemorrhage was encountered necessitating a median sternotomy to control the bleeding vessels. Her post-operative period was stormy, however she thereafter made gradual progress to warrant her discharge six weeks post surgery.
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Retrosternal thyroid accounts for a significant percentage of anterior mediastinal masses, but has been described very rarely as the cause of superior vena cava (SVC) syndrome. Most cases of SVC syndrome occur as a complication of malignancy. The authors report the case of a patient with few respiratory symptoms, mild upper airway obstruction, and SVC syndrome caused by a benign retrosternal multinodular goiter.
Primary intrathoracic goiter is a rare presentation of thyroid disease. Its removal usually necessitates thoracotomy or sternotomy. This patient having a primary intrathoracic goiter presented with posterior mediastinal mass that was removed through a right lateral thoracotomy.
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Between 1984 and 1997 year 4985 patients underwent surgical treatment due to various thyroid gland diseases, among them were 28 (0.6%) patients with intrathoracic goitre, but only in one case (0.002%) the signs of superior vena cava syndrome (SVCS) were observed: oedema and lividity of the face, enlargement of jugular veins and superior limbs' veins. In addition the patient manifested subsequently growing dyspnoea, dysphagia and hoarseness. In diagnose essential were X-ray examination of the chest (widening of mediastinal shadow), X-ray examination of the trachea (dislocation and compression of the trachea), X-ray of esophagus with contrast (compression from the outside), ultrasonography of thyroid gland. Intraoperatively, after it was confirmed that the SVCS was caused by compression of the intrathoracic right lobe of thyroid gland, the oblong sternotomy was performed to provide the proper surgical access for subtotal thyroidectomy. The weight of resected tissues of thyroid gland was 1036 g. In histopathological examination the diagnosis of multinodular toxic goitre was confirmed.
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