Posterior mediastinal goiter

POSTERIOR MEDIASTINAL GOITER* SYDNEY BRESSLER, M .D . AND SAMUEL ALCOTT THOMPSON, M .D . New fork, New York HE present concept of the term "intrathoracic goiter" is as follows : The greater part of the thyroid enlargement is situated within the thorax .' This type is differentiated from a substernal goiter which is a projection of some part of the thyroid beneath the sternum . The intrathoracie type may occur without evidence of cervical thyroid enlargement . Authoritative figures on the incidence of intrathoracic goiters based upon extant records of thyroidectomies are : McCort, 5 28 of 928 cases or 3 .1 per cent ; Wakely and Mulvany, 20 of 1,265 cases or 1 .6 per cent ; George Crile, Jr .,' 97 of i i,8oo cases or 0 .82 per cent. Most of the intrathoracic goiters are found in the anterior part of the superior mediastinum . Goiters situated in the posterior mediastinum are less common, and only rarely have goiters been found in the retroesophageal part of the superior mediastinum . McCort 5 in his series of superior mediastinal thyroids reports three located behind the esophagus . Rives' has reported one goiter located behind the esophagus . Ellis, Good and Se ybold2 from the Mayo Clinic also have reported only one partially retroesophageal goiter . The anteriorly placed niediastinal goiters originate in either the lower poles of the lateral thyroid lobes or the isthmus, and as they extend downward will lie in front of the mediastinal structures .' The posteriorly placed intrathoracic goiters originate in the posterior and lateral aspect of the lateral lobe of the cervical thyroid and descend behind the mediastinal structures . A connection between the cervical thyroid and the mediastinal goiter is usually retained as a. direct continuation of thyroid tissue or as a band of fibrous tissue .' In McCort'st series of twenty-eight superior mediastinal goiters proof of their origin in a normally situated gland in the neck was obtained at operation . In the series reported from the Mayo Clinic seven cases were encountered in which no connection between the

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mediastinal goiter and the cervical thyroid gland could he demonstrated . Lahey and Swinton' have described the mechanism by which the goiter descends into the mediastinum . The act of swallowing causes the goiter to move up and down in the thoracic inlet in its fascia! plane which leads into the mediastinum . Eventually further enlargement of the goiter will cause it to lodge in the mediastinum . We are reporting two cases of posterior mediastinal goiter, one of which was situated in the retroesophageal position . The latter is of extreme interest because of its obvious rarity . CASE REPORTS CASE u . A. G . eras admitted to the Flower and Fifth Avenue Hospitals on October 30, 1945, complaining of difficulty in breathing and of severe cough . The duration of these complaints was approximately one %car, with a gradual increase in severity of the symptoms . There had also been abundant sputum, occasionally blood-streaked . Physical examination revealed a fifty-eight year old white man, not acutely ill . The thyroid gland was not palpable . Expansion of the right hemothorax was greater than that of the left . There was an inspiratory wheeze especially on the right . N-rays submitted by the referring physician showed a. tumor in the upper left lung field . A preoperative diagnosis of carcinoma of the left lung was made and thoracotomy was performed, in the course of which a posteriorly placed goiter was encountered . This mass had pushed the trachea well over toward the right side . The upper pole of the tumor was approximately at the level of the first posterior rib, behind the innominate and subclavian arteries . The lower pole was behind and below the tipper margin of the arch of the aorta . The mass was completely encapsulated and was freed in most directions, with the exception of a superior

* From the Department of Thoracic Surgery, Metropolitan Hospital and the Phoracic Surgical Service, New York Medical College and Flower and Fifth Avenue I lospitals, New York, N . Y . February, 19S3

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Bressler, Thompson-Posterior Mediastinal Goiter

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Postero-anterior x-ray of chest and esophagram showing displacement of upper esophagus to the right . FIG . 2 . Oblique x-ray showing retroesophageal tumor and anterior displacement of esophagus . FIG . I .

attachment which was ligated and cut across for the delivery of the tumor . The exact origin of the superior attachment could not be determined . The tumor measured i r by 8 by 6.5 cm . and the microscopic diagnosis was partly degenerated follicular thyroid adenoma (fetal adenoma) . CASE t[ . L. B. was admitted to the Thoracic Surgical Service of the Metropolitan Hospital on July 31, i951, complaining of difficulty in swallowing and a slight difficulty in breathing. The duration of these complaints was approximately six weeks . The patient gave a medical history of osteoarthritis of five years' duration . Physical examination revealed a fifty-three year old, well developed and nourished white woman, not acutely or chronically ill . The thyroid was not palpably enlarged . X-ray examination (Figs . i and 2) showed a rounded mass located in the posterior portion of the superior mediastinum mainly on the left side displacing the trachea and esophagus anteriorly . An esophagoscopy was done which revealed a superior mediastinal mass apparently pushing the esophagus anteriorly and to the right . This mass was approximately i inch below the cricopharyngeus and extended downward for

i3 inches . Bronchoscopic examination revealed weakness of the right arytenoid . A preoperative diagnosis of neurogenic tumor was made because of the posterior location of the mass and a thoracotomy was performed on August 13, 1951, through the left posterior approach . The left lung appeared normal . An ovoid mass lying posterior to the esophagus and just cephalad to the aortic arch was seen . Incision of the overlying pleura exposed the mass which was recognized as thyroid tissue . The mass measured approximately 7 by 4 by 4 cm . It was easily freed from below up to a cephalic pedicle . This pedicle arose from the left lateral lobe of the cervical thyroid gland . It was clamped and ligated and the mass excised . The pathologic diagnosis was cystadenoma of the thyroid . Postoperatively the course was uneventful . On the second postoperative day the patient was able to swallow fairly well-definitely better than preoperatively . After one week swallowing was markedly improved . Immediate postoperative x-rays showed that the barium-filled esophagus was no longer displaced. In a follow-up examination three months later the patient had no complaints American Journal of Surgery



Bressler, Thompson--Posterior Mediastinal Goiter and was swallowing all solid food without difficulty . X-rays at this time revealed no abnormality . REMARKS

There are several interesting points about these two cases which are worthy of comment . In neither case was the diagnosis made preoperatively . The first case was thought to he bronchogenic carcinoma ; the second, a ncurogenic mediastinal tumor . This should emphasize the possibility that mediastinal tumors, whether anteriorly or posteriorly placed, may he of thyroid origin . Should an accurate diagnosis be mandatory before operation, the use of radioactive iodine as suggested by Touroff" will aid in making the diagnosis practically without fail . The article by Judd, , written more than thirty years ago, mentions that limitation in motion in one of the arvtenoids suggests the presence of a mediastinal goiter . It is an interesting observation that in our second case this finding was present . The posterior position of the goiters in both cases warrants additional comment . It would have been impossible, had we known the exact diagnosis preoperatively, to have removed these goiters by way of a cervical incision . This bears out the original observation made by Sweet' that posterior mediastinal goiters are best approached through the thorax .

February,

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Case )t adds one more description to the sparse medical literature on retroesophageal goiters and indicates clearly that this condition must he considered in patients presenting symptoms of dysphagia. SUMMARY

Two cases of posterior mediastinal goiter are reported with one lying in the retroesophageal position . The presence of an intrathoracic goiter should he considered in the differential diagnosis of all superior mediastinal tumors . REFERENCES I .

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C ., .la . Intrathoracic goiter . Cleveland Clip . Quart ., 6 :313, 1939. EL Is', I' . I-I ., .IR ., Gooo, C. A . and SLYBOLD, W . D . Intrathoracic goiter . Ann . Sung ., 135 : 79-
1s 149 157, 1920 . 4 . I .Aner, F . H . and

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Swtrctos, N . 14' . Intrathoracic goiter . Sung ., Gynec. & Ohst., 59 : 627-637, 1938 . titcCour, .1 . J . Intrathoracic goiter ; its incidence, symptomatology and roentgen diagnosis_ Rudiologp, 53 : 227 -237, 1949-

6 . Rives, J . D. Siediastinal aberrant goiter . T, . Am . S. A ., 65 :417, 1Q477 . Sweet, H . FL Intrathoracic goiter located in the posterior mediastinum . Sure ., Gynec . rr Obst ., 89 : 57 . 1949 . 8 . TounoFF, A . S . W . Discussion . J, Tborucir Sing ., I9 : 751, 11)50. 9 . WAKerv, C . P . G. and RIotcAw, J . Ii . Intrathoracic goiter . Surg., Gynec . er Obst ., 70 : 702, 11)40 .