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Ectopic thyroid
1952
CASE REPORT GAMBLIN ET AL ECTOPIC THYROID
Ectopic Thyroid T. Clark Gamblin, MD, G. Russell Jennings, MD, Dudley B. Christie III, BS, William M. Thompson, Jr, MD, and Martin L. Dalton, MD Department of Surgery, Mercer University School of Medicine, The Medical Center of Central Georgia, Macon, Georgia
CASE REPORTS
Primary mediastinal ectopic goiters are very rare. We report a case in which an ectopic goiter with blood supply from the thoracic vessels necessitated a transternal approach for removal, resulting in a favorable outcome. (Ann Thorac Surg 2003;75:1952–3) © 2003 by The Society of Thoracic Surgeons
T
rue primary mediastinal ectopic goiters are quite rare, occurring in less than 1% of all goiters. This mediastinal mass is typically asymptomatic. However, if of considerable size, it may cause venous obstruction or tracheal compression. The blood supply arises from the thoracic vessels; this necessitates a transternal approach for complete removal rather than a standard thryoid cervical incision. We report the case of a 62-year-old woman with a history of hyperthyroidism and multinodular goiter. She was a patient with insulin-dependent diabetes and chronic hypertension who presented to our surgery clinic with a diagnosis of substernal goiter. Seen previously by an endocrinologist, she was placed on tapazol for thyroid suppression. A previous computed tomographic chest scan revealed a large substernal mass compressing the left innominate vein (Fig 1). This mass extended from the thoracic inlet inferiorly, anterior to the heart, with severe tracheal deviation to the patient’s right. The patient reported dyspnea on exertion and stated that she was unable to sleep in a recumbent position. She described a chronic cough despite tobacco abstinence or any history of respiratory infections. On physical examination she was markedly obese and the thyroid was not palpable. After discontinuing the thyroid supplementation, a thyroid scan was obtained. The substernal mass was positive for thyroid tissue, and the patient consented for thyroid lobectomy and isthmectomy. Because of severe tracheal compression the possibility of tracheomalacia necessitating a possible tracheostomy was discussed. On exploration of the thyroid through a routine cervical incision, the left lobe was diffusely enlarged but not compressing the trachea. Below the sternal notch the superior edge of the substernal goiter was palpable and Accepted for publication Sept 27, 2002. Address reprint requests to Dr Gamblin, 777 Hemlock Street, Hospital Box 140, Macon, GA 31201; e-mail: [email protected].
© 2003 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2003;75:1952–3
no evidence of vascular supply from the neck was appreciated. The substernal goiter was clearly totally separate from the thyroid gland and could not possibly be removed through the cervical incision. The left lobe and isthmus were removed because of diffuse goiter. Median sternotomy was then performed and a large goiter with adjacent thymic tissue was removed from the anterior mediastinum (Fig 2). This ectopic goiter had no connection to the thyroid gland. The vascular supply from the left innominate vein and innominate artery was suture ligated. A frozen section confirmed the mass as mediastinal ectopic goiter. The patient had an uneventful postoperative course and was discharged home on postoperative day 5.
Comment Ectopic thyroid tissue is the result of abnormal migration of the thyroid gland as it travels from the floor of the primitive foregut to its pretracheal position. According to autopsy studies, the prevalence of ectopic thyroid tissue varies between 7% and 10%. Lingual thyroid tissue accounts for 90% of the abnormalities [1]. In contrast to typical substernal goiters, which are an extension from a neck goiter, true primary mediastinal goiters are quite rare and occur in less than 1% of all goiters. Blood supply is typically from thoracic vessels and surgical approach by median sternotomy is therefore mandatory [2]. Thyroid tissue originates at the foramen cecum, which is located at the junction of the anterior two thirds and posterior one third of the tongue. Between weeks 3 and 7 of gestation, the gland migrates caudally to its normal
Fig 1. Computed tomographic scan reveals a large anterior mediastinal mass compressing the innominate vein and displacing the trachea. 0003-4975/03/$30.00 PII S0003-4975(03)00007-9
Ann Thorac Surg 2003;75:1953–5
1953
References 1. Neinas FW, Gorman CA, Devine KD, Woolner LB. Lingual thyroid. Clinical characteristics of 15 cases. Ann Intern Med 1973;79:205–10. 2. Spinner RJ, Moore KL, Gottfried MR, Lowe JE, Sabiston DC Jr. Thoracic intrathymic thyroid. Ann Surg 1994;220:91–6. 3. Le Roux BT. Heterotopic mediastinal thyroid. Thorax 1961;16: 192–6. 4. Kaplan M, Kauli R, Lubin E, Grunebaum M, Laron Z. Ectopic thyroid gland. A clinical study of 30 children and review. J Pediatr 1978;92:205–9. 5. Kuehn PG, Newell RC, Reed JF. Exophthalmos in a woman with lingual, subhyoid and lateral-lobe thyroid glands. N Engl J Med 1966;274:652–4. 6. Willis RA. The borderland of embryology, and pathology. London: Butterworths, 1958. 7. Sand J, Pehkonen E, Mattila J, Seppanen S, Salmi J. Pulsating mass at the sternum. A primary carcinoma of ectopic mediastinal thyroid. J Thorac Cardiovasc Surg 1996;112:833–5. 8. Reeve TS, Rundle FF, Hales IB, et al. The investigation and management of intrathoracic goiter. Surg Gynecol Obstet 1962;115:223–9.
Resection of a Symptomatic Pericardial Cyst Using the Computer-Enhanced Da Vinci™ Surgical System Matthew D. Bacchetta, MD, Robert J. Korst, MD, Nasser K. Altorki, MD, Jeffrey L. Port, MD, O. Wayne Isom, MD, and Charles A. Mack, MD Department of Cardiothoracic Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
Traditionally, symptomatic pericardial cysts have been treated with thoracotomy and resection. More recently, video-assisted thoracoscopic procedures for pericardial cysts have been reported. We present the case of a 43-year-old man who was suffering from a symptomatic pericardial cyst. He underwent successful resection using a computer-enhanced robotic surgical system. This case is an example of the continued extension of roboticassisted thoracic surgery. (Ann Thorac Surg 2003;75:1953–5) © 2003 by The Society of Thoracic Surgeons
R
obotic technology using computer-enhanced surgical systems has been used in a wide range of surgical specialties including cardiac surgery, general surgery, and general thoracic surgery [1– 4]. Mohr and colleagues [1] and Chitwood and Nifong [2] have demonstrated feasibility and safety of off-pump and on-pump Accepted for publication Nov 26, 2002.
Fig 2. Gross specimen of the mediastinal goiter and inferiorly attached thymic tissue. © 2003 by The Society of Thoracic Surgeons Published by Elsevier Inc
Address reprint requests to Dr Mack, Department of Cardiothoracic Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center, M-404, 525 E 68th St, New York, NY 10021; e-mail: cmack@ med.cornell.edu.
0003-4975/03/$30.00 PII S0003-4975(02)05008-7
CASE REPORTS
pretracheal position. Ectopic anterior mediastinal thyroid tissue usually lies in the vicinity of the thymus. Patients with a relatively small mediastinal mass are usually without symptoms and present with an abnormal incidental chest radiograph [3]. The majority of patients with ectopic thyroid tissue are clinically and biochemically euthyroid, but hyperthyroidism has been described in a few case reports [4, 5]. Functionally active aberrant thyroid tissue may be found at the base of the tongue, along the normal course of the thyroglossal duct, in the anterior mediastinum, in the pericardium, or in the heart [6]. The most common site for ectopic thyroid is the tongue, with thyroid tissue being microscopically detected in up to 10% of autopsies [7]. Serum thyroid tests and thyroid nuclear scans may be useful in diagnosis and in clinical management. A positive uptake confirms a thoracic goiter, but a negative scan does not exclude its diagnosis [2]. Heterotopic thyroid tissue in the anterior mediastinum, pericardium, or heart has probably developed from rudiments of developing thyroid dragged into the chest during descent of the heart and great vessels with the development of the embryonic neck and the unfolding of the embryo [3]. During embryogenesis, as the heart descends, the thyroid is drawn caudally, and ectopic mediastinal thyroid tissue is thought to be caused by abnormal positional relationships to the heart [2]. More than one half of mediastinal goiters are symptomatic and are more common in women— especially those older than 45 years— occuring in 1 of 5,000 patients [8]. Rarely do intrathoracic goiters exist in any considerable size without producing venous obstruction and causing dilation of the superficial thoracic veins. These patients may have a characteristic cough caused by tracheal compression. In conclusion, we present an uncommon true primary ectopic mediastinal goiter resected through a median sternotomy with complete excison and relief of all symptoms.
CASE REPORT BACCHETTA ET AL RESECTION OF PERICARDIAL CYST
CASE REPORT GAMBLIN ET AL ECTOPIC THYROID
Ectopic Thyroid T. Clark Gamblin, MD, G. Russell Jennings, MD, Dudley B. Christie III, BS, William M. Thompson, Jr, MD, and Martin L. Dalton, MD Department of Surgery, Mercer University School of Medicine, The Medical Center of Central Georgia, Macon, Georgia
CASE REPORTS
Primary mediastinal ectopic goiters are very rare. We report a case in which an ectopic goiter with blood supply from the thoracic vessels necessitated a transternal approach for removal, resulting in a favorable outcome. (Ann Thorac Surg 2003;75:1952–3) © 2003 by The Society of Thoracic Surgeons
T
rue primary mediastinal ectopic goiters are quite rare, occurring in less than 1% of all goiters. This mediastinal mass is typically asymptomatic. However, if of considerable size, it may cause venous obstruction or tracheal compression. The blood supply arises from the thoracic vessels; this necessitates a transternal approach for complete removal rather than a standard thryoid cervical incision. We report the case of a 62-year-old woman with a history of hyperthyroidism and multinodular goiter. She was a patient with insulin-dependent diabetes and chronic hypertension who presented to our surgery clinic with a diagnosis of substernal goiter. Seen previously by an endocrinologist, she was placed on tapazol for thyroid suppression. A previous computed tomographic chest scan revealed a large substernal mass compressing the left innominate vein (Fig 1). This mass extended from the thoracic inlet inferiorly, anterior to the heart, with severe tracheal deviation to the patient’s right. The patient reported dyspnea on exertion and stated that she was unable to sleep in a recumbent position. She described a chronic cough despite tobacco abstinence or any history of respiratory infections. On physical examination she was markedly obese and the thyroid was not palpable. After discontinuing the thyroid supplementation, a thyroid scan was obtained. The substernal mass was positive for thyroid tissue, and the patient consented for thyroid lobectomy and isthmectomy. Because of severe tracheal compression the possibility of tracheomalacia necessitating a possible tracheostomy was discussed. On exploration of the thyroid through a routine cervical incision, the left lobe was diffusely enlarged but not compressing the trachea. Below the sternal notch the superior edge of the substernal goiter was palpable and Accepted for publication Sept 27, 2002. Address reprint requests to Dr Gamblin, 777 Hemlock Street, Hospital Box 140, Macon, GA 31201; e-mail: [email protected].
© 2003 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2003;75:1952–3
no evidence of vascular supply from the neck was appreciated. The substernal goiter was clearly totally separate from the thyroid gland and could not possibly be removed through the cervical incision. The left lobe and isthmus were removed because of diffuse goiter. Median sternotomy was then performed and a large goiter with adjacent thymic tissue was removed from the anterior mediastinum (Fig 2). This ectopic goiter had no connection to the thyroid gland. The vascular supply from the left innominate vein and innominate artery was suture ligated. A frozen section confirmed the mass as mediastinal ectopic goiter. The patient had an uneventful postoperative course and was discharged home on postoperative day 5.
Comment Ectopic thyroid tissue is the result of abnormal migration of the thyroid gland as it travels from the floor of the primitive foregut to its pretracheal position. According to autopsy studies, the prevalence of ectopic thyroid tissue varies between 7% and 10%. Lingual thyroid tissue accounts for 90% of the abnormalities [1]. In contrast to typical substernal goiters, which are an extension from a neck goiter, true primary mediastinal goiters are quite rare and occur in less than 1% of all goiters. Blood supply is typically from thoracic vessels and surgical approach by median sternotomy is therefore mandatory [2]. Thyroid tissue originates at the foramen cecum, which is located at the junction of the anterior two thirds and posterior one third of the tongue. Between weeks 3 and 7 of gestation, the gland migrates caudally to its normal
Fig 1. Computed tomographic scan reveals a large anterior mediastinal mass compressing the innominate vein and displacing the trachea. 0003-4975/03/$30.00 PII S0003-4975(03)00007-9
Ann Thorac Surg 2003;75:1953–5
1953
References 1. Neinas FW, Gorman CA, Devine KD, Woolner LB. Lingual thyroid. Clinical characteristics of 15 cases. Ann Intern Med 1973;79:205–10. 2. Spinner RJ, Moore KL, Gottfried MR, Lowe JE, Sabiston DC Jr. Thoracic intrathymic thyroid. Ann Surg 1994;220:91–6. 3. Le Roux BT. Heterotopic mediastinal thyroid. Thorax 1961;16: 192–6. 4. Kaplan M, Kauli R, Lubin E, Grunebaum M, Laron Z. Ectopic thyroid gland. A clinical study of 30 children and review. J Pediatr 1978;92:205–9. 5. Kuehn PG, Newell RC, Reed JF. Exophthalmos in a woman with lingual, subhyoid and lateral-lobe thyroid glands. N Engl J Med 1966;274:652–4. 6. Willis RA. The borderland of embryology, and pathology. London: Butterworths, 1958. 7. Sand J, Pehkonen E, Mattila J, Seppanen S, Salmi J. Pulsating mass at the sternum. A primary carcinoma of ectopic mediastinal thyroid. J Thorac Cardiovasc Surg 1996;112:833–5. 8. Reeve TS, Rundle FF, Hales IB, et al. The investigation and management of intrathoracic goiter. Surg Gynecol Obstet 1962;115:223–9.
Resection of a Symptomatic Pericardial Cyst Using the Computer-Enhanced Da Vinci™ Surgical System Matthew D. Bacchetta, MD, Robert J. Korst, MD, Nasser K. Altorki, MD, Jeffrey L. Port, MD, O. Wayne Isom, MD, and Charles A. Mack, MD Department of Cardiothoracic Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
Traditionally, symptomatic pericardial cysts have been treated with thoracotomy and resection. More recently, video-assisted thoracoscopic procedures for pericardial cysts have been reported. We present the case of a 43-year-old man who was suffering from a symptomatic pericardial cyst. He underwent successful resection using a computer-enhanced robotic surgical system. This case is an example of the continued extension of roboticassisted thoracic surgery. (Ann Thorac Surg 2003;75:1953–5) © 2003 by The Society of Thoracic Surgeons
R
obotic technology using computer-enhanced surgical systems has been used in a wide range of surgical specialties including cardiac surgery, general surgery, and general thoracic surgery [1– 4]. Mohr and colleagues [1] and Chitwood and Nifong [2] have demonstrated feasibility and safety of off-pump and on-pump Accepted for publication Nov 26, 2002.
Fig 2. Gross specimen of the mediastinal goiter and inferiorly attached thymic tissue. © 2003 by The Society of Thoracic Surgeons Published by Elsevier Inc
Address reprint requests to Dr Mack, Department of Cardiothoracic Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center, M-404, 525 E 68th St, New York, NY 10021; e-mail: cmack@ med.cornell.edu.
0003-4975/03/$30.00 PII S0003-4975(02)05008-7
CASE REPORTS
pretracheal position. Ectopic anterior mediastinal thyroid tissue usually lies in the vicinity of the thymus. Patients with a relatively small mediastinal mass are usually without symptoms and present with an abnormal incidental chest radiograph [3]. The majority of patients with ectopic thyroid tissue are clinically and biochemically euthyroid, but hyperthyroidism has been described in a few case reports [4, 5]. Functionally active aberrant thyroid tissue may be found at the base of the tongue, along the normal course of the thyroglossal duct, in the anterior mediastinum, in the pericardium, or in the heart [6]. The most common site for ectopic thyroid is the tongue, with thyroid tissue being microscopically detected in up to 10% of autopsies [7]. Serum thyroid tests and thyroid nuclear scans may be useful in diagnosis and in clinical management. A positive uptake confirms a thoracic goiter, but a negative scan does not exclude its diagnosis [2]. Heterotopic thyroid tissue in the anterior mediastinum, pericardium, or heart has probably developed from rudiments of developing thyroid dragged into the chest during descent of the heart and great vessels with the development of the embryonic neck and the unfolding of the embryo [3]. During embryogenesis, as the heart descends, the thyroid is drawn caudally, and ectopic mediastinal thyroid tissue is thought to be caused by abnormal positional relationships to the heart [2]. More than one half of mediastinal goiters are symptomatic and are more common in women— especially those older than 45 years— occuring in 1 of 5,000 patients [8]. Rarely do intrathoracic goiters exist in any considerable size without producing venous obstruction and causing dilation of the superficial thoracic veins. These patients may have a characteristic cough caused by tracheal compression. In conclusion, we present an uncommon true primary ectopic mediastinal goiter resected through a median sternotomy with complete excison and relief of all symptoms.
CASE REPORT BACCHETTA ET AL RESECTION OF PERICARDIAL CYST