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Retrosternal Goiter Associated With Chylothorax
Retrosternal Goiter Associated With Chylothorax* Carmen Delgado, MD .; Manuel Martin , MD. ; and Fernando de la Portilla, M.D.
W e d escribe a cas e of ch ylothorax in a female patient with a large retrosternal goiter. After subtotal th yroidectomy by m e ans of a Kocher cervicotomy, the chylothorax di sappeared in 48 h. At present, 2 ye ars after su rg ical removal , th e patient remain s asymptom atic, w it hout recurrent pl eural chy lous effus ion. Unt il now, to our knowl ed ge , only one suc h case had been reported . (Chest 1994; 106:1924-25) Key wo rds: chylothorax; goit er; retroesternal tumor various ca uses of chy lothorax have already M anybeenandreport ed ; th e first case of chy lothorax associ-
at ed with an intrathoracic goiter was not published until 1986 . 1 No oth er such case has been reported since (to our knowl edge). CASE R EPORT
A 70-year- old woman was ad mitted int o th e eme rge ncy department of our hospital beca use of increasing dyspn ea, left-sided thoraci c pain , solid and liquid dyspha gia , and weight loss of 12 kg.
Medical History Sixteen years ago, she und erw ent surgical int erv enti on for goit er in another hospital. Arteri al hypertension and atrial fibrillati on, occ urred. She was being tr eat ed with diuret ics and oral anticoagulants.
Clinical Examination
FIGURE 2. Com puted tom ographic chest scan: left pleural effusion. Left- sided paratracheal tumor with heterogeneous density (arrows) leading to com pression and displacem ent of th e tr achea and esophag us.
Laboratory Tests Coag ulation study was disturbed by her pr eviou s treatment. Th yroxin e level was 23.9 Jtg/dl (normal= O. 7 to 2.2 Jtg/ d l).
Thoracic Com puted Tomographi c Scan Left pleural effusion was no ted . A left-sided paratrachea l tum or was enlarged from the th yroid gland up to th e aortic crossing, show ing heterogen eous density and partial calcificati on, with comp ression and d isplacem ent of th e tra chea and esophag us (F igs 2 and 3).
Ta ch ypn ea, tach ycardia, and symptoms of left pleural eff usion wer e evide nt (F ig 1). *From the Department of Gen era l Surgery , Universitary Valme Hospital, Sevilla, Spain.
FIGURE 1. Initial chest radiograph: left pleural effusion and displacement of the trachea by tumor (arrow).
1924
FIGURE 3 Co mputed tom ographic chest scan: tumor with heterogeneous density (arrow) extend ing from th e retrosternal region up to aortic crossing.
Retrost emal Goiter Associated With Chylothorax (De/gado , Martin , de /a Portilla)
R EF ERENCES
Fernandez-Cruz L, Serra-Batlles J, Picado C. Retrosternal goiter and chylothorax: case report. Respiration 1986; 50:70-1 2 Light RW. Pleural diseases. Philadelphia: Lea & Febiger,1983; 209:19 3 Cammarata SK, Brush RE Jr, Hyzy RC. Chylothorax after childbirth. Chest 1991; 99:1539-40
Basilie Transvenous Biopsy for Investigation of Superior Vena Caval Syndrome* Andrea Frustaci, M.D ., F.G.G.P.; Gianfranco Lemmo , M.D .; and Gennaro Nuzzo, M.D .
FIGURE 4. Actual chest radiograph : Can be considered normal.
Isotope Scan With 99mTc
An area of diffuse hypocaptation , secondary to amiodar one blockade, extended to the retrosternal region. The pleural aspirate was milky in appearan ce and contained cholesterol (40 giL) and triglycerides (405 JLg/ L ). Initially she was treated by chest tube drain age, obtaining 800 to 1,500 rnl/d without tendency to diminish. With diagnosis of chylothorax secondar y to retrosternal goiter, surgical intervention was indicated , and a Kocher cervicotomy was subsequently performed. A subtotal thyroidectomy was carried out. Pathologic examination showed a multin odular coloid goiter, partiall y calcified. The postoperati ve period passed without complications. The pleural effusion disappeared 48 h after the removal of goiter, without showing symptoms of respiratory insufficiency. At present, 2 years after the intervention, the patient remains asymptoma tic, without recurr ence of chylothorax (Fig 4). DISCUSSION
The causes d escribed in th e literature as possible etiolog ies for chylothorax ar e grouped int o four classes:2,3 (1) trauma-penetrating wo unds, surgical procedures, crushing in juries; (2) tum or-m aligna nt neoplasms, lyrnphangiomyomatosis; (3) Idiopath ic ; and (4) miscellaneous childbir th , heart diseas e, cirrhosis of th e liv er , and th yroid e nla rgem ents. Through the consideration of the postoperative evolution of our patient, it is evident that there is a d irect cause-effec t relation between retrosternal goiter a nd pleu ra l chylous effusion. Our case is the second reported with these characteristics: the chylothorax disappeared after 48 h of the surgical removal of retrosternal goiter. 1 In the current ca se, thyroid enla rgem ents appear to hav e led to chylothorax, due to th e subs equent compression of thoracic duct and brachiocephalic vessels. Surgical rem oval of th e goiter allow ed control of th e ch ylothorax . The patient has continued to do well over th e 2 follow-up years.
Percutaneous t ra n sve n ou s b iop sy of an isola ted obstructing mass of superior vena cava (SVC) is reported . Ba sili c vein access and King's endomyocardial b ioptom e h a ve been successfully u sed. Metastatic cancer of SVC has been diagnosed and radiochemotherapy in st ituted, avoiding a n un desirable thoracot om y. (Chest 1994; 106:1925-26)
I SVC=superior vena cava I inv olvement of superior vena ca va (SVC) by an I solated obstructing ma ss may represent a relevant diagnostic
problem . In fact , either a resectable leiom yosarcoma of SVCl or a m etastasis , particularly from a small undet ectable lung ca nce r.f can be hypothesized . Prognosis and tr eatment of these conditions ar e remarkably diff er ent and th e histologic study of th e ca va l tumor becomes crucial. N onin vasive tools, such as computed tomography (CT) and nuclear m agnetic resonance, m a y be un able to identify th e originating tumor if it is less than 1 cm of diameter. On th e other hand, if a m etastatic cancer of SVC exists, inv asiv e diagnostic procedures, like thoracotomy, may b e undesirable. Transvenous bi op sy of SVC neoplasia has been reported occasion ally.i'-" mostly in the clinical setting of a m etastatic cancer, and following a femoral approach. W e report th e suc cessful use of basilic vein access and King's endomy oca rdial bioptome on an isolat ed obstructing mass of svc C ASE R EPOR T
A 59-year-old man was admitted to the hospital because of an edema of the face, neck, and arms that appeared progressively 3 months earlier. His clinical history was uneventful and his habitus was unremarkabl e except for being a moderate smoker (20 cigarettes daily). Physical examination showed distention of the neck and arm veins associated with an edema of the same terri*From the Departments of Card iology (Dr. Frustaci) and Geriatric Surgery (Drs. Lemm o and Nuzzo), Catholic University, Rome. Ita Iv. Reprint requests: Dr. Frusta ci, Universita Catt olica del S. Guore, Istituto di Gardiologia, Large F . Vito 1, 00168 Rom e, Ita ly CHEST I 106 I 6 I DECEMBER, 1994
1925
W e d escribe a cas e of ch ylothorax in a female patient with a large retrosternal goiter. After subtotal th yroidectomy by m e ans of a Kocher cervicotomy, the chylothorax di sappeared in 48 h. At present, 2 ye ars after su rg ical removal , th e patient remain s asymptom atic, w it hout recurrent pl eural chy lous effus ion. Unt il now, to our knowl ed ge , only one suc h case had been reported . (Chest 1994; 106:1924-25) Key wo rds: chylothorax; goit er; retroesternal tumor various ca uses of chy lothorax have already M anybeenandreport ed ; th e first case of chy lothorax associ-
at ed with an intrathoracic goiter was not published until 1986 . 1 No oth er such case has been reported since (to our knowl edge). CASE R EPORT
A 70-year- old woman was ad mitted int o th e eme rge ncy department of our hospital beca use of increasing dyspn ea, left-sided thoraci c pain , solid and liquid dyspha gia , and weight loss of 12 kg.
Medical History Sixteen years ago, she und erw ent surgical int erv enti on for goit er in another hospital. Arteri al hypertension and atrial fibrillati on, occ urred. She was being tr eat ed with diuret ics and oral anticoagulants.
Clinical Examination
FIGURE 2. Com puted tom ographic chest scan: left pleural effusion. Left- sided paratracheal tumor with heterogeneous density (arrows) leading to com pression and displacem ent of th e tr achea and esophag us.
Laboratory Tests Coag ulation study was disturbed by her pr eviou s treatment. Th yroxin e level was 23.9 Jtg/dl (normal= O. 7 to 2.2 Jtg/ d l).
Thoracic Com puted Tomographi c Scan Left pleural effusion was no ted . A left-sided paratrachea l tum or was enlarged from the th yroid gland up to th e aortic crossing, show ing heterogen eous density and partial calcificati on, with comp ression and d isplacem ent of th e tra chea and esophag us (F igs 2 and 3).
Ta ch ypn ea, tach ycardia, and symptoms of left pleural eff usion wer e evide nt (F ig 1). *From the Department of Gen era l Surgery , Universitary Valme Hospital, Sevilla, Spain.
FIGURE 1. Initial chest radiograph: left pleural effusion and displacement of the trachea by tumor (arrow).
1924
FIGURE 3 Co mputed tom ographic chest scan: tumor with heterogeneous density (arrow) extend ing from th e retrosternal region up to aortic crossing.
Retrost emal Goiter Associated With Chylothorax (De/gado , Martin , de /a Portilla)
R EF ERENCES
Fernandez-Cruz L, Serra-Batlles J, Picado C. Retrosternal goiter and chylothorax: case report. Respiration 1986; 50:70-1 2 Light RW. Pleural diseases. Philadelphia: Lea & Febiger,1983; 209:19 3 Cammarata SK, Brush RE Jr, Hyzy RC. Chylothorax after childbirth. Chest 1991; 99:1539-40
Basilie Transvenous Biopsy for Investigation of Superior Vena Caval Syndrome* Andrea Frustaci, M.D ., F.G.G.P.; Gianfranco Lemmo , M.D .; and Gennaro Nuzzo, M.D .
FIGURE 4. Actual chest radiograph : Can be considered normal.
Isotope Scan With 99mTc
An area of diffuse hypocaptation , secondary to amiodar one blockade, extended to the retrosternal region. The pleural aspirate was milky in appearan ce and contained cholesterol (40 giL) and triglycerides (405 JLg/ L ). Initially she was treated by chest tube drain age, obtaining 800 to 1,500 rnl/d without tendency to diminish. With diagnosis of chylothorax secondar y to retrosternal goiter, surgical intervention was indicated , and a Kocher cervicotomy was subsequently performed. A subtotal thyroidectomy was carried out. Pathologic examination showed a multin odular coloid goiter, partiall y calcified. The postoperati ve period passed without complications. The pleural effusion disappeared 48 h after the removal of goiter, without showing symptoms of respiratory insufficiency. At present, 2 years after the intervention, the patient remains asymptoma tic, without recurr ence of chylothorax (Fig 4). DISCUSSION
The causes d escribed in th e literature as possible etiolog ies for chylothorax ar e grouped int o four classes:2,3 (1) trauma-penetrating wo unds, surgical procedures, crushing in juries; (2) tum or-m aligna nt neoplasms, lyrnphangiomyomatosis; (3) Idiopath ic ; and (4) miscellaneous childbir th , heart diseas e, cirrhosis of th e liv er , and th yroid e nla rgem ents. Through the consideration of the postoperative evolution of our patient, it is evident that there is a d irect cause-effec t relation between retrosternal goiter a nd pleu ra l chylous effusion. Our case is the second reported with these characteristics: the chylothorax disappeared after 48 h of the surgical removal of retrosternal goiter. 1 In the current ca se, thyroid enla rgem ents appear to hav e led to chylothorax, due to th e subs equent compression of thoracic duct and brachiocephalic vessels. Surgical rem oval of th e goiter allow ed control of th e ch ylothorax . The patient has continued to do well over th e 2 follow-up years.
Percutaneous t ra n sve n ou s b iop sy of an isola ted obstructing mass of superior vena cava (SVC) is reported . Ba sili c vein access and King's endomyocardial b ioptom e h a ve been successfully u sed. Metastatic cancer of SVC has been diagnosed and radiochemotherapy in st ituted, avoiding a n un desirable thoracot om y. (Chest 1994; 106:1925-26)
I SVC=superior vena cava I inv olvement of superior vena ca va (SVC) by an I solated obstructing ma ss may represent a relevant diagnostic
problem . In fact , either a resectable leiom yosarcoma of SVCl or a m etastasis , particularly from a small undet ectable lung ca nce r.f can be hypothesized . Prognosis and tr eatment of these conditions ar e remarkably diff er ent and th e histologic study of th e ca va l tumor becomes crucial. N onin vasive tools, such as computed tomography (CT) and nuclear m agnetic resonance, m a y be un able to identify th e originating tumor if it is less than 1 cm of diameter. On th e other hand, if a m etastatic cancer of SVC exists, inv asiv e diagnostic procedures, like thoracotomy, may b e undesirable. Transvenous bi op sy of SVC neoplasia has been reported occasion ally.i'-" mostly in the clinical setting of a m etastatic cancer, and following a femoral approach. W e report th e suc cessful use of basilic vein access and King's endomy oca rdial bioptome on an isolat ed obstructing mass of svc C ASE R EPOR T
A 59-year-old man was admitted to the hospital because of an edema of the face, neck, and arms that appeared progressively 3 months earlier. His clinical history was uneventful and his habitus was unremarkabl e except for being a moderate smoker (20 cigarettes daily). Physical examination showed distention of the neck and arm veins associated with an edema of the same terri*From the Departments of Card iology (Dr. Frustaci) and Geriatric Surgery (Drs. Lemm o and Nuzzo), Catholic University, Rome. Ita Iv. Reprint requests: Dr. Frusta ci, Universita Catt olica del S. Guore, Istituto di Gardiologia, Large F . Vito 1, 00168 Rom e, Ita ly CHEST I 106 I 6 I DECEMBER, 1994
1925