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Surgical treatment of benign nontoxic intrathoracic goiter
Surgical Treatment of Benign Nontoxic lntrathoracic Goiter A Long-Term Observation
Steen Watt-Boolsen, MD, Copenhagen, Denmark Mogens Blichert-Toft, MD, Copenhagen, Denmark Kirsten Folke, MD, Copenhagen, Denmark Claus Christlansen, MD, Copenhagen, Denmark Arthur Boberg, Copenhagen, Denmark
In patients with goiter located entirely or partly in the thoracic cavity the decision for surgery, surgical procedures and related complications differ somewhat from those in patients with cervical goiters. These items have been dealt with earlier [1-101. However, knowledge of long-term results with regard to thyroid function, recurrence of goiter and voice function is limited. In the present study, these problems are addressed. Material
and Methods
During the period 1960 to 1977,29 patients aged 39 to surgical treatment for benign euthyroid intrathoracic goiter in the Department of Thoracic Surgery, Gentofte Hospital. All patients fulfilled the criteria for establishment of the diagnosis of thoracic and thoracocervical goiter [6]. In 25 patients the goiter was thoracocervical and in 4 thoracic. The indications for surgery were compression of the trachea or the superior vena cava, or both, in 18 patients, whereas 11 patients had no complaints about the goiter. In one patient, compression was life-threatening. A transverse collar incision offered sufficient access in 23 patients. In three patients the collar incision was supplemented by a partial sternotomy. In two other patients posterolateral thoracotomy was carried out, and in one sternotomy was supplemented by lateral thoracotomy. The median weight of removed goitrous tissue was 98 g (range 50 to 635). Histologic examination showed colloid goiter without malignancy. Thyroid function was measured by determination of serum total thyroxine, serum total triiodothyronine, free total thyroxine index and serum thyroid-stimulating hormone. Albumin-corrected serum calcium was also measured. Free total thyroxine was determined by competitive protein binding technique (Tetrasorb, Abbott) and 84 years underwent
From the Departments of Thoracic Surgery and Diagnostic Radiology, Gentofte Hosoital: and the Deoartment of Clinical Chemistrv and the Ear. Nose and Thrkt Departmant,‘Glostrup Hospital, Copenhagen, Denmark. ReqUeStS for reprints should be addressed to Steen Watt-Boolsen. MD, Strandboulevarden 27.2 100 Copenhagen & Denmark.
Volume 141, June 1991
serum total triiodothyronine by radioimmunoassay (Abbott). Total triiodothyronine resin uptake (Triosorb, Abbott) values were expressed in proportion to a reference serum fixed at 100. Free total thyroxine index was calculated by the formula: serum total thyroxine X total triiodothyronine - resin uptake X 10b2. Serum thyroidstimulating hormone was measured by radioimmunoassay using a kit from Pharmacia Diagnostics, Copenhagen (Table I). Before surgery vocal cord mobility was normal. After surgery indirect laryngoscopy was done. At follow-up indirect laryngoscopy was repeated, and stroboscopy was performed and general auditory impression evaluated by a logopedist. Results There were few surgical complications and no wound problems. One patient, an 84 year old woman operated on because of severe tracheal compression, died on the second day of pulmonary embolism. Three patients developed permanent unilateral immobility of the vocal cords. No clinically significant hypocalcemia was observed. No patient had hypothyroidism after goiter resection and no patient received thyroid replacement therapy. Follow-up took place in October 1978,2 to 18 years (median 10) after operation. Fifteen patients attended. Four were too old to participate. One had died postoperatively from pulmonary embolism and nine had died from unrelated causes. The obtainable records on the 14 patients who did not attend revealed no transient or permanent thyroid or parathyroid dysfunction after surgery, except in one patient in whom hypothyroidism developed 2 years after goiter resection. No patient had recurrence of goiter. The results of thyroid determinations obtained from the 15 patients who attended follow-up are
721
Watt-Boolsen
TABLE I
et al
Thyroid Function Determinations in 15 Patients Treated Surgically for Benign Nontoxic lntrathoracic Goiter 2 to 18 Years Earlier Values Median Range
Serum total thyroxine (nmol/liter) Free total thyroxine index (arbitrary units) Serum total triiodothyronine (nmol/liter) Serum thyroid stimulating hormone (mu/liter)
Normal Values Median Range
89
74-124
100
58-169
96
80-130
99
59-169
2.2
1.8-3.0
2.4
1.5-3.6
11.5
1.5-5.4
2.0
11.5-6.0
Summary
given in Table I. All values were within the reference range. Albumin-corrected serum calcium concentrations were normal. No recurrence of goiter could be demonstrated either clinically or roentgenographically. The general impression of voice function was satisfying. The findings on indirect laryngoscopy were unchanged compared with the early postoperative examination: normal in 14 patients and unilateral vocal cord immobility in 1. Stroboscopy showed a normal vibration pattern except in the patient with vocal cord immobility. Comments Even large intrathoracic goiters can be managed safely by the cervical approach. This finding is in accordance with previous reports [1-4,6-101. In our study, partial sternotomy or thoracotomy was used in only 6 of 29 patients. Still, any surgeon performing thyroid surgery should be familiar with the thoracic approach. In the present study, hypothyrodism developed in one patient after goiter resection. Of 15 patients followed up for a median of 10 years, none had biochemical evidence of impaired thyroid function. No patient had an elevated serum level of thyroidstimulating hormone. This finding, based on biochemical evidence, is consistent with earlier, mainly clinical observations indicating that impaired thyroid function seldom follows surgical treatment of large intrathoracic goiters [6,9]. In those studies recurrence of goiter was rare: 1 recurrence in 59 patients [6] and 1 in 12 patients [9], which is consistent with our experience. In this context, a normal serum level of thyroid-stimulating hormone, as measured in the present study, may be important in the low recurrence rate. Surgical damage of the parathyroid glands was not a problem in our study, as indicated by the normal
722
albumin-corrected serum calcium levels. The absence of previous reports on this subject may indicate that parathyroid damage is rarely a clinical problem. Neither was late voice function a problem, reflecting a low rate of recurrent nerve lesions and possibly also the beneficial effect on voice function of surgical treatment of nontoxic goiter [11]. The rate of permanent vocal cord immobility in the present series is consistent with previous observations [2,6]. Thyroid replacement therapy postoperatively is usually advocated. This and other studies [12] do not support this attitude. We do not find thyroid replacement therapy required routinely after resection of nontoxic intrathoracic goiter.
Twenty-nine patients underwent surgical treatment for benign nontoxic intrathoracic goiter. None received thyroid replacement therapy after operation. The time of observation varied from 2 to 18 years. Fifteen patients attended reexamination. Ten had died from unrelated causes and 4 were too old to participate. Thyroid function was normal on reexamination, and albumin-corrected serum calcium levels were normal. Recurrence of goiter was not demonstrated by palpation of the neck or roentgenographic examination of the trachea and chest. Late voice function was satisfying based on stroboscopy and clinical judgment. Our results indicate that large intrathoracic goiters can be managed safely by the cervical approach and that only rarely is the thoracic route required. Thyroid replacement therapy appears unnecessary as a postoperative routine measure. References 1. Colcock BP. lntrathoracic goiter. Surg Clin North Am 1953; 33:773-g. 2. Judd ES, Beahrs OH, Bowes DE. A consideration of the proper surgical approach for substemal goiter. Surg Gynecol Dbstet 1960;110:90-8. 3. Nielsen OV. lversen OH. lntrathoracic goitre. Dan Med Bull 1963;10:185-7. 4. Karlin S. lntrathoracic goiters. Am Surg 1963;29:499-505. 5. Smith EB. Transthoracic thyroidectomy. Am J Surg 1964: 107:751-3. 6. Hasner E, Borgeskov S. Thoracic and thoracocervical goitres. Dan Med Bull 1965;12:166-70. 7. Trotoux J, Gandon J, Zerbib J. Les goitres plongeants. Ann Dtolaryngol Chir Cervicofac 1974;91:475-84. 8. De Andrade MA. A review of 128 cases of posterior mediastinal goitre. World J Surg 1977;1:789-97. 9. Oevrum E, Birkeland S. lntrathoracalt struma. Tidsskr Nor Laegeforen 1977;97:1492-4. 10. Lamke L, Bergdahl L, Lamke B. lntrathoracic goitre. Acta Chir Stand 1979;145:83-6. 11. Watt-Boolsen S, Blichert-Toft M, Boberg A. Influence of thyroid surgery on voice function and laryngeal comphints. Br J Surg 1979;66:535-6. 12. Blichert-Toft M, Egedorf J, Christiansen C, Axelsson CK. Function of pituitary-thyroid axis after surgical treatment of nontoxic nodular goitre. Acta Med Stand 1979;206: 15-9.
The American Journal of Surgery
Steen Watt-Boolsen, MD, Copenhagen, Denmark Mogens Blichert-Toft, MD, Copenhagen, Denmark Kirsten Folke, MD, Copenhagen, Denmark Claus Christlansen, MD, Copenhagen, Denmark Arthur Boberg, Copenhagen, Denmark
In patients with goiter located entirely or partly in the thoracic cavity the decision for surgery, surgical procedures and related complications differ somewhat from those in patients with cervical goiters. These items have been dealt with earlier [1-101. However, knowledge of long-term results with regard to thyroid function, recurrence of goiter and voice function is limited. In the present study, these problems are addressed. Material
and Methods
During the period 1960 to 1977,29 patients aged 39 to surgical treatment for benign euthyroid intrathoracic goiter in the Department of Thoracic Surgery, Gentofte Hospital. All patients fulfilled the criteria for establishment of the diagnosis of thoracic and thoracocervical goiter [6]. In 25 patients the goiter was thoracocervical and in 4 thoracic. The indications for surgery were compression of the trachea or the superior vena cava, or both, in 18 patients, whereas 11 patients had no complaints about the goiter. In one patient, compression was life-threatening. A transverse collar incision offered sufficient access in 23 patients. In three patients the collar incision was supplemented by a partial sternotomy. In two other patients posterolateral thoracotomy was carried out, and in one sternotomy was supplemented by lateral thoracotomy. The median weight of removed goitrous tissue was 98 g (range 50 to 635). Histologic examination showed colloid goiter without malignancy. Thyroid function was measured by determination of serum total thyroxine, serum total triiodothyronine, free total thyroxine index and serum thyroid-stimulating hormone. Albumin-corrected serum calcium was also measured. Free total thyroxine was determined by competitive protein binding technique (Tetrasorb, Abbott) and 84 years underwent
From the Departments of Thoracic Surgery and Diagnostic Radiology, Gentofte Hosoital: and the Deoartment of Clinical Chemistrv and the Ear. Nose and Thrkt Departmant,‘Glostrup Hospital, Copenhagen, Denmark. ReqUeStS for reprints should be addressed to Steen Watt-Boolsen. MD, Strandboulevarden 27.2 100 Copenhagen & Denmark.
Volume 141, June 1991
serum total triiodothyronine by radioimmunoassay (Abbott). Total triiodothyronine resin uptake (Triosorb, Abbott) values were expressed in proportion to a reference serum fixed at 100. Free total thyroxine index was calculated by the formula: serum total thyroxine X total triiodothyronine - resin uptake X 10b2. Serum thyroidstimulating hormone was measured by radioimmunoassay using a kit from Pharmacia Diagnostics, Copenhagen (Table I). Before surgery vocal cord mobility was normal. After surgery indirect laryngoscopy was done. At follow-up indirect laryngoscopy was repeated, and stroboscopy was performed and general auditory impression evaluated by a logopedist. Results There were few surgical complications and no wound problems. One patient, an 84 year old woman operated on because of severe tracheal compression, died on the second day of pulmonary embolism. Three patients developed permanent unilateral immobility of the vocal cords. No clinically significant hypocalcemia was observed. No patient had hypothyroidism after goiter resection and no patient received thyroid replacement therapy. Follow-up took place in October 1978,2 to 18 years (median 10) after operation. Fifteen patients attended. Four were too old to participate. One had died postoperatively from pulmonary embolism and nine had died from unrelated causes. The obtainable records on the 14 patients who did not attend revealed no transient or permanent thyroid or parathyroid dysfunction after surgery, except in one patient in whom hypothyroidism developed 2 years after goiter resection. No patient had recurrence of goiter. The results of thyroid determinations obtained from the 15 patients who attended follow-up are
721
Watt-Boolsen
TABLE I
et al
Thyroid Function Determinations in 15 Patients Treated Surgically for Benign Nontoxic lntrathoracic Goiter 2 to 18 Years Earlier Values Median Range
Serum total thyroxine (nmol/liter) Free total thyroxine index (arbitrary units) Serum total triiodothyronine (nmol/liter) Serum thyroid stimulating hormone (mu/liter)
Normal Values Median Range
89
74-124
100
58-169
96
80-130
99
59-169
2.2
1.8-3.0
2.4
1.5-3.6
11.5
1.5-5.4
2.0
11.5-6.0
Summary
given in Table I. All values were within the reference range. Albumin-corrected serum calcium concentrations were normal. No recurrence of goiter could be demonstrated either clinically or roentgenographically. The general impression of voice function was satisfying. The findings on indirect laryngoscopy were unchanged compared with the early postoperative examination: normal in 14 patients and unilateral vocal cord immobility in 1. Stroboscopy showed a normal vibration pattern except in the patient with vocal cord immobility. Comments Even large intrathoracic goiters can be managed safely by the cervical approach. This finding is in accordance with previous reports [1-4,6-101. In our study, partial sternotomy or thoracotomy was used in only 6 of 29 patients. Still, any surgeon performing thyroid surgery should be familiar with the thoracic approach. In the present study, hypothyrodism developed in one patient after goiter resection. Of 15 patients followed up for a median of 10 years, none had biochemical evidence of impaired thyroid function. No patient had an elevated serum level of thyroidstimulating hormone. This finding, based on biochemical evidence, is consistent with earlier, mainly clinical observations indicating that impaired thyroid function seldom follows surgical treatment of large intrathoracic goiters [6,9]. In those studies recurrence of goiter was rare: 1 recurrence in 59 patients [6] and 1 in 12 patients [9], which is consistent with our experience. In this context, a normal serum level of thyroid-stimulating hormone, as measured in the present study, may be important in the low recurrence rate. Surgical damage of the parathyroid glands was not a problem in our study, as indicated by the normal
722
albumin-corrected serum calcium levels. The absence of previous reports on this subject may indicate that parathyroid damage is rarely a clinical problem. Neither was late voice function a problem, reflecting a low rate of recurrent nerve lesions and possibly also the beneficial effect on voice function of surgical treatment of nontoxic goiter [11]. The rate of permanent vocal cord immobility in the present series is consistent with previous observations [2,6]. Thyroid replacement therapy postoperatively is usually advocated. This and other studies [12] do not support this attitude. We do not find thyroid replacement therapy required routinely after resection of nontoxic intrathoracic goiter.
Twenty-nine patients underwent surgical treatment for benign nontoxic intrathoracic goiter. None received thyroid replacement therapy after operation. The time of observation varied from 2 to 18 years. Fifteen patients attended reexamination. Ten had died from unrelated causes and 4 were too old to participate. Thyroid function was normal on reexamination, and albumin-corrected serum calcium levels were normal. Recurrence of goiter was not demonstrated by palpation of the neck or roentgenographic examination of the trachea and chest. Late voice function was satisfying based on stroboscopy and clinical judgment. Our results indicate that large intrathoracic goiters can be managed safely by the cervical approach and that only rarely is the thoracic route required. Thyroid replacement therapy appears unnecessary as a postoperative routine measure. References 1. Colcock BP. lntrathoracic goiter. Surg Clin North Am 1953; 33:773-g. 2. Judd ES, Beahrs OH, Bowes DE. A consideration of the proper surgical approach for substemal goiter. Surg Gynecol Dbstet 1960;110:90-8. 3. Nielsen OV. lversen OH. lntrathoracic goitre. Dan Med Bull 1963;10:185-7. 4. Karlin S. lntrathoracic goiters. Am Surg 1963;29:499-505. 5. Smith EB. Transthoracic thyroidectomy. Am J Surg 1964: 107:751-3. 6. Hasner E, Borgeskov S. Thoracic and thoracocervical goitres. Dan Med Bull 1965;12:166-70. 7. Trotoux J, Gandon J, Zerbib J. Les goitres plongeants. Ann Dtolaryngol Chir Cervicofac 1974;91:475-84. 8. De Andrade MA. A review of 128 cases of posterior mediastinal goitre. World J Surg 1977;1:789-97. 9. Oevrum E, Birkeland S. lntrathoracalt struma. Tidsskr Nor Laegeforen 1977;97:1492-4. 10. Lamke L, Bergdahl L, Lamke B. lntrathoracic goitre. Acta Chir Stand 1979;145:83-6. 11. Watt-Boolsen S, Blichert-Toft M, Boberg A. Influence of thyroid surgery on voice function and laryngeal comphints. Br J Surg 1979;66:535-6. 12. Blichert-Toft M, Egedorf J, Christiansen C, Axelsson CK. Function of pituitary-thyroid axis after surgical treatment of nontoxic nodular goitre. Acta Med Stand 1979;206: 15-9.
The American Journal of Surgery