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Surgical treatment of substernal goiter: An analysis of 44 cases
G Model
ANL-2103; No. of Pages 5 Auris Nasus Larynx xxx (2016) xxx–xxx Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Surgical treatment of substernal goiter: An analysis of 44 cases Muneo Nakaya *, Akiko Ito, Ayumi Mori, Mineko Oka, Sayaka Omura, Wataru Kida, Yasuhiro Inayoshi, Aki Inoue, Teruhiko Fuchigami Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 December 2015 Accepted 29 February 2016 Available online xxx
Objective: Substernal goiters are classified as primary or secondary intrathoracic goiters. Here, we report the diagnosis, symptoms, treatment, and postoperative complications of 44 substernal goiters (2 primary mediastinal goiter and 42 secondary mediastinal goiters). Methods: A retrospective chart review of 351 patients undergoing thyroidectomy at the Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center. Between 2009 and 2015, 44 patients underwent surgery for substernal goiter. Results: The frequency of primary and secondary mediastinal goiters was 0.5% and 11.9%, respectively. The preoperative symptoms were neck mass, dyspnea, and dysphagia. Eight patients were asymptomatic. Thirty-nine patients had benign masses and 5 patients had malignant masses. Most patients were operated on for adenomatous goiters (52.2%). In ten cases beyond the aortic arch, the tumors were benign and there were eight cases of adenomatous goiter. All patients underwent a successful transcervical incision without sternotomy. Even the primary intrathoracic goiters were extracted after total thyroidectomy via the cervical approach without complications. Although one case showed unilateral recurrent nerve paralysis as a postoperative complication, phonetic function improved in 6 postoperative months. No instances of postoperative bleeding or definitive hypoparathyroidism occurred, and tracheostomy was not performed in any of the cases. Conclusion: The cervical approach was safely performed in almost all substernal goiters without an extracervical procedure. Selected cases of primary mediastinal goiter may be excised via the cervical approach. ß 2016 Published by Elsevier Ireland Ltd.
Keywords: Substernal goiter Intrathoracic goiter Thyroidectomy Ectopic thyroid Ectopic goiter Cervical approach
1. Introduction Substernal goiter is defined as one that either descends below the thoracic inlet or has more than 50% of its volume below this level [1]. Substernal goiters are usually classified as primary or secondary mediastinal goiters [2]. Primary substernal goiters result from an abnormal embryologic migration of the thyroid anlage that is closely associated with the aortic
* Corresponding author at: Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu-shi, Tokyo 183-8524, Japan. Tel.: +81 42 323 5111; fax: +81 42 312 9197. E-mail address: [email protected] (M. Nakaya).
sac. Secondary substernal goiters develop from the descent of the thyroid into the mediastinum. Surgery is the only effective treatment for substernal goiters—treatment for asymptomatic patients remains controversial [3]. Most goiters are removed through a transcervical approach [4]. In some patients with giant tumors, posterior mediastinal goiter, ectopic mediastinal goiter, or malignant tumors, median sternotomy or lateral thoracotomy may be necessary [5,6]. In the present study we report 44 patients who were operated on for substernal goiters (2 primary mediastinal goiter and 42 secondary mediastinal goiters), and these cases were retrospectively analyzed focusing on the diagnosis, preoperative symptoms, surgical therapy, and postoperative complications.
http://dx.doi.org/10.1016/j.anl.2016.02.016 0385-8146/ß 2016 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Nakaya M, et al. Surgical treatment of substernal goiter: An analysis of 44 cases. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.016
G Model
ANL-2103; No. of Pages 5 M. Nakaya et al. / Auris Nasus Larynx xxx (2016) xxx–xxx
2
2. Patients and methods We retrospectively reviewed all of the patients with substernal goiters who underwent thyroidectomy between 2009 and 2015 at the Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center. Patients were selected on the basis of preoperative imaging studies (i.e., computed tomography [CT] and/or magnetic resonance imaging [MRI] scan). We defined a substernal goiter as a thyroid gland with more than 50% of its mass located below the thoracic inlet (same as the previous report) [1]. The medical records of all identified patients were reviewed. All of the data regarding patients’ preoperative symptoms, imaging, clinical and laboratorial findings, operation, pathological diagnosis, and complications were investigated. Laryngoscopy was performed postoperatively to check vocal cord mobility in all patients. Postoperative parathyroid hormone, calcium, and phosphorus levels were measured in total thyroidectomy. 2.1. Operative procedure A lower collar incision was performed along a wrinkle. We used monopolar, bipolar electrotome, and multifunctional tissue sealing systems in all cases. The strap muscles are usually separated along the midline. In selected cases, the strap muscles are divided to obtain better exposure and then sutured at the end of the operation. The upper pole is mobilized after the superior and middle thyroid vessels are ligated close to the thyroid capsule, avoiding injury to the external branch of the superior laryngeal nerve, which is not routinely exposed. Superior parathyroid glands were identified and preserved. The recurrent nerve was visually identified and completely divided from the tumor. In some patients the isthmus was divided in order to facilitate mobilization. The retrosternal part of the thyroid gland was digitally mobilized and delivered by cervical manipulation. It is important to operate gently so that a recurrent nerve is not pulled, although sublation of the tumor is performed blindly. Using a blunt finger dissection technique, the tumor is gradually elevated out of the mediastinum, ligating the inferior vascular structures using a multifunctional tissue sealing device. The inferior parathyroid glands were preserved when possible. After complete removal, the wound was irrigated and closed over suction drains.
Table 1 Occurrence of clinical symptoms (n = 44). Patients (n)
Clinical symptoms
Patients (n)
Symptomatic
36 (81.8%)
Neck mass Oppressive feeling Dyspnea Dysphagia Cough
34 14 5 6 1
Asymptomatic
8 (18.2%)
The symptoms at presentation are outlined in Table 1. Symptoms include neck mass (77.2%), oppressive feeling (31.8%), dyspnea (11.4%), dysphagia (13.6%), and cough (2.2%). Eight patients (18.2%) were asymptomatic at the time of surgery. Postoperative pathological findings are shown in Table 2. Thirty-nine patients had benign tumors (88.6%) and five patients had malignant tumors (11.4%). Most patients were operated on for adenomatous goiters (52.2%), and adenoma (29.2%). Only one case was the schwannoma in the benign tumors. In all ten cases beyond the aortic arch, the tumor was benign and there were eight cases of adenomatous goiter (Table 2-2). Total thyroidectomy was performed in nine patients (20.5%) and hemithyroidectomy was performed in 35 patients (79.5%). The operation was accomplished through a cervical incision in all cases. The technique was also conducted in the collar incision in Case 1 (Fig. 1) where a tumor exceeded the aortic arch. Moreover, the ectopic goiters of Case 2 (Fig. 2) and Case 3 (Figs. 3 and 4) were extracted manually after total thyroidectomy through the transcervical approach without sternotomy. There were no postoperative complications in either Case 2 or Case 3. In these substernal goiters, the reason why malignant tumors could extract via cervical approach was that those were not adhered to the peripheral tissue in 5 malignant cases. However, these 5 malignant cases were diagnosed malignant postoperatively. Although a recurrent nerve palsy arose after the operation in one case, the patient’s maximum phonation time improved 20 s after half a year. No instances of postoperative bleeding or Table 2-1 Pathology in all patients (n = 44). Patients (n)
Percentage
Benign
Adenomatous goiter Adenoma Schwannoma
23 13 1
52.2 29.5 2.2
Malignant
Papillary carcinoma Follicular carcinoma
3 2
6.8 4.5
Pathology
3. Results Between 2009 and 2015, 351 patients with various benign and malignant thyroid disorders underwent thyroid surgery at the Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center. Forty-four patients had substernal goiters (12.5%). The inferior pole of the tumor extended over the aortic arch in ten cases of substernal goiters (2.8%), and the tumor extended beyond the tracheal bifurcation in three cases (0.8%). Of all operated patients, 33 were female (75.0%) and 11 were male (25.0%). The median age of the patients was 60.0 years (range: 33–93 years).
(77.2%) (31.8%) (11.4%) (13.6%) (2.2%)
Table 2-2 Pathology in patients extended beyond aortic arch (n = 10). Pathology Benign
Adenomatous goiter Adenoma
Patients (n)
Percentage
8 2
80.0 20.0
Please cite this article in press as: Nakaya M, et al. Surgical treatment of substernal goiter: An analysis of 44 cases. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.016
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Fig. 1. Case 1: A 93-year-old female complained of dyspnea and dysphagia. The tumor pressed upon the trachea profoundly and extended beyond the aortic arch. Right hemithyroidectomy through a cervical incision was performed. The pathological finding was adenomatous goiter. $: Tumor.
definitive hypoparathyroidism occurred. Additionally, there were no cases of tracheomalacia, and tracheostomy was not performed in any cases. 4. Discussion The mediastinal location of the goiter is most frequently the result of a natural descent of a goiter from a primary cervical site (secondary mediastinal goiter) facilitated by negative intrathoracic pressure, gravity, and a large potential mediastinal space [1,3]. The reported incidence of mediastinal goiter among patients operated on for goiter varies in publications by various authors, ranging from 6 to 30% [1–8]. Additionally,
primary mediastinal goiter, which arises from an ectopic mediastinal goiter, is extremely rare [3,9,10], and 98% are secondary extensions of cervical disease (only 1.7% of intrathoracic goiters represent a primary mediastinal goiter [11,12]). In this report, the frequency of primary and secondary mediastinal goiters was 0.8% (2/351) and 11.9% (42/351), respectively. Many authors have reviewed surgical approaches to substernal goiters. Additionally, several classification systems have been put forth to categorize substernal goiters. One recent system classifies goiters as 1–3 based on their anatomical location and recommended surgical approach [13]. Huins et al. [13] proposed that substernal goiters extending beyond the
Fig. 2. Case 2: A 74-year-old female complained of neck mass with hyperthyroidism. The tumor extended beyond the tracheal bifurcation (B). Ectopic mediastinal goiter was suspected since the inferior pole of the left thyroid and intrathoracic mass were divided in the CT (A). The operation was performed by the transcervical approach without postoperative complications. C: Adenomatous goiter. $: Ectopic mediastinal tumor.
Please cite this article in press as: Nakaya M, et al. Surgical treatment of substernal goiter: An analysis of 44 cases. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.016
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Fig. 3. Case 3: A 47-year-old female complained of dyspnea and dysphagia. The tumor extended beyond the tracheal bifurcation (B and E), and was situated in the posterior mediastinum (D). Ectopic mediastinal goiter was suspected since the inferior pole of the left thyroid and intrathoracic mass were divided in the CT (B). ~: Inferior pole of the tumor. $: Ectopic mediastinal tumor.
Fig. 4. The operation was performed by the transcervical approach without postoperative complications in Case 3. (A) After total thyroidectomy. (B) Ectopic mediastinal goiter was pulled up digitally without sternotomy. (C) After extraction of the ectopic thyroid tumor. (D) Adenomatous goiter of the thyroid. (E) Ectopic mediastinal goiter.
Please cite this article in press as: Nakaya M, et al. Surgical treatment of substernal goiter: An analysis of 44 cases. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.016
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aortic arch need manubriotomy or sternotomy with a cervical approach. However, based on 355 cases from a single institution, Raffaelli et al. [8] reported that the cervical approach can be safely performed in almost all patients with substernal goiters except for those with primary intrathoracic goiters and recurrent carcinoma. Resection for primary mediastinal goiters [9,10] is often achieved through median sternotomy or thoracotomy to ensure that all vessels supplying the mass are adequately ligated. Oueriachi et al. [10] indicated that extraction of the primary mediastinal goiter through the cervical approach should be prohibited because of the risk of intrathoracic hemorrhage and the difficulty of controlling it through this approach. The reason for the necessity of the extracervical approach for primary mediastinal goiters is that the blood supply for secondary mediastinal goiters differs from that of primary mediastinal goiters. We were able to extract primary mediastinal goiters via the transcervical approach in both Case 2 (Fig. 2) and Case 3 (Figs. 3 and 4) without postoperative complications. This is the third report of primary ectopic mediastinal goiter successfully resected via the cervical approach [14]. The cervical approach with gentle blunt dissection and slow traction on the mediastinal goiter leads to successful extraction without complications. The extracervical approach is not necessary to extract a primary mediastinal goiter that has touched but not adhered to the thyroid. However, in cases in which a tumor, such as a carcinoma or a recurrent tumor, has adhered to the peripheral tissue, the extracervical approach is required. There should be no hesitation to use thoracic approaches for the safe removal of tumors to avoid the potentially catastrophic results of the disruption of the intrathoracic vascular supply of ectopic mediastinal goiter. If tumors had been diagnosed malignant preoperatively, extra-cervical approach was needed for mediastinum lymph node dissection. 5. Conclusion In the present study, we reported on the clinical features of 44 substernal goiters (2 primary mediastinal goiter and 42 secondary mediastinal goiters). We were able to extract tumors using the transcervical approach in all cases without sternotomy or thoracotomy. Although a postoperative complication resulted in unilateral recurrent nerve paralysis in one case, phonetic function improved in 6 postoperative months. We propose that a thyroidectomy for a substernal goiter can be safely performed through a cervical incision in almost all
5
patients without an extracervical procedure. Additionally, selected cases of primary mediastinal goiter can be excised via a cervical approach. Conflict of interest None declared. Funding None. References [1] White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg 2008;32:1285–300. [2] Mack E. Management of patients with substernal goiters. Surg Clin North Am 1995;75:377–94. [3] Hardy RG, Bliss RD, Lennard TW, Balasubramanian SP, Harrison BJ. Management of retrosternal goitres. Ann R Coll Surg Engl 2009;91:8–11. [4] Agha A, Glockzin G, Ghali N, Iesalnieks I, Schlitt HJ. Surgical treatment of substernal goiter: an analysis of 59 patients. Surg Today 2008;38:505–11. [5] Machado NO, Grant CS, Sharma AK, Sabti HA, Kolidyan SV. Large posterior mediastinal retrosternal goiter managed by a transcervical and lateral thoracotomy approach. Gen Thorac Cardiovasc Surg 2011;59:507–11. [6] Cichon´ S, Anielski R, Konturek A, Baczyn´ski M, Cichon´ W, Orlicki P. Surgical management of mediastinal goiter: risk factors for sternotomy. Langenbecks Arch Surg 2008;393:751–7. [7] Moran JC, Singer JA, Sardi A. Retrosternal goiter: a six-year institutional review. Am Surg 1998;64:889–93. [8] Raffaelli M, Crea CD, Ronti S, Bellantone R, Lombardi CP. Substernal goiters: incidence, surgical approach, and complications in a tertiary care referral center. Head Neck 2011;10:1420–5. [9] Topcu S, Liman ST, Canturk Z, Utkan Z, Canturk Z, Corak S, et al. Necessity for additional incision with the cervical color incision to remove retrosternal goiters. Surg Today 2008;38:1072–7. [10] Oueriachi FE, Hammoumi MM, Arsalane A, Slaoui O, Diouri H, Kabiri el H. Primary mediastinal goiters. Springerplus 2014;3:503. http://dx.doi.org/10.1186/2193-1801-3-503. [11] Spinner RJ, Moore KL, Gottfried MR, Lowe JE, Sabitson DC. Thoracic intrathymic thyroid. Ann Surg 1994;220:91–6. [12] Wu MH, Chen KY, Liaw KY, Huang TS, Lee PH. Primary intrathoracic goiter. J Formos Med Assoc 2006;105:160–3. [13] Huins CT, Geogalas C, Mehizad H, Tolley NS. A new classification system for retrosternal goiter based on a systematic review of its complications and management. Int J Surg 2008;6:71–6. [14] Walz PC, Iwenofu OH, Essing GF. Ectopic mediastinal goiter successfully managed via cervical approach: case report and review of the literature. Head Neck 2013;35:E94–7.
Please cite this article in press as: Nakaya M, et al. Surgical treatment of substernal goiter: An analysis of 44 cases. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.016
ANL-2103; No. of Pages 5 Auris Nasus Larynx xxx (2016) xxx–xxx Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Surgical treatment of substernal goiter: An analysis of 44 cases Muneo Nakaya *, Akiko Ito, Ayumi Mori, Mineko Oka, Sayaka Omura, Wataru Kida, Yasuhiro Inayoshi, Aki Inoue, Teruhiko Fuchigami Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 December 2015 Accepted 29 February 2016 Available online xxx
Objective: Substernal goiters are classified as primary or secondary intrathoracic goiters. Here, we report the diagnosis, symptoms, treatment, and postoperative complications of 44 substernal goiters (2 primary mediastinal goiter and 42 secondary mediastinal goiters). Methods: A retrospective chart review of 351 patients undergoing thyroidectomy at the Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center. Between 2009 and 2015, 44 patients underwent surgery for substernal goiter. Results: The frequency of primary and secondary mediastinal goiters was 0.5% and 11.9%, respectively. The preoperative symptoms were neck mass, dyspnea, and dysphagia. Eight patients were asymptomatic. Thirty-nine patients had benign masses and 5 patients had malignant masses. Most patients were operated on for adenomatous goiters (52.2%). In ten cases beyond the aortic arch, the tumors were benign and there were eight cases of adenomatous goiter. All patients underwent a successful transcervical incision without sternotomy. Even the primary intrathoracic goiters were extracted after total thyroidectomy via the cervical approach without complications. Although one case showed unilateral recurrent nerve paralysis as a postoperative complication, phonetic function improved in 6 postoperative months. No instances of postoperative bleeding or definitive hypoparathyroidism occurred, and tracheostomy was not performed in any of the cases. Conclusion: The cervical approach was safely performed in almost all substernal goiters without an extracervical procedure. Selected cases of primary mediastinal goiter may be excised via the cervical approach. ß 2016 Published by Elsevier Ireland Ltd.
Keywords: Substernal goiter Intrathoracic goiter Thyroidectomy Ectopic thyroid Ectopic goiter Cervical approach
1. Introduction Substernal goiter is defined as one that either descends below the thoracic inlet or has more than 50% of its volume below this level [1]. Substernal goiters are usually classified as primary or secondary mediastinal goiters [2]. Primary substernal goiters result from an abnormal embryologic migration of the thyroid anlage that is closely associated with the aortic
* Corresponding author at: Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu-shi, Tokyo 183-8524, Japan. Tel.: +81 42 323 5111; fax: +81 42 312 9197. E-mail address: [email protected] (M. Nakaya).
sac. Secondary substernal goiters develop from the descent of the thyroid into the mediastinum. Surgery is the only effective treatment for substernal goiters—treatment for asymptomatic patients remains controversial [3]. Most goiters are removed through a transcervical approach [4]. In some patients with giant tumors, posterior mediastinal goiter, ectopic mediastinal goiter, or malignant tumors, median sternotomy or lateral thoracotomy may be necessary [5,6]. In the present study we report 44 patients who were operated on for substernal goiters (2 primary mediastinal goiter and 42 secondary mediastinal goiters), and these cases were retrospectively analyzed focusing on the diagnosis, preoperative symptoms, surgical therapy, and postoperative complications.
http://dx.doi.org/10.1016/j.anl.2016.02.016 0385-8146/ß 2016 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Nakaya M, et al. Surgical treatment of substernal goiter: An analysis of 44 cases. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.016
G Model
ANL-2103; No. of Pages 5 M. Nakaya et al. / Auris Nasus Larynx xxx (2016) xxx–xxx
2
2. Patients and methods We retrospectively reviewed all of the patients with substernal goiters who underwent thyroidectomy between 2009 and 2015 at the Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center. Patients were selected on the basis of preoperative imaging studies (i.e., computed tomography [CT] and/or magnetic resonance imaging [MRI] scan). We defined a substernal goiter as a thyroid gland with more than 50% of its mass located below the thoracic inlet (same as the previous report) [1]. The medical records of all identified patients were reviewed. All of the data regarding patients’ preoperative symptoms, imaging, clinical and laboratorial findings, operation, pathological diagnosis, and complications were investigated. Laryngoscopy was performed postoperatively to check vocal cord mobility in all patients. Postoperative parathyroid hormone, calcium, and phosphorus levels were measured in total thyroidectomy. 2.1. Operative procedure A lower collar incision was performed along a wrinkle. We used monopolar, bipolar electrotome, and multifunctional tissue sealing systems in all cases. The strap muscles are usually separated along the midline. In selected cases, the strap muscles are divided to obtain better exposure and then sutured at the end of the operation. The upper pole is mobilized after the superior and middle thyroid vessels are ligated close to the thyroid capsule, avoiding injury to the external branch of the superior laryngeal nerve, which is not routinely exposed. Superior parathyroid glands were identified and preserved. The recurrent nerve was visually identified and completely divided from the tumor. In some patients the isthmus was divided in order to facilitate mobilization. The retrosternal part of the thyroid gland was digitally mobilized and delivered by cervical manipulation. It is important to operate gently so that a recurrent nerve is not pulled, although sublation of the tumor is performed blindly. Using a blunt finger dissection technique, the tumor is gradually elevated out of the mediastinum, ligating the inferior vascular structures using a multifunctional tissue sealing device. The inferior parathyroid glands were preserved when possible. After complete removal, the wound was irrigated and closed over suction drains.
Table 1 Occurrence of clinical symptoms (n = 44). Patients (n)
Clinical symptoms
Patients (n)
Symptomatic
36 (81.8%)
Neck mass Oppressive feeling Dyspnea Dysphagia Cough
34 14 5 6 1
Asymptomatic
8 (18.2%)
The symptoms at presentation are outlined in Table 1. Symptoms include neck mass (77.2%), oppressive feeling (31.8%), dyspnea (11.4%), dysphagia (13.6%), and cough (2.2%). Eight patients (18.2%) were asymptomatic at the time of surgery. Postoperative pathological findings are shown in Table 2. Thirty-nine patients had benign tumors (88.6%) and five patients had malignant tumors (11.4%). Most patients were operated on for adenomatous goiters (52.2%), and adenoma (29.2%). Only one case was the schwannoma in the benign tumors. In all ten cases beyond the aortic arch, the tumor was benign and there were eight cases of adenomatous goiter (Table 2-2). Total thyroidectomy was performed in nine patients (20.5%) and hemithyroidectomy was performed in 35 patients (79.5%). The operation was accomplished through a cervical incision in all cases. The technique was also conducted in the collar incision in Case 1 (Fig. 1) where a tumor exceeded the aortic arch. Moreover, the ectopic goiters of Case 2 (Fig. 2) and Case 3 (Figs. 3 and 4) were extracted manually after total thyroidectomy through the transcervical approach without sternotomy. There were no postoperative complications in either Case 2 or Case 3. In these substernal goiters, the reason why malignant tumors could extract via cervical approach was that those were not adhered to the peripheral tissue in 5 malignant cases. However, these 5 malignant cases were diagnosed malignant postoperatively. Although a recurrent nerve palsy arose after the operation in one case, the patient’s maximum phonation time improved 20 s after half a year. No instances of postoperative bleeding or Table 2-1 Pathology in all patients (n = 44). Patients (n)
Percentage
Benign
Adenomatous goiter Adenoma Schwannoma
23 13 1
52.2 29.5 2.2
Malignant
Papillary carcinoma Follicular carcinoma
3 2
6.8 4.5
Pathology
3. Results Between 2009 and 2015, 351 patients with various benign and malignant thyroid disorders underwent thyroid surgery at the Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center. Forty-four patients had substernal goiters (12.5%). The inferior pole of the tumor extended over the aortic arch in ten cases of substernal goiters (2.8%), and the tumor extended beyond the tracheal bifurcation in three cases (0.8%). Of all operated patients, 33 were female (75.0%) and 11 were male (25.0%). The median age of the patients was 60.0 years (range: 33–93 years).
(77.2%) (31.8%) (11.4%) (13.6%) (2.2%)
Table 2-2 Pathology in patients extended beyond aortic arch (n = 10). Pathology Benign
Adenomatous goiter Adenoma
Patients (n)
Percentage
8 2
80.0 20.0
Please cite this article in press as: Nakaya M, et al. Surgical treatment of substernal goiter: An analysis of 44 cases. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.016
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Fig. 1. Case 1: A 93-year-old female complained of dyspnea and dysphagia. The tumor pressed upon the trachea profoundly and extended beyond the aortic arch. Right hemithyroidectomy through a cervical incision was performed. The pathological finding was adenomatous goiter. $: Tumor.
definitive hypoparathyroidism occurred. Additionally, there were no cases of tracheomalacia, and tracheostomy was not performed in any cases. 4. Discussion The mediastinal location of the goiter is most frequently the result of a natural descent of a goiter from a primary cervical site (secondary mediastinal goiter) facilitated by negative intrathoracic pressure, gravity, and a large potential mediastinal space [1,3]. The reported incidence of mediastinal goiter among patients operated on for goiter varies in publications by various authors, ranging from 6 to 30% [1–8]. Additionally,
primary mediastinal goiter, which arises from an ectopic mediastinal goiter, is extremely rare [3,9,10], and 98% are secondary extensions of cervical disease (only 1.7% of intrathoracic goiters represent a primary mediastinal goiter [11,12]). In this report, the frequency of primary and secondary mediastinal goiters was 0.8% (2/351) and 11.9% (42/351), respectively. Many authors have reviewed surgical approaches to substernal goiters. Additionally, several classification systems have been put forth to categorize substernal goiters. One recent system classifies goiters as 1–3 based on their anatomical location and recommended surgical approach [13]. Huins et al. [13] proposed that substernal goiters extending beyond the
Fig. 2. Case 2: A 74-year-old female complained of neck mass with hyperthyroidism. The tumor extended beyond the tracheal bifurcation (B). Ectopic mediastinal goiter was suspected since the inferior pole of the left thyroid and intrathoracic mass were divided in the CT (A). The operation was performed by the transcervical approach without postoperative complications. C: Adenomatous goiter. $: Ectopic mediastinal tumor.
Please cite this article in press as: Nakaya M, et al. Surgical treatment of substernal goiter: An analysis of 44 cases. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.016
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Fig. 3. Case 3: A 47-year-old female complained of dyspnea and dysphagia. The tumor extended beyond the tracheal bifurcation (B and E), and was situated in the posterior mediastinum (D). Ectopic mediastinal goiter was suspected since the inferior pole of the left thyroid and intrathoracic mass were divided in the CT (B). ~: Inferior pole of the tumor. $: Ectopic mediastinal tumor.
Fig. 4. The operation was performed by the transcervical approach without postoperative complications in Case 3. (A) After total thyroidectomy. (B) Ectopic mediastinal goiter was pulled up digitally without sternotomy. (C) After extraction of the ectopic thyroid tumor. (D) Adenomatous goiter of the thyroid. (E) Ectopic mediastinal goiter.
Please cite this article in press as: Nakaya M, et al. Surgical treatment of substernal goiter: An analysis of 44 cases. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.016
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aortic arch need manubriotomy or sternotomy with a cervical approach. However, based on 355 cases from a single institution, Raffaelli et al. [8] reported that the cervical approach can be safely performed in almost all patients with substernal goiters except for those with primary intrathoracic goiters and recurrent carcinoma. Resection for primary mediastinal goiters [9,10] is often achieved through median sternotomy or thoracotomy to ensure that all vessels supplying the mass are adequately ligated. Oueriachi et al. [10] indicated that extraction of the primary mediastinal goiter through the cervical approach should be prohibited because of the risk of intrathoracic hemorrhage and the difficulty of controlling it through this approach. The reason for the necessity of the extracervical approach for primary mediastinal goiters is that the blood supply for secondary mediastinal goiters differs from that of primary mediastinal goiters. We were able to extract primary mediastinal goiters via the transcervical approach in both Case 2 (Fig. 2) and Case 3 (Figs. 3 and 4) without postoperative complications. This is the third report of primary ectopic mediastinal goiter successfully resected via the cervical approach [14]. The cervical approach with gentle blunt dissection and slow traction on the mediastinal goiter leads to successful extraction without complications. The extracervical approach is not necessary to extract a primary mediastinal goiter that has touched but not adhered to the thyroid. However, in cases in which a tumor, such as a carcinoma or a recurrent tumor, has adhered to the peripheral tissue, the extracervical approach is required. There should be no hesitation to use thoracic approaches for the safe removal of tumors to avoid the potentially catastrophic results of the disruption of the intrathoracic vascular supply of ectopic mediastinal goiter. If tumors had been diagnosed malignant preoperatively, extra-cervical approach was needed for mediastinum lymph node dissection. 5. Conclusion In the present study, we reported on the clinical features of 44 substernal goiters (2 primary mediastinal goiter and 42 secondary mediastinal goiters). We were able to extract tumors using the transcervical approach in all cases without sternotomy or thoracotomy. Although a postoperative complication resulted in unilateral recurrent nerve paralysis in one case, phonetic function improved in 6 postoperative months. We propose that a thyroidectomy for a substernal goiter can be safely performed through a cervical incision in almost all
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patients without an extracervical procedure. Additionally, selected cases of primary mediastinal goiter can be excised via a cervical approach. Conflict of interest None declared. Funding None. References [1] White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg 2008;32:1285–300. [2] Mack E. Management of patients with substernal goiters. Surg Clin North Am 1995;75:377–94. [3] Hardy RG, Bliss RD, Lennard TW, Balasubramanian SP, Harrison BJ. Management of retrosternal goitres. Ann R Coll Surg Engl 2009;91:8–11. [4] Agha A, Glockzin G, Ghali N, Iesalnieks I, Schlitt HJ. Surgical treatment of substernal goiter: an analysis of 59 patients. Surg Today 2008;38:505–11. [5] Machado NO, Grant CS, Sharma AK, Sabti HA, Kolidyan SV. Large posterior mediastinal retrosternal goiter managed by a transcervical and lateral thoracotomy approach. Gen Thorac Cardiovasc Surg 2011;59:507–11. [6] Cichon´ S, Anielski R, Konturek A, Baczyn´ski M, Cichon´ W, Orlicki P. Surgical management of mediastinal goiter: risk factors for sternotomy. Langenbecks Arch Surg 2008;393:751–7. [7] Moran JC, Singer JA, Sardi A. Retrosternal goiter: a six-year institutional review. Am Surg 1998;64:889–93. [8] Raffaelli M, Crea CD, Ronti S, Bellantone R, Lombardi CP. Substernal goiters: incidence, surgical approach, and complications in a tertiary care referral center. Head Neck 2011;10:1420–5. [9] Topcu S, Liman ST, Canturk Z, Utkan Z, Canturk Z, Corak S, et al. Necessity for additional incision with the cervical color incision to remove retrosternal goiters. Surg Today 2008;38:1072–7. [10] Oueriachi FE, Hammoumi MM, Arsalane A, Slaoui O, Diouri H, Kabiri el H. Primary mediastinal goiters. Springerplus 2014;3:503. http://dx.doi.org/10.1186/2193-1801-3-503. [11] Spinner RJ, Moore KL, Gottfried MR, Lowe JE, Sabitson DC. Thoracic intrathymic thyroid. Ann Surg 1994;220:91–6. [12] Wu MH, Chen KY, Liaw KY, Huang TS, Lee PH. Primary intrathoracic goiter. J Formos Med Assoc 2006;105:160–3. [13] Huins CT, Geogalas C, Mehizad H, Tolley NS. A new classification system for retrosternal goiter based on a systematic review of its complications and management. Int J Surg 2008;6:71–6. [14] Walz PC, Iwenofu OH, Essing GF. Ectopic mediastinal goiter successfully managed via cervical approach: case report and review of the literature. Head Neck 2013;35:E94–7.
Please cite this article in press as: Nakaya M, et al. Surgical treatment of substernal goiter: An analysis of 44 cases. Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.016