Management of substernal goiter UCH KH Tse. Clinical scenario 70/F Asymptomatic. Refer for your expert opinion.

Management of substernal goiter

UCH

KH Tse

Clinical scenario

• 70/F

• Asymptomatic.

• Refer for your expert opinion.

Questions

What is the diagnosis ?

How do you manage ?

Introduction

• SSG

• First described by Haller in 1749.

• Account for 10-15% of all the mediastinal mass.

• SSG / All thyroidectomy = 2.6-20% Madjar Chest 1995

Definition

• Confused.

1. Decend inferior to the thoracic inlet. Katlic et al Am J Surg 1998

2. >50% thyroid mass inside the thorax. Wax et al J Otolaryngol 1992

Arici et al Int Surg 2001

3. Goitres extend to 4th thoracic vertebra. Lindskog and Goldenberg JAMA 1957

Anatomy

SSG classified into two groups.

1. Truly intrathoracic or aberrant goiter (1%). • Congenital• Blood supply derived from the intrathoracic

vessel entirely. • No connection to the cervical thyroid gland. Lahey & Swinton et al 1934

Anatomy

2. Arises in the cervical thyroid gland

• Acquired.

• Decends along a fascial plane through the thoracic inlet to the mediastinum.

Lahey & Swinton et al 1934

Anatomical constrain.Downward traction

Anatomy

Symptomatology

• Neck mass, SOB, dysphagia.

• 5-50% can be asymptomatic on presentation. Katlic MR Am J Surg 1985

• Prolong course of symptoms.

• From 2 weeks to 20 years with symptoms before referral. Mean = 31 months.

Rationale for operation

1. SSG is progressive, can result in sudden airway obstruction.

Singh B Am J Otolaryngol 1994.

2. Inaccessible to, inaccurate, and dangerous biopsy.

Rietz KA Acta Chir Scand 1960

3. Long history MNG does not preclude malignancy, hyperfunction or complication. Malignancy in 7-17%

Sanders Arch Surg 1992 Torre G Am Surg 1995

Rationale for operation

4. No effective alternative treatment. I131? T4? Allo MD Surgery 1983

5. Less operative complication in the asymptomatic patients.

Para-Menbrives et al Internat Surg 2003

The consensus is that substernal goiter is best managed surgically.

Katlic MR Am J Surg 1985

Investigation

CT neck and thorax is the most valuable. Netterville et tal Laryngoscope 1998

Sanders LE Arch Surg 1992

1. Outline the extent of thyromegaly.

2. Differentiate the origin of the goiter.

3. Measure the degree of narrowing of the trachea.

The operation

1. Head up, neck well extended.2. Wider and lower incision.3. Division of the strap muscles.4. Control cervical blood supply first.5. Excise the opposite lobe first, to provide

more room in the neck. Wheeler M.H. et al BJS 1999

• Sternotomy rate 2-11.7 % Michel LA Br J Surg 1988

The operation

No Progress

Manubrinectomy ClaviclectomyMedian sternotomy/Limited sternotomy

Sternotomy

The operation

Other indications for sternotomy / thoracotomy

1. Intra thoracic goitre / ectopic goitre.

2. Vasoagressive signs.

3. Retroesophageal goiters.

4. Suspected malignancy, mediastinal lymphadenectomy.

5. After a prior cervical thyroidectomy, with intra-thoracic recurrent.

Our study

Retrospective study

• From Jan 2000 to Dec 2003

• 287 cases of thyroidectomy.

• 24 (8.4%) were SSG

• M:F = 5:19

• Mean age 60.1+/-15.5 (26 - 90)

Symptoms in patients with substernal goitre

Symptoms & signs Number(%)

SOB (including 3 cases of acute airway obstruction) 8(33.3)Neck discomfort 1(4.2)Dysphagia 1(4.2)Hoarseness 1(4.2)Asymptomatic 13(54.2)

Duration of symptoms 2-120 months, mean 43.3 +/- 47.5

Histopathologic diagnoses of substernal goitre

Diagnoses Number(%) Hyperplastic nodules/nodular hyperplasia 18(75)Diffuse hyperplasia 2(8.3)Hurthle cell adenoma 1(4.2)Papillary carcinoma 1(4.2)Follicular carcinoma 1(4.2)Medullary carcinoma 1(4.2)

Morbidity of thyroidectomy for substernal goitre(N=24)

Number(%)

Recurrent laryngeal nerve injury(nerve at risk) 1(2.7)

Transient hypoparathyroidism(patients at risk N=15) 2(13.3)

Permanent hypoparathyroidism 0

Haematoma 1(4.2)

Wound infection 1(4.2)

Pneumonia 1(4.2)

Motality 0

Comparison of complications between asymptomatic and symptomatic patients

Complications Asymptomatic (13) Symptomatic (11)

Recurrent laryngeal nerve injury 0 1Transient hypoparathyroidism 1 1Haematoma 0 1Pneumonia 0 1Wound infection 0 1

Fisher exact test, p=0.033Para-Menbrives et al Internat Surg 2003

Conclusion

A substernal goiter is always indicated for resection and should be performed early, except the patient is unfit for operation.

Thank youThank you

Asymptomatic(N=13) Symptomatic(N=11) p Age(yr) 55.3 65.7 0.10Gender(F/M) 10/3 9/2 0.79Toxic goitre/non-toxic goitre 9/4 9/2 0.60Duration of presentation(month) 38.2 38.0 0.98Hemithyroidectomy/bilateral resection 5/8 6/5 0.53Previous thyroid surgery(Yes/No) 13/0 9/2 0.11Elective/emergency operation 13/0 9/2 0.11Benign/malignant histopathology 12/1 9/2 0.54Specimen weight(gm) 213.2 174.5 0.47Parathyroid autograft(Yes/No) 3/10 3/8 0.81Operative blood loss(ml) 194.9 223.8 0.86Duration of surgery(min) 178.8 196.8 0.60Postoperative hospital stay(days) 3.2 6.3 0.08

Comparison of asymptomatic vs. symptomatic patients

Our study

Reasons for more complication in the symptomatic group.

1. Patient is older.

2. More emergency operation.

3. May be a larger proportion of the goitre is intrathoracic.