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Table of Contents
CLINICOPATHOLOGICAL PEARLS
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 136-138

Giant posterior mediastinal goitergiant posterior mediastinal goiter


1 Endocrinology and Diabetes Unit, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission03-Aug-2019
Date of Decision02-Oct-2019
Date of Acceptance16-Dec-2019
Date of Web Publication02-Apr-2020

Correspondence Address:
Muhammad H Mujammami
Endocrinology and Diabetes Unit, Department of Medicine, College of Medicine, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JNSM.JNSM_35_19

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  Abstract 


Vast majority of mediastinal goiters are situated in the anterior mediastinal compartment and rarely located in the posterior mediastinum. Posterior mediastinal goiters should be differentiated from other mediastinal masses through appropriate work-up by the computed tomography which is the most valuable technique. We reported a case of symptomatic mediastinal goiter extending from the neck to the posterior mediastinum compressing the trachea and airway. The surgical intervention is considered the treatment of choice in such cases. The surgical approach was done through a classical transverse cervical incision, lateral right thoracotomy, and median sternotomy. The histopathological report was consistent with a multinodular goiter. The patient's recovery was uneventful with an excellent postoperative symptomatic relief.

Keywords: Goiter, mediastinal, thyroid


How to cite this article:
Mujammami MH, Elkhzaimy AA, Alodhayani AA, Aljasser SM, Alsaif AA. Giant posterior mediastinal goitergiant posterior mediastinal goiter. J Nat Sci Med 2020;3:136-8

How to cite this URL:
Mujammami MH, Elkhzaimy AA, Alodhayani AA, Aljasser SM, Alsaif AA. Giant posterior mediastinal goitergiant posterior mediastinal goiter. J Nat Sci Med [serial online] 2020 [cited 2020 Jun 5];3:136-8. Available from: http://www.jnsmonline.org/text.asp?2020/3/2/136/276632




  Case Report Top


A 47-year-old female was referred to the endocrinology clinic at a tertiary hospital in Saudi Arabia, for an evaluation and follow-up of hypothyroidism. The patient's main complaints were exertional shortness of breath and nocturnal dyspnea for the past 3 years but were progressive during the past year before her presentation. She has been hypothyroid for the past 8 years and stable on thyroxine replacement. There was no dysphagia or voice hoarseness beside her respiratory symptoms.

Physical examinations showed her temperature 37°C, heart rate 69 beats/min, normal respiratory rate, blood pressure 128/54 mmHg, and oxygen saturation 99% at room air. There was a decrease in the breath sounds over the right middle and upper side of the chest. Neck examination revealed enlarged left thyroid lobe with no palpable nodule or cervical lymphadenopathy. The percussion over the chest was resonant with negative Pemberton's sign. There was no appreciated tracheal deviation.

Laboratory findings were as follows: WBC 4.2 × 109/L, hemoglobin 128 g/L, platelets 325 × 109/L normal electrolytes, and renal and liver functions. Thyroid function test results were thyroid-stimulating hormone 1.15 mIU/L and FT4 19.37 pmol/L.

A chest X-ray showed a large mass in the superior mediastinum, displacing trachea anteriorly and somewhat narrowing the trachea. There is thickening of the left paratracheal stripe suggesting that it extends to the left of the trachea also. The outline of the mass appears well demarcated inferiorly [Figure 1]. Computed tomography (CT) scan showed superior mediastinal mass – the right thyroid lobe located retrotracheal with anterior displacement of the trachea and esophagus with significant compression of the trachea and esophagus (the patent lumen of the trachea is 7 mm and esophagus 5 mm). The mediastinal part of the goiter was confined anteriorly by the aortic arch and the right brachiocephalic vein (retrovascular position) [Figure 2].
Figure 1: A chest X-ray (anteroposterior and lateral) demonstrates a large mass in the superior mediastinum, displacing trachea anteriorly and somewhat narrowing the trachea

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Figure 2: Computed tomography scan shows the right thyroid lobe as superior mediastinal mass – located retrotracheal with anterior displacement of the trachea and esophagus with significant compression of the trachea and esophagus (the patent lumen of trachea is 7 mm and esophagus 5 mm)

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The ultrasound of the neck showed that the left thyroid lobe is enlarged, and there were multiple variable-sized heterogeneous nodules, with spongiform appearance suggesting very low-risk sonographic features for malignancy. Some of the nodules showed areas of cystic degeneration.

Ultrasound guided-fine needle aspiration was done from nodules bilaterally: the right sided showed follicular lesion of undetermined significance (Bethesda category: 3) and the left sided showed benign follicular nodule (Bethesda category: 2).

The management plan was discussed in a multidisciplinary team, and the decision was made to offer her surgical resection of the mass since she has obstructive symptoms and also, the retrosternal goiter was huge extending below the level of the brachiocephalic vein and occupying the superior mediastinum.

The patient was admitted for the surgery after a comprehensive discussion with the patient about the risks of it. A decision was taken to make a total thyroidectomy through a classical transverse cervical incision, lateral right thoracotomy, and median sternotomy.

First, the endocrine surgeon's team made a collar (Kocher's) incision of 8 cm on the neck. For the right side, the superior pedicle was ligated and divided. The recurrent laryngeal nerve was identified and preserved. Parathyroid superior and inferior were identified and preserved, and then, the right lobe was mobilized medially and excised. For the left side, a superior pedicle was controlled and cut, trials to find out the superior parathyroid and the recurrent laryngeal nerve were not successful because of the rotational nature of the mass. Trials to find out the limit of the cervical part of the left lobe were stopped because of serious bleeding. At this stage, the thoracic surgery team joined and did the right lateral thoracotomy through which the mass was mobilized. At the end of the mobilization, there was an area between the right lateral thoracotomy and the cervical wound, which contains thyroid tissue in the middle of hugely dilated veins. The surgical team decided to do a median sternotomy to facilitate the dissection and removal of the mass. The right thoracotomy wound was closed by placing a chest tube, the mid sternotomy wound was closed by putting a mediastinal chest tube, and the neck wound was closed by putting a neck drain. The patient was moved out to the surgery intensive care unit. The X-ray after the surgery showed the normal position of the thorax and the mediastinum. The upper gastrointestinal endoscopy was performed to rule out any esophageal abnormalities after the removal of the mass, the patient had a smooth uneventful postoperative recovery. The histopathology report was consistent with multinodular goiter.


  What Is the Diagnosis? Top



  Discussion Top


Retrosternal goiter is defined as any goiter in which at least 50% of the thyroid resides below the level of the thoracic inlet. Although the retrosternal goiter is one of the differential diagnoses of an anterior mediastinal mass, because in this case, it extends posteriorly where other diagnoses were considered, for instance, neurogenic tumors, lymphoma, sarcoma, foregut tumors, and aortic aneurysm. Posterior mediastinal goiters are rare. In a Brazilian review of 1300 patients operated for retrosternal goiters during a period of 40 years (1935–1975), only 128 had posterior mediastinal thyroid extension, all of them were aged >50 years, and 80% were female.[1]

Initially, many patients with posterior mediastinal goiters are asymptomatic, but later obstructive symptoms and signs may develop, because of compression and displacement of the trachea, bronchi, esophagus or large veins. Patients who have retrosternal goiter usually have a visible or palpable cervical mass on presentation. In addition, the tracheal deviation may be present. The most common complaint among those patients is nocturnal, exertional, or positional dyspnea, it is seen in 30%–60% of cases, and this is consistent findings as in our case. Sometimes, patients with posterior mediastinal goiter are misdiagnosed as asthma spasms.[2],[3] Usually, the abrupt respiratory function worsening is caused by acute respiratory tract infection, sudden hemorrhage in the nodules, and the posterior mediastinal goiter position causing pressure symptoms.[4] In contrast to what was reported in our case, dysphonia or hoarseness as a result of recurrent laryngeal nerve compression by the mass is considered as other common symptoms. A positive Pemberton's sign occurs primarily due to maneuver which forces the thyroid into the thoracic inlet causing signs of superior vena cava obstruction symptoms; however, in our case, Pemberton's sign was negative.[5]

Shameem et al. reported that the most valuable imaging technique for the evaluation of mediastinal and cervical masses, and diagnosing enlarged thyroid as the cause of that mass is the cervical and thoracic CT.[6] For thyroid ultrasound, it is not as accurate in the retrosternal region, as in the anterior neck due to the inaccessibility of the ultrasound transducer.[5]

This patient was a good candidate for surgical intervention, as she has progressive obstructive symptoms as well as having a huge extension of the retrosternal goiter within the mediastinum. Surgery is the treatment of choice in case of symptomatic retrosternal goiter or asymptomatic substernal goiters that extend below the level of brachiocephalic vein. However, many experts may prefer to monitor patients with asymptomatic retrosternal goiter that does not extend below the brachiocephalic vein, especially in those who are poor surgical candidates. Those patients can be monitored with serial images. Furthermore, alternative treatment modalities including radioactive iodine therapy with or without levothyroxine suppressive therapy although these treatment modalities are not curative and are not effective most of the time.[7],[8] In most cases, the procedure can be performed through a single neck incision. In this case, we did a cervical, lateral thoracotomy, and median sternotomy using a single neck collar-shaped incision with a good outcome. The literature is consistent in stating that most substernal goiter cases may be resected through a neck incision. 0%–13% of the cases need thoracotomy or sternotomy.[9] A number of surgical strategies are available for intrathoracic goiters, and the best approach is determined by several key factors, such as tumor size and location as well as the interrelationship with the critical mediastinal structures. A collar incision is the usual choice since nearly all goiters (>90%) with an intrathoracic extension are accessible through this technique.[10] Other surgical resection techniques that are also useful in this setting include partial or total median sternotomy, thoracotomy, and thoracoscopy. Median sternotomy technique is preferred and is highly recommended cases of recurrent goiters, very large intrathoracic goiters supplied by intrathoracic vessels, posterior mediastinal goiters that displace or compress aortic arch or inflict superior vena cava syndrome, and malignant substernal goiters with lymph node metastasis.[11]

Hematoma, recurrent laryngeal nerve injury, pneumonia, pneumothorax, tracheomalacia, transient hypocalcemia, postoperative pleural effusion, and cervical plexopathy are the expected complications associated with the surgical removal of a substernal goiter. In addition, there have been several reports of patients with giant mediastinal goiters who developed a negative pressure pulmonary edema and unilateral phrenic nerve paralysis postoperatively.[12] Our reported case was diagnosed with a precise orientation and appropriate incisional access, without any postoperative complications.

Final diagnosis

It includes posterior mediastinal goiter which was resolved with surgical removal, using a classical transverse cervical incision, lateral right thoracotomy, and median sternotomy.


  Clinicopathological Pearls Top


  1. Mediastinal goiters are rarely located in the posterior mediastinum and should be differentiated from other mediastinal masses through appropriate work-up, whereas CT is the most valuable technique
  2. Initially, many patients with posterior mediastinal goiters are asymptomatic, but later obstructive symptoms and signs may develop, the tracheal deviation may be present, and the most common complaint among those patients is nocturnal, exertional, or positional dyspnea
  3. Surgery with different strategies is the treatment of choice for patients with obstructive symptoms of retrosternal goiters and who have a large goiter that extends below the level of brachiocephalic vein. The best approach is determined by many factors such as tumor size and location as well as the interrelationship with the critical mediastinal structures.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
De Andrade MA. A review of 128 cases of posterior mediastinal goiter. World J Surg 1977;1:789-97.  Back to cited text no. 1
    
2.
Torres A, Arroyo J, Kastanos N, Estopá R, Rabaseda J, Agustí-Vidal A. Acute respiratory failure and tracheal obstruction in patients with intrathoracic goiter. Crit Care Med 1983;11:265-6.  Back to cited text no. 2
    
3.
Katlic MR, Grillo HC, Wang CA. Substernal goiter. Analysis of 80 patients from Massachusetts general hospital. Am J Surg 1985;149:283-7.  Back to cited text no. 3
    
4.
Veronesi G, Leo F, Solli PG, D'Aiuto M, D'Ovidio F, Mazzarol G, et al. Life-threatening giant mediastinal goiter: A surgical challenge. J Cardiovasc Surg (Torino) 2001;42:429-30.  Back to cited text no. 4
    
5.
Samokhvalov A, Loberant N, Makhoul N. Posterior mediastinal goiters: Report of two cases and literature review. Respir Med Case Rep 2012;5:65-8.  Back to cited text no. 5
    
6.
Shameem M, Bargava M, Ahmad Z, Haq F, Ahmad T. Intrathoracic goiter presenting as posterior mediastinal mass. JIACM 2005;6:343e4.  Back to cited text no. 6
    
7.
Howarth DM, Epstein MT, Thomas PA, Allen LW, Akerman R, Lan L. Outpatient management of patients with large multinodular goitres treated with fractionated radioiodine. Eur J Nucl Med 1997;24:1465-9.  Back to cited text no. 7
    
8.
Bonnema SJ, Knudsen DU, Bertelsen H, Mortensen J, Andersen PB, Bastholt L, et al. Does radioiodine therapy have an equal effect on substernal and cervical goiter volumes? Evaluation by magnetic resonance imaging. Thyroid 2002;12:313-7.  Back to cited text no. 8
    
9.
Hall TS, Caslowitz P, Popper C, Smith GW. Substernal goiter versus intrathoracic aberrant thyroid: A critical difference. Ann Thorac Surg 1988;46:684-5.  Back to cited text no. 9
    
10.
Ríos A, Rodríguez JM, Galindo PJ, Torres J, Canteras M, Balsalobre MD, et al. Results of surgical treatment in multinodular goiter with an intrathoracic component. Surg Today 2008;38:487-94.  Back to cited text no. 10
    
11.
Zhao H, Ren D, Liu Y, Li X, Wu Y, Chen G, et al. Complete transthoracic resection of giant posterior mediastinal goiter: Case report and review of surgical strategies. Onco Targets Ther 2016;9:2415-9.  Back to cited text no. 11
    
12.
Rosato L, Nasi PG, Porcellana V, Varvello G, Mondini G, Bertone P. Unilateral phrenic nerve paralysis: A rare complication after total thyroidectomy for a large cervico-mediastinal goitre. G Chir 2007;28:149-52.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]



 

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