Forgotten goiter: Diagnosis and management. A case report and literature review

IntroductionA mediastinal thyroid mass discovered years after a total thyroidectomy represents an unusual and uncommon clinical situation. Few cases have been reported and controversy exists regarding the etiology of this ectopic thyroid tissue as well as the optimal surgical approach for resection. We herein describe a case of a mediastinal thyroid goiter discovered five years after a total thyroidectomy.Presentation of caseA 54-year-old Hispanic female was diagnosed with a diffuse cervical goiter secondary to Hashimoto’s Thyroiditis and subsequently underwent a total thyroidectomy. Five years later the patient had a chest X-ray as part of a preoperative evaluation for an unrelated and elective surgical procedure. Significant tracheal deviation was identified. A computed tomography scan was obtained and demonstrated a well encapsulated mass in the superior mediastinum resulting in tracheal deviation and compression. This “forgotten” goiter was successfully resected utilizing a standard cervical approach and the patient recovered uneventfully.DiscussionA thyroid mass within the mediastinum following a total thyroidectomy is a condition often referred to as “forgotten goiter”. Prior reported cases are few, and data is limited, with some uncertainty remaining as to the exact origin of this ectopic thyroid tissue. Possible etiologies include an incomplete removal of the thyroid gland during initial cervical thyroidectomy, or perhaps an autonomous intrathoracic goiter (AIG) – a thyroid gland located in the mediastinum, independent and with no parenchymatous or vascular connection with the cervical thyroid gland.ConclusionA trans-thoracic or sternal splitting approach is generally not required for resection of a mediastinal goiter and our experience confirms that the case of the “forgotten goiter” can be safely approached through a cervical incision as well.     

Thoracoscopic approach to giant lymph node hyperplasia (Castleman's disease)

We describe the case of a thoracoscopic approach to giant lymph node hyperplasia (Castleman's disease) located in the mediastinum. In our patient the initial diagnosis was substernal goiter, but at cervical exploration the mass was found not to be continuous with the thyroid. The mass was easily identified through a lateral thoracoscopic approach and carefully removed. The postoperative course was uneventful, and the patient was discharged home on the fifth postoperative day. Histopathology revealed the features of Castleman's disease, mixed type. The prevalence, location, and pathogenesis of giant lymph node hyperplasia are described, together with the histology and clinical signs. Our report is proposed as the first case of an endoscopic approach to giant lymph node hyperplasia, which could be the best surgical approach for a mediastinal location.     

An unusual recurrent bilateral posterior mediastinal goiter after subtotal thyroidectomy: Case report

INTRODUCTION

Surgical treatment of benign thyroid diseases need to be followed up closely, since recurrent thyroid nodules can be seen after subtotal thyroidectomy. Intrathoracic goiter (ITG) occurs in 10–30% of patients following subtotal thyroidectomy. In general these goiters are benign, having a malignant rate of only 2–22%. ITG grows slowly but steadily and in its process of development, it narrows the thoracic inlet by compressing the surrounding structures. Most of these can not located in the anterior mediastinum, others located in posterior retrovascular area. Bilateral posterior retrovascular goiters are very rare.

PRESENTATION OF CASE

We report a case involving a 61-year-old woman with history of gradual-onset dyspnea who was referred to us for evaluation of a large mediastinal mass. She had undergone bilateral thyroid lobectomy for a cervical goiter 10 years ago. The mass was removed successfully via median sternotomy without complication. The patient recovered well and was discharged in 1 week.

DISCUSSION

Most anterior mediastinal goiters can be resected through a transcervical approach, but if those extending beyond the aortic arch into the posterior mediastinum are better dealt with by sternotomy or lateral thoracotomy.

CONCLUSION

Bilateral recurrent posterior mediastinal and retrovascular large goiters are better resected via sternotomy rather than lateral thoracotomy. The reason for that are the possibility of injury to large vascular structures and the difficulty of their management through lateral thoracotomy when cardiopulmonary bypass needed.     

A case of cervico-mediastinal paraganglioma mimicking an ectopic goiter

Introduction and importanceMediastinal paragangliomas are rare neuroendocrine tumors that originate from extra-adrenal paraganglia, occasionally secreting catecholamines. Nonfunctional mediastinal paragangliomas present nonspecific clinical and radiological features and represent a diagnostic challenge.Case presentationA 53-year old woman presented with cough and dyspnea increasing over time. CT-scan and ultrasonography showed a large vascularized cervico-mediastinal mass, consistent with an intrathoracic ectopic goiter. Preoperative angiography showed a blood supply from neck vessels. The lesion was completely removed through a cervical approach. The diagnosis of paraganglioma was a histological surprise. The patient is alive without recurrence 30 months after surgery.Clinical discussionWhen preoperatively diagnosed, the treatment of choice of a mediastinal paraganglioma is surgical excision. However, a preoperative diagnosis of mediastinal paraganglioma is difficult to obtain, especially in cases of nonfunctional lesions. Distinction between an intrathoracic goiter and a nonfunctional paraganglioma can be extremely difficult and, given the rarity of the latter, an ectopic goiter is suspected in first instance. CT-scan and ultrasonography are of little use in the differential diagnosis. However, scintigraphy with ¹²³I-metaiodobenzylguanidine can be an useful diagnostic tool when a paraganglioma is suspected. In case of vascularized cervico-mediastinal mass, such as paragangliomas or intrathoracic goiter, preoperative angiography should be performed to study the blood supply and orient the surgical approach.ConclusionAlthough uncommon, paragangliomas should be considered in the differential diagnosis of mediastinal masses, especially when an ectopic goiter is suspected.     

The “forgotten” goiter after total thyroidectomy

INTRODUCTION“Forgotten” goiter is an extremely rare disease which is defined as a mediastinal thyroid mass found after total thyroidectomy.PRESENTATION OF CASEWe report two cases with forgotten goiter. One underwent total thyroidectomy due to thyroid papillary cancer and TSH level was in normal range one month after surgery. The thyroid scintigraphy scan revealed mediastinal thyroid mass. The second case underwent total thyroidectomy due to Graves’ disease and TSH level was low after surgery. At postoperative seventh year, patients were admitted to our Endocrinology Division due to persistent hyperthyroidism and CT scan revealed forgotten thyroid at mediastinum. Both patients underwent median sternotomy and mass excision, there was no morbidity detected after second surgical procedures.DISCUSSIONIn the majority of cases forgotten goiter is the consequence of the incomplete removal of a plunging goiter. Although in some cases, it may be attributed to a concomitant, unrecognized mediastinal goiter which is not connected to the thyroid with a thin fibrous band or vessels. Absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray do not excluded the substernal goiter.CONCLUSIONRetrosternal goiter should be suspected if the lower poles could not be palpated on physical examination and when postoperative TSH levels remained unchanged.     

Best Approach for Posterior Mediastinal Goiter Removal: Transcervical Incision and Lateral Thoracotomy

Surgical removal of intrathoracic goiter can be performed by a cervical approach in the majority of patients. Review of literature shows that experienced surgeons need to perform an extracervical approach in 2–3% of cases. In spite of surgical management of substernal goiter is well defined, there is little available information about surgical approach of intrathoracic goiters extending beyond the aortic arch into the posterior mediastinum. We report two cases and propose combination of cervical incision and muscle-sparing lateral thoracotomy for posterior mediastinal goiter removal. In such cases, we do not favor sternotomy as posterior mediastinum is inaccessible due to the presence of heart and great vessels anterior to the thyroidal mass that would lead to perform a perilous blind dissection. Based on our experience, transcervical and thoracotomy approach is indicated for a complete and safe posterior mediastinal goiter removal.     

Mediastinal hemangioma mimicking an invasive tumor growth: A case report

Introduction and importanceMediastinal hemangiomas are a rare entity frequently developing in the anterior mediastinum. They may exhibit an infiltrating appearance into the surrounding tissue, and extensive surgery is often required despite its benign nature. We report a case of a mediastinal hemangioma mimicking an invasive tumor growth requiring a combined resection of the lung and diaphragm.Case presentationAn asymptomatic 73 year-old-man presented with a 50 mm-sized mass on his chest radiography. A combined resection of the mediastinal mass with the part of the lower lobe of left lung and diaphragm not necessitating a patch repair was performed. The pathological findings were compatible with a diagnosis of a mediastinal hemangioma. Only fibrous adhesions were observed between the tumor and resected lung and diaphragm without any histological invasion.Clinical discussionWhile imaging examinations play a key role in determining a preoperative diagnosis, mediastinal hemangiomas may pose a diagnostic challenge mainly due to its rarity. With a clinical suspicion of a hemangioma during the diagnostic work up, a dynamic CT might be helpful.ConclusionsIn mediastinal hemangiomas, a preoperative diagnosis is essential in order to avoid extensive surgery. A hemangioma should be raised as a differential diagnosis for anterior mediastinal tumors, especially in cases with an infiltrative appearance that suggests the necessity for a combined resection of the surrounding organs.     

Superior vena cava syndrome and tracheal obstruction due to multinodular goiter

Tracheal obstruction and superior vena cava (SVC) syndrome are rare complications of retrosternal goiter. These two conditions present a difficult diagnostic and therapeutic challenge. Malignancy is the most common cause of SVC syndrome. Determining whether SVC syndrome is due to a benign or malignant process is imperative before instituting treatment, but this determination may be difficult. We present a case of a patient presenting with upper airway obstruction and SVC syndrome with a large mediastinal mass. The mass was determined to be a multinodular goiter. The patient was managed by surgical removal of the goiter with complete resolution of symptoms. This case illustrates the need for careful preoperative evaluation and the importance of establishing a histologic diagnosis prior to initiating treatment for SVC syndrome. © 1994 John Wiley & Sons, Inc.     

An acute superior mediastinal syndrome with critical tracheal stenosis due to benign multinodular goiter complicated by intracystic hemorrhage

Large benign goiter with a cervical and intrathoracic retrotracheal location is uncommon, but troublesome, since it affects the upper mediastinum and usually causes dyspnea, dysphagia or vascular obstruction; on the other hand, a large mediastinal cyst of thyroid origin complicated by a massive, spontaneous hemorrhage is an exceptional event, implicating vital prognosis through an acute tracheal compression. A 45-year-old-man presented all these complications of a previously neglected nodular-cystic goiter, causing an acute respiratory distress. An emergency diagnosis and consequent surgery, in delayed urgency, were performed. This case is presented because of its rarity. Its clinic management is discussed, in the framework of the existing literature.     

Limited upper sternotomy in general thoracic surgery

Purpose To evaluate the status of limited upper sternal split in general thoracic surgery. Methods We reviewed the clinical files of 100 consecutive patients operated on through limited upper sternotomy at a hospital in Italy during the 10 years between January 1995 and December 2004. Results Thymus surgery represented the main indication for this approach (n = 51): for myasthenia without thymoma in 28 patients, for thymus neoplasms with or without myasthenia in 22, and for intrathymic parathyroid adenoma in 1. Thyroid surgery constituted the second main indication for upper sternal split (n = 32) for benign retrosternal goiter in 18 patients, for mediastinal nodal metastasis of thyroid cancer in 11, and for malignant retrosternal goiter in 3. The remaining indications were as follows: to assess residual disease following chemotherapy for Hodgkin’s disease in 7 patients and for non-Hodgkin lymphoma in 1; for tracheal surgery in 7; and for excision of nodal mediastinal metastasis of non-thyroid cancer in 2. All operations were completed through the upper sternal split. There was no surgical mortality but complications developed in eight patients. Conclusion The upper sternal split provides a satisfactory access to perform a surgical procedure in the superior mediastinum in most diseases. The procedure is safe and involves minimal surgical trauma.     

Bleeding "downhill" varices: a rare complication of intrathoracic goiter

We report a case of a 68-year-old woman with a 16-year history of a benign goiter. The patient presented with hematemesis and a clinically evident superior vena cava syndrome. Preoperative evaluation demonstrated upper esophageal varices and large posterior mediastinal goiter. The patient underwent successful resection of the mass with complete resolution of both the superior vena cava syndrome and "downhill" varices.     

Combined Cervical and Video-assisted Thoracoscopic Thyroidectomy (CAVATT): A Simplified and Innovative Approach for Goiter with Posterior Mediastinal Extension

We report a case of benign multinodular goiter with right sided posterior mediastinal extension managed by a simplified anaesthetic and surgical protocol. Single lumen endotracheal tube was used for intubation. Access to mediastinum was obtained by 2 working ports in 2nd and 4th intercostal spaces. Mediastinal extension is dissected thoracoscopically and delivered cervically. Post operative course was uneventful with no pulmonary and surgical morbidity.     

Emergency thyroidectomy: Due to acute respiratory failure

INTRODUCTION

Giant cervical and mediastinal goiter may lead to acute respiratory failure caused by laryngotracheal compression and airway obstruction. Here, we present a case admitted to the emergency service with a giant goiter along with respiratory failure and poor general health status, which required urgent surgical intervention.

PRESENTATION OF CASE

A 71-year-old female admitted to the emergency room with shortness of breath and poor general health status resulting from a giant cervical swelling progressively increased during the last 7 years and constituted severe respiratory failure which has become severe in the last one month. A giant nodular goiter of the left thyroid lobe extending retrosternally, causing tracheal compression, limiting the neck movements was detected with clinical examination and bedside ultrasound. Emergency thyroidectomy was planned. Fiberoptic-assisted awake nasal intubation was performed in the operating room. Emergency total thyroidectomy was performed for the life-threatening respiratory failure. Postoperative period was uneventful. She was transferred from intensive care unit to the ward on postoperative day 3 and was discharged from the hospital on the postoperative 7th day. Benign multinodular hyperplasia was reported on the histopathological report. Patient was included in routine follow-up.

DISCUSSION

In the present case tracheal destruction due to compression of the giant goiter was found in agreement with previous reports. Emergency thyroidectomy was performed after awake intubation since it is a common surgical option for the treatment of giant goiter causing severe airway obstruction.

CONCLUSION

Respiratory failure due to giant nodular goiter is a life-threatening situation and should be treated immediately by performing awake endotracheal intubation following emergency total thyroidectomy.     

Primary intrathoracic goiter -a rare mediastinal tumor

Primary intrathoracic goiter is a rare presentation of thyroid disease. Its removal usually necessitates thoracotomy or sternotomy. This patient having a primary intrathoracic goiter presented with posterior mediastinal mass that was removed through a right lateral thoracotomy.     

Pulmonary nodule. The surgeon's approach

Malignancy must be suspected with any pulmonary nodule detected on radiologic examination of the chest until its benign origin has been proven. This requires further evaluation of the patient. The non invasive diagnostic steps include patient's history, clinical examination, lung function testing, and standard radiographs and a computed tomography (CT) of the chest. Based on these findings the presumed diagnosis claims the next appropriate diagnostic steps. If lung cancer is the most likely diagnosis and lung function testing revealed that the patient is a candidate for lung resection than surgery may be the next step. Preoperative proof of the histologic diagnosis is not mandatory. It is the less required the more surgery may be curative. If curative resectability is indoubt or the patient is not candidate for lung resection than histologic diagnosis should be confirmed prior to introduction of radiotherapy or chemotherapy by the least invasive procedure (bronchoscopy < lymph node biopsy < needle biopsy < mediastinoscopy/-tomy < VATS). If metastatic disease must be suspected, staging should be completed as required for the primary malignancy. With local recurrence and other metastases excluded the number of pulmonary nodules detected on CT scan points to the appropriate surgical approach. In case of a solitary nodule or multiple but resectable nodules, complete (wedge) resection with lymph node dissection through a lateral thoracotomy will be the procedure of choice. With multiple and unresectable nodules, surgery allows definitive diagnosis and videothoracoscopy affords the opportunity to accomplish wedge resection of the lung along with low morbidity. When lesions are deemed indeterminate, definitive diagnosis should nevertheless be attempted. If there is no history of malignancy routine evaluation for such in asymptomatic patients is not indicated. With small nodules (less than 3 cm in diameter) located in the periphery of the lung, videothoracoscopic wedge resection is indicated without preoperative sputum cytology, bronchoscopy or transthoracic needle biopsy. The histologic diagnosis obtained by intraoperative frozen sections than determines the further surgical approach. Benign lesion: completion of surgery; lung cancer: proceed to thoracotomy with anatomic lung resection and mediastinal lymph node resection; metastatic disease: completion of surgery and further search for primary malignancy.     

Delayed sternal closure. An improved method of dealing with complications after cardiopulmonary bypass

Intraoperative closure of the median sternotomy after cardiac operations in patients with complications, including severe postoperative bleeding, impaired cardiac function caused by myocardial edema, and cardiac dilatation, may lead to a critical and possibly fatal deterioration of hemodynamic function. In an effort to prevent this complication, we delayed mediastinal closure in 15 patients, covering the wound temporarily with a sheet of rubber latex (Esmarch bandage). An oval patch of this material was sized and sutured to the skin edges with a continuous suture. This technique provided easy and fast access to the mediastinal structures in four of the 15 patients who required multiple surgical interventions in the early postoperative period. Delayed closure was indicated for severe bleeding in 10 patients, heart compression in four patients, and severe postbypass arrhythmias in one patient. Definitive closure of the chest was delayed until satisfactory hemostasis was achieved or the heart size returned to normal. Thirteen of the 15 patients were long-term survivors, none of them had wound infections, and their wounds healed well. Delayed closure of the median sternotomy was an effective and safe approach in these groups of critically ill patients.     

Natural orifice transesophageal mediastinoscopy and thoracoscopy

Background Thoracoscopy and mediastinoscopy are common procedures with painful incisions and prominent scars. A natural orifice transesophageal endoscopic surgical (NOTES) approach could reduce pain, eliminate intercostal neuralgia, provide access to the posterior mediastinal compartment, and improve cosmesis. In addition NOTES esophageal access routes also have the potential to replace conventional thoracoscopic approaches for medial or hilar lesions. Methods Five healthy Yorkshire swine underwent nonsurvival natural orifice transesophageal mediastinoscopy and thoracoscopy under general anesthesia. An 8- to 9.8-mm video endoscope was introduced into the esophagus, and a 10-cm submucosal tunnel was created with blunt dissection. The endoscope then was passed through the muscular layers of the esophagus into the mediastinal space. The mediastinal compartment, pleura, lung, mediastinal lymph nodes, thoracic duct, vagus nerves, and exterior surface of the esophagus were identified. Mediastinal lymph node resection was easily accomplished. For thoracoscopy, a small incision was created through the pleura, and the endoscope was introduced into the thoracic cavity. The lung, chest wall, pleura, pericardium, and diaphragmatic surface were identified. Pleural biopsies were obtained with endoscopic forceps. The endoscope was withdrawn and the procedure terminated. Results Mediastinal and thoracic structures could be identified without difficulty via a transesophageal approach. Lymph node resection was easily accomplished. Pleural biopsy under direct visualization was feasible. Selective mainstem bronchus intubation and collapse of the ipsilateral lung facilitated thoracoscopy. In one animal, an inadvertent 4-mm lung incision resulted in a pneumothorax. This was decompressed with a small venting intercostal incision, and the remainder of the procedure was completed without difficulty. Conclusions Transesophageal endoscopic mediastinoscopy, lymph node resection, thoracoscopy, and pleural biopsy are feasible and provide excellent visualization of mediastinal and intrathoracic structures. Survival studies will be needed to confirm the safety of this approach.     

Benign teratomas of the mediastinum

Approximately 8% of all mediastinal tumors are benign teratomas. We reviewed 86 cases of benign teratoma seen at the Mayo Clinic from 1930 through 1981. The mean age of the patients was 28 years and the sex distribution was approximately equal. The most common symptoms were chest, back, or shoulder pain, dyspnea, and cough, but 36% were asymptomatic at the time of presentation. Chest roentgenograms showed a well-circumscribed anterior mediastinal mass which often protruded into one lung field. Detectable calcification was observed in 22 patients: a calcified tumor wall in seven, bone or teeth in the mediastinum of seven, and nonspecific calcifications in eight. Surgical excision remains the best means of diagnosing and treating this benign tumor. Though the tumors are histologically benign, they may present difficult surgical problems because of the vital structures involved. Since 1952 there has been a change in the clinical presentation of patients with this entity: More patients are asymptomatic and have smaller tumors and fewer complications than prior to 1952.     

Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease.

BACKGROUND: Descending necrotizing mediastinitis represent a virulent form of mediastinal infection requiring prompt diagnosis and treatment to reduce the high mortality associated with this disease. Surgical management and a particularly optimal form of mediastinal drainage remain controversial. METHODS: Over a 10-year period, 12 patients were treated at our institution. Surgical treatment consisted of 1 or several cervical drainages, associated with drainage of the mediastinum through a thoracic approach in 11 patients. Thoracic procedures included radical surgical debridement of the mediastinum with complete excision of the tissue necrosis, decortication, and pleural drainage with adequate placement of chest tubes for mediastinopleural irrigation. Transcervical mediastinal drainage was performed in only 1 patient. RESULTS: The outcome was favorable in 10 patients, 9 of whom had mediastinal drainage through thoracotomy. Two patients were initially drained through a minor thoracic approach; the first died of tracheal fistula and the second required new drainage through a thoracotomy. The patient who had transcervical mediastinal drainage without a thoracic approach presented an abscess limited to the anterior and superior mediastinum. In 3 patients, ongoing mediastinal sepsis required a second thoracotomy. CONCLUSION: A stepwise approach with transcervical mediastinal drainage is first justified in patients with very limited disease to the upper mediastinum. However, ongoing mediastinal sepsis requires new drainage, through a major thoracic approach, without delay. Extensive mediastinitis can not be adequately treated without mediastinal drainage including a thoracotomy. This aggressive surgical policy has allowed us to maintain a low mortality rate (16.5%) in a series of 12 patients with this highly lethal disease.