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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.

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clinical scenario
Clinical scenario
  • 70/F
  • Asymptomatic.
  • Refer for your expert opinion.
questions
Questions

What is the diagnosis ?

How do you manage ?

introduction
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
Definition
  • Confused.
  • 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

  • Goitres extend to 4th thoracic vertebra.

Lindskog and Goldenberg JAMA 1957

anatomy
Anatomy

SSG classified into two groups.

  • 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

anatomy9
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

slide10

Anatomy

Anatomical constrain.

Downward traction

symptomatology
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
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 operation13
Rationale for operation
  • No effective alternative treatment. I131? T4?

Allo MD Surgery 1983

  • 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
Investigation

CT neck and thorax is the most valuable.

Netterville et tal Laryngoscope 1998

Sanders LE Arch Surg 1992

  • Outline the extent of thyromegaly.
  • Differentiate the origin of the goiter.
  • Measure the degree of narrowing of the trachea.
the operation
The operation
  • Head up, neck well extended.
  • Wider and lower incision.
  • Division of the strap muscles.
  • Control cervical blood supply first.
  • 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 operation18
The operation

Other indications for sternotomy / thoracotomy

  • Intra thoracic goitre / ectopic goitre.
  • Vasoagressive signs.
  • Retroesophageal goiters.
  • Suspected malignancy, mediastinal lymphadenectomy.
  • After a prior cervical thyroidectomy, with intra-thoracic recurrent.
our study
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 in patients with substernal goitre

Symptoms & signsNumber(%)

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
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
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
Comparison of complications between asymptomatic and symptomatic patients

Complications Asymptomatic (13) Symptomatic (11)

Recurrent laryngeal nerve injury 0 1

Transient hypoparathyroidism 1 1

Haematoma 0 1

Pneumonia 0 1

Wound infection 0 1

Fisher exact test, p=0.033

Para-Menbrives et al Internat Surg 2003

conclusion
Conclusion

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

slide26

Comparison of asymptomatic vs. symptomatic patients

Asymptomatic(N=13) Symptomatic(N=11)p

Age(yr) 55.3 65.7 0.10

Gender(F/M) 10/3 9/2 0.79

Toxic goitre/non-toxic goitre 9/4 9/2 0.60

Duration of presentation(month) 38.2 38.0 0.98

Hemithyroidectomy/bilateral resection 5/8 6/5 0.53

Previous thyroid surgery(Yes/No) 13/0 9/2 0.11

Elective/emergency operation 13/0 9/2 0.11

Benign/malignant histopathology 12/1 9/2 0.54

Specimen weight(gm) 213.2 174.5 0.47

Parathyroid autograft(Yes/No) 3/10 3/8 0.81

Operative blood loss(ml) 194.9 223.8 0.86

Duration of surgery(min) 178.8 196.8 0.60

Postoperative hospital stay(days) 3.2 6.3 0.08

our study27
Our study

Reasons for more complication in the symptomatic group.

  • Patient is older.
  • More emergency operation.
  • May be a larger proportion of the goitre is intrathoracic.