Surgical approach for substernal goiter

Approximately 8% of thyroid tumors may present with mediastinal lesions (1). Aberrant mediastinal goiter can be resected with video-assisted thoracoscopic surgery (VATS), but some substernal goiters require surgical manipulation in both the cervical and thoracic regions (2). In patients with ectopic goiter, it is often controversial whether there is fibrous continuity when the primary tumor and mediastinal lesion appear separated on imaging examination (3). However, in the report by Kwak et al., a discontinuous mediastinal nodule was pathologically diagnosed as originating from lung cancer, which was a rare case (4). Conversely, it has been reported that metastasis of differentiated thyroid carcinoma is detected at a certain rate in the superior mediastinal lymph node dissection during lung cancer surgery (5), and detailed pathological examination is important.

As a surgical approach, several reports recommend cervical collar incision (6,7). Hajhosseini et al. demonstrated the need to add a partial median sternotomy for an adequate dissection procedure (8). de Perrot et al. reported that median sternotomy is necessary after thyroid surgery and in invasive malignancies (9). On the one hand, VATS approach is less invasive and may contribute to the patients’ postoperative recovery. In the reported case as well, appropriate treatment for lung cancer was performed after surgery. Insufflation of CO₂ to create a positive intrathoracic pressure is often performed during thoracoscopic surgery (10). Patients undergoing neck collar incisions and those with weak connective tissue should be carefully considered as they may cause additional discomfort when subcutaneous emphysema develops.

As clinicians, we occasionally experience cases with complex clinical courses. In order to find a better treatment, it is important to collaborate closely with multiple clinical departments, as in the reported case.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Case Reports. The article did not undergo external peer review.

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References

1. Wakeley CPG, Mulvany JH. Intrathoracic goiter. Surg Gynecol Obstet 1940;70:702-10.
2. Amer K, Khan AZ, Rew D, et al. Video assisted thoracoscopic excision of mediastinal ectopic parathyroid adenomas: a UK regional experience. Ann Cardiothorac Surg 2015;4:527-34. [PubMed]
3. Rives JD. Mediastinal Aberrant Goiter. Ann Surg 1947;126:797-810. [Crossref] [PubMed]
4. Kwak HV, Banks KC, Hsu DS, et al. Incidental paratracheal lymph node lung adenocarcinoma in a patient with goiter: a case report. AME Case Rep 2022;6:29. [Crossref] [PubMed]
5. Sugenoya A, Asanuma K, Shingu K, et al. Clinical evaluation of upper mediastinal dissection for differentiated thyroid carcinoma. Surgery 1993;113:541-4. [PubMed]
6. Newman E, Shaha AR. Substernal goiter. J Surg Oncol 1995;60:207-12. [Crossref] [PubMed]
7. Katlic MR, Grillo HC, Wang CA. Substernal goiter. Analysis of 80 patients from Massachusetts General Hospital. Am J Surg 1985;149:283-7. [Crossref] [PubMed]
8. Hajhosseini B, Montazeri V, Hajhosseini L, et al. Mediastinal goiter: a comprehensive study of 60 consecutive cases with special emphasis on identifying predictors of malignancy and sternotomy. Am J Surg 2012;203:442-7. [Crossref] [PubMed]
9. de Perrot M, Fadel E, Mercier O, et al. Surgical management of mediastinal goiters: when is a sternotomy required? Thorac Cardiovasc Surg 2007;55:39-43. [Crossref] [PubMed]
10. Campos J, Ueda K. Update on anesthetic complications of robotic thoracic surgery. Minerva Anestesiol 2014;80:83-8. [PubMed]