Eur J Cardiothorac Surg 1998;14:393-397
© 1998 Elsevier Science NL
Surgical aspects of 175 mediastinal goiters
Paul Vadasz,
Lajos Kotsis
Thoracic Surgical Clinic of Koranyi National Institute for Pulmonology and Postgraduate Medical School, Budapest, Hungary
Received 2 February 1998;
received in revised form 22 June 1998;
accepted 8 July 1998.
Corresponding author. Thoracic Surgical Clinic of Koranyi National Institute, H-1529 Budapest, Pihenõ ut 1, Hungary; Tel.: +36 1 2002683; fax: +36 1 2002573.
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Abstract
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Objective: Clinical picture and surgical management of 175 mediastinal goiters are discussed in this retrospective study. Method: Between 1979 and 1996, 175 patients with intrathoracic goiters were operated on at the Thoracic Surgical Clinic in Budapest. The majority of the goiters were cervicomediastinal (n=138, 79%), past the level of aortic arch, and the others were complete aberrant lesions (n=37, 21%). Of the patients, 40% (n=70) were symptom-free, in the others the clinical picture was dominated by compressive symptoms, among them, in five instances, the initial false, long-lasting diagnosis was bronchial asthma and, in four cases, vena cava superior syndrome caused by advanced inoperable malignancy. Twenty-two percent of patients (n=39) were operated on previously for cervical struma. Eleven percent (n=19) of the patients had hyperthyroid symptoms. In 124 cases the goiters were located in the anterior mediastinum. The majority (n=96) of cervicomediastinal goiters (n=138) could be removed through a cervical access, in the others an additional sternotomy (n=31), or anterior thoracotomy (n=11) were necessary. For resection of complete intrathoracic goiters (n=37) standard thoracotomy (n=30) or median sternotomy (n=7) were used guided by retrotracheal or substernal position. Results: Hospital mortality was 1.1%. Minor complications occurred in 46 cases (26%) and laryngeal nerve palsy in 14 patients (8%). Tracheomalatia developed in 18 patients (10%) which were mainly solved by tracheal intubation for 4–6 days. Ninety-four percent (n=165) of the lesions proved to be diffuse colloid or adenomatous goiters by histology and 10 were (mostly follicular type) carcinomas. Conclusions: Unrecognized mediastinal goiters can produce asthma like symptoms, which may lead to late or misdiagnosis and deficient treatment. Once the diagnosis and exact extent of mediastinal goiter is established, multimodal surgical approaches are indicated for its safe removal – before occurrence of compressive symptoms.
Key Words: Mediastinal goiter • Surgery of goiters
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Introduction
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Goiters masquerading as mediastinal tumors are the most frequent masses of the superior mediastinum. Besides common cervicomediastinal goiter, as an extension of a cervical struma, totally intrathoracic, complete aberrant or ectopic thyroid tissue may occur in any mediastinal compartments. Although the `gold standards' of thyroid gland surgery have been declared since Kocher activity, diagnostic, strategical and technical dilemmas may arise in everyday practice, especially in instances of intrathoracic location. Characteristics such as symptom-free rate of patients, the presence of a previous thyroidectomy, occurrence of several symptoms, diagnostic value of isotopic scan etc., are different in the analysed materials published from different parts of Europe and the world. The diagnostic and therapeutical difficulties of mediastinal goiters referred mainly to the borderline or common field of laryngeal, general and thoracic surgery.
Our material consists of selectively admitted patients from several parts of Hungary, many of them with enlarged, intrathoracically extended goiters in advanced clinical state. Based on our 175 operated cases, the aim of the study was to point out the typical failures and cornerstones of diagnostics and to suggest an advantageous, multimodal surgical strategy.
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Material and methods
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Between 1979 and 1996 175 patients underwent removal of intrathoracic goiters at the Thoracic Surgical Clinic in Budapest. This represents 12% of all mediastinal lesions operated on during this period. Only those cervicomediastinal goiters which passed the level of the aortic arch or azygos vein were included in this series. (We excluded the simple substernal or `diving' goiters from our material.) There were 131 female and 44 male patients with an average age of 56 years. Thirty-nine patients (22%) underwent a previous resection for a cervical goiter. In 27 of them the `recurrence' appeared in complete intrathoracic and, in 12 cases, in cervicomediastinal forms. It could not be clarified in how many cases the first operation had been a recognised (or not recognised) incomplete resection when the inexperienced surgeon had finished the intervention at the level of thoracic inlet because of technical difficulties, or real ectopic tissue remained on the site.
Clinical symptoms are presented in Table 1 demonstrating correlations between the clinical features, types of goiters and pathology. Twenty-six patients had severe stridor and, in five of them, an urgent tracheal intubation was necessary prior to surgery. Four patients were admitted with tracheostoma. Five patients were misdiagnosed and treated as bronchial asthma for a long time. In four of the 21 patients with associated vena cava superior syndrome an earlier surgical intervention was refused because of a supposed, unknown `inoperable malignancy'. Eleven patients had laryngeal nerve palsy (eight due to the previous standard cervical thyroidectomy and three due to carcinoma). Seventy patients (40%) were symptom-free, and the diagnosis was established by X-ray screening or by accidental chest X-ray examination.
The cervicomediastinal goiters caused more frequent (in 91/138 cases) clinical symptoms than the complete intrathoracic lesions (in 14/37 cases).
Diagnostics
Before surgery, as well as the usual pre-operative investigations, laryngological, bronchological examination and barium swallows were routinely performed. The exact location and extent of the goiter were detected by tracheal laminography and, since 1985, by CT-scan. In all patients with cervicomediastinal lesions (n=138) a 131-J scan was performed with a low usefulness: only in 23 cases could the mediastinal portion of the lesion be detected this way. Six of the 37 complete goiters were demonstrable by 131-J scan, however, only in 27 was the scan done. In the others, thyroid abnormality was not suspected early on.
The majority (n=138, 79%) of the 175 goiters were cervicomediastinal being extensions of an enlarged cervical thyroid gland. Most of this type of lesion were substernal goiters (n=104) and the others were positioned retrotracheally in the posterior mediastinum (n=34) (Table 2). Twelve patients underwent a previous cervical subtotal thyroidectomy.
Twenty of the 37 complete aberrant goiters were situated in the anterior mediastinum and 27 of these patients had a prior collar thyroidectomy. None of them had hyperthyreotic symptoms.
Surgical approach (Table 3)
In cases of cervicomediastinal goiters we have routinely used a cervical approach. In the majority (n=73) of 104 patients with substernal extensions and in 23 of 34 retrotracheal lesions the cervical access alone provided a good exposure for resection. In the other 42 patients the cervical incision was combined with median sternotomy (27 partial and four total) on 31 occasions, or with anterior thoracotomy in 11 cases, depending on whether substernal or retrotracheal extension were present.
The 37 complete aberrant goiters were removed either by median sternotomy in seven, or by standard thoracotomy in 30 instances.
Four patients having tracheostoma were respirated through the cannula during operation. Previously a complete cervical thyroidectomy was performed in these patients, so a re-do cervical approach was unnecessary. In two cases the tracheostoma had been closed spontaneously following surgery, in the other two patients further broncho-laryngological interventions, such as T-tube and stenting, were required because of secondary stricture.
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Results
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Two patients (1.1%) were lost in the early post-operative period: one due to cardiorespiratoric failure and the other one due to pulmonary embolism. Post-operative morbidity includes: minor complications in 26% (n=46), recurrent nerve palsy in 8% (n=14) and tracheomalatia in 10% (n=18) of the patients. In three cases of bilateral paresis, further laryngological interventions (lateral fixation of local cords and/or arytenoidectomy by CO2 laser/40W) were necessary. Patients with tracheomalatia were managed either with tracheal wall anchoring stitches during the operation after removal of the goiter (in two intra-operativeally detected cases), or with tracheal intubation for 4–6 days in the post-operative period in 14 instances. During this 4–6 day duration, the tracheal wall was fixed by itself to surrounding tissues not requiring further surgical interventions. Only in two cases was the tracheostomy unavoidable.
Histology showed diffuse colloid goiter in 153, adenomatous in 12, and carcinoma in 10 cases: follicular type in eight, papillary in two.
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Discussion
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Several reports have detailed the clinical aspects and pathologic features of goiters situated in the mediastinum
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]. Their incidence is relatively high, 10–15% among the space-occupying mediastinal abnormalities. These lesions have been classified according to whether they were intrathoracic extensions of an enlarged cervical thyroid gland (cervicomediastinal goiters, struma intrathoracica falsa, partialis), or completely enclosed within the chest, without palpable cervical goiter (complete aberrant goiter, struma intrathoracica vera, completa). The enlarging cervical thyroid glands migrate into the thorax due to their weight, negative intrathoracic pressure, respiratory movements and shortness of the neck
[16]. The complete lesions arise from heterotopic thyroid tissue, which occurs most commonly in the anterio-superior mediastinum, but may also occur in the middle or posterior compartments
[6]. In the published series
[17]
[18]
[19]
[20], a previous cervical thyroidectomy is present in 3–30% of patients' histories (in 22% of our cases). According to certain theories
[7], mediastinal goiters arise from the remaining or distant ectopic tissues due to the increased TSH production following cervical strumectomy. There is a special problem of this surgery when the presence of an intrathoracic segment of the goiter is missed or not recognised during the first collar operation because of technical difficulties of an inexperienced surgeon.
Occasionally, intrathoracic goiters are detected on routine chest roentgenograms (40% of our patients), but usually present symptoms related mostly to the compression of the trachea producing cough, wheezing, dyspnea and, in advanced cases, severe stridor, superior vena cava syndrome and dysphagia. It is interesting that the proportion of symptom-free patients is different in the published series. For example, in the material of Torre
[17] only 5.5% of the 237 analysed patients were symptom-free. Pre-operative laryngeal nerve palsy had occurred in 6% of our patients, similar to other published series
[3]
[7]
[10]
[22]
[34]
[35], mostly following a previous cervical thyroidectomy (8/11 in our material), or caused by carcinoma (3/11). Like other series
[3]
[5]
[17]
[21], the majority of our patients were euthyroid and rarely hyperthyroid (11%). Dysphagia and vena cava superior syndrome were present only in 4% and 12%, respectively, and they may be considered as infrequent symptoms
[22]
[23].
For the diagnosis, conventional chest X-ray, tracheal laminography and CT-scan provide the most important information regarding location and extent of this lesion
[20]
[24]
[25]
[26]
[27]. Radioactive 131-J scans yield positive indications of the presence of mediastinal thyroid tissue (in 29 cases in our material) but, more often, are negative
[24]
[28]
[29]. The majority of intrathoracic goiters are non-functioning
[30].
Tracheomalatia usually can be recognised only following extubation. In our practice, an urgent reintubation for 4–6 days solved this problem in 14 cases. During this 4–6 day period of tracheal intubation, a fibrous connection develops between the tracheal wall and the surrounding structures, hindering its collapse. Bilateral laryngeal nerve palsy, persistent tracheomalatia and tracheal-laryngeal stricture caused by prolonged tracheostomy require further broncho-laryngeal assessment, as lateral fixation of local cords and/or laser-arytenoidectomy in cases of palsy, stenting, T-tube etc. Most of the mediastinal thyroid lesions are diffuse colloid or adenomatous goiters
[16], 165/175 in our material. In the literature, the rate of malignant transformation is 3–5% (6% in our experience). The opinions about frequency of the different carcinoma-types are unanimous
[3]
[5]
[7]
[16] (follicular type in eight of our 10 cases) Anaplastic carcinoma of mediastinal goiter is rare
[32].
Intrathoracic goiters, like other intramediastinal space-occupying lesions, may result in serious complications. Furthermore, lengthy observation may lead to progression of symptoms and finally to life-threatening tracheal compression, as in our 26 patients. Once the diagnosis and extent is established, elective resection of the intramediastinal goiter should be indicated. As to the surgical techniques and approaches, most publications present experiences mainly with substernal goiters removed by simple cervicotomy in 75–95% of the cases
[8]
[13]
[14]
[17]
[21]
[29]
[31]
[33]
[34]
[35], however, there is little available information about surgical tactics in cases of retrotracheally or really intrathoracically positioned, extended, enlarged lesions. Based on our experience, we propose the following multivariant surgical strategy:
(1) The majority of cervicomediastinal type goiters can be removed through a conventional cervical approach. For the elevation of the intramediastinal part of the gland we never used a spoon or other instrument, except traction-sutures and index finger. In these cases the use of a thoracic approach alone is contraindicated because of the upper blood supply of the lesion and the possibility of injuring the recurrent laryngeal nerves
[29]
[34]. After a prior cervical thyroidectomy, or in instances of large lesion, suspected malignancy or vasoagressive signs, the cervical access should be combined either with a median (total or partial) sternotomy, or with anterior thoracotomy for substernal or retrotracheal extensions, without changing the supine position of the patient in our practice. In our material, the rate of simple cervicotomy is lower (70%) than in other published series. Probably it stems from the fact that a significant rate of selectively admitted and operated, enlarged, intrathoracically extended goiters were unable to be removed through only a simple cervical approach. In our opinion, in these instances, surgeons should not hesitate to make the above-mentioned additional accesses for safety, in order to reduce the operative risks, especially hemorrhagic and nervous risks
[19]. Patients tolerate these combined approaches well, better than complications.
(2) In cases of complete intrathoracic goiters the surgical access should be also guided by the situation of the goiter. Most of them can be removed by anterior or high posterolateral thoracotomy, however, if location and extension require a safe exploration of the anterior mediastinum, median sternotomy is the approach of choice.
(3) There is an assessment challenge involving the group of patients with unrecognized goiter who have been treated for asthma bronchiale, or other airway-disorders for a long time, and who are admitted to surgical departments in a critical state with severe stridor. In these patients, an urgent tracheostomy should be avoided by all means because of technical difficulties, it does not solve the lower tracheal compression and it means a high risk for future operation. Our experience showed that emergent intratracheal intubation with the help of flexible bronchoscopy can always be performed. It has to be emphasized that even a unilateral, moderately enlarged gland, if it is incarcerated in the thoracic inlet, may produce severe tracheal compression, found occasionally among our patients with asthma-like symptoms.
The key to success is the accurate detection of this anomaly with careful attention to the possibility of asthma-like clinical presentation. The appropriate selection of the electively applied surgical approach avoids per-operative complications and assures a speedy post-operative recovery.
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Abstract
Introduction
