Retrosternal goitre, do humans need a sternotomy?

Abstract

Retrosternal goitre as a surgical thyroid pathology is diminishing in incidence. Though surgery is the generally accepted treatment modality, lot of uncertainties exist regarding the approach for surgery in consideration with the prognostication, surgical morbidity and the post-operative outcome. Median sternotomy, in addition to being more morbid, is generally out of the general surgeons’ perview and therefore its need necessitates preoperative arrangements for assistance by a thoracic surgeon. Cervical approach is sufficient for most of the lesions but the surgeon should be conversant with median sternotomy as to perform it expediently and without hesitation when it is indicated. The generally indications for sternotomy are extension of goitre below the aortic arch, involvement of the posterior mediastinum, large thyroid tissue extending towards tracheal bifurcation, and primary ectopic thyroid tissue in the mediastinum. Here the available literature was reviewed to identify the preoperative predictors of a sternotomy in the management of substernal goitre in order to provide better preoperative planning and patient consent in managing the patient with reference to a recently encountered case.

Mediastinal Goiter from the View of Thoracic Surgery

“…Some others stated that the shape of the goiter has an impact. Dumbbell, hourglass, conical or iceberg shaped goiter; with the largest portion of the mediastinal part exceeding the diameter of thoracic inlet or in case being larger than the cervical part with constriction at the site of inlet; all these shapes also had a higher incidence of sternotomy (4) .…”

“…Other studies mentioned that extension down to the aortic root and posterior mediastinal involvement were significant factors in predicting need for sternotomy. Therefore, the absence of this finding can predict the probability of successful transcervical excision (4) . We found also that the rate of need for extracervical approach was significantly increased in redo cases.…”

“…There have been many definitions of RSG since then till now. However, the most accepted definition of RSG nowadays describes when ≥ 50% of the mass portion of the goiter is in the mediastinum (1,3,4) . Other different definitions have been also assumed for the expression, e.g., goiter that extends beyond the thoracic inlet into the mediastinum for more than 2 cm is considered retrosternal (1) , or when the part of the goiter in the mediastinum is larger than the cervical one and it extends downwards beyond the thoracic inlet by two fingers, or by at least 4 cm (4)(5)(6) .…”

“…This happens with extension of goiter below the aortic arch, in redo surgeries, involvement of the posterior mediastinum, extension of the RSG towards carina, and primary ectopic RSG in the mediastinum (4,14) . Generally, sternotomy combined with a cervical approach is the standard favored approach for resection of anterior mediastinal goiters, while thoracotomy is advised for removal of posterior mediastinal goiters (1,5,7,12) .…”