|LETTER TO THE EDITOR
|Year : 2014 | Volume
| Issue : 3 | Page : 136-137
A primary retrosternal goiter successfully managed via a cervical approach
Department of Surgical Oncology, Cancer Institute (Women India Association), Adyar, Chennai, Tamil Nadu, India
|Date of Web Publication||13-Aug-2014|
Department of Surgical Oncology, Cancer Institute (Women India Association), 38, Sardar Patel Road, Adyar, Chennai 600 036, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Krishnamurthy A. A primary retrosternal goiter successfully managed via a cervical approach. Thyroid Res Pract 2014;11:136-7
A 72-year-old woman was referred to our institution for further evaluation of an anterior mediastinal mass. The mass was serendipitously picked up on a computerized tomography (CT) scan due to persistence of her vague symptoms of neck pain and asthma like symptoms for over a year. She gave a history of a total thyroidectomy 20 years prior, for a benign multi-nodular goiter. She had no history of dysphagia, hoarseness or stridor. Clinical examination of the neck and thyroid region was unremarkable, except for a well-healed thyroidectomy scar. The CT scan revealed a large well-circumscribed mildly enhancing anterior mediastinal mass measuring 8.2 × 5.5 × 4.2 cm extending from just above the level of the clavicle to the level of the aortic arch. Few specks of calcification were noted within the lesion.[Figure 1]a and b] The mediastinal structures (trachea and the great vessels) were displaced posteriorly. The thyroid bed appeared normal. A CT guided aspiration cytology from the anterior mediastinal mass revealed occasional groups of benign follicular epithelial cells; a provisional diagnosis of primary retrosternal goiter was made. The serum thyroid stimulating hormone (TSH), free triiodothyronine (FT3) and free thyroxine (FT4) were within normal ranges.
|Figure 1: (a) Axial view (b) Coronal view: The computerized tomography scan revealed a large well-circumscribed mildly enhancing anterior mediastinal mass measuring 8.2 × 5.5 × 4.2 cm extending from just above the level of the clavicle to the level of the aortic arch. Few specks of calcification were noted within the lesion. The mediastinal structures were displaced posteriorly|
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She underwent an exploration of the mass using a standard cervical approach. The thyroid bed was confirmed to be normal. The anterior mediasinal mass was mobilized using gentle digital dissection, carefully separated from the trachea, great vessels, recurrent laryngeal nerves, the parathyroid glands and was delivered into the neck and was completely removed [Figure 2]a and b]. The final histopathology confirmed the mass as a benign colloid goiter with cystic degeneration. The patient is now asymptomatic and is on regular follow-up on thyroxin supplementation for close to two years now.
|Figure 2: (a) Intraoperative photograph showing the primary RSG removed by a standard cervical approach. (b)The specimen photograph of the RSG|
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Masses in the anterior mediastinum commonly include thymoma's, lymphomas lymphoma and germ cell tumors. Retrosternal goiters (RSG) are a less common cause of anterior mediastinal masses. Terms such as substernal, intrathoracic, or mediastinal have also been used to describe a goitre that extends beyond the thoracic inlet. There is a lack of consensus regarding the exact definition and management of a RSG. RSG is usually referred to as enlarged thyroid gland with greater than 50% of its mass below the thoracic inlet. RSGs are classified into two groups i.e. secondary and primary. A great majority of the RSGs are of the secondary type, which are characteristically, in continuity with the cervical portion of the gland and receive their blood supply from the cervical vessels. The other is the truly primary intrathoracic or aberrant goiter, which arises from aberrant thyroid tissue that is ectopically located in the mediastinum. They receive their blood supply from mediastinal vessels and are not connected to the cervical thyroid as also seen in our case. They are rare, representing less than 1% of all RSGs. 
CT scan is considered as the imaging modality of choice for RSGs. , A CT scan clearly shows the nature and the extent of the RSG especially the relationship of the RSG with the trachea, the esophagus, and great vessels. Magnetic resonance imaging adds little information, to that obtained with CT, and is not routinely used. Nuclear imaging with Iodine-131 or Technetium- 99 scan is not considered essential in the preoperative evaluation of known RSG; moreover, not all RSGs are radioiodine avid.
The ideal surgical approach for RSG is the subject of significant debate.  Previous authors have suggested an open thoracic approach for all primary RSGs to safely divide the intra thoracic vascular supply, but favorably positioned anterior mediastinal goiter can be safely removed via cervical approach  as was also seen in our case. In conclusion, select cases of primary RSGs may be amenable to excision via cervical approach and a pre-operative CT scan is the current one-step answer to all the requirements of the pre-therapeutic evaluation of such a challenging clinical condition.
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[Figure 1], [Figure 2]