Retrosternal goitre and its management

Abstract

 Retrosternal goiter (RSG) is a term that has been used to describe a goiter that extends beyond the thoracic inlet. Retrosternal goitre is defined as a goitre with a portion of its mass ≥ 50% located in the mediastinum. Surgical removal is the treatment of choice and, in most cases, the goitre can be removed via a cervical approach. Aim of this retrospective study was to analyse personal experience in the surgical management of retrosternal goitres, defining, in particular, the features requiring sternotomy.  Retrospective study, teaching hospital-based. Retrospective analysis of 687 thyroidectomies performed between 2008 and 2019. The 47 (6.84 %) patients with RSG were analyzed further, with regard to demographics, presentation, indications, and outcome of surgical treatment.  There were 47 patients (6.84 %) with RSG, [ 34 females (72.34%), 13 males (27.66%)] (mean age: 52 years, range: 34-76)], out of 687 thyroidectomies, in a 14 -year period. The most common presentation was neck swelling (68%), followed by respiratory symptoms (46.8%) and the surgical procedure predominantly used was total thyroidectomy. The RSGs were removed by collar incision in 43 (91.5 %) of the cases, only 4 cases (8.5 %) required sternotomy, (residual thyroid in mediastinum after cervical approach in one case and due to very large thyroid reaching the main bronchial bifurcation in the other three). The final histological diagnosis revealed malignancy in 8.5 % of the thyroid specimens. There was no mortality and minor complications occurred in nine patients (19.1%). The presence of an RSG is an indication for surgery owing to the lack of effective medical treatment, the higher incidence of symptoms related to compression, low surgical morbidity, and the risk of malignancy. Surgical removal of a retrosternal goitre is a challenging procedure; it can be performed safely, in most cases, via a cervical approach, with a complication rate slightly higher than the average rate for cervical goitre thyroidectomy, especially concerning hypoparathyroidism and post-operative bleeding. The most significant criteria for selecting patients requiring sternotomy are computed tomography features, in particular the presence of an ectopic goitre, the extent of the goitre to or below the tracheae carina. If retrosternal goitre thyroidectomy is performed by a skilled surgical team, familiar with its unique pitfalls, the assistance of a thoracic surgeon may be required only in a few selected cases