Substernal goiters

M. Batori, E. Chatelou, A. Straniero, G. Mariotta, L. Palombi, P. Pastore, G. Casella, M.C. Casella

Department of Surgical Sciences and Applied Medical Technologies, “La Sapienza” University, Rome (Italy)

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• Surgery

Background: Substernal goiter, also said cervico-mediastinic goiter, is a thyroid formation with cervical departure that goes beyond, with stretched neck, the superior thoracic strait for at least 3 cm and that preserves, generally, the parenchimal or fibrous connections between the cervical and thoracic portion, maintaining a direct vascularization supplied by the thyroid arteries. The prevalence of this pathology is very variable and fluctuates between 1.7% and 30% of all thyroid damages. The actual classification is provided by the radiologic examination of the chest and, above all, by the new techniques of imaging.

Methods: In the period between January 1998 and December 2003, 332 patients with thyroid pathology have been treated surgically. Forthy-five (13.5%) of these were afflicted with a cervico-mediastinic goiter. In 32/45 (71.1%) cases a total thyroidectomy has been performed by collar carving in accordance with Kocher; in 11/45 (24.5%) cases an hemithyroidectomy has been performed by collar incision; in 2/45 (4.4%) cases, already submitted to surgical intervention of isthmus-lobectomy a totalization has been performed.

Results: The surgical technique foresees always an anterior collar neck incision. This way of access is to prefer in the substernal goiters, both for the presence of a cervical vascularization easy to control and for the possibility, nearly always realizable, to dislocate the goiter by that way. As for what concerns the results of the histological examination, in 2/45 (4.5%) cases it has been set a diagnosis of follicular carcinoma (one of them surely invading and the other, leastly invading), in 3/45 (6.6%) cases papillary carcinoma, in 4/45 (8.8%) cases colloido-cystic goiter, in 33/45 (73.5%) cases micro-macrofollicular hyperplasia (in one of which contemporarily compromise from lymphoma of Hodgkin); in 3/45 (6.6%) cases of adenomatous hyperplasia of the thyroid.

Discussion: The surgical approach has been in all cases the collar neck incision in accordance to Kocher, and it has never been necessary to associate a sternotomy or thoracotomy. After the intervention, in all the patients the symptomatology tied to the mediastinal compression has disappeared.
The goiter showed signs of neoplastic degeneration in 11.1% of the cases, with prevalence of the papillary carcinoma in the 6.6% and, in the remaining 4.5%, of follicular carcinoma. These data are superimposable to the data gathered in other surveys.
All the patients passed the post-operating hospitalization in optimal conditions and have been discharged during the fourth post-operating day with the prescription of increasing levo-thyroxine doses according to the body weigh.

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