Case report

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Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Lin YS, Chang HC. Giant intrathoracic goitre: a case report. OA Case Reports 2013 May 01;2(4):39.

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AbstractIntroduction Goitre, an enlargement of the thy-roid gland, is a common endocrine abnormality. Goitres can result from biosynthetic defects, iodine deficiency, autoimmune disease or nodular diseases. If left untreated, they can compress the trachea or oesophagus and cause clinical symptoms such as dyspnea or dys-phagia. We present a case of a giant intrathoracic goitre. Case report A 68-year-old woman presented a slowly growing mediastinal mass for three years. The huge mass was surgically removed without com-plications, proven pathologically an intrathoracic goitre. The possi-ble optimal surgical approach for this kind of huge mass and post-operative medical treatment were discussed. Conclusion Given that most intrathoracic goi-tres arise from and maintain some attachment to the cervical thyroid gland and most of its blood supply would originate from the neck, the optimal surgical approach should start with a cervical approach to reduce the possibility of uncontrol-lable bleeding.

IntroductionGoitre, an enlargement of the thy-roid gland, is a common endocrine abnormality. Goitres can result from

biosynthetic defects, iodine defi-ciency, autoimmune disease or nodu-lar diseases1. If left untreated, they can compress the trachea or oesoph-agus and cause clinical symptoms such as dyspnea or dysphagia. How-ever, the protuberance of goitres is usually easily noticed, so before they grow large enough to the size caus-ing symptoms, they are often treated medically2 or removed surgically. Intrathoracic goitres, depending on definitions, account for 0.2%–45% of all goitres3 and most commonly affect women in the sixth and seventh decades4. Because the thoracic cavity provides some interior space, goitres located within can enlarge progres-sively without symptoms and grow to a considerable size. Herein, we pre-sent a case involving the removal of an 18 cm intrathoracic goitre (Figure 2).

Case report This case involves a 68-year-old woman who had a mediastinal mass found incidentally on a chest X-ray three years prior. Based on the typi-cal radiology appearance on the chest X-ray and chest CT, she was diagnosed as having an intrathoracic goitre. (Figure 1, left). Because she had no obvious symptoms and feared undergoing surgery, she decided to do nothing about it but received reg-ular follow-ups. Recently, she started to have intermittent cough and occa-sional chest tightness and was admit-ted for further evaluation. Chest X-ray and chest CT (Figure 1, right) revealed a huge mediastinal mass compressing the trachea and irritat-ing respiratory tract. This time, she decided to receive surgery to allevi-ate her discomfort.

Giant intrathoracic goitre: a case reportYS Lin, HC Chang*

*Corresponding authorEmail: kchang@vghks.gov.tw

Division of Thoracic Surgery, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung, Taiwan 813, Republic of China

Figure 1: Chest radiographs and computed tomography of three years prior (left) and this admission (right) showing an enlarged right upper mediastinal mass shadow (arrow).

Surg

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Case report

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Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

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For citation purposes: Lin YS, Chang HC. Giant intrathoracic goitre: a case report. OA Case Reports 2013 May 01;2(4):39.

During the operation, a cervical approach was initially taken. The cervical part of the tumour was dis-sected and mobilized. We attempted to pull out the whole tumour from the cervical incision without suc-cess. Using right posterolateral thoracotomy, we mobilized the intrathoracic part of the tumour. However, due to the residual tight adhesion between tumour mass and trachea, we were still unable to pull out the whole tumour from the thoracotomy opening. Repo-sitioning the patient into a supine position again, we then completely transected the connecting portion and separated the tumour where it had adhered at the cervical level and removed the cervical part of the tumour from the neck incision. The remaining intrathoracic part was easily removed from the thoracot-omy wound. The tumour was esti-mated to be around 18 × 10 × 5 cm in size (Figure 2). The pathology report confirmed the diagnosis of nodular goitre. The patient’s preop-erative discomfort subsided and she remained stable during the follow-ing hospitalization course and the subsequent follow-up visits.

DiscussionIn this case, although an initial CT scan had already demonstrated the

typical pattern of a benign intratho-racic goitre three years prior to this case presented, the patient chose close follow-up rather than surgery. A comparison of the prior radiographs with the current radio-graphs (Figure 1) showed that even though the intrathoracic goitre had seemingly benign characteristics, it enlarged progressively to a size that made surgical excision much more complicated. Surgeons might persuade the hesitant patients with asymptomatic or minimally symptomatic intrathoracic goi-tre to receive surgery earlier in an attempt to reduce the difficulty of surgery and the possible complica-tions5. In addition, total thyroidec-tomy should be attempted to avoid recurrence6.

ConclusionGiven that most intrathoracic goi-tres arise from and maintain some attachment to the cervical thyroid gland and most of its blood supply would originate from the neck, the optimal surgical approach should start with a cervical approach to reduce the possibility of uncontrol-lable bleeding. If the intrathoracic tumour is noticed to be of a substan-tial size preoperatively, the cervi-cal portion should be removed first after delicate dissection, sparing the

recurrent laryngeal nerve and tran-secting the connecting part between cervical and intrathoracic portions. The remaining portion should then be pushed as far as possibe down into the thoracic cavity, where it can be removed by thoracotomy or ster-notomy, depending on its position in the thoracic cavity.

ConsentWritten informed consent was obtained from the patient for publi-cation of this case report and accom-panying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

References1. Jameson JL WAP. Disorders of the thy-roid gland. In: Fauci AS BE, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J, editors. Harrison’s principles of internal medicine 17th ed. New York, NY: McGraw-Hill.2. Bennedbaek FN, Hegedus L. Man-agement of the solitary thyroid nod-ule: results of a North American survey. J Clin Endocrinol Metab. 2000 Jul;85(7): 2493–98.3. Rios A, Rodriguez JM, Balsalobre MD, Tebar FJ, Parrilla P. The value of vari-ous definitions of intrathoracic goiter for predicting intra-operative and post-operative complications. Surgery. 2010 Feb;147(2):233–8.4. Thomas K, Varghese Jr. M, Christine L. Lau. The mediastinum. In: Courtney M. Townsend Jr., RDBM, Mark Evers B, Kenneth L. Mattox, editors. Townsend: Sabiston textbook of surgery 18th ed. Philadelphia, Pennsylvania: W.B. Saunders; 2007.5. Zambudio AR, Rodriguez J, Riquelme J, Soria T, Canteras M, Parrilla P. Prospec-tive study of postoperative complications after total thyroidectomy for multinodu-lar goiters by surgeons with experience in endocrine surgery. Ann Surg. 2004 Jul;240(1):18–25.6. Agarwal G, Aggarwal V. Is total thy-roidectomy the surgical procedure of choice for benign multinodular goiter? An evidence-based review. World J Surg. 2008 Jul;32(7):1313–24.

Figure 2: Specimen of an encapsulated solid mass measuring 18 × 10 × 5 cm.