A
surgical algorithm for the management of retrosternal goiters
Key points
- The
heterogeneity of retrosternal goiter size and location, nearby
anatomical structures, and evolving surgical techniques means
selecting the most appropriate individualised surgical approach
remains challenging.
- Although most retrosternal goiters can be removed transcervically, a
small proportion of patients fulfill anatomical and radiological
criteria for concurrent extracervical approaches based on decades of
experience at the London Health Sciences Centre.
- Anterior goiters above the level of the pericardium were resected
using cervical thyroidectomy with either mediastinoscopic-assisted
delivery or cervical thyroidectomy with video- assisted thyroidectomy
(VATS)
- Anterior goiters extending beyond the pericardium require median
sternotomy to facilitate sufficient vascular control and exposure.
- Posteriorly extending goiters can be managed using trans-thoracic
approaches including lateral thoracotomy or VATS.
Introduction
Retrosternal goiter refers to those which partially or completely extend
posterior to the sternum. They may be classified either as primary, due
to ectopic thyroid tissue, or secondary, due to the direct downwards
migration of thyroid
tissue.1The primary goal in the treatment of retrosternal goiters is often to
relieve obstructive symptoms using surgical resection, with numerous
grading systems being developed to help clinicians guide operative
choices.
Delbridge 2 based his classification on the
relationship between the cervical and thoracic components of the thyroid
tissue;
Page,
Strunski 3 and Huins, Georgalas, Mehrzad, Tolley4 based their classification on the extent of inferior
extension of the goiter; and Randolph, Shin, Grillo, Mathisen, Katlic,
Kamani, Zurakowski 5 based their classification on the
direction of extension, either into the anterior or posterior
mediastinum. Still, the heterogeneity of goiter size and location,
nearby anatomical structures, and evolving surgical techniques means
selecting the most appropriate individualised surgical approach remains
challenging.