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CASE REPORT
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 79-81

Forgotten retrosternal goiter


Department of Endocrine and Breast Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Date of Web Publication6-Sep-2019

Correspondence Address:
Abdulmalik M Ismail
Prince Sultan Military Medical City, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_39_18

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  Abstract 

The presence of thyroid tissue in the mediastinum after total thyroidectomy is commonly known as “forgotten goiter,” which is considered as an extremely rare condition with controversy regarding the etiological causes. We report a 57-year-old female who has had a total thyroidectomy. Postoperatively, she underwent a computed tomography scan which revealed a retrosternal goiter. A reexploration was performed utilizing the previous collar incision. The mass was totally below the thoracic inlet separated from the central neck compartment. Forgotten goiter, though a rare pathology, can be prevented by meticulous preoperative imaging and can be managed during the first operation; however, surgical treatment for forgotten goiter, when performed in specialized centers, can be achieved through cervical approach and is associated with low morbidity.

Keywords: Forgotten goiter, retrosternal goiter, thyroid, thyroidectomy


How to cite this article:
Ismail AM, AlFehaid MS, Binyousef H. Forgotten retrosternal goiter. Saudi Surg J 2019;7:79-81

How to cite this URL:
Ismail AM, AlFehaid MS, Binyousef H. Forgotten retrosternal goiter. Saudi Surg J [serial online] 2019 [cited 2019 Sep 16];7:79-81. Available from: http://www.saudisurgj.org/text.asp?2019/7/2/79/266211


  Introduction Top


Ectopic thyroid tissue is a common abnormality due to the abnormal embryological migration of the thyroid tissue.[1] The most common noncervical location of ectopic thyroid tissue is the thoracic cavity.[2] A retrosternal goiter occurs when the thyroid grows downward into the chest. It was defined by Candela in 2007 as any goiter that descends below the thoracic inlet or grows into the mediastinum for more than 2 cm.[3] The majority of retrosternal goiters are extensions from the neck, but isolated intrathoracic goiters do occur in <1%. These isolated goiters remain asymptomatic and are discovered incidentally through radiological investigation.[3]


  Case Presentation Top


A 57-year-old female known to have hypertension, diabetes mellitus, and bronchial asthma presented to Prince Sultan Military Medical City with symptomatic neck mass for 1½ year. Thyroid function test was normal; ultrasound showed an enlarged thyroid gland with interval increase in the size of previously known thyroid nodules, the largest on the left side measuring 3 cm × 2.4 cm, and there were multiple benign-looking cervical lymph nodes. Fine-needle aspiration of the thyroid nodule was reported as BETHESDA Category II. A total thyroidectomy was performed. Intraoperatively, there was enlarged nodular thyroid gland with no signs of retrosternal extension. On 1st postoperative day, the patient complained of shortness of breath and chest pain that lasts for 10 min with episodes of oxygen desaturation. Vocal cords assessment confirmed bilaterally mobile cords. A spiral computed tomography (CT) was obtained to rule out PE, and there was no sign of PE; however, there was a retrosternal mass compressing 40% of the trachea and measuring 8.4 cm × 4.2 cm × 6 cm suggestive of retrosternal goiter. A contrast-enhanced CT of the head and neck was obtained for further evaluation of the mass [Figure 1] and [Figure 2]. The patient was taken back for a reexploration and excision of the retrosternal goiter. The previous collar incision was utilized, the thoracic inlet was completely intact, and the superior mediastinum was approached where an isolated mass was identified, with a separate inferiorly based blood supply [Figure 3]. After excision of the mass through the cervical incision, a thorough mediastinoscopy confirmed no remaining thyroid tissue. The patient tolerated the surgery well and was discharged home on the 2nd postoperative day. Two weeks later, she presented to the clinic in good condition [Table 1]. Histopathological examination confirmed that the retrosternal mass was composed of thyroid tissue and that both the thyroid gland and the retrosternal mass were negative for malignancy. An informed consent was obtained from the patient to publish this case report.
Figure 1: Head-and-neck computed tomography scan showing enlarged mass (arrows) compressing 40% of the trachea and displacing it toward the right side

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Figure 2: Chest CT scan showing the same mass compressing and displacing the trachea posterior-laterally towards the right side

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Figure 3: Mediastinal mass measuring 9 cm in the longitudinal axis with a separate blood supply

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Table 1: Summary of the case reports discussing forgotten retrosternal goiter

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  Discussion Top


“Forgotten goiter” is an extremely rare situation, which is described as a mediastinal thyroid mass that is found after total thyroidectomy.[1] In the literature, it is known that forgotten goiters are usually the consequence of incomplete removal of a plunging goiter during initial cervical thyroidectomy. However, it may be attributed to a concomitant, unrecognized mediastinal goiter, which is not connected to the thyroid: autonomous intrathoracic goiter (AIG). AIG is a thyroid gland located in the mediastinum that has neither parenchymatous nor vascular connection with the cervical thyroid gland.[4],[5],[6] While substernal extension of a cervical goiter is a far more common presentation, only 1% of mediastinal masses are intrathoracic thyroid tumors.[7] Few cases have been reported with controversy regarding the etiology of this ectopic thyroid tissue as well as the optimal surgical approach for resection.[4] Massard et al. reported seven cases of mediastinal thyroid tissue that were discovered after total cervical thyroidectomy and described these findings as “goiter oublié” or the “forgotten goiter”[8] [Table 1]. Patel and Parsons reported a case of “forgotten” goiter 5 years after total thyroidectomy managed through a standard cervical approach [Table 1].[4]


  Conclusion Top


A retrosternal mass should always be suspected if the patient is complaining of shortness of breath even if the patient does not have apparent signs of retrosternal extension by physical examination. A posteroanterior and lateral chest X-ray should be done to evaluate the cause of shortness of breath and to exclude a retrosternal extension. A suspicious chest X-ray should be followed by a chest CT to confirm the diagnosis of a retrosternal goiter. If a forgotten goiter is diagnosed postoperatively, the patient should be consented for a redo thyroidectomy. Contrary to the recent reported experiences of others, we found that complete resection of the forgotten goiter can be safely accomplished using the same standard cervical approach commonly utilized for thyroidectomy and does not require sternotomy.[9] Surgical management of retrosternal goiter is highly dependent on the experience of the surgeon.[10] Forgotten goiter is a rare pathology which can be prevented if particular attention is paid to preoperative imaging and intraoperative findings and can be managed during the first operation; however, surgical treatment for forgotten goiter, when performed in specialized centers, is associated with low morbidity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Calò PG, Tatti A, Medas F, Petruzzo P, Pisano G, Nicolosi A, et al. Forgotten goiter. Our experience and a review of the literature. Ann Ital Chir 2012;83:487-90.  Back to cited text no. 1
    
2.
Mace AD, Taghi A, Khalil S, Sandison A. Ectopic sequestered thyroid tissue: An unusual cause of a mediastinal mass. ISRN Surg 2011;2011:313626.  Back to cited text no. 2
    
3.
Retrosternal Goitre – Endocrinesurgery. Net. Au; 2017. Available from: http://www.endocrinesurgery.net.au/retrosternal-goitre/. [Last accessed on 2017 Mar 13].  Back to cited text no. 3
    
4.
Patel KM, Parsons CC. Forgotten goiter: Diagnosis and management. A case report and literature review. Int J Surg Case Rep 2016;27:192-4.  Back to cited text no. 4
    
5.
Riquet M, Deneuville M, Debesse B, Chrétien J. Autonomous intrathoracic goiter. Apropos of 2 new cases. Rev Pneumol Clin 1986;42:267-73.  Back to cited text no. 5
    
6.
Casadei R, Perenze B, Calculli L, Minni F, Conti A, Marrano D, et al. “Forgotten” goiter: Clinical case and review of the literature. Chir Ital 2002;54:855-60.  Back to cited text no. 6
    
7.
David Sabiston C Jr. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed. Philadelphia: W.B. Saunders; 1996. p. 1. 924MD. Available from: https://www.elsevier.com/books/sabiston-textbook-of-surgery/townsend/978-0-323-40162-3. [Last accessed on 2018 Oct 28].  Back to cited text no. 7
    
8.
Massard G, Wihlm JM, Jeung MY, Roeslin N, Dumont P, Witz JP, et al. Forgotten mediastinal goiter: Seven cases. Ann Chir 1992;46:770-3.  Back to cited text no. 8
    
9.
Sahbaz A, Aksakal N, Ozcinar B, Onuray F, Caglayan K, Erbil Y, et al. The “forgotten” goiter after total thyroidectomy. Int J Surg Case Rep 2013;4:269-71.  Back to cited text no. 9
    
10.
Batori M, Chatelou E, Straniero A. Surgical treatment of retrosternal goiter. Eur Rev Med Pharmacol Sci 2007;11:265-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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