SESSION TITLE: Surgery Student/Resident Case Report Posters
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Incomplete resection of thyroid can lead to recurrent substernal goiter decades after the initial surgery. Symptoms usually manifest when thyroid tissue grows large enough to compress nearby structures. We present one of the largest substernal goiters in a patient who underwent thyroidectomy over 30 years prior.
CASE PRESENTATION: 54-year-old woman presented with chief complaint of left anterior chest pain. Pain was described as stabbing and pressure-like, with radiation to the right anterior chest, independent of exertion. Postural changes and deep breathing were exacerbating factors with no alleviating factors reported. The pain was associated with shortness of breath, headache, positional dizziness, dry cough, subjective fever, and fatigue, which all started 2 days prior. She reported approximately 40 lbs weight loss in the last year. The only pertinent medical history was a thyroid surgery due to unclear etiology 32 years ago. Physical exam noted: temperature 39.3C, heart rate 86, respiratory rate 18, blood pressure 90/55, saturating well on room air. Patient was in moderate distress secondary to pain; with dry mucous membranes; trachea midline, no JVD, no lymphadenopathy, no thyromegaly, and well healed nontender 2 cm kocher incision scar; heart exam was regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops; collateral venous circulation on the anterior chest; diminished breath sounds at the bases of the lungs bilaterally with bibasilar crackles present. The pertinent laboratory results were Hemoglobin: 11.7, TSH: 1.380, Thyroglobulin: 4,596, LDH: 417. CT of the chest reported a large anterior mediastinal mass that was enhancing, heterogeneous in nature, measuring approximately 14x9x11cm. The mass seemed to be originating from the right thyroid lobe. Superior vena cava was patent but compressed. The mass was resected using combined cervical and transsternal approach, followed by re-implantation of the parathyroid tissue. Retrosternal mass was sent to pathology and found to be a 680 gram thyroid with nodular hyperplasia, scarring and focal calcification consistent with a goiter.
DISCUSSION: Incomplete thyroidectomy may lead to intrathoracic growth of remnant thyroid tissue, which can grow unrecognized for several years until it manifests with SVC, trachea compression or acute chest symptoms. Such large intrathoracic goiters require addition of sternotomy to cervical incision, which is associated with slightly higher perioperative morbidity.
CONCLUSIONS: Although not the current standard of care, this case underlies the necessity of surveillance neck and chest imaging following thyroidectomies to prevent future recurrent goiters that may extend into the intrathoracic space.
Reference #1: Tsakiridis K, Visouli AN et al. Resection of a giant bilateral retrovascular intrathoracic goiter causing severe upper airway obstruction, 2 years after subtotal thyroidectomy: a case report and review of the literature. J Thorac Dis. 2012 Nov 4:41-8.
DISCLOSURE: The following authors have nothing to disclose: Amelie Romelus, Metin Kurtoglu, Yvonne Diaz
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