İlker ÖZGÜR, İsmail Cem SORMAZ, Fatih TUNCA, Tarık TERZİOĞLU, Artur SALMASLIOĞLU, Derya S UYMAZ, Ahmet Y İŞCAN, Yasemin G ŞENYÜREK

The Value of Preoperative Volumetric Analysis by Computerised Tomography of Retrosternal Goiter to Predict the Need for an Extra- Cervical Approach

Background: A thyroidectomy can be performed via acervical incision in most patients with retrosternal goiter.Aims: To investigate the correlation between the volumeof the mediastinal portion of the thyroid gland and theneed for an extra-cervical approach for retrosternalgoiter.Study Design: Diagnostic accuracy study.Methods: The measurement of craniocaudal lengthand the volume of the mediastinal component of thethyroid gland on computerised tomography images wasperformed in 47 patients with retrosternal goiter. Ofthese 47 patients, 8 (17%) required an extra-cervicalapproach and were classified as group 1, and 39 (83%)patients that required a cervical incision were classifiedas group 2. Receiver operating characteristic analysiswas performed to determine the cut-off value for thecraniocaudal length and the volume of the mediastinalthyroid mass, which significantly correlated with anextra-cervical approach for retrosternal goiter.Results: Reoperative surgery was significantly morefrequent in group 1 than in group 2 (50% vs 13%; p=0.03).The craniocaudal length of the mediastinal thyroid glandwas significantly longer in group 1 than in group 2(77±11 mm vs 31±21 mm, respectively; p=0.0001). Thevolume of the mediastinal component was significantlylarger in group 1 compared to group 2 (264±106 cm3vs 40±41 cm3, respectively; p=0.0001). The receiveroperating characteristic curve of craniocaudal lengthand the volume of the mediastinal component identified≥66 mm and ≥162 cm3 as the cut-off values with themaximum accuracy, respectively. The craniocaudallength of the thyroid mass below the thoracic inlet ≥66mm or a volume of the mediastinal portion ≥162 cm3 weresignificantly associated with an extra-cervical approach(p=0.0001). For predicting an extra-cervical approach,the sensitivity, positive predictive value and negativepredictive value of the cut-off value for craniocaudallength was 87.5%, 64% and 97%, respectively. Forpredicting an extra-cervical approach, the sensitivity,positive predictive value and negative predictive valueof the cut-off values for the mediastinal volume were100%, 89% and 100%, respectively.Conclusion: A thyroid volume of ≥162 cm3 extendingbelow the thoracic inlet was a significant determiningfactor for an extra-cervical approach, with a negativepredictive value for the extra-cervical approach of100% for retrosternal goiter with smaller volumes.Further studies with an increased number of patients areneeded to determine the value of volumetric analysisof retrosternal goiter to predict the need for an extracervicalapproach in retrosternal goiter.

PDF

___

Sand ME, Laws HL, McElvein RB. Substernal and intrathoracic goiter. Reconsideration of surgical approach. Am Surg 1983;49:196-202.
Hedayati N, McHenry CR. The clinical presentation and operative management of nodular and diffuse substernal thyroid disease. Am Surg 2002;68:245-51.
Makeieff M, Marlier F, Khudjadze M, Garrel R, Crampette L, Guerrier B. Substernal goiter. Report of 212 cases. Ann Chir 2000;125:18-25.
Moron JC, Singer JA, Sardi A. Retrosternal goiter: a six year institutional review. Am Surg 1998;64: 889-93.
Rodriguez JM, Hernandez Q, Piñero A, Ortiz S, Soria T, Ramirez P, et al. Substernal goiter: clinical experience of 72 cases. Ann Otol Rhinol Laryngol 1999;108:501-4.
Torre G, Borgonovo G, Amato A, Arezzo A, Ansaldo G, De Negri A, et al. Surgical management of substernal goiter: analysis of 237 patients. Am Surg 1995;61:826-31.
Allo MD, Thompson NW. Rationale for the operative management of substernal goiters. Surgery 1983;94:969-77.
Sitges-Serra A, Sancho JJ. Surgical management of recurrent and intrathoracic goiters. In: Clark OH, Duh Q-Y, Kebebew E, editors. Textbook of Endocrine Surgery, 2nd ed. Philadelphia: Elsevier Saunders; 2005:304-17.
Katlic MR, Wang CA, Grillo HC. Substernal goiter. Ann Thorac Surg 1985;39:391-9.
Qureishi A, Garas G, Tolley N, Palazzo F, Athanasiou T, Zacharakis E. Can pre-operative computed tomography predict the need for a thoracic approach for removal of retrosternal goitre? Int J Surg 2013;11:203-8.
Grainger J, Saravanappa N, D'Souza A, Wilcock D, Wilson PS. The surgical approach to retrosternal goiters: the role of computerized tomography. Otolaryngol Head Neck Surg 2005;132:849-51.
White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg 2008;32:1285-300.
Cichoń S, Anielski R, Konturek A, Baczyński M, Cichoń W, Orlicki P. Surgical management of mediastinal goiter: risk factors for sternotomy. Langenbecks Arch Surg 2008;393:751-7.
Mercante G, Gabrielli E, Pedroni C, Formisano D, Bertolini L, Nicoli F, et al. CT cross-sectional imaging classification system for substernal goiter based on risk factors for an extracervical surgical approach. Head Neck 2011;33:792-9.
Huins CT, Georgalas C, Mehrzad H, Tolley NS. A new classification system for retrosternal goitre based on a systematic review of its complications and management. Int J Surg 2008;6:71-6.
Ríos A, Rodríguez JM, Balsalobre MD, Tebar FJ, Parrilla P. The value of various definitions of intrathoracic goiter for predicting intra-operative and postoperative complications. Surgery 2010;147:233-8.
de Perrot M, Fadel E, Mercier O, Farhamand P, Fabre D, Mussot S, et al. Surgical management of mediastinal goiters: when is a sternotomy required? Thorac Cardiovasc Surg 2007;55:39-43
Testini M, Gurrado A, Avenia N, Bellantone R, Biondi A, Brazzarola P, et al. Does mediastinal extension of the goiter increase morbidity of total thyroidectomy? A multicenter study of 19,662 patients. Ann Surg Oncol 2011;18:2251-9.
Cohen JP. Substernal goiters and sternotomy. Laryngoscope 2009;119:683-8.
Raffaelli M, De Crea C, Ronti S, Bellantone R, Lombardi CP. Substernal goiters: incidence, surgical approach, and complications in a tertiary care referral center. Head Neck 2011;33:1420-5.
Sari S, Erbil Y, Ersöz F, Saricam G, Salmaslioğlu A, Işsever H, et al. Predictive value of thyroid tissue density in determining the patients on whom sternotomy should be performed. J Surg Res 2012;174: 312-8.
Nankee L, Chen H, Schneider DF, Sippel RS, Elfenbein DM. Substernal goiter: when is a sternotomy required? J Surg Res 2015;199:121-5.
Malvemyr P, Liljeberg N, Hellström M, Muth A. Computed tomography for preoperative evaluation of need for sternotomy in surgery for retrosternal goitre. Langenbecks Arch Surg 2015;400:293-9.