Preoperative Evaluation of Substernal Goiter by Computed Tomography in the Extended Neck Position

Abstract

Sternotomy is indicated when a goiter cannot be resected via a cervical incision, such as in the case of a substernal goiter extending beyond the aortic arch. In this article, we report a case of a large substernal goiter that was successfully removed using the cervical approach only. This is a case of a 68-year-old woman, diagnosed with goiter 20 years ago, who complained of a neck mass enlargement with associated cough. Pathological examination revealed no malignancy. Computed tomography (CT) scan showed an 11-cm thyroid mass reaching the level of the aortic arch. Preoperatively, we evaluated the substernal extent of the goiter via CT in the extended neck position to decide whether sternotomy was necessary. With the patient's neck extended, the goiter withdraws cranially above the aortic arch. The mass was then removed via the cervical approach without sternotomy. Preoperative CT in the extended neck position was thus deemed helpful in deciding whether or not sternotomy was required.

Keywords: Extended neck computed tomography; Sternotomy; Substernal goiter; Transcervical approach.

Fig. 1

Preoperative CT imaging. The arrowheads indicate the extent of the goiter. The bars show the width between the caudal endings of the goiter and sternal notch. a CT imaging (sagittal plane). The extent of the substernal goiter toward the mediastinum and the depth from the sternal notch was 37 mm. b CT imaging (coronal plane). The 11-cm mass from the left thyroid lobe extended toward the mediastinum, and the caudal end was situated above the superior edge of the aortic arch. c CT imaging in the extended neck position (sagittal plane). The goiter was withdrawn cranially to 18 mm from the sternal notch. d CT imaging in the extended neck position (coronal plane). The caudal end was withdrawn above the aortic arch. CT, computed tomography.

Fig. 2

Preoperative pathological examination. a Fine-needle aspiration cytology (×400) revealed follicular cells with less dysplasia in the nuclei (Papanicolaou class IIIa). b Fine-needle biopsy (×100) revealed a variable thyroid follicle with less dysplasia, suggesting adenomatous goiter as a diagnosis.

Fig. 3

Intraoperative findings and postoperative pathology. a The goiter was resected from the surrounding tissues. b The lower pole of the goiter was bluntly dissected and dislocated. c The goiter was successfully resected without sternotomy. d Postoperative pathology reports adenomatous goiter as a diagnosis, and no malignancy was suspected.