Retrosternal Goitre: What Options?

Goitre is a multifactorial disease whose development is influenced by both genetic and environmental factors. The literature presents no univocal definition of retrosternal goitre. There are more than ten different definitions, making actual classification non-homogeneous. There is no clear consensus concerning the proportion of the gland that must be located in a retrosternal position, nor the depth to which it must descend into the thoracic cavity to be classified as a retrosternal goitre. The therapeutic choice depends on the size of the goitre, the symptomatology, the patient's age, and other patient characteristics. A multidisciplinary evaluation is essential to choosing the best therapeutic approach. Most retrosternal goitres can be safely resected through a cervical approach; however, up to 2% of cases may require a combined cervicothoracic approach. The purpose of this study is to analyze the different surgical approaches used in cases of cervico-mediastinal goitre with real sinking into the thorax, which required a joint surgical procedure with surgeons from the thoracic surgery unit.

From June 2022 to February 2024, 449 patients underwent surgery for thyroid disease at the general surgery unit of the University Hospital of Parma. Of these patients, we analysed the cases of cervico-mediastinal goitre with real sinking into the thorax, which required a joint surgical procedure with colleagues from the thoracic surgery unit due to the goitre's size and location. We identified a series of 5 cases of thoracic goitre, for an incidence rate of 1.1% of the treated patients. In all 5 cases, there was preoperative tracheal compression or dislocation. Of our cases, we found that 2 patients were treated with Kocher cervicotomy, 2 were treated with cervicotomy associated with thoracoscopy (in 1 case, a concomitant mini-thoracotomy at the IV intercostal space was performed), and 1 was treated with cervicotomy associated with manubriotomy. In 2 cases, total thyroidectomy was performed; in 2 cases, two-stage thyroidectomy was performed; and in 1 case, left lobectomy was performed.

Although thoracic goitre is a low-incidence disease, the risks and complications are significantly higher than those of cervical thyroidectomy. Preoperative imaging enables the evaluation of morphology, extension, relationships, and vascularisation, which facilitates preoperative multidisciplinary planning of surgical procedures. Advances in surgical techniques reduce procedure invasiveness by using minimally invasive techniques, which in turn reduce the impact of surgical access, perioperative complications, hospitalisation times, and postoperative recovery.

In our experience, a multidisciplinary approach-in particular, collaboration with thoracic surgeons-is fundamental to improving surgical outcomes.