Surgical management of retrosternal thyroid disease: a decennial retrospective analysis

TL;DR

This paper analyzes surgical approaches and outcomes for thyroid disease extending into the chest, emphasizing the importance of definitions and imaging for effective treatment.

Contribution

The study introduces a combined classification system to predict surgical needs for retrosternal thyroid disease.

Findings

The cervical approach suffices for most retrosternal thyroid surgeries, with less than 1% requiring thoracic access.

CT or MRI is recommended for accurate pre-operative assessment of retrosternal thyroid extension.

Combining Huins and Cohen & Cho classifications helps predict the need for extended surgical approaches.

Abstract

Thyroid disease with retrosternal extension lacks a universally accepted definition in the literature, contributing to significant variability in the reported prevalence across series. This study aims to present the experience of a high-volume center in the management of retrosternal thyroid pathology and to identify potential predictive factors that may assist in surgical planning.

Between 1 January 2014 and 31 December 2024 we performed 1347 thyroidectomies: 355 (26,3%) thyroid surgical procedures were performed in patients whose thyroid pathology was identified intra-operatively as retrosternal extension. We analyzed patient comorbidities, any pre-operative treatments, pre-operative imaging, the type of surgical procedure performed, the surgical approach adopted, and post-operative complications. Four definitions of retrosternal thyroid pathology, selected among those most frequently cited in the literature and deemed applicable in clinical practice, were compared.

Benign retrosternal goiter accounted for 84.2% of cases, thyroid malignancies represented 6.2% of the cohort, while retrosternal goiters with indeterminate cytology comprised 9.6% of the total. Total thyroidectomy was performed in 80% of patients. Among the 355 patients operated on, a classical cervical approach (Kocher incision, optionally with split cutaneous layer) was used in 99.2% of cases; only 0.8% required an additional thoracic approach. Pre-operative diagnosis of malignancy and the type of surgical procedure performed emerged as the principal factors associated with the development of recurrent laryngeal nerve palsy and hypocalcaemia in the postoperative period.

A universally recognized definition of retrosternal thyroid pathology remains elusive. In high-volume centers the cervical approach is sufficient and the rates of thoracic surgical approach is less than 1%. Computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical region are the modalities of choice for investigating the retrosternal component of the thyroid, as they allow accurate assessment of mediastinal extension and facilitate surgical planning. In our study, the integration of the Huins classification and the Cohen & Cho classification proved to be a valid predictive factor for identifying cases that may require a surgical approach beyond the classical Kocher-type cervicotomy. We recommend that retrosternal thyroid pathologies be managed in referral centers equipped with multidisciplinary expertise and adequate surgical experience to ensure optimal outcomes.

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