Soft-tissue images. Mediastinal goitre
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* John D. Urschel
* Timothy M. Anderson

A 52-year-old woman complained of intermittent dyspnea. Examination of the neck and chest was unremarkable. A chest radiograph showed a mediastinal mass (Fig. 1). Thyroid scanning showed heterogeneous uptake in the left lobe, minimal uptake in the right lobe and no uptake below the sternal notch. The patient refused further investigation and treatment.

![FIG. 1](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/43/4/250/F1.medium.gif)

[FIG. 1](http://canjsurg.ca/content/43/4/250/F1)

FIG. 1 

Over the next 20 years, chest radiographs showed slow growth of the mediastinal mass (Fig. 2). She complained of dysphagia and progressive dyspnea. Chronic congestive heart failure was responsible for some of her dyspnea. Computed tomography of the chest showed a huge mediastinal mass that communicated with the right thyroid lobe and compressed the trachea (Fig. 3). She declined surgical intervention.

![FIG. 2](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/43/4/250/F2.medium.gif)

[FIG. 2](http://canjsurg.ca/content/43/4/250/F2)

FIG. 2 

![FIG. 3](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/43/4/250/F3.medium.gif)

[FIG. 3](http://canjsurg.ca/content/43/4/250/F3)

FIG. 3 

Approximately 5% of thyroid goitres descend to a “substernal” or mediastinal location, and 5% of mediastinal masses are thyroid goitres.1 Small mediastinal goitres may be asymptomatic, but larger goitres cause symptoms by compressing the trachea, esophagus or vena cava. Most patients are euthyroid. Mediastinal goitres often appear “non-functional” on thyroid scanning, so this test is of limited value. CT is usually diagnostic. Suppressive therapy with thyroid hormone and gland ablation with radioactive iodine are rarely effective. Surgical resection (thyroid lobectomy) is the preferred treatment for symptomatic or large mediastinal goitres, and many surgeons recommend excision for asymptomatic patients also.2 Most mediastinal goitres can be removed through a standard cervical approach, but very large ones may also require a partial sternotomy. Occult thyroid cancer is found in about 5% of resected specimens.1,2 Our patient would have benefited from surgical resection at the time of initial presentation.

## Footnotes

*   Section Editors: David P. Girvan, MD, and Nis Schmidt, MD

*   Submissions to Surgical Images, soft-tissue section, should be sent to Dr. David P. Girvan, Victoria Hospital Corporation, PO Box 5375, Station B, London ON N6A 5A5 or to Dr. Nis Schmidt, Department of Surgery, St. Paul’s Hospital, 1081 Burrard St., Vancouver BC V6Z 1Y6.

## References

1.  Creswell LL, Wells SA Jr.. Mediastinal masses originating in the neck. Chest Surg Clin North Am 1992;2:23–55.
    
    

2.  1.  Pearson FG
    
    Shields TW. Thyroid. In: Pearson FG, editor. Thoracic surgery.New York: Churchill Livingstone; 1995. p.1454–64.