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A comparison of plasma TSH levels in patients with diffuse and nodular non-toxic goiter.

Plasma TSH levels were measured in 115 euthyroid patients with simple goiter, of whom 52 had diffuse and 63 nodular enlargement of the thyroid gland, and in 191 euthyroid patients without goiter. There was no significant difference between the plasma TSH levels in the patients with diffuse goiter and the non-goitrous controls, implying that the maintenance of diffuse hyperplasia is not dependent upon a raised level of plasma TSH. On the other hand, plasma TSH levels in the patients with nodular goiter were significantly lower than those recorded in either the patients with diffuse goiter (P less than 0.01) or in the patients without goiter (P less than 0.0001), supporting the view that thyroid function may be autonomous in nodular goiters.

Adenoma↗

Suppressive therapy with levothyroxine for euthyroid diffuse and nodular goiter.

In this study, 35 patients with euthyroid diffuse goiter and 35 patients with euthyroid nodular goiter were treated with Levothyroxine (L-T4) for six months. The aim was to evaluate the efficacy of treatment on thyroid and nodule volumes and to evaluate the correlation between volume changes and thyroglobulin levels. Serum thyroid hormones, TSH, thyroglobulin, thyroid and nodule volumes were measured at the initial visit and after 6 months. Radioactive iodine uptakes of the thyroid gland were evaluated before treatment. The mean decrease of thyroid volume at six months was about 20% (20.4 +/- 8.8 ml vs. 16 +/- 7.9 ml, P<0.001) in patients with diffuse goiter. All patients with diffuse goiter showed some decrement in their goiter sizes. Thyroid nodules, in response to thyroid hormone treatment, showed a variable behavior. A reduction of 50% or more in volume was detected in 31% (11/35) of the patients. 54% of the patients (19/35) showed a 10-49% decrease in nodule volume. Five of the patients were found to be insensitive to the therapy. Their nodule volumes either increased or did not change during therapy. Free T4 and free T3 levels increased and TSH levels decreased with L-T4 treatment in all patient groups. Patients with higher TSH levels (within normal limits) showed more volume reduction in the diffuse goiter group. No uniform correlation was found between volume changes and thyroglobulin levels in either of the patient groups. In conclusion, suppressive thyroxine treatment is effective in reducing the size of the goiter, and nodules and thyroglobulin levels cannot be taken as an indicator of the efficacy of L-T4 therapy.

Female↗

Iodine and goiter in children.

Goiter examination was performed on 7,785 children aged 9 to 16 years in four areas of the United States--Michigan, Kentucky, Texas, and Georgia. Urinary iodine and creatinine, thyroxine, protein-bound iodine, and plasma inorganic iodide determinations were made on 377 matched pairs of goitrous and nongoitrous control children. The overall prevalence of goiter was 6.8%. Most children with goiter had palpably but not visibly enlarged thyroids and showed no evidence of clinical or biochemical thyroid abnormalitymmean urinary iodine excretion was 452 mug/gm of creatinine, many times the 50 mug/gm of creatinine level used to define deficiency. Children with goiter and areas with high goiter prevalence tended to have higher rather than lower iodine excretion. These findings are consistent with other data indicating high iodine intakes in the United States and suggest that goiter in American children cannot be assumed to be related to iodine deficiencymthe possible role of high iodine intake in the causation of goiter is discussed.

Adolescent↗

Evolution of endemic goiter in the Valea Jiului area after 30 years of iodine prophylaxis.

After 30 years of iodine prophylaxis the incidence of goiter in the Valea Jiului area was reassessed. A number of 7,892 pupils aged 7-16 years were examined, of whom goiter was found in 32%. Before iodine prophylaxis started the incidence was 91.8%. The present survey shows that the small-sized goiters markedly prevail over middle-sized ones, while large-sized goiters became extinct. The diffuse to nodular goiter ratio changed by the disappearance of the nodular forms. The neurologic and psychic complications in goiter-bearing children disappeared. Attempts to correlate taste sensitivity to thiocarbamide with goiter failed. Examination of the digito-palmar dermatoglyphics showed a greater incidence of the higher atd angle, with transition forms of sulcus palmaris.

Adolescent↗

Associations of HLA-C alleles with multinodular goiters: study in a population from southeastern Spain.

HYPOTHESIS: Several immunological alterations have been found in patients with multinodular goiter (MG). These alterations, together with the association described between certain autoimmune thyroid diseases and alleles of the major histocompatibility complex (HLA alleles), justify the need for studies of the HLA alleles and MG in an attempt to identify associations. DESIGN: Case-control study. SETTING: Tertiary referral center. PATIENTS: Ninety consecutive patients underwent surgical procedures for MG. The control group comprised 100 unrelated, healthy, white subjects. INTERVENTION: Genotyping for HLA-C alleles was done using the molecular biological technique of polymerase chain reaction using sequence-specific primers and was carried out for all of the patients. MAIN OUTCOME MEASURES: The analyzed variables included age, sex, family history of thyroid pathological abnormalities, clinical features of the patient, clinical grading of the goiter, intrathoracic thyroid component, goiter weight, associated carcinoma, and the HLA-C gene. RESULTS: A significant association was observed between the lower incidence of the HLA-Cw4 allele and the appearance of MG (15.5% vs 8.3%, respectively; P = .001; relative risk [RR] = 0.49). These results suggest that the HLA-Cw4 allele can exert a protective effect against MG. Analysis of the different clinical variables shows the most significant association to be the absence of the HLA-Cw4 allele in patients with goiters with an intrathoracic component (P = .001; RR = 0.19) and in patients with goiters weighing more than 200 g (P = .02; RR = 0.17). Associations between the HLA-C alleles and MG were also observed, such as the presence of the HLA-Cw7 allele and a family history of thyroid pathological abnormalities (P = .03; RR = 3.91) as well as the HLA-Cw1 allele and the presence of goiter-associated thyroid carcinoma (P = .02; RR = 8.60). CONCLUSIONS: The HLA-Cw4 allele can act as a protector against the development of MG, as it occurs less frequently in the population with MG, and those with this allele develop smaller goiters with no intrathoracic component.

Alleles↗

Low environmental selenium availability as an additional determinant for goiter in East Java, Indonesia?

Iodine deficiency, which is most visibly indicated by goiter, is highly prevalent in Indonesia. Since 1994, Indonesia has a decree that all salt used for human, livestock, and industry must be iodized. However, despite the increased distribution of iodized salt, pockets with significantly higher prevalence of goiter still remain. This situation may be consequence of selenium (Se) deficiency. This study aimed to assess the Se level in the environment of goiter prevalent areas. Five hundred eleven school children participated in this study. Goiter was measured using both ultrasound and palpation. Ninety-nine eggs were collected from free-living chicken in 11 villages, and the Se contents of egg yolk and egg white were determined by neutron activation analysis. In the villages studied, Se concentration in egg yolk ranged from 0.15 to 1.52 microg/g and in egg white from 0.18 to 2.97 microg/g. The prevalence of goiter measured by palpation ranged from 18.4% to 70% and by ultrasound from 0% to 100%. Because of the inconsistency of goiter rate measured by palpation and ultrasonography, the question remains whether low availability of Se in the environment might be an additional contributing factor for goiter.

Child↗

Normal values for thyroid ultrasonography, goiter prevalence and urinary iodine concentration in schoolchildren of the Veneto Region, Italy.

Goiter prevalence in school-age children and median urinary iodine concentration (UIC) are the main indicators of iodine deficiency in a population. In areas of mild iodine deficiency, where goiters are small, ultrasound is preferable to physical examination to estimate goiter prevalence. The World Health Organization (WHO) has adopted thyroid volume ultrasonography results from a survey of European schoolchildren as an international reference, but these values have recently been questioned. The aims of the study were: a) to determine regional normal echographic reference values of thyroid volume in children aged between 11 and 14 yr in the Veneto Region, in North-East Italy; b) to determine goiter prevalence by physical and ultrasonographic examination; c) to determine UIC in this section of the population. A cross-sectional study was carried out on 1730 schoolchildren, aged between 11 and 14, living in towns in low-lying areas, in the valleys of the pre-Alps and in the mountains between 600 and 1200 m. Thyroid volume was evaluated by inspection and palpation using the WHO criteria. In 560 children thyroid volume was determined by ultrasound. UIC was measured in 1368 children. On physical examination a grade I goiter was found in 7.5% of children. No goiter grade II or grade III was found. The regional thyroid volume reference values by ultrasonography were similar, or slightly lower (5-20%), to the corresponding WHO reference values. Mean UIC was 148 +/- 110 microg/l, with no difference between lowlands and uplands; UIC values less than 100 microg/l were found in about 30-35% of the children. UIC was higher in children using iodized salt than in non-users. No correlation was found between thyroid volume by ultrasonography and UIC. Thyroid volume was found to be bigger in upland children than in those in low-lying areas, probably because of low iodine intake in people living in the mountains in previous generations. This data show that Veneto is not a iodine-deficient area, with no presence of endemic goiter. However, the great number of children with a UIC of less than 100 microg/l also suggests the use of iodized salt in the Veneto Region.

Adolescent↗

Study of an endemic goiter area in northern Campania.

The purpose of this paper was the determination, in the endemic goiter area of Teano (Caserta, Italy), of: i) The goiter prevalence in a group of 920 patients who attended the Outpatient Endocrinology Department; ii) The urinary iodine excretion in 150 adults (20-73-year-old) and 502 children (10-16-year-old; iii) The thyroid size in the 502 children; iv) The environmental iodine levels. Out of 920 patients a total of 750 (81.5%) goiters were detected. Out of these 750 cases, 415 (55.3%) were of grades 1b and 2, 335 (44.7%) of grades 3 and 4. A statistically significant association between goiter size and age was found (p less than 0.05). Laboratory data were entirely available for 506 goitrous patients. Serum TG levels was increased with goiter size and age, whereas there was a progressive decrease in mean serum TSH levels with increasing goiter size and age. The screening program performed on 502 schoolchildren aged 10 to 16 yr found a 68.3% prevalence of grade 1 goiter and a mean urinary ratio iodine/creatinine of 52 +/- 32 (SD) micrograms/g. A mean urinary ratio iodine/creatinine of 60 +/- 27 (SD) micrograms/g was reported in a sample of 150 adult inhabitants. Iodine measurements in water supplies showed levels equal to or less than 1 microgram/l. The area investigated can be identified as a moderate iodine deficient area and classified as grade 1-2 according to the Pan American Health Organization criteria.

Adolescent↗

Natural course of iodine-induced thyrotoxicosis (Jodbasedow) in endemic goiter area: a 5 year follow-up.

In the Balsas region of North Brazil (85% prevalence of goiter), 1876 goitrous subjects (1663 with goiter grade I and II and 103 with grade III multinodular goiter) were treated with 1 ml of iodized oil im (l-oil). From the population with grade III goiter we were able to follow-up for 5 yr 13 euthyroid goitrous patients (group 1) and 8 goitrous individuals (group 2) who developed iodine-induced thyrotoxicosis (IIT, 0.42% of the total population or 7.76% of the multinodular goiter subjects). The two groups were matched for age and goiter size, and had no significant differences in the baseline levels of thyroid hormone concentration, T3/T4 ratio or mean serum TSH. However, group 2 had a higher concentration of serum Tg, and 48 h after challenge with 10 U of bovine TSH (bTSH) had a significantly higher absolute release of T3 and Tg than group 1. In 4 patients IIT was transitory and resolved by 12 months. Four other subjects, however, maintained a mild clinical form of IIT that only normalized at 50 months. Only one patient needed treatment with methylmercaptoimidazol. There was no evidence of autoantibodies (TSH-receptor inhibiting antibody, anti-Tg or anti-microsomal antibodies) against thyroid antigens in group 2 patients. All subjects, including those with thyrotoxicosis, showed a remarkable shrinkage of the goiter by 60 months which was reflected by a significantly lower absolute response of T3 and Tg after bTSH.(ABSTRACT TRUNCATED AT 250 WORDS)

Brazil↗

Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany.

Risk factors for postoperative complications of benign goiter surgery have not been investigated systematically. To this end, a prospective multicenter study (January 1 through December 31, 1998) was conducted involving 7266 patients with surgery for benign goiter from 45 East German hospitals. High-volume providers (>150 operations per year) performed 69% (5042/7266), intermediate-volume providers 27% (50-150), and low-volume providers 4% (258/7266) of operations. Among the hospital groups, the pattern of thyroid disease did not vary significantly, but there was a trend that small-volume providers tended to perform more operations for uninodular goiter and high-volume providers treated more patients with Graves' disease and recurrent goiter. Extent of resection (p < 0.0001) and remnant size (multinodular goiter and recurrent goiter, p < 0.001), differed significantly, with total thyroidectomy being performed more often in hospitals with more than 150 operations compared to hospitals with an operative volume of less than 150 procedures per year. Despite the larger extent of resection and smaller remnant size, rates of recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism were not increased. When the logistic regression analyses were fitted to evaluate the impact of risk factors on transient and permanent RLN palsy and hypoparathyroidism, larger extent of resection [relative risk (RR) 1.5-2.1] and recurrent goiter (RR 1.8-3.4) consistently evolved as independent risk factors. With hypoparathyroidism, additional significant factors included patient gender (RR 2.1-2.4), hospital operative volume (RR 0.8-1.5), and Graves' disease (RR 2.8). Unlike parathyroid gland identification during hypoparathyroidism, RLN identification (RR 1.6) significantly (p = 0.01) reduced permanent RLN palsy rates. The multivariate analyses clearly confirmed the pivotal role of routine RLN identification, independent of the extent of the thyroid resection. These findings might help hospitals with lower operative volumes to identify patients at increased risk whom they might consider for specialist care.

Adult↗

Expression profile of malignant and non-malignant diseases of the thyroid gland reveals altered expression of a common set of genes in goiter and papillary carcinomas.

Using cDNA microarrays with 3800 cDNA fragments, we determined the expression profile of normal thyroid tissue, goiter, adenoma and papillary carcinoma (10 samples from each class). After background correction and statistical analysis, we identified a set of 160 genes as being differentially expressed in all pair-wise comparisons. Here we demonstrate that, at least on the basis of these differentially expressed genes, a positive correlation between goiter and papillary carcinomas could be observed. We identified a common set of genes whose expression is diminished in both goiter and papillary carcinomas as compared to normal thyroid tissue. Moreover, no genes with inverse correlation in samples from goiter and papillary carcinomas could be detected. Using Real-Time PCR and/or tissue microarrays, we confirmed the altered expression of some of the identified genes. Of notice, we demonstrate that the reduced mRNA levels of p27(kip1) observed in papillary carcinomas as compared to either goiter or normal thyroid tissues (P<0.001) is accompanied by an altered protein distribution within the cell. In papillary carcinomas, P27(KIP1) is preferentially cytoplasmic as opposed to goiter or normal thyroid tissue, where P27(KIP1) is preferentially located in the nucleus. The exploitation of the data presented here could contribute to the understanding of the molecular events related to thyroid diseases and gives support to the notion that common molecular events might be related to the frequent observation of areas of papillary carcinomas in the gland of patients with goiter.

Carcinoma, Papillary↗

Substernal goiter. Analysis of 80 patients from Massachusetts General Hospital.

Eighty patients at the Massachusetts General Hospital underwent resection of substernal goiter in the years 1976 to 1982. Mean age of the 50 women and 30 men was 56 years, and 10 (19 percent) had undergone prior thyroid surgery. The most common symptoms were cervical mass (69 percent), dysphagia (33 percent), and dyspnea (28 percent); 13 percent were asymptomatic. On examination, cervical mass was present in most (90 percent) but not all patients, 51 percent were obese, and more than one third had tracheal deviation. Fifty-one of 52 patients tested were euthyroid and one was mildly hypothyroid. Chest radiographs showed tracheal deviation in 79 percent and soft tissue mass in 56 percent. Seventy-eight patients underwent resection through a cervical collar incision only; one had cervical incision plus upper partial sternotomy; and one required cervical incision plus full median sternotomy. Pathologic examination revealed multinodular goiter in 41 (51 percent), follicular adenoma in 35 (44 percent), and Hashimoto's thyroiditis in 4 (5 percent). Mean goiter weight was 104 g, and the mean greatest dimension was 9 cm. Occult papillary carcinoma was found in two patients. There were no deaths or major complications. Analysis of our data indicate the following: (1) Substernal goiter may exist in the absence of symptoms or signs. (2) Extensive radiologic evaluation and thyroid function testing are rarely required. (3) With rare exceptions, substernal goiter represents an extension of a cervical growth through the thoracic inlet and can be approached through a cervical collar incision. (4) Histologically, these are multinodular goiters or follicular adenomas, although Hashimoto's thyroiditis may occur. (5) Given the small but present risks of acute stridor or occult malignancy and the negligible surgical risk, operation should be recommended. (6) Patients should be followed since, with or without levothyroxine, goiters may recur.

Adult↗

Substernal goiter.

The literature on substernal goiter from the seventeenth century to the present is reviewed. Substernal goiter may be defined as any thyroid enlargement that has its greater mass inferior to the thoracic inlet. Truly ectopic mediastinal goiters are rare, and most substernal goiters arise from and maintain some attachment to the cervical thyroid gland. Patients are generally in the fifth decade of life, and women predominate. Most patients experience dyspnea, stridor, or dysphagia, but 15 to 50% are asymptomatic; symptoms are often positional, and acute stridor may occur. Ten to twenty percent have no cervical mass or tracheal deviation on examination, and virtually all patients are euthyroid. Standard chest roentgenograms are often diagnostic, but computed tomographic or radioactive iodine scans may be helpful. The presence of a substernal goiter in all but the highest-risk patients is an indication for resection, usually through a cervical collar incision; an occasional patient will require sternotomy or thoracotomy. Death or major complications should be rare postoperatively. Substernal goiters are adenomatous and benign, but carcinoma occurs in 2 to 3% and may be occult. Patients should be followed closely, as these goiters may recur.

Adolescent↗

Thyroid function in term newborn infants with congenital goiter.

Eighty-four term newborn infants without goiter and 45 newborn infants with congenital goiter were studied with regard to thyroid function. The radiologic development of the femoral and tibial epiphyses was evaluated in those with goiter. Fifty-eight percent of the patients had retarded bone age, markedly elevated TSH levels, elevated TBI, decreased total T4I, and decreased PBI values. Forty-two percent of newborn infants with congenital goiter had a normal bone age, normal values for TSH, PBI, and total T4I, and elevated values for TBI. It is concluded that the 58% of the newborn infants with congenital goiter had subtle hypothyroidism. They require substitution therapy with thyroid hormones in order to avoid possible retardation of normal brain development. Patients with congenital goiter who have no biochemical evidence of hypothyroidism should also be treated with thyroid hormones to achieve rapid regression of goiter.

Bone Development↗

Model of the athymic nude mouse for the study of benign goiter disease.

Since Shimosato et al., in the mid 70s transplanted for the first time thyroid carcinoma tissue onto nude mice, other research groups have made use of the nude mouse model for the investigation of xenotransplanted thyroid tissue. The use of this model for the investigation of benign goiters is briefly discussed in this article. Normal human thyroid tissue has been transplanted either as a control in experiments with benign and malignant goiter tissue, or for the study of thyroid tissue response to stimulators such as TSH or thyroid stimulating antibodies (TSAb). Thyroid glands from 8- to 10-week old human fetuses obtained at the time of legal abortion were cryopreserved in liquid nitrogen and successfully transplanted into nude mice. Moreover, all the variants of human benign goiter tissue have been xenotransplanted: tissue from nodular and diffuse goiters, hot and cold nodules or goiter areas, rapidly growing nodules, etc. Two examples of animal thyroid tissue xenotransplantation onto nude mice are briefly discussed: Nude mice bearing normal thyroid tissue transplants from 4 different species (man, rat, pig, guinea-pig) have been used for the study of the species specific effect of bovine TSH and TSAb. In studies aiming at elucidating the pathogenesis of hyperthyroidism, toxic goiter tissue from hyperthyroid cats has been transplanted. In methodological terms, these experiments have shown that surgically removed goiter tissue can be shipped by air in cell culture medium at 4 degrees C over long distances and then successfully transplanted.-Finally, cell lines such as the rat cell line FRTL-5 can be transplanted onto nude mice either as cell suspension or embedded in collagen, for example for the study of proliferation and folliculogenesis. Using the xenotransplantation model, function and proliferation, morphogenesis and differentiation, as well as thyroid autonomy and response to stimulators have all been studied in xenotransplanted human and animal thyroid thyroid tissue and cell lines under various experimental conditions. Although new research tools, for example transgenic animals, are now increasingly and successfully used, xenotransplantation still offers the possibility of addressing some specific questions which cannot be answered so easily with other experimental models. For example, studies with human tissue, involving drugs or radioactive tracers which cannot be applied to the intact human being, can relatively easily be performed with xenotransplanted human tissue and application of the drug or tracer to the host mouse. Or embryological development can be followed and studied using fetal thyroid (and other) tissue transplanted onto nude mice; here, of course, difficult ethical issues have to be considered. Finally, it should be mentioned that, although many scientific questions can be studied nowadays by cell culture or other in vitro systems, animal models are still needed. Extrapolation to the human being, however, should always be done with caution and we should always keep in mind that for the understanding of a human disease indeed human experimental models remain the goldstandard.

Animals↗

Activin A and activin receptors in the human thyroid: a link to the female predominance of goiter?

Activin A belongs to the TGF-beta family of growth factors involved in control of tissue formation by growth inhibition and to a family of hormones involved in human reproduction. Serum levels of dimeric activin A display a sexual dimorphism with significantly higher circulating hormone concentrations in men than in women after menopause. Since goiter is far more frequent in women than in men, we investigated the role of this sex-related growth factor in the human thyroid. Primary cultures were obtained from 3 patients with goiter, and 4 with recurrent goiter. Activin A significantly inhibited the proliferation of human thyroid follicular epithelial cells in vitro in concentrations between 0.5 and 50 ng/ml and was almost as potent as TGFbeta-1. Analysis in native tissues from 12 normal thyroids, 16 goiters, and 5 Graves thyroids demonstrated mRNA expression of the activin subunit betaA, TGFbeta-receptor type I and II, activin receptors type I receptors alk2 and alk4, and activin type II receptors actRII and actRIIb. Isoform analysis of the major functional type I activin receptor alk4 revealed the full-length transcript SKR2-1 and transcripts for the partially truncated proteins SKR2-2 and SKR2-3 in normal thyroids and goiters. Semi-quantitative RT-PCR revealed a significant 2.5-fold decrease of mRNA for alk4-1 type I activin receptors in goiter as compared to normal thyroid (p < 0.05), whereas expression of the type II receptor actRII was unchanged. These data identify a novel growth inhibitory pathway by activin in the human thyroid. Down-regulation of activin receptor type lb in goiter hints towards end-organ changes which could contribute to deficient growth inhibition. These data provide a mechanistic model how the sexually dimorphic hormone activin A may protect males from goitrogenesis.

Activin Receptors↗

Abnormal cellular localization of thyroglobulin mRNA associated with hereditary congenital goiter and thyroglobulin deficiency.

The goiters in a breed of hypothyroid goats contain only minute amounts of thyroblobulin-related antigens (0.01% of normal value). We have analyzed these goiters for the presence of mRNA coding for thyroglobulin. Using DNA complementary to beef 33S thyroglobulin mRNA as a probe, we found that the mRNA sequence is present in the goat goiter but at a concentration 1/10-1/40 that of normal goat thyroid. Hybrids of cDNA with either goiter or normal thyroid RNA exhibited identical sharp melting curves which suggests that the same RNA sequence is responsible for hybridization in both tissues. Normal goat thyroid contains a population of large membrane-bound polysomes engaged in throglobulin synthesis. In contrast, such polysomes are absent in the goiter. In regard to subcellular distribution, the relative amount of the thyroglobulin mRNA sequences from the goiter in nuclear RNA was 42% of normal, in cytoplasmic RNA was 7% of normal, and in the membrane fraction was only 1-2% of normal. Our results suggest that the lack of thyroglobulin in these goiters is due to a defect in thyroglobulin mRNA which leads to aberrant processing and/or transport of it from its site of synthesis to the endoplasmic reticulum.

Animals↗

Management of substernal and intrathoracic goiters.

Goiters that descend into the mediastinum can cause respiratory embarrassment, dysphagia, vascular compression, vocal cord paralysis, and sudden death. Although many such goiters remain clinically silent, their ability to produce sudden and unpredictable respiratory distress is well known. The condition was not considered uncommon in the first half of the twentieth century; some authors reported series of hundreds of thyroidectomies for intrathoracic goiter. Though seen less frequently today, the only effective treatment for mediastinal goiter is surgical removal. We report our experience with the management of 70 consecutive patients with substernal or intrathoracic goiters. The clinical presentation, preoperative evaluation, operative technique, and results and complications of therapy are discussed. Consideration is also given to the pathogenesis of intrathoracic extension. The transcervical approach for resection is emphasized--even goiters extending to the aortic arch were safely removed without requiring sternotomy. A multidisciplinary team approach, including the surgeon, anesthesiologist, and endocrinologist, is essential. Because of more conservative trends in the selection of patients for thyroidectomy, the incidence of mediastinal goiter may be increasing.

Adult↗