Total Thyroidectomy with Resection of Superficial Thoracic Varicose Veins Due to Papillary Thyroid Cancer

Abstract

Abstract

Introduction:

A goiter is an enlarged thyroid gland defined as a substernal goiter (SG) if at least 50% of the goiter is extending below the level of the thoracic inlet ¹ or > 3 cm below the sternal manubrium. ² Prevalence of SGs is 1.7% to 30% ³ depending on underlying etiology, including iodine deficiency. SGs are more common in patients above age 60 years. More than 60% SGs are symptomatic due to compression of surrounding structures. ² Most common symptoms are dyspnea (59%) and dysphagia (32%). ⁴ Superior vena cava (SVC) syndrome is uncommon, presenting in 5% to 9% of patients, some of whom may have large superficial veins. “Pemberton's sign” with facial plethora and venous engorgement due to the movement of clavicles compressing venous vasculature against the enlarged thyroid may occur. ⁵ Management includes a total thyroidectomy performed by an experienced team using an anterior collar neck incision, which allows for control of cervical vascularization. ² Most SGs are benign, with papillary thyroid cancer (PTC) present in 6.8% of cases, ² most of them being microcarcinomas. Postoperative complications including bleeding, airway compromise, recurrent laryngeal nerve (RLN) damage, and hypoparathyroidism are rare.

Materials and Methods:

A 50-year-old white male presented with multiple large varicosities across his chest that increased over 3 years. He had dyspnea with exertion and obstructive sleep apnea. A CT scan of his chest showed an enlarged left thyroid lobe with substernal extension with rightward tracheal deviation. Venous collateralization prominent in superficial tissues of the anterior chest with narrowing of the right innominate vein was noted. Anesthesia was induced and an endotracheal tube was placed with nerve monitoring. A low-lying midline neck incision was outlined and carefully infiltrated with 1% lidocaine and 1:100,000 epinephrine, avoiding the large varicosities. The incision was then made, multiple subcutaneous varices were noted, and tied off with silk suture. RLNs were identified and the thyroid gland was removed easily with appropriate dissection. Once the gland was removed, the RLNs were reidentified and confirmed with the nerve stimulator. Postoperative course was unremarkable. Histologic findings showed a 7 cm PTC, follicular type, in the left thyroid lobe. No extra thyroidal extension was noted. The right thyroid lobe showed nodular hyperplasia. Postsurgically, the patient was treated with radioactive iodine and continues to do well on suppressive levothyroxine therapy.

Results:

Our patient presented with large superficial varicosities of the chest wall and compressive symptoms due to a large PTC of the left thyroid lobe. Varicosities were identified preoperatively and carefully ligated before removing the enlarged thyroid gland through a standard thoracotomy incision. Intraoperative nerve monitoring and identification of parathyroid glands led to avoidance of postoperative complications like hypoparathyroidism and RLN damage.

Conclusions:

Rare cases of PTC causing SCV syndrome have been described. ⁶ Our patient presented with prominent superficial chest varicosities and a positive Pemberton's sign caused by a large PTC. Total thyroidectomy by an expert team with careful ligation of varicosities followed by radioactive iodine ablation is key to effective outcome as in our patient.

No competing financial interests exist.

Runtime of video: 5 mins 4 secs