EXTENSION- A rare case report
Raj Nagarkar1, Shirsendu Roy1, Mohammad Akheel2, Nayana Kulkarni3
1-Surgical oncologists 2-Senior Registrar, 3-Anesthetist, Dept of head & neck oncology services, HCG Curie Manavata cancer centre, Nashik, India. ABSTRACT:
Retrosternal goitre is very rare condition which account for 5 to 20 % of thyroidectomy patients. Though rare, it can be better managed surgically. In this article we report a rare case of 55 year old female who had nodular goiter with huge retrosternal extension associated with hyperthyroidism. Majority of retrosternal thyroid can be removed safely by conventional cervical approach. Our patient had around 12 x 8 x 7 cm mass which was impossible to remove it from conventional approach and hence total thyroidectomy by a combined cervical/sternotomy approach. Procedure was uneventful and patient is doing fine in 2 months of follow-up. The role of thyroidectomy in patients with retrosternal goitre provides yet another area of surgical controversy. KEYWORDS: Thyroid neoplasm, retrosternal goitre, sternotomy
Retrosternal goiter is defined when 50 % of the thyroid is below the thoracic inlet. This can also be called as intrathoracic goiter. Retrosternal goiter is a very rare condition which account for 5 to 20 % of thyroidectomy patients. Mediastinal extension is more common in huge goiters with a peak incidence in 5th to 6th decade. This is usually rare when the patient has associated hyperthyroidism which may increase the risk of complications. The reported incidence of goiters with thyroid malignancy is around 3 to 17 %. Retrosternal goitre occurs when the thyroid enlarges downwards into the chest. Although the great majority of retrosternal goitres are extensions from the neck, pure intrathoracic goitres are very rare. Retrosternal goitres are more likely to be left sided and very rarely a left sided cervical goitre

descends into the right side of the chest which is called a "crossed substernal goitre". With few exceptions huge goiters can be removed by cervical approach but less than 2 % patients require cervical/sternotomy approach. All these factors will influence the perioperative management of the patient. In this article we report a rare case of 55 year old female who had nodular goiter with huge retrosternal extension associated with hyperthyroidism. The tumor was removed surgically by a combined cervical/sternotomy approach. CASE REPORT:
A 55 year old reported to our cancer centre with a chief complaint of difficulty in breathing and eating from 2 years. General examination was insignificant. Local examination revealed a diffuse swelling of left lobe of thyroid (Fig 1). Her medical history revealed hyperthyroidism from 2 years. A provisional diagnosis of Thyroid swelling was made. Radiological examination was done. Computed tomography of neck revealed 12 x 8 x 7 cm retrosternal mass arising from left lobe of thyroid with tracheal compression (Fig 2). There was no cervical lymphadenopathy. Thyroid function test (T3, T4 and TSH) were done. T3 was 2.11 nmol/l, T4 was 228.86nmol/l and TSH was less than 0.06uIU/Ml. Fine needle aspiration of the lesion gave a final diagnosis of nodular colloid goitre with cystic changes. Since T4 was high, patient was started on Tab Neomarkazole 2.5mg, Tab Inderal 80 mg and Lugol Iodine solution orally for 10 days to avoid Thyrotoxicosis. After 5 days T3 was 0.98nmol/L, T4 was 180.36 nmol/L and TSH was less than 0.05 Uiu/Ml. Patient was taken FIG1: Diffuse swelling of left lobe of thyroid

FIG 2: Computed tomography of neck revealed 12 x 8 x 7 cm retrosternal mass arising from left lobe of thyroid with tracheal FIG 3: Excised specimen Fig 4: Closure with drains. Fibreoptic laryngoscopy was done to visualise the tracheal patency. Awake intubation was done. General anesthesia was administered. Necklace incision was given 2 cm above the sternum. Strap muscles were dissected. Thyroid gland was exposed. First left thyroid gland was mobilised followed by right thyroid gland. Bilateral recurrent laryngeal nerve was identified and preserved. The left thyroid mass was dissected. Sternotomy was done to enucleate the retrosternal mass from anterior mediastinum. Thyroid gland along with retrosternal mass was excised (Fig 3). Hemostasis was achieved. Drains were kept and closure was done in layers (Fig 4). Postoperatively patient was started on Tab Neomaracazole 2.5 mg and Tab Inderal 80 mg. Postoperative T4 was 145 nmol/L. Patient was discharged on 4th postoperative day. DISCUSSION:
The definition of retrosternal goiter is not uniform and often varies among authors. Goldenberg and Lindskog defined retrosternal goiter as a lesion of the thyroid gland extending downward the fourth thoracic vertebra on chest imaging or a structure with an inferior margin extending down to the level of the arch of the aorta. According to Katlic and colleagues retrosternal goiter is defined when more than 50% of the mass lies distally to the thoracic outlet. Patients often complains with slow and progressive growth commonly seen in 5th or 6th decade of life. When the age of clinical presentation advances there is increased medical co-morbidity implying that surgery at an earlier stage may be associated with reduced complications related to co-existing disease. Other symptoms can be cough, dyspnoea, dysphagia , stridor , and symptoms of choking which are absolute indications for surgery. Our patient had all these clinical symptoms. Radiological Imaging indicators may include compression of trachea , tracheal deviation, compression of other adjacent vital structures. Imaging often helps in correlating the symptoms with size of goiter, presence of tracheal deviation or extent of retrosternal extension. The cause for acute airway obstruction /orthopnoeaneeds to be considered which may be due to haemorrhage within the thyroid gland or may be secondary to prolonged mechanical pressure with acute laryngeal oedema and congestion. Although rare these acute problems can contribute for around 5 – 11% and may lead to catastrophic consequences providing a clear indication for thyroidectomy in patients with retrosternal goiter. The majority of nodular goitres, limited to the neck and including a retrosternal component are often benign in nature. Clinical and ultrasonography examination can be done for cervical goitres and needle biopsy of suspicious areas can be taken , with cytological determination of malignant nodules, leading to patient selection for surgery. Retrosternal or subternal components of goitres are not easily imaged by ultrasound due to artefact generated by bony structures and needle biopsies are difficult to perform in routine practice. This can lead to exclusion of malignancy thought with difficulty in retrosternal goitres. Prospective studies reveals the incidence of development of malignancy in goitres is 1.3–3.7 new cases per 1000 patients. A recent review of evidence-based management of substernal goitres concluded the incidence of malignant transformation is equivalent in retrosternal goitres to those residing entirely in the neck. With few exceptions huge goiters can be removed by cervical approach but less than 2 % patients require conventional cervical approach combined with sternotomy/ manubriotomy/ thoracotomy. Review of the literature regarding the complications of recurrent laryngeal nerve injury, hyperthyroidism, hypoparathyroidism and tracheomalacia after retrosternal goitre excision reveals conflicting results as to whether these specific complications are increased by comparison to cases of excision of simple cervical goitre. Total Thyroidectomy for retrosternal goitres with associated medical co-morbidities should be performed by surgeons who are experienced in thyroid surgery to prevent complications and a cervical approach is successful in the maximum number of cases. Graves disease is one of the most common cause for thyrotoxicosis or thyroid storm. It can be precipitated by systemic insults like trauma , surgery surgery, trauma, myocardial infarction, pulmonary thromboembolism and severe infection. In the past, thyroid storm was most commonly caused in thyroid surgery patients who had uncontrolled hyperthyroidism. Though this condition has been decreased by newer imaging modalities , but has not been completely eliminated the incidence of thyroid storm. Preoperative management of the thyrotoxic patient includes preparation for elective or nonurgent procedures and preparation for emergent procedures. When the case is nonemergent , there must be control of thyrotoxicosis to achieve euthyroidism before surgery. In this cases, thionamide therapy preferably Neomercazole would be recommended and would facilitate euthyroidism within several weeks. The use of iodine (lugols iodine) as a method of decreasing thyroid vascularity and friability before thyroid surgery ( TABLE 1) . Postoperatively Beta adrenergic receptors may be required for a period of 10 days . In our patient , Tab Neomarkazole 2.5mg , Tab Inderal 80 mg and Lugol Iodine solution orally were given for 1 week preoperatively to avoid Thyrotoxicosis followed by 5 days postoperatively. There is always a controversy to perform a Total thyroidectomy in patients with retrosternal goitre. There was historical surgical dogma to operate the patient with retrosternal goitre. But due to increased use of radiological investigations, particularly advanced Computed tomography scans has identified the often asymptomatic retrosternal goitre. These developments have prompted some thyroid surgeons to challenge the traditional surgical doctrine. Today it remains generally accepted that patients of retrosternal goitre with clinical symptoms of stridors / dysphagia and/or radiological evidence of significant tracheal narrowing, oesophageal compression or SVC syndrome are ideal candidates for surgery Table 1: Management of thyroid storm Courtesy: Bindu Nayak et al , Thyrotoxicosis and thyroid storm: Endocrine Metabolic clin Am, 35(2006)663-686 CONCLUSION:
Total Thyroidectomy in retorsternal goitre with hyperthyroidism patients must be performed with utmost precautions. Thyrotoxicosis and thyroid storm pose a critical diagnostic and therapeutic challenge to the clinician. Recognition of life-threatening thyrotoxicosis and prompt use of the arsenal of medications aimed to prevent the thyrotoxic process at every level is essential to successful management. Surgery is usually associated with increased risk of complications and hence must be performed by an experienced surgeon. 1. Huins, Charles T., et al. "A new classification system for retrosternal goitre based on a systematic review of its complications and management."International Journal of Surgery 6.1 (2008): 71-76. 2. Chauhan, Ajay, and Jonathan W. Serpell. "Thyroidectomy is safe and effective for retrosternal goitre." ANZ journal of surgery 76.4 (2006): 238-242. 3. Rugiu, M. G., and M. Piemonte. "Surgical approach to retrosternal goitre: do we still need sternotomy?." Acta otorhinolaryngologica Italica 29.6 (2009): 331. 4. Hashmi, S. M., et al. "Management of retrosternal goitres: results of early surgical intervention to prevent airway morbidity, and a review of the English literature." The Journal of Laryngology & Otology 120.08 (2006): 644-649. 5. McKay, Gary D., et al. "Giant functioning parathyroid cyst presenting as a retrosternal goitre." ANZ journal of surgery 77.4 (2007): 297-304. 6. Shah, Pallav J., et al. "Large retrosternal goitre: a diagnostic and management dilemma." Heart, Lung and Circulation 15.2 (2006): 151-152. 7. Wheeler, M. H. "Retrosternal goitre." British journal of surgery 86.10 (1999): 1235-1236. 8. Bennett, A. M. D., et al. "The myth of tracheomalacia and difficult intubation in cases of retrosternal goitre." The Journal of Laryngology & Otology 118.10 (2004): 778-780. 9. Hardy, R. G., et al. "Management of retrosternal goitres." Annals of the Royal College of Surgeons of England 91.1 (2009): 8. 10. Tsang, Flora HF, et al. "Management of retrosternal goitre with superior vena cava obstruction." Heart, Lung and Circulation 16.4 (2007): 312-314. 11. Armour, R. H. "Retrosternal goitre." British Journal of Surgery 87.4 (2000): 519-519. 12. Cooper, John C., Richard Nakielny, and C. H. Talbot. "The use of computed tomography in the evaluation of large multinodular goitres." Annals of the Royal College of Surgeons of England 73.1 (1991): 32. 13. Madjar, Shahar, and Dov Weissberg. "Retrosternal goiter." CHEST Journal108.1 (1995): 78- 14. Qureishi, Ali, et al. "Can pre-operative computed tomography predict the need for a thoracic approach for removal of retrosternal goitre?." International Journal of Surgery 11.3 (2013): 203-208. 15. Abraham, Deepak, et al. "Benign nodular goitre presenting as acute airway obstruction." ANZ journal of surgery 77.5 (2007): 364-367. 16. Dave, S. T., et al. "Anaesthesia management for subtotal thyroidectomy in a case of multinodular goitre with retrosternal extension and superior vena caval syndrome." Journal of postgraduate medicine 47.3 (2001): 219. 17. Xu, Jinzhi, et al. "Enormous goiter in posterior mediastinum: report of 2 cases and literature review." Journal of the Formosan Medical Association 108.4 (2009): 337-343. SUPPORT – NIL

Dr. Mohammad Akheel MDS, FHNCS, FACS, FADI
Snr Registrar, Head & Neck Services,
CMCC, Nasik, India
Email id-
Cite this article: Raj Nagarkar, Shirsendu Roy, Mohammad Akheel,Nayana Kulkarni, Nodular goitre with retrosternal extention- A rare case report, Arch. Of Head & Neck Surg. Vol 1 Issue 1, 2016 pg- 13-21


Neighbor stability-based vanet clustering for urban vehicular environments

J Supercomput (2016) 72:161–176DOI 10.1007/s11227-015-1517-6 Neighbor stability-based VANET clustering for urban Jung-Hyok Kwon1 · Hyun Soo Chang2 ·Taeshik Shon2 · Jai-Jin Jung3 · Eui-Jik Kim1 Published online: 11 September 2015© Springer Science+Business Media New York 2015 Abstract In this paper, we propose a neighbor stability-based VANET clustering(NSVC) that can efficiently deliver data in urban vehicular environments. The salientfeatures of urban vehicles are their high mobility and unpredictable direction ofmovement, so vehicle-to-vehicle and vehicle-to-infrastructure (V2X) communicationshould take into consideration the frequent changes in the topology of vehicular adhoc networks (VANETs). These technical challenges are addressed with NSVC byincluding a neighbor stability-based VANET clustering scheme and the correspondingsupplementary transmission scheduling method. Thereby, NSVC supports fast clusterformation, minimizes the number of cluster head elections, and moreover guaranteesthe reliable delivery of data for emergency messages. The results of the simulationindicate that NSVC achieves better network performance when compared to existingapproaches.


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