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Weekly Chest CasesArchive of Old Cases

Case No : 67 Date 1999-02-06

  • Courtesy of Jae-Woo Song, M.D. / Seoul City Boramae Hospital
  • Age/Sex 64 / F
  • Chief ComplaintLeft lower neck mass
  • Figure 1
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Diagnosis With Brief Discussion

Diagnosis
Intrathoracic Goiter
Radiologic Findings
Posteroanterior chest radiograph shows displacement and compression of the trachea to the right side by a soft tissue mass in the left side of lower neck and superior mediastinum. Precontrast CT scan shows a well-defined, homogeneous, and slightly high attenuation mass just left lateral to the trachea. Post-contrast enhanced CT scans demonstrate the cystic portion within the highly enhancing mass, which is continuous with the lower pole of left thyroid gland. Tc99m TcO4 thyroid scan (not shown here) demonstrated massive enlargement and uneven uptake in the left lobe of thyroid gland. Operation and pathologic examination revealed it as a 7 x 7cm-sized nonfunctioning goiter of cervicothoracic type.
Brief Review
Goiters in the superior mediastinum arise from one or both lower poles of the thyroid gland or from the isthmus. With growth of the goiter, aided by deglutition, gravity, and negative intrathoracic pressure, the goiter enters the thorax, generally taking its cervical blood supply with it. Intrathoracic goiters can be classified primary and secondary. The presence of vascular stalks with cervical thyroid gland makes intrathoracic goiter secondary, while absence of in, primary (or ectopic). Primary intrathoracic goiters are very rare, with a reported incidence of 0.2 to 1 per cent of all goiters. Although clear continuity between the cervical and intrathoracic components should be present in cases of mediastinal goiter extension, the connection may only be a narrow fibrous or vascular pedicle. In such cases, as well as in the presence of a primary intrathoracic goiter, lack of continuity between the cervical gland and the thoracic mass does not exclude goiter as the diagnosis. Pathologically the nontoxic nodular goiter has distended follicles with colloid and hyperplasia of the thyroid tissue. The follicles can rupture with resultant inflammatory changes, and ultimate degeneration can occur with hemorrhage, infarction, fibrosis, cyst formation, and calcification. Normal thyroid tissue has higher attenuation values than soft tissue because of its high iodine content and shows intense postcontrast enhancement. The high attenuation of an intrathoracic goiter may depend on the density of iodine per unit volume and the extent of degeneration. The typical CT features of intrathoracic goiter can be summarized as follows: 1. continuity with the cervical thyroid gland, 2. well-defined borders, 3. punctate, coarse, or ringlike calcifications, 4. nonhomogeneity often with minimal or nonenhancing, well defined, low-density areas, 5. precontrast attenuation values often at least 15 H greater than adjacent musculature with at leas 25 H enhancement after intravenous contrast, 6. patterns of extension of the goiter into the mediastinum with cradling of the goiter by the right and left bracheocephalic vessels high in the mediastinum and extension behind the great vessels to the paratracheal or retrotracheal region.
References
1. Bashist B, Ellis K, Gold RP. Computed tomography of intrathoracic goiters. AJR 1983;140:455-460
2. Lee KS, Im J-G, Han MC. Computed tomographic findings of a primary intrathoracic goiter. J Korean Radiol Society 1984;20:525-527
Keywords
Mediastinum, Benign tumor,

No. of Applicants : 34

▶ Correct Answer : 24/34,  70.6%
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  • - AZ Vesalius Tongeren, Belgium Dr. Rudi Stokmans
  • - Northwestern Memorial Hospital, Chicago, IL. USA Mitchell J. Kline
  • - Sir H N Hospital, Mumbai, India Dr. Bhavin Jankharia
▶ Semi-Correct Answer : 8/34,  23.5%
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