What is the management of a retrosternal thyroid nodule?

Management of Retrosternal Thyroid Nodules

Surgical management is the recommended approach for retrosternal thyroid nodules, particularly when they cause compression symptoms, show suspicious features for malignancy, or demonstrate progressive growth with increasing symptoms. 1

Diagnostic Evaluation

• CT imaging is the preferred modality for evaluating thyroid nodules with retrosternal extension, as it provides superior visualization of substernal extension and defines the degree of tracheal compression 1
• While ultrasound is the first-line imaging for initial thyroid nodule evaluation, it has significant limitations in visualizing retrosternal extension 1
• Complete evaluation should include assessment of:
  • Nodule characteristics (size, composition, echogenicity) 2
  • Extent of retrosternal extension 1
  • Relationship to surrounding vital structures (trachea, esophagus, major vessels) 1
• Fine-needle aspiration (FNA) should be considered for cytological evaluation when suspicious features are present 3

Clinical Assessment

• Evaluate for obstructive symptoms caused by retrosternal extension:
  • Dyspnea and orthopnea (from tracheal compression) 1, 4
  • Dysphagia (from esophageal compression) 1, 5
  • Hoarseness of voice (from recurrent laryngeal nerve involvement) 1, 5
  • Superior vena cava syndrome (facial edema, venous distension) 4, 5
  • Obstructive sleep apnea 1

Management Options

Surgical Approach

• Surgery remains the treatment of choice for retrosternal thyroid nodules, especially when:
  • Causing significant compression symptoms 1, 5
  • Suspected malignancy 1
  • Progressive growth with increasing symptoms 1, 4
• Surgical considerations:
  • Most retrosternal goiters (approximately 86.7%) can be removed through a cervical incision alone 5
  • Total thyroidectomy or lobectomy may be performed depending on the extent of disease 5
  • Complete symptom resolution is typically achieved with surgical removal 5

Alternative Management Options

• Thermal ablation may be considered for benign retrosternal nodules when:
  • The patient has contraindications to surgery 1
  • The patient refuses surgical intervention 1
  • The nodule is causing compression symptoms but surgery is not feasible 2

Observation

• For asymptomatic, benign retrosternal nodules:
  • Regular monitoring with annual follow-up is recommended 1
  • Follow-up should include thyroid and neck ultrasound to assess nodule size and characteristics 2, 1
  • CT imaging may be necessary for periodic assessment of retrosternal extension 1

Potential Complications

• Compression of vital structures:
  • Tracheal compression leading to respiratory distress 1, 4
  • Esophageal compression causing dysphagia 1, 5
  • Vascular compression affecting venous return 1, 4
• Surgical complications may include:
  • Voice changes due to recurrent laryngeal nerve injury 2, 1
  • Bleeding and hematoma 1
  • Pleural effusion 5
  • Hypoparathyroidism (rare with experienced surgeons) 5

Follow-up Protocol

• For surgically treated patients:
  • Initial follow-up one month after procedure 2
  • Subsequent assessments at 3,6, and 12 months during the first year 2
  • Annual follow-up thereafter 2, 1
• For patients undergoing thermal ablation:
  • Immediate post-ablation assessment with contrast-enhanced ultrasound (CEUS) 2
  • Follow-up schedule similar to surgical patients 2
• For patients under observation:
  • Annual imaging to monitor for growth 1, 6
  • Prompt reassessment if new symptoms develop 1