Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions

Diagnosis of a posterior mediastinal goitre via endobronchial ultrasound-guided transbronchial needle aspiration

V. Jeebun, S. Natu, R. Harrison
European Respiratory Journal 2009 34: 773-775; DOI: 10.1183/09031936.00046309
V. Jeebun
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
S. Natu
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
R. Harrison
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

To the Editors:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a rapidly developing diagnostic tool. Its utility as a minimally invasive and safe procedure in mediastinal node staging in lung cancer is defined and gaining widespread acceptance. The role of this procedure in the diagnosis of benign diseases is less clear. We report the first case of a posterior mediastinal intrathoracic goitre diagnosed with the aid of EBUS-TBNA.

A 46-yr-old female was referred to the outpatient chest clinic for further investigation of a superior mediastinal mass. She complained of a 4-month history of progressive shortness of breath on exertion. She denied any dysphagia. Examination was unremarkable. A chest radiograph showed a right superior mediastinal mass. Her thyroid function tests were within normal limits. Contrast-enhanced thoracic computed tomography revealed a large posterior mediastinal mass, containing areas of punctate calcification (fig. 1⇓). There was no associated mediastinal adenopathy and the lung parenchyma was normal. Histological confirmation was considered necessary to the planning of surgical intervention. Oesophageal endoscopic ultrasound-guided needle aspiration was abandoned, as the scope was unable to pass down the oesophagus due to extrinsic compression. We performed endobronchial ultrasound guided transtracheal needle aspiration of the posterior mediastinal mass under conscious sedation, using a linear array ultrasonic bronchoscope and a 22-gauge needle. A large heterogeneous mass was identified adjacent to the posterior wall of the upper trachea. Three separate passes into the mass were performed. The procedure was well tolerated with no complications. Cytology revealed low cuboidal and columnar epithelium with follicle formation containing small amounts of colloid. Thyroglobulin (fig. 2⇓) and thyroid transcription factor 1 stains were positive, confirming thyroid origin. A diagnosis of posterior mediastinal intrathoracic goitre was made. The patient was referred for total thyroidectomy, which was successfully performed using a transcervical approach. The histology was in keeping with a benign multinodular goitre with areas of cystic change, old and recent haemorrhage, fibrosis and patchy calcification. No evidence of malignancy was found.

Fig. 1—
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig. 1—

a) Contrast-enhanced computed tomography (CT) showing a large retrotracheal and retro-oesophageal mass with heterogeneous enhancement and punctate calcification. b) Coronal view of the thorax CT showing mediastinal mass in continuity with left lobe of thyroid gland.

Fig. 2—
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig. 2—

Endobronchial ultrasound-guided transbronchial needle aspiration specimen of posterior mediastinal mass showing uptake of follicles with thyroglobulin stain. Scale bar = 1.5 mm.

The differential diagnosis of a posterior mediastinal mass is wide and includes neurogenic tumours, Castleman disease, bronchogenic cysts, Bochdalek hernia, mesenchymal tumours and intrathoracic goitre. The radiological features of a goitre include: heterogeneous attenuation, focal punctate or curvilinear calcification within the mass, rapid and prolonged enhancement of the mass after contrast injection, and continuity of the mass with one of the lobes of the thyroid gland 1.

The majority of intrathoracic goitres are acquired and arise from the cervical thyroid gland. In 1934, Lahey and Swinton 2 proposed anatomic factors that facilitate cervical goitres to extend downward into the mediastinum through the thoracic inlet as they grow. These include gravity, the absence of fasciae inferiorly, the weight of the goitre and the intrathoracic pressure changes with respiration and swallowing. Most intrathoracic goitres are pre-tracheal and retrosternal. However, posterior mediastinal location of the goitres has been reported, with up to 15% of cases of intrathoracic goitres 3 being predominantly retrotracheal and, less frequently, as in our case, retro-oesophageal. More rarely, extension of the goitres to the contralateral side of origin in the cervical goitre has been reported 4. Less than 1% of surgically removed goitres are aberrant thyroid tissues, which can be found anywhere in the mediastinum, with no apparent connection with the cervical goitre. These are congenital in nature and derive their blood supply directly from the intrathoracic vessels 4.

Given the progressive nature of the goitres, even in the absence of symptoms, early surgical resection is recommended, unless the patient is deemed unfit 5. The most pressing indications include the compression of adjacent organs, including the trachea, oesophagus and superior vena cava. Cases of sudden enlargement of the intrathoracic goitres with respiratory compromise have been reported and are usually due to haemorrhage into the cystic lesions or infection within the mass 6, 7. Surgery also enables a tissue diagnosis. It is noteworthy that small foci of papillary microcarcinoma can be found within the intrathoracic goitres 8.

In cases of diagnostic doubt, particularly when surgery is being considered, histological confirmation may be needed. So far, the role of EBUS-TBNA has been predominantly centred towards the sampling of mediastinal and hilar nodes to stage lung cancer 9 and to sample peri-bronchial tumours. Increasingly, however, the technique has been used to diagnose benign disease, notably sarcoidosis 10. To our knowledge, this is the first report of its use in the diagnosis of a posteriorly situated mediastinal goiter.

Our report highlights that endobronchial ultrasound should be considered in the diagnostic algorithm when evaluating an unexplained posterior mediastinal mass.

Statement of interest

None declared.

    • © ERS Journals Ltd

    References

    1. ↵
      Bashist B, Ellis K, Gold RP. Computed tomography of intrathoracic goiters. AJR Am J Roentgenol 1983;140:455–460.
      OpenUrlCrossRefPubMedWeb of Science
    2. ↵
      Lahey FH, Swinton NW. Intrathoracic goiter. Surg Gynecol Obstet 1934;59:627–637.
      OpenUrlWeb of Science
    3. ↵
      Chin SC, Rice H, Som PM. Spread of goiters outside the thyroid bed: a review of 190 cases and an analysis of the incidence of the various extensions. Arch Otololaryngol Head Neck Surg 2003;129:1198–1202.
      OpenUrlCrossRef
    4. ↵
      Hilton HD, Griffin WT. Posterior mediastinal goiter. Am J Surg 1968;116:891–895.
      OpenUrlCrossRefPubMedWeb of Science
    5. ↵
      Hashmi SM, Premachandra DJ, Bennett AMD, et al. Management of retrosternal goitres: results of early surgical intervention to prevent airway morbidity, and a review of the literature. J Laryngol Otol 2006;120:644–649.
      OpenUrlPubMedWeb of Science
    6. ↵
      Ket S, Ozbudak O, Ozdemir T, et al. Acute respiratory failure and tracheal obstruction in patients with posterior giant mediastinal (intrathoracic) goiter. Interact Cardiovasc Thorac Surg 2004;3:174–175.
      OpenUrlAbstract/FREE Full Text
    7. ↵
      Karadeniz A, Hacihanefioglu U. Abscess formation in an intrathoracic goitre. Thorax 1982;37:556–557.
      OpenUrlFREE Full Text
    8. ↵
      Shah BC, Ravichand CS, Juluri S, et al. Ectopic thyroid cancer. Ann Thorac Cardiovasc Surg 2007;13:122–124.
      OpenUrlPubMed
    9. ↵
      Herth FJ, Rabe KF, Gasparini S, et al. Transbronchial and transoesophageal (ultrasound-guided) needle aspirations for the analysis of mediastinal lesions. Eur Respir J 2006;28:1264–1275.
      OpenUrlAbstract/FREE Full Text
    10. ↵
      Wong M, Yasufuku K, Nakajima T. Endobronchial ultrasound: new insight for the diagnosis of sarcoidosis. Eur Respir J 2007;29:1182–1186.
      OpenUrlAbstract/FREE Full Text
    View Abstract
    PreviousNext
    Back to top
    View this article with LENS
    Vol 34 Issue 3 Table of Contents
    European Respiratory Journal: 34 (3)
    • Table of Contents
    • Index by author
    Email

    Thank you for your interest in spreading the word on European Respiratory Society .

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Diagnosis of a posterior mediastinal goitre via endobronchial ultrasound-guided transbronchial needle aspiration
    (Your Name) has sent you a message from European Respiratory Society
    (Your Name) thought you would like to see the European Respiratory Society web site.
    CAPTCHA
    This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
    Print
    Citation Tools
    Diagnosis of a posterior mediastinal goitre via endobronchial ultrasound-guided transbronchial needle aspiration
    V. Jeebun, S. Natu, R. Harrison
    European Respiratory Journal Sep 2009, 34 (3) 773-775; DOI: 10.1183/09031936.00046309

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero

    Share
    Diagnosis of a posterior mediastinal goitre via endobronchial ultrasound-guided transbronchial needle aspiration
    V. Jeebun, S. Natu, R. Harrison
    European Respiratory Journal Sep 2009, 34 (3) 773-775; DOI: 10.1183/09031936.00046309
    del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
    Full Text (PDF)

    Jump To

    • Article
      • Statement of interest
      • References
    • Figures & Data
    • Info & Metrics
    • PDF
    • Tweet Widget
    • Facebook Like
    • Google Plus One

    More in this TOC Section

    • Obesity in COPD: the effect of water-based exercise
    • Burden of CAP in Italian general practice
    • Neutrophilia independently predicts death in tuberculosis
    Show more Letters

    Related Articles

    Navigate

    • Home
    • Current issue
    • Archive

    About the ERJ

    • Journal information
    • Editorial board
    • Reviewers
    • Press
    • Permissions and reprints
    • Advertising

    The European Respiratory Society

    • Society home
    • myERS
    • Privacy policy
    • Accessibility

    ERS publications

    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS books online
    • ERS Bookshop

    Help

    • Feedback

    For authors

    • Instructions for authors
    • Publication ethics and malpractice
    • Submit a manuscript

    For readers

    • Alerts
    • Subjects
    • Podcasts
    • RSS

    Subscriptions

    • Accessing the ERS publications

    Contact us

    European Respiratory Society
    442 Glossop Road
    Sheffield S10 2PX
    United Kingdom
    Tel: +44 114 2672860
    Email: journals@ersnet.org

    ISSN

    Print ISSN:  0903-1936
    Online ISSN: 1399-3003

    Copyright © 2023 by the European Respiratory Society