Mediastinal mass
A 79-year-old man went to his local emergency department and asked the doctor to check on a mediastinal mass that was first detected on a routine chest film 3 years earlier. The patient was asymptomatic; his medical history was unremarkable except for vitamin B12 deficiency. Physical examination revealed no abnormalities, except for minor ataxia that was attributed to the lack of sufficient vitamin B12. A chest radiograph revealed a mass located in the upper right thorax with a slight deviation of the trachea to the left, consistent with previous x-ray findings.
What's your diagnosis?
A retrosternal goiter was the most plausible diagnosis because of the patient’s advanced age, the asymptomatic behavior of the tumor, and its development over several years. The multilobular heterogenous appearance in a CT scan (not shown) supported this diagnosis and made other disorders, such as thymoma and non-Hodgkin’s disease unlikely. In addition, the noninfiltrative behavior of the tumor suggested a benign mass, and CT images obtained from the neck demonstrated that the mass originated from the right thyroid lobe without infiltrative or obstructive growth.
Benign mediastinal goiters are relatively common in adults, and the incidence increases with age. When a goiter affects adjacent structures or obstructs the trachea, common symptoms include dyspnea, wheezing, coughing, jugular vein compression, dysphagia, vocal cord palsy, phrenic nerve palsy, and Horner’s syndrome.
Treatment of asymptomatic retrosternal goiter remains controversial. Levothyroxine suppression has a limited role in reducing the size or stopping the growth of the thyroid. Surgery is the method of choice in patients with obstructive symptoms, given the risk of progressive tracheal compression.
In the present case, the physicians decided to watch and wait because of the patient’s age, history, and lack of any signs of obstruction of the trachea, esophagus, or mediastinal vessels. The patient was told to come back for a follow-up visit in 6 to 12 months.
Adapted from:
Haas CS, Haap M. Photo Rounds: A mediastinal mass. J Fam Pract. 2010;59:347-350.