Management of a massive retrosternal goiter after prior thyroid surgery: a clinical case

Журнал "Сеченовский вестник".  Лист редактора к этой статье можно посмотреть здесь.

Sechenov Medical Journal. Editor's checklist for this article you can find here.

РЕЦЕНЗЕНТ А / REVIEWER A

ПЕРВЫЙ РАУНД РЕЦЕНЗИРОВАНИЯ / FIRST ROUND OF PEER-REVIEW

Scientific quality: Grade C: Good

Language quality: Grade B: Minor language polishing

General consideration

The presented case describes a rare challenging condition of largely expanding retrosternal thyroid nodules with successful surgical treatment.

The authors describe this case as a “recurrence” of retrosternal goiter after partial resection of the left thyroid lobe. However, there is no supporting evidence indicating that there were no retrosternal nodules at the time of the first surgery. Therefore, the authors can suggest this case as a “progression of multinodular goiter with retrosternal extension”.

There are also some other topics requiring the authors’ attention. These points are listed below.

Page 2:

“Neck ultrasonography (USG) demonstrated bilateral thyroid nodules classified as TIRADS 1, without suspicious cervical lymphadenopathy (Figure 2)”

Reviewer’s comment:

The authors should consider describing ultrasound features of the thyroid nodule and indicating the variant of TIRADS system (with a corresponding reference) used in their case description, because different TIRADS systems describe thyroid nodules non-equally.

Moreover, the use of the TIRADS 1 category in the present case appears unusual because it usually indicates a completely normal thyroid gland without any nodules. Therefore, consider regrading US characteristics of the nodule in the present case or provide a clear explanation for the use of the TIRADS 1 category.

Page 2:

“Laboratory evaluation revealed suppressed TSH (0.215 µIU/mL) with normal FT4 (1.23 ng/dL), consistent with subclinical hyperthyroidism.”

Reviewer’s comment:

The patient has subclinical hyperthyroidism which very likely resulted from hyperfunctioning retrosternal thyroid nodule. The authors should consider describing the results of nuclear imaging (thyroid scintigraphy with 99mTc or 123I). It is also worth discussing why radio-iodine therapy - as a non-invasive treatment option that may result in thyroid nodule shrinkage - was not done or proposed.

Page 3:

“A complete thyroidectomy with sternotomy was performed ….”. The patient was discharged “without dysphagia, hoarseness, or hypocalcemia.”

Reviewer’s comment:

It is worth describing whether any additional approaches (e.g. neuromonitoring, optical tools) were used to prevent surgical injury to the recurrent laryngeal nerve or parathyroid gland damage.

Page 4-5:

In the DISCUSSION section, the authors should clearly and with more details describe the risks and prognosis associated with sternotomy compared to the conventional cervical approach in patients with retrosternal goiter. They should also describe the methods and approaches which they used to reduce this risk in the presented case.

Recommendation: major revision and re-review.

THE SECOND ROUND OF PEER REVIEW

Authors have revised the text substantially and answered all the reviewers’ questions.

There is only one meaningful discrepancy left, which requires revision.

After its correction, the manuscript can be accepted for the publication.

The discrepancy is as follows:

Page 3

original text: “Radio-iodine therapy was not planned because postoperative histopathology confirmed a benign adenomatous goitre and no residual thyroid tissue remained after total thyroidectomy. The patient’s subclinical hyperthyroidism resolved following surgery, making radio-iodine treatment unnecessary”.

Reviewer’s comment:

In this fragment of the text, the authors try to explain that Radio-iodine therapy (RIT) could have been used only in case of thyroid cancer.

However, radio-iodine therapy is a very common, safe and efficient treatment option for benign thyroid nodules associated with hyperthyroidism [ Ceccarelli, C., Bencivelli, W., Vitti, P., Grasso, L., & Pinchera, A. (2005). Outcome of radioiodine-131 therapy in hyperfunctioning thyroid nodules: a 20 years' retrospective study. Clinical endocrinology, 62(3), 331–335. https://doi.org/10.1111/j.1365-2265.2005.02218.x].

Therefore, it would be quite reasonable not to mention RIT in the present case description, if it was not discussed as an alternative to surgery.

РЕЦЕНЗЕНТ B / REVIEWER B

ПЕРВЫЙ РАУНД РЕЦЕНЗИРОВАНИЯ / FIRST ROUND OF PEER-REVIEW

Scientific quality: Grade C: Good

Language quality: Grade B: Minor language polishing

While the presented clinical case is not extremely rare, every description of a large retrosternal goiter is traditionally considered interesting and instructive. The title of the article accurately reflects the essence of the clinical case and does not require correction. The relevance of the descriptive work is clearly presented. Apart from sex and age, the manuscript does not contain any personal information about the patient. The complaints, medical history, and results of the physical examination are presented exhaustively. However, it would be advisable to supplement the medical history with information about levothyroxine replacement therapy after the initial surgery. The authors describe the examination process in sufficient detail, and the results are confirmed by clear, high-quality illustrations. While one would always like to see more illustrations, the ones presented are quite sufficient. The diagnosis appears well justified. The choice of surgical intervention is fully justified and confirmed by a favorable outcome.

The discussion section of the paper is equally informative and will undoubtedly be of interest to fellow surgeons. The authors analyzed a substantial amount of contemporary literature. Mohib's retrosternal goiter classification system, published in 2025, is indeed simple and may be considered a universal classification system that allows one to determine the advisability of sternotomy for retrosternal goiter. This work is interesting and has been carried out at an appropriate scientific and methodological level. It may be published in the Sechenov Medical Journal

РЕКОМЕНДАЦИИ НАУЧНЫХ РЕДАКТОРОВ ЖУРНАЛА / RECOMMENDATIONS  OF THE SCIENTIFIC EDITORS OF THE JOURNAL

1. Clinical information

• Add details regarding the hormonal therapy received by the patient throughout the entire observation period.

• Clarify the patient’s condition and the reason for the absence of follow-up examinations between 2009 and 2024.

2. Timeline of observation and examinations

• Specify the exact dates of surgery, CT and ultrasound examinations, and discharge.

• If available, include postoperative follow-up examinations and attach the corresponding images.

3. Description of the surgical procedure

• Expand the description of the operative procedure to include details of anaesthesia; surgical approaches used; stages of separation of vital structures;

intraoperative control techniques.

• Describe the implementation of structured preoperative planning and multidisciplinary teamwork (how it was applied, which specialists were involved,

and what decisions were made collaboratively). These details should be consistent with the Discussion and Conclusion sections.

4. Illustrative material

• It is recommended to remove Fig. 1.
• Expand the illustrative section to include up to four intraoperative figures showing key stages of the procedure.

• Replace the last figure with a more informative one — for example, showing the tumour bed and preserved adjacent structures.

• In the operative images, clearly indicate the laryngeal nerves and major vessels.

Image submission requirements:

• Submit each figure (Fig. 1A, Fig. 1B, Fig. 2A, Fig. 2B, etc.) as a separate file of high quality (at least 300 dpi).

• Do not place any text or labels directly inside the images.
• Boundaries of the lesion and arrows should be overlaid in the Word file of the article rather than embedded in the original images.

5. Postoperative follow-up

• Provide information on the planned follow-up and management strategy for the patient.