Perioperative management of an asymptomatic giant retrosternal goiter with high-risk imaging findings and an unanticipated cancer diagnosis: a case report

Introduction

Retrosternal goiter (RSG) can be classified as primary or plunging based on its origin. Clinically, the overwhelming majority (approximately 8–90%) are of the plunging type, originating from cervical thyroid tissue. It is defined as any part of the thyroid gland extending below the thoracic inlet in the surgical position (1). This condition is a key focus in thyroid surgery due to its unique anatomical location, which predisposes it to compressing the trachea, major blood vessels, and lung tissue, leading to corresponding clinical symptoms (2,3). Notably, the clinical manifestations of RSG (e.g., dyspnea, dysphagia, hoarseness) often do not correlate with the degree of compression observed on imaging. Some patients may present no subjective symptoms despite imaging revealing a large mass compressing critical structures such as the lung—a state termed “asymptomatic high-risk”. This significantly increases the complexity of clinical management and demands greater foresight and proactivity in perioperative care (4).

Surgical intervention remains the definitive treatment for RSG (5). Traditionally, it was believed that low-lying RSG often required more invasive approaches such as sternotomy. However, with advances in surgical techniques and accumulated experience, it is now recognized that the majority (>90%) of plunging RSGs, due to their primary blood supply originating from the neck, can be safely resected via a traditional low-collar neck incision. This approach avoids thoracotomy, significantly reducing surgical trauma (1,6). The case presented herein successfully removed a giant plunging RSG, with its inferior pole extending to the level of the lung, via a cervical approach, reflecting the trend toward minimally invasive surgical management. The unexpected postoperative discovery of papillary thyroid carcinoma (PTC), particularly when the initial diagnosis anticipated a benign condition, presents another clinical challenge. Lesions with a diameter ≤1 cm are classified as papillary thyroid microcarcinoma (PTMC). According to authoritative international and national guidelines, the management strategies have shifted from uniformly aggressive surgery to individualized, risk-adapted approaches, including active surveillance (7). In summary, perioperative care for such cases faces a dual challenge. We present this article in accordance with the CARE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0074/rc).

Case presentation

The patient was a 61-year-old female. She said that during a routine health checkup at an external hospital in January 2023, a plain chest computed tomography (CT) scan revealed a small nodule in the upper lobe of the right lung and an intrathoracic goiter (size not specified). In 2024, a follow-up targeted CT scan of the lung nodules showed a space-occupying lesion in the right upper mediastinum, measuring approximately 27 mm × 38 mm, and a contrast-enhanced CT scan was recommended. The patient only experienced occasional discomfort in the precordial area, with no accompanying symptoms such as neck compression, dyspnea, dysphagia, choking upon drinking water, or hoarseness. There was also no lump visible on the surface. So no further diagnosis or treatment was pursued. In April 2025, a follow-up high-resolution plain CT scan of the lungs showed that the right upper mediastinal mass had enlarged to approximately 44 mm × 35 mm. In September 2025, the patient visited our outpatient clinic for further examination. A thyroid ultrasound was performed, revealing multiple bilateral nodules, classified as Chinese-Thyroid Imaging Reporting and Data System (C-TIRADS) 3. A contrast-enhanced mediastinal 1.5T magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) showed a mass in the right upper mediastinum, measuring approximately 55 mm × 33 mm × 68 mm (Figure 1), connected to the thyroid gland with similar signal characteristics, suggesting a mediastinal goiter. Surgery was recommended, and the patient was admitted. Upon admission, her blood pressure was 153/95 mmHg, height 1.60 m, weight 86 kg, and body mass index (BMI) 33.59 kg/m².

Figure 1 September 2, 2025 mediastinal enhanced + DWI mediastinal imaging. DWI, diffusion-weighted imaging.

Her medical history included hypertension for 6 years, managed with regular medication and stable blood pressure control; unilateral oophorectomy 8 years ago; and lumbar disc surgery in 2022 (details unspecified). She denied any history of infectious diseases such as hepatitis or tuberculosis, as well as any history of malignancy. She had an allergy to CT contrast medium. She reported no significant personal history; no smoking or alcohol use. And there is also no significant family history of hereditary diseases.

Based on the preoperative evaluation, the patient underwent total resection of the right retrosternal thyroid gland with peripheral nerve release under general anesthesia on September 18, 2025 (specimen shown in Figure 2). A curved cervical arc incision was used. Intraoperatively, the right thyroid gland was found to be filled with multiple nodules ranging in size from 0.5 to 3.0 cm, some of which were retrosternal and with marked adhesion to the recurrent laryngeal nerve. A precise Posterior Capsule dissection technique was employed to preserve the parathyroid glands in situ, along with their blood supply, and to dissect and release the recurrent laryngeal nerve. The intraoperative blood loss was 10 mL. Postoperative management included analgesia, hemostasis, and nebulizer inhalation to prevent airway complications. The patient recovered steadily postoperatively and was discharged on the fourth day.

Figure 2 Pathological specimen removed during the surgical procedure.

Postoperative findings

Intraoperative frozen section pathology reported nodular goiter with focal follicular epithelial atypia; papillary carcinoma could not be entirely ruled out. Pathological examination of the totally resected right retrosternal thyroid gland specimen identified two foci of papillary carcinoma, measuring 0.5 cm (invasive encapsulated follicular variant) and 0.2 cm, respectively. No lymphovascular, perineural, or capsular invasion was observed. The surrounding thyroid parenchyma showed changes consistent with nodular goiter, accompanied by follicular epithelial hyperplasia and focal cystic degeneration. Immunohistochemical staining results were as follows: CK19⁺, HBME-1⁺, Galectin 3⁺, CD56⁻ (as shown in Figure 3). The final diagnosis was thus established as occult PTC (multifocal, micropapillary) arising in a right retrosternal nodular goiter.

Figure 3 Postoperative histopathology of the total right substernal thyroidectomy specimen. Hematoxylin and eosin staining; scale bar: left, 1.25 mm; right, 400 μm.

Summary of case characteristics

Firstly, discrepancy between clinical presentation and imaging: the patient remained asymptomatic with no subjective symptoms related to neck compression or respiration. However, imaging confirmed the presence of a large RSG compressing the lung parenchyma, representing an “asymptomatic high-risk” state. Secondly, minimally invasive nature of the treatment: the retrosternal mass was completely resected through a traditional low-collar neck incision, successfully avoiding sternotomy. This demonstrates the principles of precise surgical technique and minimally invasive philosophy. Thirdly, unanticipated Pathology Diagnosis: Both preoperative evaluation and intraoperative frozen section strongly suggested benign disease. However, final paraffin-embedded pathology unexpectedly revealed two foci of PTC (largest diameter 0.5 cm), which significantly altered the nature of the disease and subsequent management strategy. The chronology of key events from discovery to diagnosis is summarized in Figure 4.

Figure 4 Timeline of diagnosis and management for a patient with asymptomatic giant RSG. CT, computed tomography; RSG, retrosternal goiter.

Patient perspective

The patient expressed that her journey from an incidental finding to an unexpected cancer diagnosis was psychologically impactful. “I came in thinking I was having a routine surgery for a benign growth, so learning it was cancer afterwards was a profound surprise and initially caused me significant worry,” she shared. She emphasized that the proactive and integrated support from the nursing team was pivotal in navigating this shock. “Beyond the excellent physical care, the nurses consistently acknowledged my anxiety. They took time to explain the prognosis clearly, answered all my family’s questions with patience, and made me feel in control of the next steps. This holistic approach turned a frightening discovery into a manageable health episode.” She concluded by stating that she felt well-informed, supported, and confident in the long-term follow-up plan.

Nursing assessment

• Respiratory system risk: CT imaging indicates compression of the lung parenchyma by the mass. Postoperatively, there was a risk of pneumothorax or hemothorax due to surgical manipulation at the thoracic cavity apex and tissue retraction. Additionally, edema or hematoma in the residual cavity following resection of a large mass could potentially compress the airway.
• Nerve injury risk: intraoperatively, the mass was found to be densely adherent to the recurrent laryngeal nerve, necessitating assessment for potential postoperative complications, including hoarseness and dysphagia (with aspiration risk).
• Hemorrhage and hematoma risk: the mediastinum is highly vascular, which significantly increases the risk of postoperative hemorrhage.
• Parathyroid function risk: given the surgical involvement of the posterior thyroid region, there was a risk of postoperative hypocalcemia, potentially manifesting as symptoms like perioral or extremity numbness and muscle cramps.

Comorbidity risk: the patient is obese (BMI: 33.59 kg/m²), which is an independent risk factor for postoperative deep vein thrombosis (DVT) and pulmonary embolism (PE) (8). Using the Caprini Risk Assessment Model, her score was 4, placing her in the moderate-risk category for venous thromboembolism (VTE) and necessitating targeted perioperative prophylactic measures.

Assessment of psychological stress: given the patient’s preoperative expectation of a benign condition, the postoperative pathological upgrade to “carcinoma” was assessed for its potential to trigger acute psychological stress reactions such as shock, denial, fear, and anxiety.

Assessment of illness perception: the assessment focused on evaluating the patient’s and family’s understanding of PTMC, specifically examining whether there was excessive fear (e.g., “cancer phobia”) or a lack of awareness regarding its typically indolent nature and excellent prognosis.

Assessment of informational support needs: the assessment aimed to identify the patient’s specific questions and informational needs regarding subsequent treatments [such as thyroid-stimulating hormone (TSH) suppression therapy], follow-up protocols (including thyroglobulin testing and ultrasound surveillance), and long-term health management.

Preoperative nursing implementation

Based on the nursing assessment, we developed a systematic and proactive nursing care plan, which was implemented in phases as follows:

• Respiratory preparation: the patient was instructed in effective deep breathing exercises (e.g., blowing up a balloon) and coughing/expectoration techniques to enhance pulmonary function and prepare for potential postoperative respiratory challenges. These exercises were performed three times daily for 5–10 minutes each session.
• Posture adaptation training: the patient was advised to practice the neck hyperextension position daily. This involved lying supine with a pillow under the shoulders to allow the head to tilt back and fully expose the neck. Training was conducted 2–3 times daily, with each session lasting 30–60 minutes, to improve tolerance for the required surgical posture. The importance of this training needs to be clearly explained.
• VTE prophylaxis measures: the risks of thrombosis and the importance of prevention were explained to the patient and family members to ensure cooperation. Both legs were accurately measured to prepare appropriately sized intermittent pneumatic compression (IPC) devices and graduated compression stockings (GCS).
• Psychological preparation and information groundwork: when explaining the necessity of surgery and standard risks, the managing physician intentionally provided preliminary information: “An intraoperative frozen section pathology examination will be performed, but the final diagnosis is based on the permanent paraffin section results, which is standard medical procedure.” This provides a slight psychological buffer for potential diagnostic changes, reducing the impact of suddenness.

Postoperative nursing

• High-risk respiratory monitoring: during the first 24 hours postoperatively, respiratory rate, rhythm, and oxygen saturation were monitored hourly. Bilateral breath sounds were auscultated for symmetry and clarity, with vigilant observation for early signs of pneumothorax, hemothorax, or hematoma compression, such as dyspnea, progressive neck swelling, or subcutaneous emphysema. Nebulized inhalation (e.g., budesonide) was administered as prescribed to reduce airway edema. Help the patient to effectively cough, and back percussion was provided as needed to aid expectoration.
• Neurological and parathyroid function monitoring: immediately upon regaining consciousness from anesthesia, the patient’s voice quality (for hoarseness) was assessed. Close observation for choking was conducted during the first oral intake. Serum calcium levels were routinely monitored postoperatively. The patient was asked and observed daily for symptoms of hypocalcemia, such as numbness or tingling around the mouth or fingertips, and signs like facial muscle twitching (Chvostek’s sign).
• Hemorrhage and hematoma observation: the color, consistency, and volume of neck drainage were closely monitored. A drainage volume exceeding 50 mL of bright red blood within 1 hour, or patient complaints of neck pressure or breathing difficulty, were reported to the physician immediately. The patient was instructed to avoid forceful coughing, vomiting, and excessive neck movement.
• Management of comorbidities: blood pressure was monitored for changes. Antihypertensive medications were administered on schedule as prescribed to maintain stable blood pressure.
• Implementation of postoperative bundle of preventive measures: use of the IPC device was initiated immediately upon return to the ward. The patient was instructed to perform ankle pump exercises every hour. Early ambulation was encouraged postoperatively, and the patient was educated to recognize warning signs such as lower limb swelling/pain, chest pain, and dyspnea.

Specialized nursing care for addressing the “unexpected cancer” diagnosis

• Strategic information disclosure and psychological crisis intervention: after the pathological results were confirmed, the information was delivered to the patient and family in a private, quiet setting, jointly with the attending physician. A “good news before bad news” communication strategy was employed. First, it was affirmed that the surgery was very successful, and the mass had been completely removed. Then, the new pathological findings were disclosed. Finally, the excellent prognosis was strongly emphasized, highlighting that due to the early detection, there were currently no risk factors for metastasis. Only need regular follow-up. Offer emotional support throughout the discussion, allowing the patient to express their feelings while acknowledging their distress. Provide patient explanation throughout.
• Systematic health education: utilize easily understandable charts and manuals, the patient was educated on the indolent nature of PTMC, emphasizing its distinction from the common perception of “cancer”. Regarding postoperative management, it was specifically clarified that adjuvant radioactive iodine (RAI) therapy is not needed due to the absence of high-risk features (no metastasis, no vascular invasion), as the potential risks of RAI outweigh the benefits in such low-risk cases. The patient was clearly informed about the necessary next steps, including scheduled tests (such as regular blood tests for thyroid function and neck ultrasound follow-ups) and the necessity of lifelong follow-up.

Outcomes and evaluation

Following systematic perioperative nursing interventions, the patient was discharged smoothly. The nursing outcomes were evaluated using the following indicators:

• Physiological outcome evaluation: the patient experienced no postoperative complications such as pneumothorax, hemothorax, hoarseness, or limb numbness. The wound healed well, and the drainage tube was removed as scheduled, allowing for timely discharge.
• Psychological and cognitive outcome evaluation: through strategic communication and psychological support, the patient’s initial anxiety and fear were significantly alleviated. The patient was able to recall core information about PTMC, expressed understanding and acceptance of the long-term follow-up plan, and demonstrated confidence in the treatment.

In summary, the nursing care achieved the intended goals. The patient not only navigated the perioperative period safely in physiological terms but also successfully transitioned on psychological and cognitive levels, resulting in satisfactory nursing outcomes.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

This case presents a patient with a giant RSG and a long history of asymptomatic presentation. The diagnostic and therapeutic journey—from the preoperative “asymptomatic high-risk” status to the unexpected turn in the postoperative pathological report—offers a valuable example for an in-depth exploration of the professional dimensions of modern surgical nursing.

Constructing predictive risk assessment based on imaging evidence

RSG is a relatively uncommon clinical condition, accounting for approximately 1% to 20% of all goiters (9). Its distinctiveness lies in the intrathoracic extension of the mass, which can compress critical mediastinal structures. This introduces significant difficulties and risks into the surgical management of RSGs. The uniqueness of the present case stems not only from the retrosternal extension but also from its prolonged asymptomatic clinical course, which contrasts sharply with the majority of cases reported in the literature. Previous studies indicate that approximately 70% of patients with RSGs present with compressive symptoms, such as dyspnea or dysphagia (10). In this case, over a two-year follow-up period, the condition manifested only as radiographic enlargement of the mass without any typical symptoms. Such long-term stability of an asymptomatic presentation is exceptionally rare in the literature, with only a few isolated case reports mentioning similar scenarios (11). This characteristic imposes a higher demand on nursing evaluation, necessitating a shift in the nursing model from the traditional “symptom-driven” approach to an “evidence-driven” proactive nursing model. By relying on objective high-risk indicators, such as lung compression revealed by CT imaging, rather than patient-reported symptoms, we preemptively formulated a proactive monitoring plan targeting complications like airway obstruction and nerve injury. This strategy formed the cornerstone for ensuring the patient’s safe navigation through the perioperative period.

Communication as a core interventional role in therapeutic nursing

This case series of imaging studies illustrates the dynamic process of tumor growth, with MRI characteristics aiding in its differentiation from mediastinal tumors (12). However, the discrepancy between the intraoperative frozen section and the final paraffin-embedded pathology results highlights the inherent uncertainty in clinical diagnosis. This diagnostic shift directly constituted a significant psychological stressor for the patient. Research indicates that an unexpected cancer diagnosis can trigger acute stress reactions, anxiety, and adjustment disorders (13). At this critical juncture, the core focus of nursing care expanded from physiological monitoring to the psychosocial domain. Nursing staff assumed the crucial roles of “information interpreter” and “psychological comforter”. Drawing on evidence-based communication frameworks such as the “SPIKES” protocol for delivering bad news (14), we implemented a structured communication strategy. This involved collaborating with the physician in a private setting, employing a “good news before bad news” sequence, and using non-technical, easily understandable language such as “indolent cancer”, while also providing prognostic data based on authoritative guidelines [e.g., the American Thyroid Association (ATA) guidelines] (7). This intervention aimed to facilitate the patient’s “cognitive reappraisal”, transforming the catastrophic label of “cancer” into the more manageable concept of a “chronic condition”. This cognitive shift is crucial for promoting the patient’s long-term psychosocial adaptation (15). Our practice confirms that effective nursing communication itself constitutes a therapeutic intervention.

Collaboration between minimally invasive surgery and precision nursing

In terms of surgical technique, this case employed surgery via a cervical-only approach, successfully avoiding sternotomy, which aligns with the philosophy of minimally invasive therapy (16). This also demanded more precise postoperative nursing care. We implemented a bundled care protocol, which included early (≤1 hour) and dynamic assessment of voice and respiratory function, systematic monitoring of serum calcium levels and screening for symptoms of hypocalcemia, and vigilant observation of neck lymph node drainage and signs of swelling. This protocol was designed for the early identification of complications such as recurrent laryngeal nerve injury, hypoparathyroidism, and postoperative hemorrhage. The patient’s smooth recovery in this case demonstrates the synergistic value of nursing interventions and surgical techniques in collectively achieving the goals of enhanced recovery after surgery (ERAS) (17).

Establishing a dual-track integrated psychological-psychological care pathway

In summary, the diagnostic, therapeutic, and nursing management of this case provides significant insights for managing RSG. We recognize that the successful management of such cases depends on an integrated dual-track model featuring deep “medical-nursing” collaboration:

• Medical track: focuses on determining the optimal timing for intervention in asymptomatic patients, optimizing surgical approaches, and ensuring diagnostic precision in pathology.
• Nursing track: emphasizing imaging-evidence-guided proactive physiological risk prevention and psychological support centered on diagnostic transition and information translation.

The primary strength of this report lies in its presentation of an exemplary clinical case that not only highlights a significant gap in existing management guidelines for patients with “asymptomatic yet radiologically high-risk” RSGs but also underscores the unexpected postoperative diagnosis of papillary microcarcinoma. While this incidental finding might typically raise considerations for adjuvant therapies such as RAI, the current guidelines reverse RAI for cases with high-risk features (e.g., tumor size >4 cm, extrathyroidal extension, or lymph node metastases). Given the low-risk nature of the microcarcinoma (≤1 cm with no aggressive characteristics) in our patient, RAI was not indicated (18). This scenario, where a significant diagnosis does not alter the therapeutic course, shifts the clinical focus entirely onto the patient’s psychological journey. Therefore, we not only addressed this clinical dilemma through successful surgical intervention but, more importantly, systematically developed and implemented an integrated dual-track perioperative care model. This model proactively addresses both physiological risks and psychological distress, thereby proposing a structured framework to fill this specific gap in nursing practice. A limitation of this study is its basis on a single-center case, which may limit generalizability. Future efforts could explore the systematization of this “assessment-early warning-communication” nursing model into a standardized care pathway, aiming to enhance systematic care for similar patients. These experiences provide empirical evidence for refining the overall clinical and nursing management protocols for RSG.

Conclusions

This case supports considering high-risk imaging features as a surgical indication in asymptomatic retrosternal goiter, it enabled the incidental detection of occult papillary thyroid microcarcinoma. A strong collaboration between surgeons and nursing staff contributed significantly to the patient’s care. Notably, postoperative nursing care provided crucial psychological support, helping the patient navigate the emotional impact of an unexpected pathological finding. This highlights the importance of a multidisciplinary approach that combines surgical decision-making with attentive psychological care, alongside thorough preoperative counseling and shared decision-making.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0074/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0074/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0074/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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