What is the appropriate therapy for an intrathoracic (substernal) goiter?
- Intrathoracic goiters are typically cervical goiters with mediastinal extension.
- Although commonly asymptomatic, up to 40% of patients present with compressive symptoms resulting from impingement on the esophagus, airway, vascular structures, or nerves. There is general agreement that medical therapy (thyroid hormone suppression and/or radioiodine) is ineffective for intrathoracic goiters.
- Controversy exists as to whether there is an increased risk of unexpected malignancy in intrathoracic compared with cervical goiters; however, when cases of incidental microcarcinoma are excluded, there does not appear to be an increased risk of malignancy in intrathoracic goiters.
- Despite this, the presence of an intrathoracic goiter is considered by many as an indication for thyroidectomy.
- Because the arterial supply of intrathoracic goiters originates in the neck, the vast majority of these tumors can be resected through a cervical approach.
- Extension into the posterior mediastinum, malignancy, or compression of the vena cava may necessitate a combined cervical and sternotomy approach, although this is required in < 5% of cases.