Specific issues in the therapeutic approach of substernal goiter

The surgical approach of substernal goiter (SSG) may be technically demanding. The intrathoracic extension brings the thyroid gland (TG) in close relation with vital intrathoracic structures, disturbing normal anatomy. The successful surgical removal of a goiter requires proper preoperative planning with computerized tomography (CT) or Magnetic Resonance Imaging (MRI).Material and Methods: The English medical literature published in "PubMed " database from 2010-2021 was investigated, using the terms "substernal goiter " and "retrosternal goiter ". From 294 articles that were received, 17 were further studied, while some additional ones from the references of these 17 were also included, which presented anatomical data or specific clinical and laboratory information.Results: SCG is usually removed through a cervical incision, although difficult cases may require transthoracic approach through a sternotomy. The latter permits the control of the disease in the thorax, broadens the surgical field although it increases operative and postoperative complications. Anatomical and morphological features of SCG may determine the potential need for an extracervical approach, which should be carefully prepared preoperatively, in cooperation with radiologists, anesthetists and thoracic surgeons. Contemporary techniques, such as mediastinoscopy may be employed as part of an extracervical approach instead of sternotomy, although further studies and experience are needed.Conclusions: SCG remains a challenge for endocrine surgery, even in specialized high volume centers. Sternotomy may constitute a reliable and necessary extracervical approach, but is also associated with higher complications. Evolution of radiological imaging and endoscopic surgical techniques which aid the better and more secure thoracic access limit sternotomy indications. The latter should be nominated preoperatively under strict criteria and should be a rare intervention.