Patient-tailored management of an asymptomatic massive substernal goiter presenting as brachiocephalic vein occlusion. Report of a case and review of sternotomy indications.

INTRODUCTION: Substernal goiters are characterized by the protrusion of at least 50% of the thyroid mass below the level of the thoracic inlet. Still their definition is controversial.

CASE PRESENTATION: The case refers to a 44year old male who presented to our department due to swelling and a feeling of 'heaviness' of his left upper extremity for the past 6 months. CT scan revealed a massive substernal goiter extending to the great vessels. Intraoperatively, a median sternotomy was performed due to the size of the gland and the close adhesion of the isthmus and lower left thyroid lobe to the brachiocephalic vein. Resection of the gland revealed the vein to have a cord-like shape, leading to reduced venous return and upper extremity symptoms. Recovery was uneventful for the patient who was discharged on the 7th postoperative day.

DISCUSSION: While most substernal goiters can be surgically managed through a cervical incision, there are cases in which a median sternotomy is indicated. Those cases include excessive gland size, thoracic pain, ectopic thyroid tissue and the extent of the goiter to the aortic arch. Median sternotomy is associated with a number of intra and postoperative complications, although when performed by an experienced surgeon, mortality and morbidity rates along with long-term recovery are not affected.

CONCLUSSION: The lack of a uniform definition and variety of indications, lead to a patient-tailored approach regarding the execution of sternotomy during surgical management of massive substernal goiters.