Evidence-Based Surgical Management of Substernal Goiter
Matthew L. White
Division of Endocrine Surgery, Department of Surgery, University of Michigan, 2920 Taubman Center, 1500 East Medical Center Drive, 48109-0331 Ann Arbor, Michigan, USA
Department of Surgery, St. Joseph Mercy Hospital, Ann Arbor, Michigan, USA
Search for more papers by this authorGerard M. Doherty
Division of Endocrine Surgery, Department of Surgery, University of Michigan, 2920 Taubman Center, 1500 East Medical Center Drive, 48109-0331 Ann Arbor, Michigan, USA
Search for more papers by this authorCorresponding Author
Paul G. Gauger
Division of Endocrine Surgery, Department of Surgery, University of Michigan, 2920 Taubman Center, 1500 East Medical Center Drive, 48109-0331 Ann Arbor, Michigan, USA
[email protected]Search for more papers by this authorMatthew L. White
Division of Endocrine Surgery, Department of Surgery, University of Michigan, 2920 Taubman Center, 1500 East Medical Center Drive, 48109-0331 Ann Arbor, Michigan, USA
Department of Surgery, St. Joseph Mercy Hospital, Ann Arbor, Michigan, USA
Search for more papers by this authorGerard M. Doherty
Division of Endocrine Surgery, Department of Surgery, University of Michigan, 2920 Taubman Center, 1500 East Medical Center Drive, 48109-0331 Ann Arbor, Michigan, USA
Search for more papers by this authorCorresponding Author
Paul G. Gauger
Division of Endocrine Surgery, Department of Surgery, University of Michigan, 2920 Taubman Center, 1500 East Medical Center Drive, 48109-0331 Ann Arbor, Michigan, USA
[email protected]Search for more papers by this authorAbstract
Background
A number of reports have been published concerning the surgical treatment of substernal goiters; however, there is yet to be a comprehensive review of this body of literature using evidence-based methodology.
Methods
This article is a systematic review of the literature using evidence-based criteria and a review of unpublished data from our institution.
Results
Issue 1. Limited level III/IV data suggest that the incidence of cancer in substernal goiters is not higher than the incidence of cancer in cervical goiters. Risk factors for malignancy in substernal goiters may include a family history of thyroid pathology, a history of cervical radiation therapy, recurrent goiter, and the presence of cervical adenopathy (grade C recommendation). Issue 2. Prospective level V data suggest that, for most patients, expert endocrine surgeons utilize an extracervical approach approximately 2% of the time to remove a substernal goiter safely; a sternotomy or thoracotomy appears more likely in cases of a primary substernal goiter or a mass larger than the thoracic inlet (no recommendation). Issue 3. There may be a higher rate of permanent hypoparathyroidism and unintentional permanent recurrent laryngeal nerve injury when total thyroidectomy is performed for removal of a substernal goiter than for removal of a cervical goiter alone (grade C recommendation). Injury of the external branch of the superior laryngeal nerve was not specifically addressed and is almost certainly underreported. Issue 4. The presence of a substernal goiter, especially being present more than 5 years and causing significant tracheal compression, is likely a risk factor for tracheomalacia and tracheostomy (grade C recommendation). Tracheomalacia with substernal goiter is an infrequent occurrence, and many cases of tracheomalacia can be managed without tracheostomy (no recommendation). Issue 5. Prospective level V data suggest that about 5% to 10% of operations for substernal goiters are performed because of recurrent or persistent disease, although retrospective level V data report an even higher rate, up to 37%. The most common initial operations with recurrence or persistence appear to be subtotal or hemithyroidectomy (no recommendation).
Conclusion
Evidence-based recommendations provide reliable information regarding the pathologic findings and operative management of substernal goiters in expert hands.
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