Retrosternal goiter: the need for thoracic approach based on CT findings: surgeon's view

The incidence of retrosternal goiter (RSG) varies from 2% to 26% of all thyroidectomies, depending on the defining criteria. There are no clear guidelines to identify patients that require an intrathoracic approach. So, we tried to correlate, between the size and/or anatomical site of the RSG based on preoperative CT findings and the surgical approaches used, aiming at defining those patients with RSG who are in need for thoracic approach.

Out of 1481 patients underwent thyroidectomy at the National Cancer Institute (NCI), Cairo University, between January 2000 and December 2009, only 73 (4.93%) of them had retrosternal extension. Demographic, clinical, operative, anatomical, and pathological data of patients with RSG were recorded and analyzed.

The intraoperative extension of the goiter correlated with the extension seen in the CT in all except two patients. Laterality and longitudinal extension found in preoperative CT, correlated well with the surgical findings. The approach used was cervical in 66 cases (90.4%); combined approach in six patients (8.2%). Pure thoracic (full sternotomy) was used alone in one case (1.4%). Extension of the RSG down to or below the arch was associated with an increased risk of using a thoracic approach p<0.0001.

Preoperative CT, can be used effectively to guide the indications for using a thoracic approach. Reaching the aortic arch or beyond and loss of fat planes in CT, recurrent and malignant disease, are significant risk factors for using a thoracic approach.