Mediastinal goiters. The need for an aggressive approach.

We reviewed the cases of 52 patients with substernal goiters to examine clinical presentation, workup, technique of removal, malignancy, and outcome. Half of the patients were asymptomatic; half had at least one compressive symptom. Chest film was the most used; computed tomography or magnetic resonance imaging was by far the most useful study. Thyroid scans often failed to show the intrathoracic goiter. Fine-needle aspiration was not helpful because of the gland's inaccessibility. Seventeen percent (nine) of the thyroids showed malignancy, 21% (11) including incidental papillary carcinomas. These were not identified by duration of goiter, symptoms, or fine-needle aspiration. Except for lymphomas, prognosis was good after resection. Removal was almost always accomplished via cervical incision, with low morbidity and no deaths. The threat of compression, the substantial chance of malignancy, and the safety of resection mean that the presence of substernal goiter is an indication for surgery.