Surgical Management of Substernal Goiters: A Systematic Review and Meta‐Analysis

Objective Defining indication for intervention in substernal goiter, and secondarily define when thoracic intervention may be required. Data Sources PubMed, Scopus, CINAHL. Methods A systematic review and meta‐analysis were performed on studies employing thyroidectomy for substernal goiters. Meta‐analysis of continuous measures, proportions, and comparison of weighted proportions was performed for patient characteristics, symptoms, and outcomes. Results Data from 102 studies were included, with a total study population of 15,719 patients undergoing substernal thyroidectomies. Criteria for classifying substernal goiter were heterogeneous across studies, with a plurality (21/102) defining diagnosis by > 50% of the goiter mass located below the thoracic inlet. There was a female predominance at 67% (CI 64.2–69.9) with a mean age of 58 years old (10–94). Most common preoperative symptoms were a described “neck mass” (71.1%, CI 57.6–82.9) and overall compressive symptoms (64.8%, CI 52.4–76.2). 27.6% (CI 22.4–33.1) of the population remained asymptomatic. On radiologic imaging, tracheal deviation and compression were identified in 60.6% (CI 52.5–68.5) and 48.6% (CI 37.6–59.6) of the population, respectively. Cervical approach alone was performed in 88.7% (CI 86.0–91.1) of the population, while 10.4% (CI 8.2–12.8) required additional thoracic intervention. Malignancy was moderate and seen in 12.4% (CI 10.4–14.6) of cases. Conclusion Results highlight the indication for substernal surgery is largely due to the presence of clinical symptoms or compressive findings on imaging; however, over a quarter of the population is asymptomatic and over 50% are without compressive findings on imaging. When surgery is undertaken, a cervical approach is often adequate, suggesting that only a minority of the population may require thoracic intervention.