HighlightsSubsternal goiter definition is controversial, while they are generally defined as goiters which at least 50% of the thyroid mass extends bellow the thoracic inlet.Our patient had a massive substernal multinodular goiter, the left lobe of which caused compression of the braciocephalic vein with symptoms from his left upper extremity.The massive size of the gland along with the strict adhesion of the isthmus and left thyroid lobe to the brachiocephalic vein led to the decision of performing a median sternotomy.Despite the extensive procedure, patient recovery was uneventful.The lack of a uniform definition on substernal goiter and the diversity of thoracotomy indications, lead to a patient-tailored surgical approach. Still the execution of thoracotomy is considered safe in the hands of an experienced surgeon.