BACKGROUND Retrosternal goiter is a common cause of compression of adjacent structures, and it may harbor cancer. METHODS During a 22-year period, we treated 44 patients with intrathoracic multinodular goiter. RESULTS The goiter was resected in 40 patients; 4 patients were rejected because of prohibitive risk. There were three minor complications and no deaths. CONCLUSIONS The specific indications for resection include compression of adjacent structures, prevention of future complications, and obtaining a diagnosis. Fine-needle aspiration for diagnosis is not always possible and rarely reliable, and there is no effective medical therapy. Cervical incision is nearly always adequate, with few exceptions, such as very large posterior goiter, mediastinal blood supply, or carcinoma necessitating mediastinal dissection.