THE NECK MASS General Sx Topic

Reviewed and present by Mr. Patinya Yutchawit, Miss Kaewalin Thongsawangjang, Miss Withunda Akaapimand, Miss Rattanaporn Sirirattanakul, Miss Tritraporn Sawantranon, Mr. Yotdanai Namuangchan, Mr. Jirarot Wongwijitsook

THYROID Introduction and anatomy

Follicles -> Lobule

Principal cells (ie, follicular) formation of the colloid (iodothyroglobulin),

Parafollicular cells  :calcitonin

Superior thyroid artery

Inferior thyroid artery

Thyroidima artery

Superior thyroid artery

Inferior thyroid artery

Thyroidima artery

Superior thyroid vein

Middle thyroid vein

Inferior thyroid veins

Nerve

Parasympathetic fibers vagus nerves

Sympathetic fibers : superior, middle, and inferior ganglia of the sympathetic trunk.

APPROACH TO NECK MASS

Start

access

• Origin• Cause

Hx

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PE

• Local examination• Regional examination• General examination

Local examination• Location• Size > 1.5 cm , <1.5cm. 2ข�าง• Shape• Surface• Consistency• Tenderness• Fluctuation• Tranlumination• Attachment• Skin • Punctum• Pulsation• Miscellaneaeous: move follow tongue prtusion,swallowing

Location

Mid line Ant. Triangle Post. Triangle

Congenital-thyroglossal duct cyst-dermoid cyst-laryngocele

Inflammation-adenditis

Tumor-thyroid-lymphoma

Other-sternocleidomastoid hematoma/fibroma

Congenital-brachial cleft cyst-thymic cyst-sialadenopathy(parotid,submandibular)Inflammation-adenitis(viral,bact., glanulomatous)-sialadenitisTumor-metastasic -upper jugular -submandibular -middle jugular-lymphoma-vascular(carotid tumor, hemangioma)Other- False aneurysm

Congenital-lymphangioma

Inflammation-adenitis(viral,bact., glanulomatous)

Tumor-lymphoma-metastatic -supraclavicular

OtherNeuroma

investigation

• Blood– CBC, ESR, LFT, Ca, heteropliie Ab, HIV Ab, EBV Ab

• Imaging– X-ray, U/S, CT, MRI (submucosal),radionuclide scan– sialography

• Cytology– FNA

• Tissue– biopsy

THYROGLOSSAL DUCT CYST

THYROGLOSSAL DUCT CYST

Neck mass that develops from cells and tissues remaining after the formation of the thyroid gland during embryonic development

Pathogenesis

• The primitive thyroid descended from its origin at the base of the tongue to its permanent location, low in the neck. Failure of subsequent closure and obliteration of this tract predisposes to thyroglossal cyst formation.

Types of thyroglossal duct cysts

– Infrahyoid type : 65 %– Suprahyoid type : 20 %

–Juxtahyoid cysts : 15 %– Intralingual location– Suprasternal variety – Intralaryngeal

Clinical presentation• A small,soft,round mass

in the midline of neck

• Mass rise with swallowing or protrusion of the tongue

•It is most commonly diagnosed in preschool-aged children or during mid-adolescence

CLINICAL PRESENTATION

Infected cysts may manifest as tender masses withDysphagiaDraining sinusFeverEnlarging neck mass

Diagnosis

• Clinical : upward when tongue is extended and swallowing

• Contain thyroid tissue– TFT– Thyroid scan–Ultrasound

a midline infrahyoid unilocular mass with a homogeneously hypoechoic internal echotexture, typical of a TDC.

Pathology

• Cyst cavity and thyroid tissue

On rare occasion, turn to carcinoma

Treatment

• Antibiotic if infected• Surgery : Sistrunk’s Operation

- Removal of the cyst, the tract, and the central portion of the hyoid bone as well as a portion of the tongue base up to the foramen cecum.

Solitary thyroid nodule

Euthyroid Hyperthyroid

FNA biopsy cytology

I-131/Sx

FSH,FT3

Hot nodule

Cold nodule

TMG

Thyroid scan

TSH FT3

FNA

Reaspirate

Benign

Solid/Mix

Negative SuspiciousPositive

Malignant

Hormone suppressive,F/U

Sx Sx

Lobectomy Sx +/- I-131

Cyst

GRAVE’S DISEASE

GRAVES DISEASE

Graves’ Disease

• Graves’s disease , Primary toxic goiter , Basedow’s disease , Exopthalmicgoiter

• autoimmune disease : antibody against the thyroid-stimulating hormone (TSH) receptor (Thyroid stimulating immunoglobulin ,TSI)

stimulates the gland to synthesize and secrete excess thyroid hormone

• Characterized by hyperthyroidism, diffuse goiter, opthalmopathy and, sometimes, dermopathy.

• Most common cause of hyperthyroidism

Age: 20-50 years Sex: female : male 7-8:1 60-90% of all causes of

thyrotoxicosis  100-200 cases /100,000 population /year

EPIDEMIOLOGY

• 50 % Genetic inheritance• Other factors, such as smoking, sex

steroids, life stresses, and dietary iodine intake, bacterial or viral infection are possible causes of Graves’ disease

ETIOLOGY

• 1.Increase metabolic rate of all cells• 2.Increase sensitivity of beta-adrenergic

receptors• 3.Stimulate all cells to grow

Thyroid hormone effects

Metabolic:ravenous appetite, weight loss, excessive sweating, heat intolerance

CVS: Palpitations, shortness of breath, tiredness, irregular heart beat

CNS: irritability, insomnia, depression

CLINICAL

• GI: Change in appetite and weight, Increase

frequency of bowel movement, diarrhea• RP: reduction in the quantity of menses,

amenorrhea, decreased fertility, increased incidence of miscarriages

• MS: wasting and weakness of small muscle of

hand, shoulder, face

• GA: looks thin and wasting of face and hands, sweating

• CVS: tachycardia at rest, persist during sleep. AF, collapsing pulses, heart failure• CNS: fine tremor• Skin: warm and moist, pretibial myxedema• MS: muscle wasting, proximal muscle weakness,

hyperactive tendon reflex, digital clubbing

Physical examination

• Signs in the neck Diffused, symmetrically enlarged thyroid gland Systolic bruit audible over its lateral lobe,palpable thrill• Signs in the eyes Lid retraction and lid lag Exopthalmos Ophthalmoplegia: proptosis, limitation of upward and latral gaze Chemosis: conjunctival swelling and congestion

Physical examination

Exophthalmos

Pretibial myxedema

Thyroid function testHigh T3, T4 ; Low TSH

Thyroid stimulating antibodies (TSAb) 123I uptake and scan : Increase

Diagnostic tests

• Medication• Radioactive 131I• Thyroidectomy

Management

• Beta blocker : Propranolol 20-40 mg qid offer relief of the adrenergic symptoms

of hyperthyroidism such as tremor, palpitations, heat intolerance, and nervousness

Medication

• Reserve for - Small, non toxic goiters less than 40 g - Mildly elevated thyroid hormone levels - Rapid decrease in gland size with antithyroid

medication• PTU: 100-300 mg tid • MMI: 10-30 md tid, then once daily • Side effects: skin rash, fever, vasculitis,rarely

agranulocytosis, aplastic anemia• High relapse rate when discontinued drug 1-2 year (40-

80%)

Antithyroid drugsMedication

• Recommended in - Older patients with small or moderate-size goiter - Relapse after medical or surgical therapy - Antithyroid drugs or surgery are contraindicated

Radioactive Iodine therapy

• Woman who are pregnant or breastfeeding

Relative contraindications• Children and adolescent• Patient with thyroid nodule• Patient with ophthalmopathy

Absolute contraindications

Radioactive Iodine therapy

Recommend in - RAI is contraindication - Have confirmed cancer or suspicious thyroid nodules - Young - Pregnant or desire to conceive soon after treatment - Severe reaction to antithyroid medication or poor

compliance - Large goiters causing compressive symptoms or for

cosmetic reason - Reluctant to undergo RAI therapy

Surgical treatment

• Euthyroid by continue antithyroid drug until the day of surgery

• Lugol’s iodine solution or saturated K iodine 3 drops bid for 7-10 day preoperatively → reduce vascularity of gland and decrease risk of precipitating thyroid storm

Prep. For surgery

Hemithyroidectomy - Entire isthmus is removed along with 1 lobe. Done in benign diseases of only 1 lobe.

Subtotal thyroidectomy- Done in toxic thyroid, primary or secondary, and also for toxic multinodular goiter (MNG).

Partial thyroidectomy - Removal of gland in front of trachea after mobilization. Done in nontoxic MNG. Its role is controversial.

Near total thyroidectomy- Both lobes are removed except for a small amount of thyroid tissue (on one or both sides) in the vicinity of the recurrent laryngeal nerve entry point and the superior parathyroid gland. Done in papillary thyroid carcinoma.

Total thyroidectomy- Entire gland is removed. Done in case of follicular carcinoma of thyroid, medullary carcinoma of thyroid.

Hartley Dunhill operatio - Removal of 1 entire lateral lobe with isthmus and partial/subtotal removal of opposite lateral lobe. Done in nontoxic MNG.

• Total or near total thyroidectomy - Coexistent thyroid cancer - Refuse RAI - Severe ophthalmopathy - Life threatening reaction to antithyroid

medication e.g. vasculitis, agranulocytosis, liver failure

* High rate of hypothyroidism• Subtotal thyroidectomy (4-7 g remain) - All remaining patients Higher recurrent rate of hyperthyroidism

Bleeding Hypocalcemia Recurrent laryngeal nerve injury Superior laryngeal nerve injury Thyroid crisis

COMPLICATION

THYROID CANCER

• Benign follicular adenoma• Malignant : primary

–Follicular epithelium-differentiated : papillary ,follicular

–Follicular epithelium-undiffentiated : anaplstic

–Parafollicular cells : medullary–Lymphoid cells : lymphoma

• Malignant : Secondary - Metastasis

Thyroid cancer

THYROID CANCER Follicular epithilial – differentiated Papillary carcinoma (75 – 80%) Follicular carcinoma (15 – 20 %)

Follicular epithilial – undifferentiated Anaplastic carcinoma (<5%)

Parafollicular cell Medullary carcinnoma (5%)

Lymphoid cell lymphoma

PAPILLARY CARCINOMA

Most common thyroid cancer***

Age 30-50 years old

Risk factor = Previous exposure to Ionizing radiation

Most common presentation = Asymptomatic thyroid mass/nodule

Excellent prognosis = 10 years survival rate >95%

SPREADING

Lymphatic spreading (35-43%)

Blood vessels invasion (40%)

Distant metastasis (3-7%)

SIGNS AND SYMPTOMS

Asymptomatic Thyroid mass

If advanced CA Hoarsness Dysphagia Cough Dyspnea

INVESTIGATION

Fine Needle Aspiration

Ultrasonography distinguish solid from cystic lesions and identify calcifications

Thyroid scan Cold nodule

HISTOPATHOLOGY

mixed papillary and follicular growth patterns

Orphan Annie eye nuclei (= characteristic pale empty nuclei)

Papillary finger-like projection

Psammoma body

FOLLICULAR CARCINOMA

2nd common thyroid cancer High incidence in iodine-depleted countries Common in patient > 50 years Closely resemble to follicular adenoma capsular or vascular invasion is defined malignat status Hematologic spreading distant metastasis difficult to control May be involve cervical lymph node 10-year survival rate > 90%

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•follicular carcinomas demonstrate capsular invasion (B, arrow-heads) that may be minimal, as in this case, or widespread with extension into local structures of the neck. The presence of vascular invasion is another feature of follicular carcinomas.•Hurthle cell tumor-Variant of follicularNeoplasm in which oxyphil cells predominate

histology

• recurrent laryngeal nerve palsy 2-7%• permanent hypoparathyroidism 1-3%• hematoma 1-2%• wound infection < 1%• hypertrophy of the scar

• anaplastic carcinomas are aggressive tumors, with a mortality rate approaching 100%. Survival calculated in months

• mean age of 65 years.• About half of the patients have a history of multinodular

goiter, Spread by lymphatic and by the bloodstream

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Anaplastic carcinoma

ANAPLASTIC CARCINOMA

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highly anaplastic cells, which may take one of several histologic patterns: (1) large, pleomorphic giant cells, including occasional osteoclast-like multinucleate giant cells; (2) spindle cells with a sarcomatous appearance; (3) mixed spindle and giant cells; and (4) small cells resembling those seen in small cell carcinomas arising at other sites.

• Advanced or metastatic disease 

–no effective therapy for advanced or metastatic anaplastic thyroid cancer

–median survival from diagnosis ranges from three to seven months

–Death is usually attributable to upper airway obstruction

–Radiation therapy  does not prolong survival, most have local recurrences

–Chemotherapy response duration is generally short, and long-term survival (as well as local control in the neck) probably unaffected

MEDULLARY CARCINOMA Tumors of Parafollicular cells (C cells) derived from neural crest

Neuroendocrine neoplasms

Secrete Calcitonin (useful in diagnosis and follow up)

INCIDENCE

80% of cases are sporadical tumors

Age 50-60 years old

Lymphatic metastasis 50-60%

May occur in combination known as MEN 2A or 2B

SIGNS AND SYMPTOMS

a lump at the base of the neck, which may interfere with or become more prominent during swallowing.

If locally advanced disease : hoarseness, dysphagia, and respiratory difficulty.

Various paraneoplastic syndromes, including Cushing or carcinoid syndrome (uncommon)

+/- Diarrhea

Distant metastases : weight loss, lethargy, and bone pain

INVESTIGATION

Serum Calcitonin level The higher the greater of likelihood to be MTC Basal level >100 pg/mL

PATHOLOGY

Medullary carcinoma of thyroid. These tumors typically show a solid pattern of growth and do not have connective tissue capsules

Medullary carcinoma of the thyroid. These tumors typically contain amyloid stroma

STAGING

TREATMENT

Total Thyroidectomy

Prophylactic/Therapeutic resection of central and bilateral cervical lymph nodes

POSTOPERATIVE MANAGEMENT  Thyroxine therapy maintain euthyroidism

adjuvant therapy with radioiodine

SURGERY FOR RESIDUAL DISEASE 

Serum calcitonin and CEA  should be measured 6 months after surgery detect the presence of recurrence

WRAP-UP! Approach to neck mass

Mr. Patinya Yutchawit

THE HALF-BAKED CONCEPT

IS OKAY, AS LONG AS IT’S IN THE OVEN.

Let’s continue baking!

CASE : A PAINLESS LUMP IN THE NECK History

A 40-year-old woman has been referred to the surgical outpatients with a painless lump in the neck. She had noticed the lump 2 weeks previously when looking in the mirror.

She had not noticed any other lumps and does not complain of any other symptoms. She has not gained or lost any weight recently and her bowel habit has remained normal.

CASE : A PAINLESS LUMP IN THE NECK Examination

Examination reveals a solitary 2x2 cm swelling to the left of the midline just above the manubrium. The swelling is firm, smooth and fixed. The swelling moves on swallowing, but does not move on protrusion of the tongue. There are no associated palpable lymph glands. General examination reveals no further abnormalities.

INVESTIGATION

Hemoglobin 12.0 g/dL

Mean cell volume 77 fL

White cell count 10.4x109/L

Platelets 250x109/L

Sodium 137 mmol/L Potassium 3.7 mmol/L

Urea 5 mmol/L (2.5–6.7 mmmol/L)

Creatinine 71 μmol/L (44–80 μmol/L)

Thyroid-stimulating hormone (TSH) 0.62mu/L (0.5–5.7 mu/L)

Free tri-iodothyronine (T3) 3.4 pmol/L (2.5–5.3 pmol/L)

Free thyroxine (T4) 19 pmol/L (9–22 pmol/L)

QUESTIONS

1. What is the differential diagnosis for a lump in the anterior triangle of the neck?

2. Where is this lump likely to be originating from?

3. What steps would you take in the assessment of this lump?

4. Which factors may suggest malignancy?

5. What are the commonest types of malignancy?

TAKE YOUR FRIEND’S ANSWER SHEET, TAKE A

LOOK AND GIVE THEM GRADE.

Talk about it.

WHAT IS THE DIFFERENTIAL DIAGNOSIS FOR A LUMP IN THE ANTERIOR TRIANGLE OF THE NECK? Multiple: lymph nodes

Solitary: does it move with

swallowing?

• yes:

- thyroid origin

- thyroglossal cyst (moves with protrusion of the tongue)

• no:

- salivary gland

- dermoid cyst

- carotid body tumur

- lymph node

- branchial cyst

- cold abscess (TB)

WHERE IS THIS LUMP LIKELY TO BE ORIGINATING FROM?

… to the left of the midline just above the manubrium

… The swelling moves on swallowing, but does not move on protrusion of the tongue.

“Thyroid origin”

The majority of patients are clinically euthyroid and have normal thyroid function. The presence of abnormal thyroid function suggests a benign diagnosis.

WHAT STEPS WOULD YOU TAKE IN THE ASSESSMENT OF THIS LUMP? Less than 20 per cent of thyroid nodules are malignant, with the majority being cystic or benign. Many solitary thyroid nodules are dominant nodules in a multinodular goitre,which carry a 5 per cent risk of malignancy.

Ultrasound is used to distinguish between solid and cystic nodules as well as differentiating a solitary nodule from a dominant nodule in a multinodular goitre.

Fine-needle aspiration has a high sensitivity and specificity for distinguishing benign from malignant lumps in the thyroid. The main limitation of fine-needle aspiration is in the differentiation of benign follicular adenoma from malignant follicular cancer. If a follicular neoplasm is diagnosed on fine-needle aspiration, the lesion will need to be fully excised to exclude malignancy.

WHAT STEPS WOULD YOU TAKE IN THE ASSESSMENT OF THIS LUMP? Radio-isotope scanning provides a functional assessment of the thyroid nodule, which can be classified as cold or hot.

Most solitary thyroid nodules are cold, with a risk of cancer at around 20 per cent.

WHICH FACTORS MAY SUGGEST MALIGNANCY? • age younger than 20 years or older than 70 years

• male sex

• recent origin and rapid growth or increase in size

• firm, hard, or immobile nodule

• presence of cervical lymphadenopathy

• associated symptoms of dysphagia or dysphonia

• history of neck irradiation

• prior history of thyroid carcinoma or a positive family history.

WHAT ARE THE COMMONEST TYPES OF MALIGNANCY?

Type frequency

age Behavior Prog

Papillary 70% 20-40s Slow growing,lymphatic spreadto nodes

Good10 yr 80%

Follicular 20% 35-50s Bloodstream spread, metastasis to lung and bone

Good 10 yr 60%

Anaplastic <5% 60-70s Aggressive, local spread

Poor 10 yr 10%

Medullary 5% Familial From parafollicular C cell, MEN

TAKE’EM HOME! A brief review.

POINTS

>20% of adult neck masses are malignant

70% of pediatric neck masses are infectious in nature

Know your anatomy then develop a differential diagnosis

Close observation

Generally, one course of a broad spectrum antibiotic is acceptable then ….. It is never wrong to refer to a specialist for evaluation and probable biopsy

Imaging is important but tissue is everything

If you don’t get an answer with a FNA, repeat it up to three times. Consider ultrasound guided or CT guided FNA.

Never violate a neck if you’ve no idea about it.

POINTS

Avoid excisional biopsies Use CT but consider MRI for salivary gland problems Role of nonionizing ultrasoundLike a stethoscope

REFERENCE

- An introduction to the symptoms and sing of surgical disease:

Norman L.Browse

- Bailey and Love's Short Practice of Surgery - 25th Edition

- 100 cases in surgery

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HEY GUY! FIN. DO YOU HAVE SOME

QUESTIONS??Thank you foryour attention.