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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
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THYROID Introduction and anatomy
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Follicles -> Lobule
Principal cells (ie, follicular) formation of the colloid (iodothyroglobulin),
Parafollicular cells :calcitonin
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Superior thyroid artery
Inferior thyroid artery
Thyroidima artery
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Superior thyroid artery
Inferior thyroid artery
Thyroidima artery
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Superior thyroid vein
Middle thyroid vein
Inferior thyroid veins
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Nerve
Parasympathetic fibers vagus nerves
Sympathetic fibers : superior, middle, and inferior ganglia of the sympathetic trunk.
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APPROACH TO NECK MASS
Start
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access
• Origin• Cause
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Hx
• ความชุ�กชุ�มของโรค• อายุ�• เพศ• ระยุะเวลา• ความเจ็�บปวด• อาการทั่��วไป : ไข� อ�อนเพล�ยุ เสี�ยุงแหบ กล#นล$าบาก
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ปาก ล)%น
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PE
• Local examination• Regional examination• General examination
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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
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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
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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
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THYROGLOSSAL DUCT CYST
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THYROGLOSSAL DUCT CYST
Neck mass that develops from cells and tissues remaining after the formation of the thyroid gland during embryonic development
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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.
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Types of thyroglossal duct cysts
– Infrahyoid type : 65 %– Suprahyoid type : 20 %
–Juxtahyoid cysts : 15 %– Intralingual location– Suprasternal variety – Intralaryngeal
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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
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CLINICAL PRESENTATION
Infected cysts may manifest as tender masses withDysphagiaDraining sinusFeverEnlarging neck mass
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Diagnosis
• Clinical : upward when tongue is extended and swallowing
• Contain thyroid tissue– TFT– Thyroid scan–Ultrasound
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a midline infrahyoid unilocular mass with a homogeneously hypoechoic internal echotexture, typical of a TDC.
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Pathology
• Cyst cavity and thyroid tissue
On rare occasion, turn to carcinoma
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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.
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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
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GRAVE’S DISEASE
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GRAVES DISEASE
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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
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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
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• 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
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• 1.Increase metabolic rate of all cells• 2.Increase sensitivity of beta-adrenergic
receptors• 3.Stimulate all cells to grow
Thyroid hormone effects
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Metabolic:ravenous appetite, weight loss, excessive sweating, heat intolerance
CVS: Palpitations, shortness of breath, tiredness, irregular heart beat
CNS: irritability, insomnia, depression
CLINICAL
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• 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
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• 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
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• 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
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Exophthalmos
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Pretibial myxedema
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Thyroid function testHigh T3, T4 ; Low TSH
Thyroid stimulating antibodies (TSAb) 123I uptake and scan : Increase
Diagnostic tests
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• Medication• Radioactive 131I• Thyroidectomy
Management
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• Beta blocker : Propranolol 20-40 mg qid offer relief of the adrenergic symptoms
of hyperthyroidism such as tremor, palpitations, heat intolerance, and nervousness
Medication
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• 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
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• 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
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• Woman who are pregnant or breastfeeding
Relative contraindications• Children and adolescent• Patient with thyroid nodule• Patient with ophthalmopathy
Absolute contraindications
Radioactive Iodine therapy
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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
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• 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
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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.
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• 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
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Bleeding Hypocalcemia Recurrent laryngeal nerve injury Superior laryngeal nerve injury Thyroid crisis
COMPLICATION
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THYROID CANCER
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• Benign follicular adenoma• Malignant : primary
–Follicular epithelium-differentiated : papillary ,follicular
–Follicular epithelium-undiffentiated : anaplstic
–Parafollicular cells : medullary–Lymphoid cells : lymphoma
• Malignant : Secondary - Metastasis
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Thyroid cancer
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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
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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%
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SPREADING
Lymphatic spreading (35-43%)
Blood vessels invasion (40%)
Distant metastasis (3-7%)
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SIGNS AND SYMPTOMS
Asymptomatic Thyroid mass
If advanced CA Hoarsness Dysphagia Cough Dyspnea
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INVESTIGATION
Fine Needle Aspiration
Ultrasonography distinguish solid from cystic lesions and identify calcifications
Thyroid scan Cold nodule
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HISTOPATHOLOGY
mixed papillary and follicular growth patterns
Orphan Annie eye nuclei (= characteristic pale empty nuclei)
Papillary finger-like projection
Psammoma body
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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
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• recurrent laryngeal nerve palsy 2-7%• permanent hypoparathyroidism 1-3%• hematoma 1-2%• wound infection < 1%• hypertrophy of the scar
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• 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
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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.
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• 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
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MEDULLARY CARCINOMA Tumors of Parafollicular cells (C cells) derived from neural crest
Neuroendocrine neoplasms
Secrete Calcitonin (useful in diagnosis and follow up)
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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
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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
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INVESTIGATION
Serum Calcitonin level The higher the greater of likelihood to be MTC Basal level >100 pg/mL
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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
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STAGING
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TREATMENT
Total Thyroidectomy
Prophylactic/Therapeutic resection of central and bilateral cervical lymph nodes
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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
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WRAP-UP! Approach to neck mass
Mr. Patinya Yutchawit
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THE HALF-BAKED CONCEPT
IS OKAY, AS LONG AS IT’S IN THE OVEN.
Let’s continue baking!
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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.
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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.
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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)
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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?
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TAKE YOUR FRIEND’S ANSWER SHEET, TAKE A
LOOK AND GIVE THEM GRADE.
Talk about it.
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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)
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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.
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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.
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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.
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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.
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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
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TAKE’EM HOME! A brief review.
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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.
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POINTS
Avoid excisional biopsies Use CT but consider MRI for salivary gland problems Role of nonionizing ultrasoundLike a stethoscope
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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
- พ#%นฐานศ�ลยุศาสีตร,และอาการของโรคศ�ลยุกรรมสี$าหร�บแพทั่ยุ,เวชุปฏิ)บ�ต)ทั่��วไป
คณะแพทั่ยุศาสีตร, ม. ศร�นคร)นทั่รว)โรฒ - ต$ารา ห& คอ จ็ม&ก คณะแพทั่ยุศาสีตร, ม.ขอนแก�น - Uptodate : neck mass
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HEY GUY! FIN. DO YOU HAVE SOME
QUESTIONS??Thank you foryour attention.