Approach to neck lump, thyroid

lumps and cancers, and parathyroid

disorders
MRCS teaching
01 September 2015
Current Surgical Therapy: Evaluation of the isolated neck mass by Philip, Smith et al
Clinical Anatomy: Applied Anatomy for Students and Junior Doctors by Ellis and Mahadevan
Clinical Anatomy: Applied Anatomy for Students and Junior Doctors by Ellis and Mahadevan
Current Surgical Therapy: Evaluation of the isolated neck mass by Philip, Smith et al
 Differential diagnosis
• Congenital, inflammatory, neoplastic
• 2-9% of head and neck cancers present as
cervical masses without a known primary
• Up to 80% of neck masses that occur outside
the thyroid are neoplastic in adults over age of
40 years

Current Surgical Therapy: Evaluation of the isolated neck mass by Philip, Smith et al
 History
• Age
• Personal or family history of malignancy
• Smoking/tobacco use or heavy alcohol
• Sun and radiation exposure
• Persistent mass, dysphagia, hoarseness,
neurologic deficit, epistaxis, radiating pain
• Constitutional symptoms
• Rapidly developing tender masses are often
infectious/inflammatory
• Prior treatment/surgery

Current Surgical Therapy: Evaluation of the isolated neck mass by Philip, Smith et al
Surgery At A Glance, Fifth Edition, by Pierce and Niel
Current Surgical Therapy: Evaluation of the isolated neck mass by Philip, Smith et al
 Imaging
• Chest X-ray/CT thorax
• Ultrasound scan
– Hyper or hypoechogenicity, cystic degeneration, punctuate calcifications,
unclear borders with surrounding structures perinodal oedema
• CT scan
– Invasion or distortion of normal anatomy
– If thought to be nodal metastasis, can identify primary source in 20%
• MRI
– Presence of invasion into surrounding structures especially vascular or neural
structures
• PET
– Not first-line
– Metastatic squamous cell carcinoma of unknown primary
– Further workup for known diagnosis

Current Surgical Therapy: Evaluation of the isolated neck mass by Philip, Smith et al
 Tissue diagnosis
• FNA
• Core biopsy
• Excision biopsy
• Panendoscopy and biopsy
– Laryngoscopy, bronchoscopy and esophagoscopy
– Biopsy
– Tonsillectomy (tonsils are found to be the primary
source in 20-40% of these patients)

Current Surgical Therapy: Evaluation of the isolated neck mass by Philip, Smith et al
Thyroid
 Work-up
• Thyroid function test
• Serum Tg (not initial evaluation)
• Calcitonin (if suspect MTC)
• Ultrasound
– Ill-defined borders, microcalcifications, internal
vascularity, absence of colloid halo sign, hypoechogenicity,
suspicious lymph nodes
• FNA
• Radionuclide thyroid scan (if TSH subnormal)
• CT/MR neck/PET
• Nasopharyngolaryngoscopy

Current Surgical Therapy: Management of Thyroid Nodules

Cooper, David S, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer: the
American Thyroid Association (ATA) guidelines taskforce on thyroid nodules and differentiated thyroid cancer. Thyroid 19.11 (2009): 1167-1214.
National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Thyroid Carcinoma Version
Current Surgical Therapy: Management of Thyroid Nodules
 Thyroid carcinoma
• Papillary thyroid cancer
• Follicular cancer
• Hürthle cell cancer
• Anaplastic cancer
• Medullary thyroid cancer
• Lymphoma
 Thyroid carcinoma
• Papillary thyroid cancer (80%)
– Young, irradiation, FAP, Gardner’s syndrome, Cowden
disease, Wegener’s syndrome
– Lymph node spread
– Total thyroidectomy + neck dissection if any of:
• age <15 or >45, radiation history, known distant metastasi,
bilateral nodularity, tumour >4cm, cervical LN metastasis,
aggressive variant
– Completion total thyroidectomy if
• Tumour >4cm, positive margins, gross extrathyroidal extension,
macroscopic multifocal disease, confirmed nodal metastasis,
vascular invasion
– RAI
– Surveillance with TSH, Tg, antithyroglobulin Ab and US
National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Thyroid Carcinoma Version 2.2013
Cooper, David S, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer: the
American Thyroid Association (ATA) guidelines taskforce on thyroid nodules and differentiated thyroid cancer. Thyroid 19.11 (2009): 1167-1214.
 Thyroid carcinoma
• Follicular cancer (10%) and Hürthle cell cancer
– Middle age
– Blood spread
– Total thyroidectomy if invasive cancer, metastatic
cancer or patient preference
• Central neck dissection if lymph node positive
• Lateral neck dissection if clinically involved
– Completion thyroidectomy if invasive cancer
– RAI
– Surveillance with TSH, Tg, antithyroglobulin Ab and US

National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Thyroid Carcinoma Version
 Thyroid carcinoma
• Medullary thyroid cancer
– MEN2
– Serum calcium, calcitonin, CEA, pheochromocytoma screen, RET
proto-oncogene
– Total thyroidectomy + central neck dissection ± lateral neck
dissection
– Adjuvant EBRT
• Anaplastic cancer
– 10 year <1%, poor prognosis
– FBC, calcium, TSH, CT/PET
– Local disease: total thyroidectomy and selective resection of
local/regional structures and lymph nodes
– EBRT, chemotherapy, best supportive care

National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Thyroid Carcinoma Version
Parathyroid
 Primary hyperparathyroidism
• Most common cause for hypercalcaemia
• Excessive PTH production
• Incidence 1%, 2% after age 55
• Women 2-3 times more likely
• Single adenoma in 80-85%
• Parathyroid carcinoma in 1%
• Present in nearly all patients with MEN 1 and
25% in MEN 2A

Current Surgical Therapy: Primary Hyperparathyroidism

 Work-up
• High or high-normal calcium
• Elevated or high normal (nonsuppressed) PTH
• Decreased serum phosphate
• Increased or high-normal chloride
• 24-hour urinary calcium and creatinine
– To rule out familial hypercalcemia hypocalciuria
• Sestamibi scan
• US neck

Current Surgical Therapy: Primary Hyperparathyroidism

 Indications for surgery
• Symptomatic
• Younger than 50 years old
• Serum calcium levels over 1 mg/dL above
upper limit of normal (2.8 mmol/L)
• Creatinine clearance less than 60mL/min
• Bone mineral density T score ≤2.5

Current Surgical Therapy: Primary Hyperparathyroidism

 Treatment
• Minimally invasive parathyroidectomy with intra-
operative parathyroid hormone monitoring
– 50% drop in the intact parathyroid hormone level
– Complication rate 1%
• Bilateral neck exploration
– Procedure of choice for MEN
– Trachea-oesophageal groove, thymus, within thyroid,
carotid sheath
– Complication rate (including RLN injury) 4%

Current Surgical Therapy: Primary Hyperparathyroidism