TRUE

APPLE
ADAM’S

Roland E. Mallarez
AdZU SOM
Medical Clerk
OBJECTIVES:

▪ To present a history and physical examination of a patient presenting

with neck mass
▪ To formulate a differential diagnoses of anterior neck mass
▪ To discuss the anatomy and physiology of the thyroid
▪ To discuss on the diagnostic approach and therapeutic and surgical
management of thyroid carcinoma

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GENERAL DATA:

S.S. Housewife
52 y.o /Female Roman Catholic
Taway, Ipil Filipino
Married High School Graduate

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CHIEF COMPLAINT: Lateral Neck Mass, Right

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HISTORY OF PRESENT ILLNESS:

2 Y E A R S P TA :

( + ) G R A D U A L LY E N L A R G I N G PA I N L E S S N E C K
MASS, 1 X 1 CM, RIGHT

(+) FIXED, DOES NOT MOVE WITH

DEGLUTITION

( -) DYSPNEA, DYSPHAGIA, HOARSENESS OF

VOICE FEVER, COLD O R H E AT I N T O L E R A N C E
OR ANOREXIA

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HISTORY OF PRESENT ILLNESS:

2 M O N T H S P TA :

(+) ANOTHER GROWTH ON THE POSTERIOR NECK,

S U D D E N I N O N S E T, APPROX. 1 X 1 CM

(+) PRIMARY MASS HAS INCREASED (2 x 2 CM) IN

S I Z E W I T H D Y S P H A G I A B U T ( - ) D Y S P N E A ( - ) PA I N

 C O N S U L T I N P R I VA T E H O S P I T A L : U T Z & C T
SCAN OF THE NECK AND INCISION BIOPSY DONE 
REFERRED TO ZCMC, HENCE, THIS ADMISSION

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PAST MEDICAL HISTORY:

▪ Known hypertensive (BP ranges 140-160/ 90-100

mmHg);maintenance: Losartan 50 mg tablet OD
▪ (-) DM, (-) CVD, (-) PTB
▪ No prior history of exposure to ionizing radiation
▪ No previous surgery
▪ No known allergies

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FAMILY HISTORY:

(+) DM – maternal side

(+) HPN – maternal side
(-) CVD
(-) Malignancy

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PERSONAL AND SOCIAL HISTORY:

▪ A housewife
▪ Non-smoker
▪ Nonalcoholic beverage drinker
▪ Uses iodized salt

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REVIEW OF SYSTEMS:

▪ No weakness or weight loss

▪ No Hair loss or skin changes
▪ No light-headedness or headache
▪ No cough or loss of voice
▪ No chest pain, palpitation or orthopnea
▪ No abdominal pain, increased appetite or anorexia
▪ No claudication or muscular pain
▪ No easy bruising or bleeding

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PHYSICAL EXAMINATION:
Awake, coherent and not in respiratory distress

BP = 160/ 90 mmHg T= 36 C PR = 79 bpm RR = 19 bpm 02 sat = 98%

No rashes or discoloration; warm to touch

5 x 6 cm hard, fixed, ill-defined margins, non-tender mass on the lateral

neck, right; does not move with deglutition
3 x 4 cm hard, fixed, non-tender mass on the posterior neck
Palpable cervical lymphadenopathies, level III, IV & V
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PHYSICAL EXAMINATION:
Equal chest expansion, no tenderness, resonant, clear breath sounds

Adynamic precordium, PMI at 5th ICS MCL, normal rate and regular rhythm

Flabby abdomen, no scars, normoactive bowel sounds, tympanic, soft, non-tender

No edema, strong pulses, CRT < 3 sec

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INITIAL IMPRESSION: Lateral Neck Mass, Right Probably Malignant

History Physical Exam

1. Dysphagia 1. 5 x 6 cm firm, hard, fixed, non-tender mass on

2. History of gradually enlarging the lateral neck, right; does not move with
mass deglutition
3. Female 2. 3 x 4 cm firm, hard, fixed, non-tender mass on
the posterior neck, right
4. 52 years old 3. Palpable cervical lymphadenopathies, level III,
IV & V
4. Enlarged Thyroid

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Secondary impression:
▪ MULTIPLE COLLOID ADENOMATOUS
GOITER
History
1. Epidemiology: Most common
cause of thyroid enlargement
2. History of gradually enlarging
mass
3. Sex: Female
4. Age: 52 years old
Physical Exam
1. Multiple irregular, variable-sized nodules:
5 x 6 cm firm, hard, fixed, non-tender mass on the
lateral neck, right; does not move with deglutition
2. Enlarged thyroid
3. Hypertension (May be due to Hyperthyroidism
caused by Toxic MCAG)
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Source: 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and 15
Differentiated Thyroid Cancer, P. 13
Paraclinical Diagnostic Procedures:
Diagnosis: Certainty Treatment Modality
1. Lateral Neck Mass, right 80% (based on prevalence, signs, Total thyroidectomy with
probably malignant symptoms and physical findings modified radical neck
particularly nodal involvement – dissection
secondary mass, as mentioned
above)

2. Multinodular Colloid 60% (based on prevalence, signs Total thyroidectomy

Adenomatous Goiter and symptoms as mentioned above)

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Paraclinical Diagnostic Procedures:
Diagnostic Procedure Benefit Risk Cost Availability

1. Serum TSH • Easy to do No known risk   Available at ZCMC

determination • Yield immediate result associated with P 600 (Nuclear Medicine
• Provides information if patient is serum TSH. Department M-F)
euthyroid, hypo- or hyper-

2. Neck ultrasound • Stratify the risk of malignancy Thyroid P 600 Available at ZCMC
• Aid decision-making about whether ultrasound is not (Ultrasound
FNA is indicated associated with Department, Ward 5)
• No ionizing radiation any risks.
• Dynamic Picture

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paraclinical diagnostic procedures done to this patient are:

PARACLINICA RESULT INTERPRETATION

L
1. Serum TSH 1.090 uIU/ ml Normal.
2. CT Scan of the Ill-defined, hypodense mass right of the larynx Consistent with malignant
neck involving right parapharyngeal space & right carotid features with nodal
space; 4.6 x 3.6 x 6 cm involvement.
Lateral to the mass- elongated chunky
calcifications, within enlarged cervical lymph
nodes  levels III, IV, V 1.8 x 3.9 x 7.6 cm
Both lobes of thyroid gland are enlarged.

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paraclinical diagnostic procedures done to this patient are:

PARACLINICAL RESULT INTERPRETATION

3. Incision Biopsy Malignant cells arranged in papillary These features are highly
configurations. indicative of a papillary thyroid
The individual cell chromatin clearing carcinoma.
and margination (Orphan Annie Nuclei)
and the nuclear membrane has irregular
contour, groves and nuclear pseudo-
inclusions.

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TREATMENT:

1. Pretreatment diagnosis: Thyroid Carcinoma Stage I (cT3N1bM0)

2. Treatment Goals:
a. Improve overall and disease-specific survival
b. Reduce risk of persistent/recurrent disease and associated morbidity
c. Permit accurate disease staging and risk stratification
d. Remove the primary tumor, disease that has extended beyond the thyroid capsule and
clinically significant lymph node metastasis.
e. Minimize the risk of disease recurrent and metastatic spread.
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TREATMENT:
Modalities Benefit Risk Cost Availability
Operative:        
Near-Total or Total • Remove the primary tumor, Injury to RLN in <1% of patients P 46, 500 This type of
Thyroidectomy with disease that has extended beyond   (PHIC case operation is
Modified Radical Neck the thyroid capsule and lymph Transient hypocalcemia – 50% of rate) done in ZCMC.
Dissection node metastasis. cases
 
• Minimize the risk of disease Permanent hypoparathyroidism –
recurrent and metastatic spread. 2% of cases
 

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ER MANAGEMENT

HGB: 95 g/L
▪ DX: CBC W/ BT
HCT: 0 .2 9 %
▪ C X R PA
P LT : 2 3 4
▪ TSH
▪ PLAN: FOR T O TA L
THYROIDECTOMY
▪ MRND, RIGHT TSH: 1.090 mIU/mL
▪ SECURE 2 “U” PRBC

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Treatment procedure done

Modified Radical Neck Dissection type II, Right; Total thyroidectomy.

Intra-Op Findings: Noted multiple Cervical Lymph Nodes from level I to VI of varying sizes.
Right IJ vein was ligated. The SCM and SAN were preserved.

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POST OP DAY 1

S O A P

Circumoral Chvostek’s sign Hypocalcemia secondary 1. Dx: S. Ca Ca- 1.80

tingling (+) to total thyroidectomy 2. Ca Gluconate
10 ml + 500
ml NSS x 24h

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POST OP DAY 2

S O A P
Ca- 2.0
Circumoral Chvostek’s sign Hypocalcemia 1. Repeat S. Ca
tingling (-) (+) secondary to total 2. Vit D + Ca tab BID
thyroidectomy 3. Ca Gluconate 20
mEqs in 1L PNSS x
30 gtts/ min x 24 h

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POST OP DAY 3

S O A P

No Subjective Awake, NIRD Papillary Thyroid 1. May go home.

complaints No Chvostek’s Carcinoma Stage I 2. Co- Amoxiclav
sign (sT3N1bM0) 625 mg tab PO Ca- 2.0
Good wound BID x 7 days
status S/P Total Thyroidectomy , 3. Ca Carbornate
Modified Radical Neck tab PO BID
Dissection Type II, Right
(3/02/2020, ZCMC)

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FINAL DIAGNOSIS:

▪ PAPILLARY THYROID CARCINOMA STAGE I (sT3N1bM0)

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PREVENTION:

▪ Avoid Ionizing Radiation

▪ Use iodized salt in food preparation.
▪ Eat at least five servings of fruits and vegetables every day.
▪ Maintain a healthy weight.

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Monitoring:

▪ For high-risk thyroid cancer patients, initial TSH suppression to 0.1 to 0.5
mU/L is recommended.
▪ Cervical ultrasound to evaluate the thyroid bed and central and lateral
cervical nodal compartments should be performed at 6-12 months and
then periodically.

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REFERENCES:

▪ Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ Et. Al.
2015 American Thyroid Association Management Guidelines for Adult
Patients with Thyroid Nodules and Differentiated Thyroid Cancer.
▪ Katzung BG. 2018 Basic & Clinical Pharmacology 38: 701.

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THANK YOU!

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