NECK MASSES:
UNC MS III SURGERY
• Case discussions by students
• Discussion of thyroid disorders
• Discussion of how to develop a
differential diagnosis
• Management algorithm
THYROID
COLIN G THOMAS, Jr. MD
Professor, Department of Surgery
University of North Carolina
Incidence of Thyroid Disorders in Connecticut
(Annual physical Examination, 1544 Patients – One Year)
Simple goiter
Graves’ disease
Iatrogenic hyperthyroidism
Hot nodule
Multinodular goiter
Thyroiditis
Single cold nodule
Hypothyroidism
Cancer
Total
#
29
15
2
9
13
8
8
6
0
90
%
1.88
0.97
0.10
0.58
0.84
0.51
0.51
0.39
0.00
5.78
Cancer Incidence and Deaths
Estimated- U.S. 2005
Organ System
Lung
Colon
Rectum
Pancreas
Breast
Stomach
Thyroid
Prostate
New Cases
172,570
104,950
42,000
32,180
212,930
24,000
25,690
232,090
Deaths
163,510
56,290
7,000
31,800
40,870
14,000
1,490
30,050
Thyroid Cancer
1985
1994
New Cases 10,000
13,900
17,200 (↑ 72%)
1,120
1,200 (↑8%)
Deaths
1,100
American Cancer Society 1998
1998
Evaluations of Nodular Thyroid
Disease
• History- symptoms, duration, familial
• Physical findings, i.e. topography,
firmness, surface, lymphadenopathy
• Thyroid functions tests- TFT (s) - TSH
Diagnostic Studies- Thyroid Cancer
Fine Needle Aspiration- Establishes Cytologic
Diagnosis
Thyroid function tests (TSH- 1st in
Thyroiditis)
Technetium Scan- reflects trapping
function, “hot nodule”
Ultrasonography- reflects volume,
composition, occult nodules
Thyroid Cancer- Diagnosis
• Cytology
• Scans
– Technetium
– Radioiodine
– Sestamibi
– MR/CT/PET
• Ultrasound
• Frozen Sections
• Fixed Sections
Thyroid Cancers*
Papillary
Follicular
Hürthle
Medullary
Anaplastic
*National Cancer Data Base
31,513 patients (1985-1995)
80%
11%
3%
4%
2%
Biological Characteristics
• Thyrotropin Receptor– Adenylate Cyclase Systems
• Iodine Trapping/Organification
• Thyroglobin Production
Papillary Carcinoma
• Ames (Age, Distant Metastases, Extent,
Size)
• 89%- Low risk; Mortality 1.8% and
• 11% High Risk, Mortality 46%
Adjuvant Therapy
Thyroxine → TSH Suppression
Radiodiodine (Ablation/Rx)
Thyroxine ↓ → TSH ↑
Recombinant TSH
External Radiation (?)
Chemotherapy (?)
Neck Masses
Marion Couch, MD PhD
Department of OHNS
University of North Carolina
Some pearls:
• 90% of adult neck masses are malignant
• 90% 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 or I will come after
you.
HISTORY
•
•
•
•
•
•
•
Age
Duration
Acute symptoms
Recent travel
Trauma
Insect bites, pets
Tobacco, alcohol, XRT
CONGENITAL
• Central neck:
– Thyroglossal duct cysts
• Pyramidal lobe of thyroid
–
–
–
–
Sebaceous cysts
Hemangiomas
Laryngocele
Ectopic thyroid
• Lateral neck:
– Branchial cleft cysts
– Cystic hygromas
– Dermoids
Branchial cleft cyst
Branchial cleft cysts
Branchial cleft cyst
Branchial cleft cyst
Inflammation
• Reactive lymphadenopathy
• Sialoadenitis
• Cervical adenitis
Infectious
•
•
•
•
•
•
•
•
•
•
Staph and strep
EBV – mono
TB
Atypical TB
HIV
Cat scratch fever (Bartonella henselae)
Toxoplasmosis
Actinomycosis
Tick-borne: Rocky Mountain Spotted Fever
Lemierre’s Syndrome: septic thromb. IJV
Trauma
• Hematoma
–Acute and expanding
–Chronic and organizing
• AV fistula
• Pseudoaneurysm
Metabolic, Idiopathic,
Autoimmune
• Castleman’s disease
• Sarcoidosis
• Kimura’s disease
Neoplasms
• Benign:
–Lipomas
–Neuromas
–Fibromas
–Hemangiomas
–Carotid body tumors
–Angiomas
Neoplasms
• Malignant
– Thyroid
– Squamous cell carcinoma (SCAA)
– Lymphoma
– Sarcoma
– Salivary gland tumors
– Metastasis:
• SCCA, adenocarcinoma, undifferentiated
carcinoma, melanoma
Management
• 1 course of broad spectrum
antibiotics
• Consider bloodwork and
imaging
• REFERAL
Pearls
• Avoid excisional biopsies
• Use CT but consider MRI for
salivary gland problems
• Role of nonionizing ultrasound
–Like a stethoscope?
National Comprehensive Cancer
Network
• Use www.nccn.org for evidence-based,
consensus guidelines for:
– Staging
– Evaluation
– References
– Treatment
– All sites
– Updated annually.