Approach to neck lump, thyroid lumps and cancers, and parathyroid disorders MRCS teaching 01 September 2015

Approach to neck lump, thyroid lumps and cancers, and parathyroid

disordersMRCS 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


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


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


Surgery At A Glance, Fifth Edition, by Pierce and Niel


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


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)


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 NodulesCooper, 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 2.2013

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 2.2013Cooper, 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


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


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


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


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%


Documents

Approach to neck lump, thyroid lumps and cancers, and parathyroid disorders MRCS teaching 01 September 2015