Upload
aldous-briggs
View
218
Download
0
Tags:
Embed Size (px)
Citation preview
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
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 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
National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Thyroid Carcinoma Version 2.2013
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 2.2013
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