NECK MASSES:NECK MASSES:UNC MS III SURGERYUNC MS III SURGERY

• Case discussions by studentsCase discussions by students

• Discussion of thyroid disordersDiscussion of thyroid disorders

• Discussion of how to develop a Discussion of how to develop a differential diagnosisdifferential diagnosis

• Management algorithmManagement algorithm

THYROIDTHYROID

COLIN G THOMAS, Jr. MDCOLIN G THOMAS, Jr. MD

Professor, Department of SurgeryProfessor, Department of Surgery

University of North CarolinaUniversity of North Carolina

Incidence of Thyroid Disorders in ConnecticutIncidence of Thyroid Disorders in Connecticut(Annual physical Examination, 1544 Patients – One Year)(Annual physical Examination, 1544 Patients – One Year)

## %%Simple goiterSimple goiter 2929 1.881.88Graves’ diseaseGraves’ disease 1515 0.970.97Iatrogenic hyperthyroidismIatrogenic hyperthyroidism 22 0.100.10Hot noduleHot nodule 99 0.580.58Multinodular goiterMultinodular goiter 1313 0.840.84ThyroiditisThyroiditis 88 0.510.51Single cold noduleSingle cold nodule 88 0.510.51HypothyroidismHypothyroidism 66 0.390.39CancerCancer 00 0.000.00TotalTotal 9090 5.785.78

Cancer Incidence and DeathsCancer Incidence and DeathsEstimated- U.S. 2005Estimated- U.S. 2005

Organ SystemOrgan System New CasesNew CasesDeathsDeaths

LungLung 172,570 172,570 163,510163,510

Colon Colon 104,950104,95056,29056,290

RectumRectum 42,00042,0007,000 7,000

PancreasPancreas 32,18032,18031,80031,800

BreastBreast 212,930212,93040,87040,870

StomachStomach 24,00024,00014,00014,000

ThyroidThyroid 25,69025,6901,4901,490

Prostate 232,090 30,050Prostate 232,090 30,050

Thyroid CancerThyroid Cancer

19851985 19941994 19981998

New CasesNew Cases 10,00010,000 13,90013,900 17,20017,200 ( (↑ 72%)↑ 72%)

DeathsDeaths 1,1001,100 1,1201,120 1,200 (↑8%) 1,200 (↑8%)

American Cancer Society 1998American Cancer Society 1998

Evaluations of Nodular Thyroid Evaluations of Nodular Thyroid DiseaseDisease

• History- symptoms, duration, familialHistory- symptoms, duration, familial

• Physical findings, i.e. topography, Physical findings, i.e. topography, firmness, surface, lymphadenopathyfirmness, surface, lymphadenopathy

• Thyroid functions tests- TFT (s) - TSHThyroid functions tests- TFT (s) - TSH

Diagnostic Studies- Thyroid CancerDiagnostic Studies- Thyroid Cancer

Fine Needle Aspiration- Establishes Cytologic Fine Needle Aspiration- Establishes Cytologic DiagnosisDiagnosis

Thyroid function tests (TSH- 1Thyroid function tests (TSH- 1stst in in Thyroiditis)Thyroiditis)Technetium Scan- reflects trapping Technetium Scan- reflects trapping function, “hot nodule”function, “hot nodule”Ultrasonography- reflects volume, Ultrasonography- reflects volume, composition, occult nodulescomposition, occult nodules

Thyroid Cancer- DiagnosisThyroid Cancer- Diagnosis

• CytologyCytology

• ScansScans– TechnetiumTechnetium– RadioiodineRadioiodine– SestamibiSestamibi– MR/CT/PETMR/CT/PET

• UltrasoundUltrasound

• Frozen SectionsFrozen Sections

• Fixed SectionsFixed Sections

Thyroid Cancers*Thyroid Cancers*

PapillaryPapillary 80%80%

FollicularFollicular 11%11%

HHürthleürthle 3%3%

MedullaryMedullary 4%4%

AnaplasticAnaplastic 2%2%

*National Cancer Data Base*National Cancer Data Base

31,513 patients (1985-1995)31,513 patients (1985-1995)

Biological CharacteristicsBiological Characteristics

• Thyrotropin Receptor-Thyrotropin Receptor-– Adenylate Cyclase SystemsAdenylate Cyclase Systems

• Iodine Trapping/OrganificationIodine Trapping/Organification

• Thyroglobin ProductionThyroglobin Production

Papillary CarcinomaPapillary Carcinoma

• Ames (Age, Distant Metastases, Extent, Ames (Age, Distant Metastases, Extent, Size)Size)

• 89%- Low risk; Mortality 1.8% and 89%- Low risk; Mortality 1.8% and

• 11% High Risk, Mortality 46%11% High Risk, Mortality 46%

Adjuvant TherapyAdjuvant Therapy

Thyroxine Thyroxine → TSH Suppression→ TSH Suppression

Radiodiodine (Ablation/Rx)Radiodiodine (Ablation/Rx)

Thyroxine ↓ → TSH ↑Thyroxine ↓ → TSH ↑Recombinant TSHRecombinant TSH

External Radiation (?)External Radiation (?)Chemotherapy (?)Chemotherapy (?)

Neck MassesNeck Masses

Marion Couch, MD PhDMarion Couch, MD PhD

Department of OHNSDepartment of OHNS

University of North CarolinaUniversity of North Carolina

Some pearls:Some pearls:

• 90% of adult neck masses are malignant90% of adult neck masses are malignant

• 90% of pediatric neck masses are 90% of pediatric neck masses are infectious in natureinfectious in nature

• Know your anatomy then develop a Know your anatomy then develop a differential diagnosisdifferential diagnosis

• Close observationClose observation

• Generally, one course of a broad spectrum Generally, one course of a broad spectrum antibiotic is acceptable then …..antibiotic is acceptable then …..

• It is never wrong to refer to a specialist for It is never wrong to refer to a specialist for evaluation and probable biopsyevaluation and probable biopsy

• Imaging is important but tissue is Imaging is important but tissue is everythingeverything

• If you don’t get an answer with a FNA, If you don’t get an answer with a FNA, repeat it up to three times. Consider repeat it up to three times. Consider ultrasound guided or CT guided FNA.ultrasound guided or CT guided FNA.

• Never violate a neck or I will come after Never violate a neck or I will come after you.you.

HISTORYHISTORY• AgeAge

• Duration Duration

• Acute symptomsAcute symptoms

• Recent travelRecent travel

• TraumaTrauma

• Insect bites, petsInsect bites, pets

• Tobacco, alcohol, XRTTobacco, alcohol, XRT

CONGENITALCONGENITAL

• Central neck:Central neck:– Thyroglossal duct cystsThyroglossal duct cysts

• Pyramidal lobe of thyroidPyramidal lobe of thyroid

– Sebaceous cystsSebaceous cysts– HemangiomasHemangiomas– LaryngoceleLaryngocele– Ectopic thyroidEctopic thyroid

• Lateral neck:Lateral neck:– Branchial cleft cystsBranchial cleft cysts– Cystic hygromasCystic hygromas– DermoidsDermoids

Branchial cleft cystBranchial cleft cyst

Branchial cleft cystsBranchial cleft cysts

Branchial cleft cystBranchial cleft cyst

Branchial cleft cystBranchial cleft cyst

InflammationInflammation

• Reactive lymphadenopathyReactive lymphadenopathy

• SialoadenitisSialoadenitis

• Cervical adenitisCervical adenitis

InfectiousInfectious

• Staph and strepStaph and strep• EBV – monoEBV – mono• TBTB• Atypical TBAtypical TB• HIVHIV• Cat scratch fever (Bartonella henselae)Cat scratch fever (Bartonella henselae)• ToxoplasmosisToxoplasmosis• ActinomycosisActinomycosis• Tick-borne: Rocky Mountain Spotted FeverTick-borne: Rocky Mountain Spotted Fever• Lemierre’s Syndrome: septic thromb. IJVLemierre’s Syndrome: septic thromb. IJV

TraumaTrauma

• HematomaHematoma

–Acute and expanding Acute and expanding

–Chronic and organizingChronic and organizing

• AV fistulaAV fistula

• PseudoaneurysmPseudoaneurysm

Metabolic, Idiopathic, Metabolic, Idiopathic, AutoimmuneAutoimmune

• Castleman’s diseaseCastleman’s disease

• SarcoidosisSarcoidosis

• Kimura’s diseaseKimura’s disease

NeoplasmsNeoplasms

• Benign:Benign:

–LipomasLipomas

–NeuromasNeuromas

–FibromasFibromas

–HemangiomasHemangiomas

–Carotid body tumorsCarotid body tumors

–AngiomasAngiomas

NeoplasmsNeoplasms

• MalignantMalignant– ThyroidThyroid– Squamous cell carcinoma (SCAA)Squamous cell carcinoma (SCAA)– LymphomaLymphoma– SarcomaSarcoma– Salivary gland tumorsSalivary gland tumors– Metastasis:Metastasis:

• SCCA, adenocarcinoma, undifferentiated SCCA, adenocarcinoma, undifferentiated carcinoma, melanomacarcinoma, melanoma

ManagementManagement

• 1 course of broad spectrum 1 course of broad spectrum antibioticsantibiotics

• Consider bloodwork and Consider bloodwork and imagingimaging

• REFERALREFERAL

PearlsPearls

• Avoid excisional biopsiesAvoid excisional biopsies

• Use CT but consider MRI for Use CT but consider MRI for salivary gland problemssalivary gland problems

• Role of nonionizing ultrasoundRole of nonionizing ultrasound

–Like a stethoscope?Like a stethoscope?

National Comprehensive Cancer National Comprehensive Cancer NetworkNetwork

• Use Use www.nccn.orgwww.nccn.org for evidence-based, for evidence-based, consensus guidelines for:consensus guidelines for:– StagingStaging– EvaluationEvaluation– ReferencesReferences– TreatmentTreatment– All sitesAll sites– Updated annually.Updated annually.