MRCS teaching 01 September 2015 Approach to neck lump, thyroid lumps and cancers, and parathyroid disorders MRCS 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 CT scan MRI PET 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 Nodules Cooper, 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 2.2013 Cooper, 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 Anaplastic 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