1. “A lump in the neck” Robert Schmidli
Senior Lecturer, ANU Medical School
Senior Staff Specialist, The Canberra Hospital

2. Case 1 45 year old lady Neck mass to right of midline
Present for years
Presented with unrelated complaint

3. History No increase in size No dysphagia No stridor No cough
No sensation of constriction on raising arms
“nervousness”, reduced sleep

4. Examination Rather overweight Weight 109.4kg
Pulse 80 per minute regular
No tremor, thyroid eye signs
Skin warm
Thyroid generally enlarged
Retrosternal dullness
Large 6x6cm mass right of midline
Another smaller mass in left lobe
No lymphadenopathy
Pemberton’s sign negative

5. Thyroid function tests
FT4 20 pmol/l [normal]
FT3 8.5 pmol/l [N ]
TSH <0.005 mU/l [N ]

6. Investigations Thyroid antibodies Thyroid stimulating immunoglobulin
Thyroglobulin
Neck ultrasound
Nuclear scan
Fine needle aspiration
CT thoracic inlet
Chest X-ray

7. Nuclear scan
Both lobes are enlarged. Heterogeneous uptake is seen in both lobes. There are multiple large areas of reduced uptake in both lobes. These are suggestive of non-functioning nodules and the largest of them are in the upper/mid pole of the left lobe. There are also a few small areas of increased uptake in both lobes suggesting functioning nodules. No retrosternal extension is noted. Uptake is normal at 3.3%

8. Ultrasound
Both lobes of the thyroid are increased in size by large solitary nodules.
The right lobe measures 6.5cm in bipolar length ad contains a solitary wee defined smooth hypoechoic solid mass measuring 5x1.8x2cm.
The left lobe measures 7.3c in bipolar length and contains a central 3.4x4.9x2.1 predominantly hyperechoic solid mass which is well defined but contains cystic spaces.

9. Treatment “Wait and see” Antithyroid drugs Radioactive iodine
Thyroxine suppression
Lugol’s iodine drops
Total thyroidectomy

10. Case 2 “Jennifer” 40 year old public servant
Painless lump in neck since Nov 2006
Good general health

11. Features Increasing size since onset No dysphagia No stridor No cough
No sensation of constriction on raising arms
No weight loss
No symptoms thyroid dysfunction

12. Examination Firm mass 3.5 x 3.5cm mass to right of midline
No lymphadenopathy
Pemberton’s sign negative
No stridor
No retrosternal dullness
Clinically euthyroid

13. Aspiration cytology
The smears show variable cellularity and variable colloid. On some of the smears there is an abundant cellularity with little colloid while other smears there is abundant colloid with fewer cells. In the more cellular areas these cells form microfollicles with little luminal colloid. The nuclei are small and regular with a follicular appearance. The cytoplasm is relatively delicate. Nuclear crowding is minimal and mitotic figures are not seen.
In the areas of abundant colloid these cells are relatively few suggesting aspiration from macrofollicles or a cystic lesion. The cells that are present are small and benign appearing with bare nuclei or a moderate amount of delicate cytoplasm. In addition, haemosiderin laden macrophages are present.
The overall appearances are somewhat atypical due to the areas of cellularity with little colloid. This however, may represent an area of hyperplasia in a colloid nodule.
CONCLUSION:
This an atypical follicular lesion and further investigation is warranted.

14. Options Repeat fine needle aspirate Core biopsy
Repeat ultrasound in 3 months
Nuclear scan
Lumpectomy and histology
Total thyroidectomy

15. Case 3 30 year-old student Type 1 diabetes – regular visit
Tremulous voice
Warm sweaty skin, tremor
Pulse 100/m

16. Symptoms Tremor Muscle weakness Palpitations Sweaty Heat intolerance
 frequency bowel motions
Light periods
Eye irritation

17. Examination Tachycardia Warm skin Tremor Brisk reflexes
Proximal weakness
Diffusely enlarged thyroid, bruit
Conjunctivitis

18. Investigations FT4 53.8 nmol/l [10-24] FT3 36.1 pmol/l [4.3-8.1]
TSH <0.03 mU/l [ ]
TSI 22 mU/l [<10]
TGAb <20 U/ml [<40]
TPOAb [<35]

19. Imaging
None required
Thyroid ultrasound
Nuclear scan

20. Nuclear scan
There is a uniform increase in tracer uptake throughout the gland with an uptake ration of 9.1% (normal ). The frontal area of the gland is normal.

21. Treatment options Antithyroid drugs Radioactive iodine
Complete ablation
Partial ablation
Partial thyroidectomy
Total thyroidectomy