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

2. Current Surgical Therapy: Evaluation of the isolated neck mass by Philip, Smith et al

3. Clinical Anatomy: Applied Anatomy for Students and Junior Doctors by Ellis and Mahadevan

4. Clinical Anatomy: Applied Anatomy for Students and Junior Doctors by Ellis and Mahadevan

7. Current Surgical Therapy: Evaluation of the isolated neck mass by Philip, Smith et al

8. 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

9. 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

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

11. Current Surgical Therapy: Evaluation of the isolated neck mass by Philip, Smith et al

12. 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

13. 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

14. Thyroid

15. 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 (2009):

16. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Thyroid Carcinoma Version

17. Current Surgical Therapy: Management of Thyroid Nodules

18. Thyroid carcinoma Papillary thyroid cancer Follicular cancer
Hürthle cell cancer
Anaplastic cancer
Medullary thyroid cancer
Lymphoma

19. 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
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 (2009):

20. 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

21. 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

22. Parathyroid

23. 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

24. 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

25. 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

26. 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