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NECK MASSES: UNC MS III SURGERY

NECK MASSES: UNC MS III SURGERY. Case discussions by students Discussion of thyroid disorders Discussion of how to develop a differential diagnosis Management algorithm. THYROID. COLIN G THOMAS, Jr. MD Professor, Department of Surgery University of North Carolina.

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NECK MASSES: UNC MS III SURGERY

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  1. NECK MASSES:UNC MS III SURGERY • Case discussions by students • Discussion of thyroid disorders • Discussion of how to develop a differential diagnosis • Management algorithm

  2. THYROID COLIN G THOMAS, Jr. MD Professor, Department of Surgery University of North Carolina

  3. Incidence of Thyroid Disorders in Connecticut(Annual physical Examination, 1544 Patients – One Year) #% Simple goiter 29 1.88 Graves’ disease 15 0.97 Iatrogenic hyperthyroidism 2 0.10 Hot nodule 9 0.58 Multinodular goiter 13 0.84 Thyroiditis 8 0.51 Single cold nodule 8 0.51 Hypothyroidism 6 0.39 Cancer 0 0.00 Total 90 5.78

  4. Cancer Incidence and DeathsEstimated- U.S. 2005 Organ System New Cases Deaths Lung 172,570 163,510 Colon 104,950 56,290 Rectum 42,000 7,000 Pancreas 32,180 31,800 Breast 212,930 40,870 Stomach 24,000 14,000 Thyroid 25,690 1,490 Prostate 232,090 30,050

  5. Thyroid Cancer 1985 1994 1998 New Cases 10,000 13,900 17,200 (↑ 72%) Deaths 1,100 1,120 1,200 (↑8%) American Cancer Society 1998

  6. Evaluations of Nodular Thyroid Disease • History- symptoms, duration, familial • Physical findings, i.e. topography, firmness, surface, lymphadenopathy • Thyroid functions tests- TFT (s) - TSH

  7. Diagnostic Studies- Thyroid Cancer Fine Needle Aspiration- Establishes Cytologic Diagnosis Thyroid function tests (TSH- 1st in Thyroiditis) Technetium Scan- reflects trapping function, “hot nodule” Ultrasonography- reflects volume, composition, occult nodules

  8. Thyroid Cancer- Diagnosis • Cytology • Scans • Technetium • Radioiodine • Sestamibi • MR/CT/PET • Ultrasound • Frozen Sections • Fixed Sections

  9. Thyroid Cancers* Papillary 80% Follicular 11% Hürthle 3% Medullary 4% Anaplastic 2% *National Cancer Data Base 31,513 patients (1985-1995)

  10. Biological Characteristics • Thyrotropin Receptor- • Adenylate Cyclase Systems • Iodine Trapping/Organification • Thyroglobin Production

  11. Papillary Carcinoma • Ames (Age, Distant Metastases, Extent, Size) • 89%- Low risk; Mortality 1.8% and • 11% High Risk, Mortality 46%

  12. Adjuvant Therapy Thyroxine → TSH Suppression Radiodiodine (Ablation/Rx) Thyroxine ↓ → TSH ↑ Recombinant TSH External Radiation (?) Chemotherapy (?)

  13. Neck Masses Marion Couch, MD PhD Department of OHNS University of North Carolina

  14. Some pearls: • 90% of adult neck masses are malignant • 90% of pediatric neck masses are infectious in nature • Know your anatomy then develop a differential diagnosis • Close observation • Generally, one course of a broad spectrum antibiotic is acceptable then …..

  15. It is never wrong to refer to a specialist for evaluation and probable biopsy • Imaging is important but tissue is everything • If you don’t get an answer with a FNA, repeat it up to three times. Consider ultrasound guided or CT guided FNA. • Never violate a neck or I will come after you.

  16. HISTORY • Age • Duration • Acute symptoms • Recent travel • Trauma • Insect bites, pets • Tobacco, alcohol, XRT

  17. CONGENITAL • Central neck: • Thyroglossal duct cysts • Pyramidal lobe of thyroid • Sebaceous cysts • Hemangiomas • Laryngocele • Ectopic thyroid • Lateral neck: • Branchial cleft cysts • Cystic hygromas • Dermoids

  18. Branchial cleft cyst

  19. Branchial cleft cysts

  20. Branchial cleft cyst

  21. Branchial cleft cyst

  22. Inflammation • Reactive lymphadenopathy • Sialoadenitis • Cervical adenitis

  23. Infectious • Staph and strep • EBV – mono • TB • Atypical TB • HIV • Cat scratch fever (Bartonella henselae) • Toxoplasmosis • Actinomycosis • Tick-borne: Rocky Mountain Spotted Fever • Lemierre’s Syndrome: septic thromb. IJV

  24. Trauma • Hematoma • Acute and expanding • Chronic and organizing • AV fistula • Pseudoaneurysm

  25. Metabolic, Idiopathic, Autoimmune • Castleman’s disease • Sarcoidosis • Kimura’s disease

  26. Neoplasms • Benign: • Lipomas • Neuromas • Fibromas • Hemangiomas • Carotid body tumors • Angiomas

  27. Neoplasms • Malignant • Thyroid • Squamous cell carcinoma (SCAA) • Lymphoma • Sarcoma • Salivary gland tumors • Metastasis: • SCCA, adenocarcinoma, undifferentiated carcinoma, melanoma

  28. Management • 1 course of broad spectrum antibiotics • Consider bloodwork and imaging • REFERAL

  29. Pearls • Avoid excisional biopsies • Use CT but consider MRI for salivary gland problems • Role of nonionizing ultrasound • Like a stethoscope?

  30. National Comprehensive Cancer Network • Use www.nccn.org for evidence-based, consensus guidelines for: • Staging • Evaluation • References • Treatment • All sites • Updated annually.

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