11. History
Developmental time course
Associated symptoms (dysphagia, otalgia, voice)
Personal habits (tobacco, alcohol)
Previous irradiation or surgery
Physical Examination
Complete head and neck exam (visualize & palpate)
Emphasis on location, mobility and consistency
12. Inflammatory mass suspected
Two week trial of antibiotics
Follow-up for further investigation
14. Standard of diagnosis
Indications
Any neck mass that is not an obvious
abscess
Persistence after a 2 week course of
antibiotics
Small gauge needle
Reduces bleeding
Seeding of tumor – not a concern
No contraindications (vascular ?)
15.
16. Distinguish cystic from
solid
Extent of lesion
Vascularity (with contrast)
Detection of unknown
primary (metastatic)
Pathologic node (lucent,
>1.5cm, loss of shape)
Avoid contrast in thyroid
lesions
17. Similar
informati
on as CT
Better for
upper
neck and
skull
base
Vascular
delineati
on with
infusion
18. Less important
now with FNAB
Solid versus cystic
masses
Congenital cysts
from solid
nodes/tumors
Noninvasive
(pediatric)
19. Salivary and thyroid
masses
Location – glandular
versus extra-glandular
Functional information
FNAB now preferred for
for thyroid nodules
Solitary nodules
Multinodular goiter
with new increasing
nodule
Hashimoto’s with new
nodule
20. Any solid asymmetric mass MUST
be
considered a metastatic neoplastic
lesion until proven otherwise
Asymptomatic cervical mass
12% of cancer
~ 80% of these are SCCa
21. Ipsilateral otalgia with normal otoscopy –
direct attention to tonsil, tongue base,
supraglottis and hypopharynx
Unilateral serous otitis – direct examination
of nasopharynx
22. Panendoscopy
FNAB positive with no primary on repeat exam
FNAB equivocal/negative in high risk patient
Directed Biopsy
All suspicious mucosal lesions
Areas of concern on CT/MRI
None observed – nasopharynx, tonsil
(ipsilateral tonsillectomy for jugulodigastric
nodes), base of tongue and piriforms
Synchronous primaries (10 to 20%)
23. Unknown primary
University of Florida (August, 2001)
Detected primary in 40%
Without suggestive findings on CT or panendoscopy
yield dropped to 20%
Tonsillar fossa in 80%
24. Open excisional biopsy
Only if complete workup negative
Occurs in ~5% of patients
Be prepared for a complete neck dissection
Frozen section results (complete node
excision)
Inflammatory or granulomatous – culture
Lymphoma or adenocarcinoma – close
wound
25. Congenital masses
Benign lesions
Vascular and lymphatic malformations
Infectious and inflammatory conditions
Malignant lesions
26. Thyroid mass Carotid body
Lymphoma and glomus
Salivary tumors tumors
Lipoma Neurogenic
tumors
27. Leading cause of anterior
neck masses
Children
Most common neoplastic
condition
Male predominance
Higher incidence of
malignancy
Adults
Female predominance
Mostly benign
28. Lymph node metastasis
Initial symptom in 15% of papillary
carcinomas
40% with malignant nodules
Histologically (microscopic) in >90%
FNAB has replaced USG and radionucleotide
scanning
Decreases # of patients with surgery
Increased # of malignant tumors found at
surgery
Doubled the # of cases followed up
Unsatisfactory aspirate – repeat in 1 month
32. Usually picked up on routine physical exam or
as incidental finding
Patients may have clinical or subclinical
thyrotoxicosis
Patients may have compressive symptoms:
tracheal, vascular, esophageal, recurrent
laryngeal nerve
34. Antithyroid Drugs
May require prolonged therapy
Radioactive iodine
May worsen ophthalmopathy unless
followed by steroids
Surgery
Make patient euthyroid prior to surgery
Potassium iodide two weeks prior to surgery
can decrease the vascularity of the gland
35. Autonomously functioning thyroid nodule
hypersecreting T3 and T4 resulting in
thyrotoxicosis (Plummer’s disease)
Almost never malignant
Manage with antithyroid drugs followed by
either I-131 or surgery
36. Also known as Hashimoto’s disease
Probably the most common cause of
hypothyroidism
Autoantibodies include: thyroglobulin
antibody, thyroid peroxidase antibody, TSH
receptor blocking antibody
37. Painless goiter in a patient who is either
euthyroid or mildly hypothyroid
Low incidence of permanent hypothyroidism
May have periods of thyrotoxicosis
Treat with levothyroxine
38. Also known as De Quervain's
thyroiditis
Most common cause of thyroid pain and
tenderness
Acute inflammatory disease most likely due to
viral infection
Transient hyperthyroidism followed by
transient hypothyroidism; permanent
hypothyroidism or relapses are uncommon
39. Symptomatic: NSAIDS or a
glucocorticoid
Beta-blockers indicated if there are
signs of thyrotoxicosis
Levothyroxine may be given during
hypothyroid phase
40. Rare disorder usually affecting middle-aged
women
Likely autoimmune etiology
Fibrous tissue replaces thyroid gland
Patients present with a rapidly
enlarging hard neck mass
41. 1.0%-1.5% of all new cancer cases
tenfold less than that of lung,
breast, or colorectal cancer
8,000-14,000 new cases diagnosed each year
(Sessions, 1993, Geopfert, 1998)
3% of patients who die of other causes have
occult thyroid cancer and 10% have microscopic
cancers (Robbins, 1991)
35% of thyroid gland at autopsy in some studies
have papillary carcinomas (<1.0cm) (Mazzaferri,
1993)
42. 1,000-1,200 patients in the U.S. die each year of
thyroid cancer (Goldman, 1996)
4%-7% of adults in North America have
palpable thyroid nodules (Mazzaferri, 1993, Vander,
1968)
4:1 women to men (Mazzaferri, 1993)
Overall, fewer than 5% of nodules are malignant
(Mazzaferri, 1988)
43. Symptoms
The most common presentation of a thyroid
nodule, benign or malignant, is a painless mass
in the region of the thyroid gland (Goldman, 1996).
Symptoms consistent with malignancy
Pain
dysphagia
Stridor
hemoptysis
rapid enlargement
hoarseness
44. Risk factors
Thyroid exposure to irradiation
low or high dose external irradiation (40-50 Gy
[4000-5000 rad])
especially in childhood for:
large thymus, acne, enlarged tonsils, cervical
adenitis, sinusitis, and malignancies
30%-50% chance of a thyroid nodule to be
malignant (Goldman, 1996)
Schneider and co-workers (1986) studied, with
long term F/U, 3000 patients who underwent
childhood irradiation.
1145 had thyroid nodules
318/1145 had thyroid cancer (mostly papillary)
45. Family History
History of family member with medullary
thyroid carcinoma
History of family member with other endocrine
abnormalities (parathyroid, adrenals)
History of familial polyposis (Gardner’s
syndrome)
46. Examination of the thyroid nodule:
consistency - hard vs. soft
size - < 4.0 cm
Multinodular vs. solitary nodule
multi nodular - 3% chance of malignancy
(Goldman, 1996)
solitary nodule - 5%-12% chance of
malignancy (Goldman, 1996)
Mobility with swallowing
Mobility with respect to surrounding tissues
Well circumscribed vs. ill defined borders
47. Examine for ectopic thyroid tissue
Indirect or fiberoptic laryngoscopy
vocal cord mobility
evaluate airway
preoperative documentation of any
unrelated abnormalities
Systematic palpation of the neck
Metastatic adenopathy commonly found:
in the central compartment (level VI)
along middle and lower portion of the
jugular vein (regions III and IV) and
Attempt to elicit Chvostek’s sign
49. Advantages
Most sensitive procedure or identifying lesions
in the thyroid (2-3mm)
90% accuracy in categorizing nodules as solid,
cystic, or mixed (Rojeski, 1985)
Best method of determining the volume of a
nodule (Rojeski, 1985)
Can detect the presence of lymph node
enlargement and calcifications
Noninvasive and inexpensive
50. Currently considered to be the best first-line
diagnostic procedure in the evaluation of the thyroid
nodule:
Advantages:
Safe
Cost-effective
Minimally invasive
Leads to better selection of patients for
surgery than any other test (Rojeski, 1985)
51. Mechanism/Rationale
Exogenous thyroid hormone feeds back to
the pituitary to decrease the production of
TSH
Cancer is autonomous and does not require
TSH for growth whereas benign processes do
Thyroid masses that shrink with suppression
therapy are more likely to be benign
Thyroid masses that continue to enlarge are
likely to be malignant
52. Limitations:
16% of malignant nodules are suppressible
Only 21% of benign nodules are suppressible
Provides little use in distinguishing benign from
malignant nodules
(Geopfert, 1998)
53. Uses:
Preoperative
patients with nonoxyphilic follicular neoplasms
patients with solitary benign nodules that are
nontoxic (particularly men and premenopausal
women)
women with repeated nondiagnostic tests
Postoperative
Use in follicular, papillary and Hurthle cell
carcinomas
(Geopfert, 1998, Mazzaferri, 1993)
54. How to use thyroid suppression
administer levothyroxine
maintain TSH levels at <0.1 mIU/L
use ultrasound to monitor size of nodule
if the nodule shrinks, continue L-thyroxine
maintaining TSH at low-normal levels
if the nodule has remained the same size after 3
months, reaspirate
if the nodule has increased in size, excise it
(Geopfert, 1998,)
56. Pathogenesis - unknown
Papillary has been associated with the RET proto-
oncogene but no definitive link has been proven
(Geopfert, 1998)
Certain clinical factors increase the likelihood of
developing thyroid cancer
Irradiation - papillary carcinoma
Prolonged elevation of TSH (iodine deficiency) -
follicular carcinoma (Goldman, 1996)
relationship not seen with papillary carcinoma
mechanism is not known
57. 60%-80% of all thyroid cancers (Geopfert, 1998, Merino, 1991)
Histologic subtypes
Follicular variant
Tall cell
Columnar cell
Diffuse sclerosing
Encapsulated
Prognosis is 80% survival at 10 years (Goldman, 1996)
Females > Males
Mean age of 35 years (Mazzaferri, 1994)
58. Lymph node involvement is common
Major route of metastasis is lymphatic
46%-90% of patients have lymph node involvement
(Goepfert, 1998, Scheumann, 1984, De Jong, 1993)
Clinically undetectable lymph node involvement does not
worsen prognosis (Harwood, 1978)
59. 20% of all thyroid malignancies
Women > Men (2:1 - 4:1) (Davis, 1992, De Souza, 1993)
Mean age of 39 years (Mazzaferri, 1994)
Prognosis - 60% survive to 10 years (Geopfert, 1994)
Metastasis - angioinvasion and hematogenous
spread
15% present with distant metastases to bone and lung
Lymphatic involvement is seen in 13% (Goldman,
1996)
60. Variant of follicular carcinoma
First described by Askanazy
“Large, polygonal, eosinophilic thyroid follicular cells
with abundant granular cytoplasm and numerous
mitochondria” (Goldman, 1996)
Definition (Hurthle cell neoplasm) - an
encapsulated group of follicular cells with at least
a 75% Hurthle cell component
Carcinoma requires evidence of vascular and
capsular invasion
4%-10% of all thyroid malignancies (Sessions, 1993)
61. Depending on variables, patients are categorized
in to one of the following three groups:
1) Low risk group - men younger than 40
years and women younger than 50 years
regardless of histologic
type
- recurrence rate -11%
- death rate - 4%
(Cady and Rossi, 1988)
62. 1) Intermediate risk group - Men older than 40
years and women older than 50 years who have
papillary carcinoma
- recurrence rate - 29%
- death rate - 21%
2) High risk group - Men older than 40 years and
women older than 50 years who have follicular
carcinoma
- recurrence rate - 40%
- death rate - 36%
63. 10% of all thyroid malignancies
1000 new cases in the U.S. each year
Arises from the parafollicular cell or C-cells of the
thyroid gland
derivatives of neural crest cells of the branchial arches
secrete calcitonin which plays a role in calcium
metabolism
64. Familial MTC:
Autosomal dominant transmission
Not associated with any other endocrinopathies
Mean age of 43
Multifocal and bilateral
Has the best prognosis of all types of MTC
100% 15 year survival
(Farndon, 1986)
65. Multiple endocrine neoplasia IIa (Sipple’s
Syndrome):
MTC, Pheochromocytoma, parathyroid
hyperplasia
Autosomal dominant transmission
Mean age of 27
100% develop MTC (Cance, 1985)
85%-90% survival at 15 years (Alexander, 1991,
Brunt, 1987)
66. Multiple endocrine neoplasia IIb (Wermer’s
Syndrome, MEN III, mucosal syndrome):
Pheochromocytoma, multiple mucosal
neuromas, marfanoid body habitus
90% develop MTC by the age of 20
Most aggressive type of MTC
15 year survival is <40%-50%
(Carney, 1979)
67. Highly lethal form of thyroid cancer
Median survival <8 months (Jereb, 1975, Junor, 1992)
1%-10% of all thyroid cancers (Leeper, 1985, LiVolsi, 1987)
Affects the elderly (30% of thyroid cancers in
patients >70 years) (Sou, 1996)
Mean age of 60 years (Junor, 1992)
53% have previous benign thyroid disease
(Demeter, 1991)
47% have previous history of WDTC (Demeter, 1991)
68. Surgery is the definitive management of thyroid
cancer, excluding most cases of ATC and lymphoma
Types of operations:
lobectomy with isthmusectomy - minimal operation
required for a potentially malignant thyroid nodule
total thyroidectomy - removal of all thyroid tissue
- preservation of the contralateral
parathyroid glands
subtotal thyroidectomy - anything less than a total
thyroidectomy
69. Rationale for total thyroidectomy
1) 30%-87.5% of papillary carcinomas involve
opposite lobe (Hirabayashi, 1961, Russell, 1983)
2) 7%-10% develop recurrence in the contralateral
lobe (Soh, 1996)
3) Lower recurrence rates, some studies show
increased survival (Mazzaferri, 1991)
4) Facilitates earlier detection and tx for recurrent
or metastatic carcinoma with iodine (Soh, 1996)
5) Residual WDTC has the potential to
dedifferentiate to ATC
70. Rationale for subtotal thyroidectomy
1) Lower incidence of complications
Hypoparathyroidism (1%-29%) (Schroder, 1993)
Recurrent laryngeal nerve injury (1%-2%)
(Schroder, 1993)
Superior laryngeal nerve injury
2) Long term prognosis is not improved by
total thyroidectomy (Grant, 1988)
71. Indications for total thyroidectomy
1) Patients older than 40 years with papillary or follicular
carcinoma
2) Anyone with a thyroid nodule with a history of
irradiation
3) Patients with bilateral disease
72. Postoperative therapy/follow-up
Radioactive iodine (administration)
Scan at 4-6 weeks postop
repeat scan at 6-12 months after ablation
repeat scan at 1 year then...
every 2 years thereafter
73. Postoperative therapy/follow-up
Thyroglobulin (TG) (Gluckman)
measure serum levels every 6 months
Level >30 ng/ml are abnormal
Thyroid hormone suppression (control TSH
dependent cancer) (Goldman, 1996)
should be done in - 1) all total thyroidectomy
patients
2) all patients who have had
radioactive ablation of any
remaining thyroid tissue
74. Most have extensive extrathyroidal
involvement at the time of diagnosis
surgery is limited to biopsy and tracheostomy
Current standard of care is:
maximum surgical debulking, possible
adjuvant radiotherapy and chemotherapy
(Jereb and Sweeney, 1996)