This document provides an overview of evaluating neck masses, with a focus on the thyroid gland. It discusses the anatomy of the neck, characteristics of common neck masses, diagnostic tools such as biopsy and imaging, and characteristics and management of various thyroid conditions. Prominent topics include thyroid cancer risk factors, symptoms of malignant thyroid nodules, and examination findings suggestive of thyroid cancer.

1. Evaluation of the Neck:
The Thyroid Gland
Frederick Untalan MD

2.  Common clinical finding – NECK MASS
 All age groups
 Very complex differential
diagnosis!
 Systematic approach essential

4.  Prominent
landmarks
 Triangles of
the neck
 Carotid bulb
 Lymphatic
levels

5.  Prominent
landmarks
 Triangles of the
neck
 Carotid bulb
 Lymphatic levels

6.  Prominent
landmarks
 Triangles of the
neck
 Carotid bulb
 Lymphatic levels

9.  Patient age
 Pediatric (0 – 15 years): 90% benign
 Young adult (16 – 40 years): similar to pediatric
 Late adult (>40 years): “rule of 80s”
 Location
 Congenital masses: consistent in location
 Metastatic masses: key to primary lesion

10. Metastasis Location according
to Various Primary Lesions

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

13.  Fine needle aspiration biopsy (FNAB)
 Computed tomography (CT)
 Magnetic resonance imaging (MRI)
 Ultrasonography
 Radionucleotide scanning

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 ?)

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

30. Nodular goiter
Goiter displacing the trachea

31.  Benign Nontoxic Conditions
 Diffuse and Nodular Goiter
 Benign Toxic Conditions
 Toxic Multinodular Goiter
 Graves’ Disease
 Toxic Adenoma
 Inflammatory Conditions
 Chronic (Hashimoto’s) Thyroiditis
 Subacute (De Quervain’s) Thyroiditis
 Riedel’s Thyroiditis

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

33.  Suppressive Therapy
 Antithyroid Medications: Propylthiouracil and
Methimazole
 I-131
 Surgical Therapy

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

48.  Thyroid function tests
 thyroxine (T4)
 triiodothyronin (T3)
 thyroid stimulating hormone (TSH)
 Serum Calcium
 Thyroglobulin (TG)
 Calcitonin

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,)

55.  Papillary carcinoma  Medullary Carcinoma
 Follicular variant  Miscellaneous
 Sarcoma
 Tall cell
 Lymphoma
 Diffuse sclerosing  Squamous cell carcinoma
 Encapsulated  Mucoepidermoid
 Follicular carcinoma carcinoma
 Overtly invasive  Clear cell tumors
 Pasma cell tumors
 Minimally invasive
 Metastatic
 Hurthle cell carcinoma
 Direct extention
 Anaplastic carcinoma
 Kidney
 Giant cell  Colon
 Small cell  Melanoma

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)