Download Anterior Neck Mass

Thyroid Malignancy
• 39 y/o female from Bicol
• C/C: anterior neck mass
HPI
• History of slow growing nodular anterior neck mass
10 yrs PTC • No other accompanying symptoms
• Rapid increase in size of mass
2 yrs PTC
• Hoarseness and difficulty swallowing
6 mo PTC
ROS
• No fever, weight loss and tremors
• No chest pain and easy fatigability
• No abdominal pain
• Past medical and family history both
unremarkable
Physical Examination
• PR = 100/min
RR = 20/min
Temperature = 37 °C
• No exophthalmos
• Neck:
– 12x10 cm multilobulated firm mass on the left
neck, moves with deglutition
What is your clinical impression?
What are the differential diagnosis?
Differential Diagnoses
Patient
Thyroid Carcinoma
Toxic Multinodular
Goiter
Rapid increase in size of
the mass
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Hoarseness and
difficulty in swallowing
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Weight loss
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Tremors
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Exophthalmos
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Easy Fatigability
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Palpable cervical
lymphadenopathy
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Thyroid cancer
• Most common malignancy of the endocrine
system
• Accounts for less than 1% of all malignancies
• Common among chinese males & filipino
females
Risk factors for thyroid carcinoma in
patients with thyroid nodule
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History of head & neck irradiation
Age <20 or > 70 y/o
Increased nodule size (>4cm)
New or enlarging neck mass
Male gender
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Family history of thyroid cancer or MEN 2
Vocal cord paralysis, hoarse voice
Nodule fixed to adjacent structures
Suspected lymph node involvement
Iodine deficiency (follicular)
Clinical features:
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Lump in the neck
Gradually enlarging mass
Firm or hard
Rapidly growing: soft or fluctuant
May be painful
May present with hoarseness, dysphagia,
dysphonia, dyspnea
• Rare: hyperthyroidism
Papillary Carcinoma
• 80-85%
• Predominant: children & individuals exposed to
external radiation
• 2:1 F:M ratio
• Mean age: 30-40 y/o
• S/Sx: slow growing painless mass
– Dysphagia, dyspnea, dsyphonia
– Lymph nodes metastases (common)
– Distal mets uncommon (lungs, bone, liver, brain)
• Characteristic cellular patterns: Orphan Annie
nuclei
• Psamomma bodies
• Multifocality (85%)
• Prognosis: excellent (95% 10 yr survival rate)
Diagnosis
• discovered when a hard nodule is found in
multinodular goiter
• when enlarged cervical lymph nodes are detected
• when there are unidentified metastatic lesions
elsewhere in the body
• Other clinical signs that could indicate papillary
thyroid are:
– fixation to the trachea, stony hardness, damage to
recurrent laryngeal or cervical sympathetic nerves.
Follicular Carcinoma
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Second most common (10%)
Iodine deficient areas
3:1 F:M ratio
Mean age: 50 y/o
Usually solitary (rapid size increase & goiter)
s/sx: pain & cervical lymphadenopathy
uncommon initial presentation
• 1%: hyperfunctioning - thyrotoxicosis
• Solitary & encapsulated
• Prognosis: mortality 15% at 10 yrs, 30% at 20
yrs
Hurthle Cell CA
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3-5%
Variant of follicular CA
Vascular or capsular invasion
Multifocal & bilateral
Metastasize to local & distant sites
Higher mortality rate
Medullary CA
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5%
From parafollicular or C cells
1.5:1 F:M ratio
Mean age: 50-60 y/o
70-80% are sporadic
20-30% familial autosomal dominant
syndromes
• s/sx:neck mass w/ cervical lymphadenopathy
- local pain
- dysphagia, dyspnea or dysphonia
• 2-4%: Cushing’s syndrome
• Unilateral (sporadic); multicentric (familial)
• Presence of amyloid
• Prognosis: related to disease stage
Anaplastic CA
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1%
F>M
Mean age: 65 y/o
s/sx: rapidly enlarging, long standing neck
mass, painful
- dysphonia, dysphagia, dyspnea
• Tumor: large, hard, poorly circumscribed &
fixed
• Palpable lymph nodes
• Metastatic spread
• Prognosis: one of the most aggressive, few
survive beyond 6 months
Lymphoma
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<1%
Most: Non-Hodgkin’s B-cell type
2-3xF>M
Age: 62 y/o
Patients with chronic lymphocytic thyroiditis
Prognosis: overall 5 yr survival rate: 50%
2. What work ups are needed, if
any?
Evaluation of a Thyroid Nodule
• History
– Risk factors for thyroid cancer
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History of thyroid irradiation, especially in infancy or childhood
Age < 20 yr
Male sex
Family history of thyroid cancer or multiple endocrine neoplasia
A solitary nodule
Dysphagia
Dysphonia
Increasing size (particularly rapid growth or growth while receiving thyroid
suppression treatment)
• Physical Examination
– Signs that suggest thyroid cancer
• stony hard consistency or fixation to surrounding structures
• cervical lymphadenopathy
• hoarseness due to recurrent laryngeal nerve paralysis
Testing
Testing
• Fine-Needle Aspiration Biopsy (FNAB)
– Cornerstone in the evaluation of solitary thyroid
nodules and also dominant nodules within
multinodular goiters
– Currently considered to be the best first-line
diagnostic procedure in the evaluation of the
thyroid nodule
Fine-Needle Aspiration Biopsy
• Advantages:
– Safe
– Cost-effective
– Minimally invasive
– Leads to better selection of patients for surgery
than any other test (Rojeski, 1985)
– Halved the number of patients requiring
thyroidectomy (Mazzaferri, 1993)
– Double the yield of cancer in those who do
undergo thyroidectomy (Mazzaferri, 1993)
Fine-Needle Aspiration Biopsy
• Four Categories of Cytologic Diagnosis
– Benign (Negative) – 69%
– Suspicious (Indeterminate) – 10%
– Malignant (Positive) – 4%
– Unsatisfactory (Nondiagnostic) – 17%
Reference: Gharib, H. (2008). Fine-Needle Aspiration Biopsy of the Thyroid Gland. Thyroid Disease Manager.
Fine-Needle Aspiration Biopsy
• Limitations
– Skill of the aspirator
– Expertise of the cytologist
– Difficulty in distinguishing some benign cellular adenomas from
their malignant counterparts (follicular and Hurthle cell)
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Sensitivity: 65 – 98% (avg. 83%)
Specificity: 72 – 100% (avg. 92%)
Positive Predictive Value: 50 – 96% (avg. 75%)
False-negative Rates: 1.5 – 11.5% (avg. < 5%)
False-positive Rates: 0 – 8% (avg. 3%)
Reference: Gharib, H. (2008). Fine-Needle Aspiration Biopsy of the Thyroid Gland. Thyroid Disease Manager.
CT/MRI
Low risk:
Younger patients (men =/< 40, women =/<
50) with no metastases
Older patients (intrathyroid papillary, minor
capsular invasion for follicular lesions)
Primary cancers <5 cm
AMES
No distant metastases
High risk:
All patients with distant metastases
Extrathyroid papillary, major capsular
invasion follicular
Primary cancers >/= 5 cm in older patients
(men >40, women >50)
Survival by AMES risk-groups (20-yr):
Low risk = 99%
High risk = 61%
MAICS
AMES
Surgical Treatment: Papillary CA
High risk or bilateral tumors:
Total or near - total thyroidectomy
Minimal Papillary Thyroid Tumor
Unilateral lobectomy and isthmusectomy
Total Thyroidectomy
Unilateral Lobectomy
•Enables the use of RAI for
•Lower complication rate
detecting and treating residual
•Recurrence is unusual (5%)
thyroid tissue and metastatic
•Excellent prognosis
disease.
•Makes serum Tg level a more
sensitive marker of recurrent or
persistent disease
•Eliminates contralateral occult
cancer as sites of recurrence
•Reduces risk of recurrence
•Increases survival
•Decreases 1% risk of progression
to ATC
•Reduces need for reoperative
surgery
Why Thyroidectomy?
• Recurrence rates are lowered and survival is
improved when a patient underwent
thyroidectomy
• Diminished survival was noted in patients with
low-risk disease
Total Thyroidectomy
• Enables the use of RAI for detecting and treating
residual thyroid tissue and metastatic disease.
• Makes serum Tg level a more sensitive marker of
recurrent or persistent disease
• Eliminates contralateral occult cancer as sites of
recurrence
• Reduces risk of recurrence
• Increases survival
• Decreases 1% risk of progression to ATC
• Reduces need for reoperative surgery
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 RAI (Soh, 1996)
5) Residual WDTC has the potential to
dedifferentiate to ATC
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
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)
Complications
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Injury to RLN, Superior Laryngeal Nerve
Transient hypocalcemia (50%)
Permanent hypoparathyroidism (<2%)
Postoperative hematoma
Bilateral vocal cord dysfunction
Postoperative Management of
Differentiated Thyroid Cancer
• Thyroid Hormone
– After thyroidectomy, should placed on
thyroxine to ensure that the patient remains
euthyroid
– serves as a replacement therapy and also
suppresses TSH
– reduces growth stimulus to possible
residual cancer cells
– reduces recurrence rates (papillary ca)
– risk of tumor recurrence must be balanced
with the side effects associated with
prolonged TSH suppression, including
osteopenia and cardiac problems,
particularly in older patients
Postoperative Management of
Differentiated Thyroid Cancer
• Thyroglobulin Measurement
– levels in patients who have undergone total
thyroidectomy should be below 2 ng/mL when
the patient is taking T4, and below 5 ng/mL
when the patient is hypothyroid
– level above 5ng/mL is highly suggestive of
metastatic disease or persistent normal thyroid
tissue. In this situation, radioiodine scan should
be performed.
– Measure serum levels every 6 months, and then
annually if the patient is clinically disease free
– Level >30 ng/ml is abnormal
– High-risk patients should also have an
ultrasound of the neck and CT or MRI scan of
the neck and mediastinum for early detection of
any persistent or recurrent disease.
Postoperative Management of
Differentiated Thyroid Cancer
• Radioiodine Therapy
– I-131 whole body scan to detect residual normal thyroid tissue
&/or metastatic disease
– Metastatic differentiated thyroid carcinoma can be
detected and treated by radioactive iodine in about
75 % of patients.
– Administration
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Scan at 4-6 weeks postoperatively
repeat scan at 6-12 months after ablation
repeat scan at 1 year then...
every 2 years thereafter
• External Beam Radiotherapy and Chemotherapy
– External beam radiotherapy is required occasionally
to control unresectable locally invasive or recurrent
disease
– It also is of value for the treatment and control of
pain from bony metastases when there is no
appreciable radioiodine uptake.