1. NECK MASSES: UNC MS III SURGERY Case discussions by studentsCase discussions by students Discussion of thyroid disordersDiscussion of thyroid disorders Discussion of how to develop a differential diagnosisDiscussion of how to develop a differential diagnosis Management algorithmManagement 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 goiter291.88 Graves’ disease150.97 Iatrogenic hyperthyroidism20.10 Hot nodule90.58 Multinodular goiter130.84 Thyroiditis80.51 Single cold nodule80.51 Hypothyroidism60.39 Cancer00.00 Total905.78

5. Cancer Incidence and Deaths Estimated- U.S. 2005 Organ SystemNew CasesDeaths Lung172,570 163,510 Colon 104,95056,290 Rectum42,0007,000 Pancreas32,18031,800 Breast212,93040,870 Stomach24,00014,000 Thyroid25,6901,490 Prostate 232,090 30,050

6. Thyroid Cancer 198519941998 New Cases10,00013,90017,200 (↑ 72%) Deaths1,1001,120 1,200 (↑8%) American Cancer Society 1998

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

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

15. Thyroid Cancer- Diagnosis CytologyCytology ScansScans –Technetium –Radioiodine –Sestamibi –MR/CT/PET UltrasoundUltrasound Frozen SectionsFrozen Sections Fixed SectionsFixed Sections

16. Thyroid Cancers* Papillary80% Follicular11% Hürthle3% Medullary4% Anaplastic2% *National Cancer Data Base 31,513 patients (1985-1995)

17. Biological Characteristics Thyrotropin Receptor-Thyrotropin Receptor- –Adenylate Cyclase Systems Iodine Trapping/OrganificationIodine Trapping/Organification Thyroglobin ProductionThyroglobin Production

18. Papillary Carcinoma Ames (Age, Distant Metastases, Extent, Size)Ames (Age, Distant Metastases, Extent, Size) 89%- Low risk; Mortality 1.8% and89%- Low risk; Mortality 1.8% and 11% High Risk, Mortality 46%11% High Risk, Mortality 46%

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

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

26. Some pearls: 90% of adult neck masses are malignant90% of adult neck masses are malignant 90% of pediatric neck masses are infectious in nature90% of pediatric neck masses are infectious in nature Know your anatomy then develop a differential diagnosisKnow your anatomy then develop a differential diagnosis Close observationClose observation Generally, one course of a broad spectrum antibiotic is acceptable then …..Generally, one course of a broad spectrum antibiotic is acceptable then …..

28. It is never wrong to refer to a specialist for evaluation and probable biopsyIt is never wrong to refer to a specialist for evaluation and probable biopsy Imaging is important but tissue is everythingImaging 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.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.Never violate a neck or I will come after you.

29. HISTORY AgeAge DurationDuration Acute symptomsAcute symptoms Recent travelRecent travel TraumaTrauma Insect bites, petsInsect bites, pets Tobacco, alcohol, XRTTobacco, alcohol, XRT

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

31. Branchial cleft cyst

32. Branchial cleft cysts

33. Branchial cleft cyst

36. Inflammation Reactive lymphadenopathyReactive lymphadenopathy SialoadenitisSialoadenitis Cervical adenitisCervical adenitis

38. Infectious Staph and strepStaph and strep EBV – monoEBV – mono TBTB Atypical TBAtypical TB HIVHIV Cat scratch fever (Bartonella henselae)Cat scratch fever (Bartonella henselae) ToxoplasmosisToxoplasmosis ActinomycosisActinomycosis Tick-borne: Rocky Mountain Spotted FeverTick-borne: Rocky Mountain Spotted Fever Lemierre’s Syndrome: septic thromb. IJVLemierre’s Syndrome: septic thromb. IJV

39. Trauma HematomaHematoma –Acute and expanding –Chronic and organizing AV fistulaAV fistula PseudoaneurysmPseudoaneurysm

40. Metabolic, Idiopathic, Autoimmune Castleman’s diseaseCastleman’s disease SarcoidosisSarcoidosis Kimura’s diseaseKimura’s disease

41. Neoplasms Benign:Benign: –Lipomas –Neuromas –Fibromas –Hemangiomas –Carotid body tumors –Angiomas

43. Neoplasms MalignantMalignant –Thyroid –Squamous cell carcinoma (SCAA) –Lymphoma –Sarcoma –Salivary gland tumors –Metastasis: SCCA, adenocarcinoma, undifferentiated carcinoma, melanomaSCCA, adenocarcinoma, undifferentiated carcinoma, melanoma

45. Management 1 course of broad spectrum antibiotics1 course of broad spectrum antibiotics Consider bloodwork and imagingConsider bloodwork and imaging REFERALREFERAL

47. Pearls Avoid excisional biopsiesAvoid excisional biopsies Use CT but consider MRI for salivary gland problemsUse CT but consider MRI for salivary gland problems Role of nonionizing ultrasoundRole of nonionizing ultrasound –Like a stethoscope?

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