CPC cases CASE 1: NECK MASS

Patient with Upper-Left Neck Mass 32 year old female complaining of a non-tender nodule on left side of the neck. Temp 37C BP 110/72, HR 85 beats/min. A 3cm non-tender nodule palpated along the left sternocleidomastoid near the superior aspect of the thyroid cartilage. The thyroid was symmetrical except for a hard 2.5 cm nodule on the left lobe of the thyroid. The rest of the exam was noncontributory. CBC normal, normal differential, urine normal. Which of the following courses of action would be the best? 1. Do you want to see an X-ray of the neck? 2.Do you want to see a radioactive iodine scan? 3. Do you want to tell the patient to come back in a week ?

1. Do you want to see an X-ray of the neck? You just cost the patient 500 Dollars of unnecessary X-rays!

2.Do you want to see a radioactive iodine scan? Radioactive thyroid scan showed a cold nodule . You just saved the patient five days of unnecessary hospitalization.

3. Do you want to tell the patient to come back in a week ? You just lost your patient! A friend of her's told her she knew of another friend who had similar symptoms and it turned out to require surgery, so your patient went to another doctor.

Radioactive thyroid scan showed a cold nodule . You would now do the following: Open biopsy of the thyroid Fine needle aspirate of the thyroid Surgical ablation of thyroid and parathyroids.

Open biopsy of the thyroid Not the best course of action, if the nodule is a cyst you just caused the patient $2000 worth of unnecessary surgery.

Fine needle aspirate of the thyroid You made the right choice! Fine needle aspiration is a relatively non-invasive procedure and should be tried first, before doing an open bx of the thyroid. The sample is sent to pathology and cells similar to the following figure are observed. Papillary Carcinoma of the thyroid

Notice that some of the nuclei have groves and a ground glass appearance. On further exam of the neck you find another mass in the right base of the neck. You would now recommend

Sampling the other mass in the neck. Radical neck dissection Complete ablation of the gland

Sampling the other mass in the neck. Your approach is correct, the patient had metastatic papillary Ca in the lymph-node

Radical neck dissection The surgeon refuses your request before sampling the node and sending to pathology!

Complete ablation of the gland The surgeon refuses and suggests sampling the other mass first.

You would now refer your patient to the surgical oncologist for treatment and follow-up you have completed this case successfully!