Dr Nick McIvor. Dr John Chaplin. Head & Neck Surgeon Auckland City Hospital Auckland. Auckland Head & Neck Surgeon Gillies Hospital Auckland
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1 Dr Nick McIvor Head & Neck Surgeon Auckland City Hospital Auckland Dr John Chaplin Auckland Head & Neck Surgeon Gillies Hospital Auckland 14:00-14:55 WS #148: Case Studies of Lumps in the Neck 15:05-16:00 WS #160: Case Studies of Lumps in the Neck (Repeated)
2 Size Site Consistency Edge Colour Fixity Transillumination Pulsation Tenderness Nodes Primary site Diagnostic features of a lump
3 Most important diagnostic features of a neck lump Age of patient Site of lump Duration Progression
4 Age Child Infective/inflammatory Congenital Young adult Congenital inflammatory Adult Neoplastic
5 Anterior Suprahyoid Infrahyoid Lateral Carotid/Jugular Posterior supraclavicular Submandibular Angle of Jaw Post Auricular Occipital Back of Neck Site
6 Back of Neck Occiptal post auric Lipoma Sebaceous/epidermoid Cyst Vascular/ lymphatic malformations Node Abscess (nodal/ mastoiditis)
7 ) Midline neck mass Infrahyoid Thyroid related Thyroid nodule/ Goitre 90% Thyroglossal duct cysts Node related Pretracheal lymph node (delphian node) Thyroid or laryngeal malig Suprahyoid Thyroid related 10% Thyroglossal duct cysts Lingual or undescended thyroid Node related Metastatic skin, lip, floor mouth malig Inflammatory- acne, dental Other Dermoid
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10 Anterior neck Slightly lateral to midline Rises with swallow May be multiple/ bilateral May be retrosternal May be Nodes Toxicity/ hypothyroidism Pain with thyroiditis or recent bleed Thyroid
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12 Is it malignant? ultrasound Solid Hypoechoic Taller than wide shape Irregular margin Microcalcification Associated nodes with similar features TIRADS 1-6 Auckland Head and Neck Associates
13 Malignant thyroid nodules
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15 Is it malignant? US guided FNA cytology FNA is a safe test with negligible risk of seeding Auckland Head and Neck Associates
16 Is it malignant? FNA cytology Bethesda category malig% I. Non diagnostic 3-8% II. Benign 0-3% III. Atypical follicular 8-15% IV. Follicular neoplasm 20-30% V. Suspicious for cancer 50-60% VI. Carcinoma % Auckland Head and Neck Associates
17 Is it malignant? FNA cytology Bethesda category malig% I. Non diagnostic 3-8% II. Benign 0-3% III. Atypical follicular 8-15% IV. Follicular neoplasm 20-30% V. Suspicious for cancer 50-60% VI. Carcinoma % observation vs surgery surgery Auckland Head and Neck Associates
18 Is it malignant? FNA cytology Bethesda category malig% I. Non diagnostic 3-8% II. Benign 0-3% III. Atypical follicular 8-15% IV. Follicular neoplasm 20-30% V. Suspicious for cancer 50-60% VI. Carcinoma % repeat FNA observation vs surgery repeat FNA vs surgery surgery Auckland Head and Neck Associates
19 Is it malignant? bloods TSH, T3, T4 - standard. TSH usually normal in ca. Rapid swelling with hypothyroid consider lymphom? Thyroglobulin, Tg Ab - useful for surveillance? Calcitonin -?Bethesda 4-6 solitary nodule, +FH Auckland Head and Neck Associates
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25 Lateral Neck Swelling Solid Malignant Primary Lymphoma Sarcoma Secondary SCC skin/mucosa/unknown melanoma, thyroid, salivary Cystic Congenital Branchial cleft cyst, lymph/haemangioma, vasc malformation Acquired Cystic malignant node, abscess Benign Inflammatory node, carotid body tumour, neural tumour
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33 Beware Metastatic SCC from HPV related Tonsil or Tongue Base Primary presenting as a Cystic Mass in the Lateral Neck in Adults
34 Oropharyngeal ca in men now more common than cervical ca in women Oropharyngeal cancer incidence New Zealand Chaturvedi AK et al. J Clin Onc 2011;29: : 96 men, 26 women diagnosed with oropharyngeal cancer
35 OPC in Auckland % of 55 cases oropharyngeal SCC HPV related ANZ J Surg Sept 2016
36 Submandibular Swelling Salivary gland related Sialadenitis/ sialolithiasis Salivary tumour Plunging ranula Lymph node related Metaststic skin, lip, oral cancer Dental abscess
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41 Lump at the Angle of the Jaw Parotid Gland Related Benign salivary gland tumour Malignant- salivary gland tumour Metastatic cutaneous malignancy Sialadenitis/sialolithiasis Congenital Cyst 1st branchial arch Upper cervical node
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48 Management of a neck lump History General Specific UADT Pain-Odynophagia Dysphagia Dysphonia Epistaxis nasal obstruction Skin malignancies SCC, Melanoma, Merkel Lymphoma Night sweats/ fevers Weight loss Risk Factors Smoking Oral sex Examination Site Upper aerodigestive Skin scalp/face/neck Thyroid Remainder of neck Axilla, groin Salivary flow Investigations FNA Endoscopy Imaging
49 FNA Result SCC Melanoma Salivary neoplasm Epithelial cyst Thyroid ( Bethesda I-VI) Lymphoid Reactive vs lymphoma Granulomatous Non diagnostic Cystic vs solid
50 Lymphoid FNA Suggest reactive change cannot exclude monoclonal population If obvious source of inflammation- treat and observe If node is large (>3cm) remove If single site but no obvious source Blood screen: FBC, Toxoplasmosis, EBV, cat scratch disease, HIV Observe over one to two months and remove if still present or larger Continue to observe if smaller
51 Non Diagnostic FNA Particularly if cystic Age, Site, Risk factors If suspicious of malignancy If Solid DO NOT REFER FOR OPEN BIOPSY Endoscopy biopsy of ipsilateral tonsil/tongue base Repeat under ultrasound guidance Consider neurogenic tumour (partic if FNA painful)
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56 Case 1 Young man 4 weeks 1.6 cm neck mass Non tender, no change Ultrasound= solid FNA = reactive features but cannot exclude a monoclonal population, assess in clinical context Auckland Head and Neck Associates
57 No obvious inflammatory source What do you do? a. Refer for excision b. Arrange serology for Toxo, EBV, CMV and observe c. Discharge with no follow up d. Prescribe amoxy-clav b. serology: Toxo particularly common Auckland Head and Neck Associates
58 Case 2 20 yr old woman Month history of very sore throat, pain on cough and swallow radiating to ears. Very tender and hard right thyroid nodule T4 = 32, TSH= ESR =40 No toxic symptoms or signs Auckland Head and Neck Associates
59 Case 2 Most likely diagnosis a. Subacute thyroiditis b. Graves disease c. Bleed into a thyroid nodule d. Hashimotos thyroiditis Auckland Head and Neck Associates
60 Case 2 Most likely diagnosis a. Subacute thyroiditis b. Graves disease c. Bleed into a thyroid nodule d. Hashimotos thyroiditis a. Subacute or de Quervain s or painful thyroiditis Auckland Head and Neck Associates
61 de Quervains subacute thyroiditis What is best confirming test? a. FNA b. Ultrasound c. Thyroid lobectomy d. scintigraphy Auckland Head and Neck Associates
62 de Quervains subacute thyroiditis What is best confirming test? a. FNA b. Ultrasound c. Thyroid lobectomy d. scintigraphy d. scintigraphy- shows reduced uptake in gland Auckland Head and Neck Associates
63 de Quervains subacute thyroiditis Inflammatory condition Thought to be viral origin (occurs in clusters) Can be ipsilateral, bilateral or sequential Ultrasound can show a suspicious, infiltrative pattern FNA Painful, shows inflammatory lymphocytes with giant cells Treatment Responds very well to anti-inflammatory steroids Follow up Repeat thyroid function tests monthly as high risk of developing hypothyroidism Auckland Head and Neck Associates
64 Case 3 45 yr old female Never smoked 3 week history right neck mass No pain No cutaneous malignancy No pharyngeal symptoms Auckland Head and Neck Associates
65 Most approp test a. Oral cavity exam b. Flexible endoscopy c. FNA d. skin examination e. All of the above e. All these are appropriate Auckland Head and Neck Associates
66 FNA shows fluid with mild atypical epithelial cells. Pathologist suggests excision of mass. Do you? a. Refer for excision of neck mass b. Send to another pathologist for repeat FNA c. Send patient away with no follow up d. Refer for upper airway exam and biopsy of potential primary sites d.need to rule out a cystic metastases from upper airway SCC Auckland Head and Neck Associates
67 What is the most likely primary site a. Tongue tip for this nodal metastases b. Oropharynx (tonsil tongue/ base) c. parotid gland d. larynx b. oropharynx Auckland Head and Neck Associates
68 Case 7 71 yr old man Biopsy proven SCC scalp Excised March 2016 Poorly differentiated SCC Clear margins No LVI or PNI Recommended and had 6 weeks electrons RT
69 Case 7 Sept 2016 Presents with lump right neck No other symptoms What is most appropriate? A. Excision node.b. FNA +CT Scan neck C. FNA + CT neck and chest D. FNA only C. FNA CT neck and chest
70 Case 7 FNA = malignant cells suggestive of SCC CT= multiple level 5a nodes some with cystic change Parotids, contralateral neck and chestnegative
71 Case 7 High risk features? >2cm Poorly difftd/ infiltrative LVI/ PNI Depth >4mm Lip Ear
72 Case 7 Histology shows 3 matted neck nodes with extensive ECS and clear margins No parotid nodes Post op treatment?
73 Case 3 50 yr old man Hard mass low right neck CT as shown FNA mass suggests benign thyroid follicular cells Level IV neck mass Thyroid cyst Auckland Head and Neck Associates
74 Case 3 What is this most likely to be. a. metastatic thyroid cancer b. missed biopsy (thyroid cyst) c. lateral aberrant thyroid tissue d. pathologist error a. Metastatic thyroid cancer Auckland Head and Neck Associates
75 Case 3 Papillary cancer is well differentiated and cells can look benign. Mass wont elevate like thyroid even though in same position Can confirm by frozen section intraoperatively Auckland Head and Neck Associates
76 John Chaplin & Nick McIvor
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