Assessment of neck lump and thyroid cancer

Question 1

What should you ask in a hx of a patient presenting with a neck lump?

Answer 1

How long has the lump been present?
Is it painful?
Has it changed? If so, over what time frame?
Are there symptoms of recent infection of nearby structures (cough, cold, sore throat, earache, toothache, skin problems, head lice, bites)?
Has there been a fever?
Does eating affect the lump?
Is there pain on swallowing?
Is there any effect on voice?
Does the person smoke?
Is there a history of travel?
Is there a past history of cancer?
Are there red flag symptoms of systemic illness such as:
-Night sweats.
-Weight loss.
-Unexplained bruising or bleeding.
-Persistent fatigue.
-Breathlessness.

Question 2

How do you examine a neck lump?

Answer 2

Location of the lump.
Examine the:
-Anterior triangle (bordered by the midline, the body of the mandible and the anterior border of sternocleidomastoid).
-Posterior triangle (bordered by the posterior border of sternocleidomastoid, the clavicle and the trapezius).
-Midline.
Whether it is tender, hot, red, inflamed.
Consistency, size, mobility.
How deep the lump is: whether it is intradermal (suggesting sebaceous cyst with a central punctum, or a lipoma), subcutaneous or within deeper tissue.
Whether it is pulsatile.
Whether it is a solitary lump or if there is more than one.
Whether it moves on swallowing (thyroid, thyroglossal cysts).
Whether it moves when the person sticks out their tongue (thyroglossal cysts).

Question 3

Which further examination can you do to establish the cause of a neck lump?

Answer 3

Examination of the skin of the head and neck for rashes, lesions or infection.

Examination of the ears, nose and throat.

Examination of the mouth - for malignancy, dental issues. If parotid disease is suspected, identify the orifice of parotid duct and palpate with the patient’s head tilted backwards.

Examination of the chest.

Examination for lymphadenopathy or organomegaly elsewhere.

Checking for compression of the airway or vasculature.

Taking note of general clues of systemic illness, such as jaundice, pallor, petechiae, bruising, excoriation.

Question 4

What are the differentials of a neck lump?

Answer 4

Reactive lymph nodes
Bacterial causes such as s.aureus, TB and secondary syphilis.
Viral causes such as EBV, CMV, HIV and HSV.
Parasitic causes such as head lice, fungal infections and toxoplasmosis
Non-infective causes such as sarcoidosis
In children, consider cat scratch disease and Kawasaki disease
Malignant lymph nodes: leukaemia, lymphoma and mets.
Lipomas and other benign tumours such as fibromas, neuromas and vascular tumours.
Thyroid swellings including nodules and cancers
Thyroglossal cysts, cystic hygroma and dermoid cyst.
Branchial cyst, laryngocele and pharyngeal pouch.
Sarcoma and skin malignancy.

Question 5

How does thyroid swellings present?

Answer 5

May be hypo-, eu- or hyperthyroid symptomatically

Moves upwards on swallowing

Question 6

How do thyroglossal cysts form?

Answer 6

The thyroid develops from the floor of the pharynx and descends into the neck during its development.

It is connected to the tongue by the thyroglossal duct. The foramen cecum is the point of attachment of the thyroglossal duct to the tongue. The thyroglossal duct normally atrophies but in some people may persist and give rise to a thyroglossal duct cyst.

Question 7

How does thyroglossal cyst present?

Answer 7

Thyroglossal cyst is more common in patients < 20 years old

• Usually midline, between the isthmus of the thyroid and the hyoid bone
• Moves upwards with protrusion of the tongue
• Non-tender and mobile
• May be painful if infected

Question 8

What is cystic hygroma?

Answer 8

Cystic hygroma is a congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side

Most are evident at birth, around 90% present before 2 years of age

Question 9

What are dermoid cysts?

Answer 9

Dermoid cysts are derived from pluripotent stem cells and are located in the midline

• Most commonly in a suprahyoid location
• They have heterogeneous appearances on imaging and contain variable amounts of calcium and fat

Question 10

What is a pharyngeal pouch?

Answer 10

The pharyngeal pouch is more common in older men

• Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
• Usually not seen but if large then a midline lump in the neck that gurgles on palpation
• Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

Question 11

What is a brachial cyst?

Answer 11

A brachial cyst is an oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx

• Develop due to failure of obliteration of the second branchial cleft in embryonic development
• Usually present in early adulthood (late teens)

Question 12

What are the differentials for a neck lump in children?

Answer 12

Congenital: branchial cyst, thyroglossal cyst, dermoid cyst, vascular malformation

Inflammatory: reactive lymphadenopathy, lymphadenitis.

Neoplastic: lymphoma, thyroid tumour, salivary gland tumour

Neck lumps are more likely to be inflammatory than malignant in children and young people.

Congenital and developmental lumps are also more likely in children and young people.

Question 13

When do neck lumps develop acutely?

Answer 13

Inflammatory lumps usually arise suddenly and resolve within 2-6 weeks. Progressive enlargement over a short time is more likely to be malignant.

A transient nature to the swelling and an association with eating suggest salivary gland blockage. Associated symptoms often give the clue to the cause of reactive lymph nodes or indeed malignant nodes.

Question 14

Which neck lumps are hard?

Answer 14

A hard mass is more likely to be malignant.

Question 15

Which neck lumps are mobile?

Answer 15

Congenital masses are usually smooth and mobile.

Reactive lymph nodes are mobile.

Thyroid gland swellings and thyroglossal cysts move on swallowing, and a thyroglossal cyst moves when the tongue is moved outwards.

A fluctuant mass suggests a cystic nature. Tenderness suggests infection. A laryngocele enlarges with blowing or the Valsalva manoeuvre.

Question 16

Which neck lumps present in the midline?

Answer 16

Midline lumps are likely to be thyroid in origin or thyroglossal/dermoid cysts.

Submandibular swellings may be related to the submandibular gland.

Question 17

Which neck lumps present in the posterior triangle?

Answer 17

Posterior triangle lumps are most commonly lymph nodes, although lymph nodes are a common cause of swellings in all areas of the neck.

Question 18

Which neck lumps are likely to be bilateral?

Answer 18

Bilateral swellings (tender) crossing the mandibular angle are likely to be parotid infection (mumps).

Question 19

Which neck lump is likely to present in the supraclavicular fossa?

Answer 19

A lump in the left supraclavicular fossa (a Virchow’s node) may indicate an infraclavicular metastatic malignancy such as lung or upper gastrointestinal tumours.

Question 20

What are the investigations done to assess neck lumps?

Answer 20

Investigations will be guided by clinical assessment but may include:

• FBC and ESR (within 48 hours if generalised lymphadenopathy to exclude leukaemia).
• TFTs.
• Viral serology - eg, EBV, cytomegalovirus, toxoplasmosis.
• Throat swab.
• CXR (within two weeks for supraclavicular lymph node swelling or persistent cervical node in a person over 40 years old)
• Ultrasound scan - for thyroid swellings and as a first-line imaging option where diagnosis is unclear, with or without a view to ultrasound-guided fine-needle aspiration biopsy.
• Radionucleotide scanning (if masses of parathyroid or thyroid glands).
• CT or MRI scan.

Question 21

When should you refer a patient with a neck lump?

Answer 21

Referral is usually to an ear, nose and throat (ENT) specialist but findings may dictate referral to a dermatologist, oral surgeon, dermatologist, or chest physician.

Any new neck mass persisting beyond six weeks should be referred. Referral more immediately may be appropriate in some cases.

Question 22

When should a GP make an urgent referral for a neck lump?

Answer 22

Make an urgent two-week wait referral through the suspected cancer pathway if:

• The person has lost weight.
• There is associated hoarseness, difficulty swallowing (dysphagia), or dyspnoea for three weeks or more.
• There has been haemoptysis.
• There are associated symptoms suggestive of lymphoma (weight loss, night sweats, fever, breathlessness, pruritus or bleeding) - two-week wait referral for adults but a 48-hour referral for children and young people up to the age of 24.
• An unexplained enlarged lymph node is persistent.
• There are suspicious clinical features.
• Diagnosis is unclear.

Question 23

What is the management of neck lumps?

Answer 23

Depends on the cause.

Benign reactive lymph nodes settle on their own within six weeks, needing no treatment.

Question 24

What is the classification of thyroid cancers?

Answer 24

Differentiated thyroid carcinoma, including papillary, follicular, and Hürthle cell cancers. These arise from follicular cells of the thyroid and account for 90-95% of all thyroid malignancies.

Medullary thyroid carcinoma arises from parafollicular cells and accounts for another 6%.

Anaplastic thyroid carcinoma accounts for less than 1% of thyroid malignancies.

Question 25

What is the most common form of thyroid cancer?

Answer 25

Papillary is the most common form and presents between 35-40 years of age. It is more common in women. Spreads locally and may compress the trachea. Follicular is the second most common form and it occurs in areas of low iodine and is three times more common in women.

Question 26

Which gender is more likely to get Hurthle cell cancer?

Answer 26

Hurthle cell is more common in women and surgical excision is the main treatment.

Question 27

What is the marker for medullary thyroid cancer?

Answer 27

Elevated serum calcitonin

Question 28

What are the prognostic factors for medullary thyroid cancer?

Answer 28

Prognostic factors that predict adverse outcome include calcitonin doubling time, advanced age at diagnosis, extent of the primary tumour, nodal disease and distant metastases.

Question 29

What is the clinical picture of anaplastic thyroid cancer?

Answer 29

The clinical diagnosis is usually easy with a large, hard mass invading the neck and causing compression (dyspnoea, cough, vocal cord paralysis, dysphagia and hoarseness). Almost 50% of the patients present with distant metastases, mostly in the lungs but also in the bones, liver and brain.

Question 30

Which type of lymphoma is thyroid lymphoma?

Answer 30

Thyroid lymphomas are almost always non-Hodgkin's lymphomas, representing 4-10% of thyroid malignancies. More common in women. Patients usually present with a rapidly growing mass in the neck, which may cause symptoms of obstruction such as dyspnoea and dysphagia.

Question 31

What are the risk factors for thyroid cancer?

Answer 31

Exposure to ionising radiation. The risk, especially for papillary carcinomas, is greater when exposure has occurred at a younger age. Other risk factors include a history of goitre, thyroid nodule or thyroiditis, family history of thyroid disease, female gender and Asian race. Genetics: approximately 20-25% of MTC are hereditary because of mutations in the RET proto-oncogene. Mutations in the RET gene cause multiple endocrine neoplasia type 2 (MEN 2), which is an autosomal dominant disorder associated with a high lifetime risk of MTC. Cowden's syndrome (macrocephaly, mild learning difficulties, carpet-pile tongue, with benign or malignant breast disease). Familial adenomatous polyposis. Obesity.

Question 32

How does thyroid cancer present?

Answer 32

Thyroid cancer presents as a thyroid nodule. Thyroid nodules are frequent (4-50% depending on the diagnostic procedures and the patient's age); however, thyroid cancer is rare (c. 5% of all thyroid nodules). Solitary thyroid nodules can vary from soft to hard. Hard and fixed nodules are more suggestive of malignancy than soft mobile nodules. Thyroid carcinoma is usually non-tender to palpation. Firm cervical masses are suggestive of regional lymph node metastases. Vocal cord paralysis implies involvement of the recurrent laryngeal nerve.

Question 33

What are the differentials of thyroid cancer?

Answer 33

``` Goitre Lymphoma Lymphadenopathy Cat scratch disease HIV ```

Question 34

What are the investigations of thyroid cancer?

Answer 34

TFTs Serum calcitonin USS: -Thyroid ultrasound is extremely sensitive for thyroid nodules and is used as a first-line diagnostic procedure. Ultrasound should also be used to explore the neck carefully to assess the status of lymph node chains. Fine-needle aspiration cytology (FNAC): -The results of FNAC are very sensitive for the differential diagnosis of benign and malignant nodules, although limitations include inadequate samples and follicular neoplasia. Radionuclide imaging: distinguishing functioning toxic nodules and thyroid metastases from follicular and papillary carcinomas is best with 123iodine uptake studies -Normal iodine uptake is seen in 'warm' nodules. Lesions that take up excessive amounts of iodine are called 'hot' and those that do not take it up are called 'cold'. CT and MRI scan: CT scans and MRI scans are valuable to detect local and mediastinal spread and regional lymph nodes.

Question 35

What are the USS features of thyroid cancer?

Answer 35

Ultrasound features associated with malignancy include hypoechogenicity, microcalcifications, absence of peripheral halo, irregular borders, solid aspect, intranodular blood flow and shape (taller than wide).

Question 36

What is the management of thyroid cancer?

Answer 36

Total thyroidectomy is recommended for patients with tumours greater than 4 cm in diameter, or tumours of any size in association with multifocal disease, bilateral disease, extra-thyroidal spread, familial disease, and those with clinically or radiologically involved nodes and/or distant metastases. Radioiodine remnant ablation and therapy for differentiated thyroid cancer: - Patients in the definite indications include tumour larger than 4 cm, or any tumour size with gross extra-thyroidal extension or distant metastases. - Patients with no indications include tumour 1 cm or smaller, classical papillary or follicular variant or follicular minimally invasive without angioinvasion and no invasion of thyroid capsule. Adjuvant external beam radiotherapy for differentiated thyroid cancer should be considered for patients with a high risk of recurrence/progression with: - Gross evidence of local tumour invasion at surgery with significant macroscopic residual disease; or - Residual or recurrent tumour that fails to concentrate radioiodine, ie loco-regional disease where further surgery or radioiodine is ineffective or impractical.

Question 37

What are the complications of thyroid cancer?

Answer 37

In expert hands surgical complications such as laryngeal nerve palsy and hypoparathyroidism are rare (<1-2%). The primary disease can cause nerve damage, both in benign and in malignant conditions.

Question 38

What is a branchial cyst?

Answer 38

A branchial cyst is a benign, developmental defect of the branchial arches. The cyst is filled with acellular fluid with cholesterol crystals and encapsulated by stratified squamous epithelium.

Question 39

When are brachial cysts prone to infections?

Answer 39

Branchial cysts may have a fistula and are therefore prone to infection. They may enlarge following a respiratory tract infection.

Question 40

How do branchial cysts present?

Answer 40

They typically present in late childhood or early adulthood and present as asymptomatic neck lateral neck lumps and are usually located anterior to the sternocleidomastoid muscle. There is a slight male predisposition and account for around 20% of paediatric neck masses.

Question 41

What are the typical examination findings of branchial cysts?

Answer 41

``` Typical examination features: Unilateral, typically on the left side Lateral, anterior to the sternocleidomastoid muscle Slowly enlarging Smooth, soft, fluctuant Non-tender A fistula may be seen No movement on swallowing No transillumination ```

Question 42

How do you diagnose branchial cysts?

Answer 42

Consider and exclude other malignancy Ultrasound Referral to ENT Fine-needle aspiration

Question 43

How are branchial cysts managed?

Answer 43

Branchial cysts are treated by Ear Nose and Throat (ENT) surgeons and can be treated conservatively or surgically excised. Antibiotics are required for acute infections.