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GP Section

This area is designed specifically for GPs to help in streamlining the management of patients with disorders of the head & neck. The aim is to be informative. What requires investigation? What are the best tests? How to evaluate the test results? What is the most likely diagnosis? What is the best management...and when to refer.

Thyroid

By far, most thyroid lumps are benign. However, thyroid lumps and thyroid cancer is increasing worldwide and NZ is no exception. We are iodine deficient but that is not the sole cause.

Around 85% cancers are papillary carcinoma, around 12% are follicular carcinoma, 5% medullary, and fortunately only 1-2% are anaplastic. Papillary and follicular are what we call "differentiated thyroid cancers"

About 6% of all patients with differentiated thyroid cancer will die of their disease....94% are either cured or live with dormant or active disease. As doctors we try to minimise the number dying by early diagnosis and treatment.

Differentiated (papillary and follicular)

Age at diagnosis is the single most important factor.

Under 45yrs age

  • The cure rate of a younger patient who is treated for a small intrathyroidal cancer is around 99%.
  • It appears that having nodal disease has no impact on the prognosis! However these patients are at risk of nodal recurrences and may require repeated surgery which can increase morbidity (nerve palsy, hypocalcaemia).
  • Even if there are systemic metastases the Cancer staging is only II (out of I -!V)! These young patients often live in a symbiotic relationship with their disease or perhaps eventually clear it through their own immune mechanisms.

Over the age of 45 yrs

  • these patients usually also have a high cure rate.
  • extension beyond the thyroid into surrounding neck tissues can occur.
  • nodal disease appears to carry a worse prognosis longterm (higher risk of systemic metastases).
  • higher rate of systemic metastases (yet these can often be kept under control or slowed by radioiodine).

Papillary (PTC)

  • PTC is frequently present in an occult state.
  • 4% of thyroids that I remove for other reasons have occult PTC!
  • clinically significant PTC is frequently multifical and is therefore treated with total thyroidectomy rather than just lobectomy. Usually also radioiodine.

Follicular (FTC)

  • Much less common
  • Pathologists have difficulty with the interpretation of these histologically
  • They are usually "minimally invasive" meaning the tumour is just extending through the capsule of the nodule into surrounding thyroid tissue.
  • The most important feature is whether there is vascular invasion. A minimally invasive tumour without vascular invasion appears to have the same prognosis as a benign tumour.
  • "Minimally invasive with vascular invasion" is treated with total thyroidectomy and radioiodine because of risk of metastases.
  • "Widely invasive follicular carcinomas" have vascular invasion and have a poorer prognosis. Treated with total thyroidectomy and radioiodine.

Medullary carcinoma (MTC)

  • Intermediate grade cancers.
  • Most are sporadic and unilateral.
  • High rate of nodal involvement.
  • Some are familial and may be part of MEN 2 syndrome.
  • Treated with total thyroidectomy and neck node clearance (neck dissections). No radioiodine as from C-cells and not thyroid follicular cells.

Anaplastic

  • Aggressive malignancies that have average life expectancy of 6 months.
  • Arise from a sequence of genetic hits on a thyroid cell. There is an evolution from low grade malignancy to higher grade to undifferentiated to anaplasia.
  • Present as rapidly growing hard thyroid mass with airway compression.
  • Urgent referral to surgeon for diagnosis and airway management.
  • Critical to differentiate from lymphoma which can present in same way and is very treatable with radiotherapy.

 

 

TFT's

  • TSH is the best measure of thyroid function
  • Most patients whether with nodule or goitre will have normal thyroid function.
  • Previously we did thyroid isotope scans to see whether a nodule was hot or cold. We now simply measure TSH. If the patient is not on thyroid medication, TSH suppression indicates thyroid autonomy. If T4, T3 are in the normal range then it is likely to be subclinical hyperthyroidism. If T4 and/or T3 is elevated then it is likely to be clinical and some form of treatment (carbimazole, radioiodine, surgery) required.

Thyroid antibodies

  • Useful when hypothyroidism present.
  • Not helpful for solitary nodule.
  • Required in the surveillance following treatment for a thyroid cancer. The presence of anti-thyroglobulin antibodies negates the usefulness of thyroglobulin screening in this situation.

 

Thyroglobulin

  • Elevated whenever there is increased thyroid cell turnover or damage (hyperthyroidism, thyroiditis, goitre, cancer).
  • It is nonspecific and therefore not useful for the initial investigation of a thyroid nodule or goitre. It is a very useful marker for thyroid cancer AFTER surgical and radioiodine ablation of the thyroid and the cancer (i.e. it should be unmeasurable after treatment).

 

Calcitonin

  • Not required unless indicated by the suspicion of medullary thyroid cancer from the FNA or family history. It is then an essential marker prior to surgery and for surveillance.

 

Ultrasound

  • The single best modality and certainly more sensitive than scintigraphy, CT or MRI for the assessment of the thyroid.
  • Very operator dependent. The gland is studied in real-time and therefore the report is generally of more value than the pictures.
  • There is a lot of inter-observer variablility.
  • Consider it a descriptor of the thyroid architecture.
  • Useful in determining whether a nodule is in the thyroid or is a node or other tissue mass.
  • Useful in determining whether the nodule is solitary or part of a multinodular goitre.
  • Differentiates between solid, complex (mixed solid/cystic,) and cystic
  • CANNOT reliably tell the difference between a benign and malignant nodule.
  • There are features that are characteristically seen in malignancy such as intranodular vascularity, poorly defined margin, microcalcification but when the radiologist is suspicious of malignancy my figures show they are correct in only 50%. Of course when they think the nodule is benign (and the majority are!) their accuracy is very high.
  • The single best feature on ultrasound to indicate malignancy is an enlarged regional node with intranodular vascularity and microcalcification (a feature of papillary cancer).
  • Extremely useful in guiding FNA biopsy- thereby increasing the accuracy of FNA

Thyroid FNA Cytology

  • The most useful of all the tests in determining the nature of a thyroid nodule
  • Accuracy is increased by ultrasound guidance (but not essential where a solid nodule is palpable)
  • The interpretation of the report is crucial. Each finding has to be considered in the context of the overall situation e.g. a dominant nodule in a multinodular goitre present for 10 years is quite different from a solitary nodule that has been noticed for only 3 months -yet they may produce the same cytology report.

There are only 6 possible cytology reports:

     Insufficient material

  • Often indicates a cystic lesion. When there are few thyroid follicular cells in the aspirate the pathologist is obliged to give this report (as the pathologist is looking for malignancy within thyroid cells this stands to reason). Typically there is colloid, haemosiderin from old haemorrhage and macrophages to mop up the blood. Risk of maligancy is low 
  • The above is quite different from a report that says"insufficient" because the aspirate only contains blood. Here, there is nothing to go on...especially if the nodule is solid. A repeat FNA is required and preferably under ultrasound guidance.

Benign follicular lesion/ colloid nodule

  • The pathologist has obtained follicular cells all of which look bland, and colloid- this is typical of a benign lesion.
  • Risk of malignancy

Indeterminate i.e. cannot differentiate between benign follicular and follicular neoplasm

  • The pathologist is unsure whether this is clearly benign or a tumour which is also usually benign. The aspirate contains colloid and lots of follicular cells.
  • Risk of malignancy 10-15%

Atypical follicular pattern - consistent with follicular neoplasm

  • The pathologist notes plenty of closely packed follicular cells(microfollicular pattern) with very lttle colloid. There may be some atypia.
  • Risk of malignacy 20%

Suspicious of papillary thyroid carcinoma

  • There are some cellular features of papillary carcinoma such as nuclear grooves and vacuolation, and possibly some microcalcificaation but these features are not dominant or widespread. The pathologist is sitting on the fence!
  • Risk of malignancy 50%
  • consistent with malignancy
    • there is definite malignancy ...100%
      • PTC - reliably diagnostic
      • MTC - can be confused with follicular carcinoma, and poorly differentiated carcinoma.
      • Anaplastic - reliable diagnosis. Awful disease requiring attention paid to airway management. Must be differentiated from lymphoma which is very treatable
      • Lymphoma - treatable with radiotherpy - patients get better quickly. Often hypothyroid from autoimmune thyroiditis and lymphomatous destruction. These patients curable.

Investigation of a thyroid nodule

  • most thyroid nodules will be benign but some are malignant.
  • some nodules are solitary while others are part of a multinodularity.
  • any nodule can be malignant regardless of size or multinodularity.
  • size of a nodule is a prognostic feature if it proves to be malignant.

The aim of investigation is to determine the risk of the patient coming to harm if the nodule is left...in other words, to determine which nodules should be removed.

All require TFT's, ultrasound. Most require FNA cytology.

Most thyroid nodules require a specialist opinion (endocrinologist or surgeon) regardless of the TFT's, ultrasound, FNA cytology.

TFTs (for more information see bloods)

  • In the vast majority, TFT's will be normal. If TSH is suppressed the nodule is most likely responsible - a toxic nodule. Treatment determined by symptoms, and T3,T4 levels.
  • Elevated TSH raises the possibility of autoimmune thyroiditis. Autoantibodies then required. The patient may well have nodular Hashimotos thyroiditis but malignancy is still possible. US and FNA required.
  • Thyroid antibodies can be done at presentataion but I tend to be more selective...only if hypothyroid.
  • Do not measure thyroglobulin...too nonspecific

Ultrasound

(for more information see imaging)

  • ultrasound is a descriptor of thyroid architecture
  • to determine whether nodule is solid, cystic or complex (solid/cystic)
  • If a complex nodule, malignancy still possible and FNA of the solid component is required. This is best done under ultrasound control
  • to determine whether solitary or part of a multinodular goitre. If the dominant nodule in a multinodular goitre, it still requires FNA.

 

  • if radiologist considers there are benign features, he/she is probably right but a solitary nodule or a dominant nodule in a goitre still requires FNA.
  • If radiologist thinks there are features suspicious of malignancy there is a 50% risk. FNA required.
  • almost all patients with a palpable nodule will require FNA regardless of TFT's and ultrasound.

FNA cytology

  • the single most useful test
  • evaluate the report in context i.e. duration of nodule, solid vs cystic, solitary vs dominant in nodular goitre, age of patient, other masses etc.
  • If the nodule is solid and palpable then FNA does not require ultrasound control. If impalpable or complex ( mixed solid/cystic) then must do under Ultrasound.
  • risk of malignancy is reflected by the wording of the cytology report (see FNA cytology)

 

Investigation for a Goitre

  • most goitres in this country are multinodular. Some of these are part of autoimmune thyroiditis.

Goitres are clinically significant when

  • there is a dominant nodule
  • there is alteration in thyroid function as indicated by TSH
  • there are symptoms of airway or oesophageal compression.
  • there is cosmetic concern

The aim of investigation is to determine the risk of the patient coming to harm if the goitre is left...in other words, to determine which thyroids should be removed.

All require TFT's, ultrasound. Some require FNA cytology.

Most thyroid nodules require a specialist opinion (endocrinologist or surgeon) regardless of the TFT's, ultrasound, FNA cytology.

TFTs (for more information see "bloods")

  • In the vast majority, TFT's will be normal. If TSH is suppressed there is thyroid autonomy either from the whole thyroid or a specific nodule. This can be determined by an isotope scan (thyroid scintigraphy). Treatment determined by symptoms, and T3,T4 levels.
  • Elevated TSH raises the possibility of autoimmune thyroiditis. Autoantibodies then required. The patient may well have nodular Hashimotos thyroiditis.
  • Thyroid antibodies can be done at presentataion but I tend to be more selective...only if hypothyroid.
  • Do not measure thyroglobulin...too nonspecific

Ultrasound

(for more information see "imaging")

  • ultrasound is a descriptor of thyroid architecture
  • when there is general thyroid enlargement ultrasound is done to determine whether there is a dominant nodule with any particular suspicious features i.e a nodule that should be targeted with ultrasound guided FNA.
  • to determine whether a dominant nodule is solid, cystic or complex (solid/cystic)
  • If a complex nodule, malignancy still possible and FNA of the solid component is required. This is best done under ultrasound control
  • if radiologist considers there are benign features, he/she is probably right but a solitary nodule or a dominant nodule in a goitre still requires FNA.
  • If radiologist thinks there are features suspicious of malignancy there is a 50% risk. FNA required.
  • almost all patients with a palpable nodule will require FNA regardless of TFT's and ultrasound.

Chest XRay

  • where there are symptoms of compression. These can very subtle and are insidious, developing over months or years. Patients often first become aware of a feeling of pressure like a hand on the throat which can be in certain head positions. Thes epatients generally proceed to surgery. The surgeon might request a CT scan depending on extent of compression.
  • gives an indication of tracheal deviation, compression and the extent of projection of thyroid tissue into the mediastinum.

FNA cytology

  • the single most useful test of a thyroid nodule
  • evaluate the report in context i.e. duration of nodule, solid vs cystic, solitary vs dominant in nodular goitre, age of patient, other masses etc.
  • If the nodule is solid and palpable then FNA does not require ultrasound control. If impalpable or complex ( mixed solid/cystic) then must do under Ultrasound.
  • risk of malignancy is reflected by the wording of the cytology report (see FNA cytology)

Parotid


Whole gland or just lump?

It is important to establish whether the whole parotid is swollen or whether it is a lump within the gland. Remember that 80% of parotid lumps will appear in the tail. The parotid tail is just behind the angle of the mandible and is in the upper part of the neck.

Whole gland swelling:

  • inflammation
    • mumps - acute parotitis. Prodrome.
    • ductal obstruction - recurrent swelling with eating
    • autoimmune - generally other symptoms of autoimmune disease (arthritis, sicca symptoms, hypothyroid etc)
    • sarcoid
    • HIV (multicystic disease)
  • lymphoma
    • usually a low grade lymphoma presenting with long term parotid swelling. May transition from autoimmune parotid disease. However high grad elymphoma also occurs.

Parotid lump:

  • benign neoplasm - most common overall
  • malignant neoplasm -increases particularly from age 40. Usually metastatic from skin primary but also primary adenocarcinoma.
  • inflammatory node - from skin/scalp, toxoplamosis.
  • benign cyst

 

whole parotid swelling

In association with eating...

  • look for the parotid duct papilla opposite the 2nd upper molar. Apply pressure to the gland against the ramus and angle of mandible and look for discoloured saliva coming from the papilla. If pus then do swab for C&S. These glands tend to be exquisitely tender.
  • ultrasound
    • to confirm whole gland swelling. (If exquisitely tender and overlying oedema will most likely require admission for IV antibiotis and ultasound to exclude abscess formation. )
    • to look for ductal dilatation +/- calculi
  • If no calculi: FBC ESR, autoantibodies, ANA, RF. Autoimmune disease predisposes to sialectasis and gland swelling. Furthermore can be precursor to lymphomatous change.

Not associated with eating

  • FBC ESR, autoantibodies, ANA, RF. Autoimmune disease predisposes to sialectasis and gland swelling. Furthermore can be precursor to lymphomatous change.
  • Mumps serology if clinically suspicious.
  • HIV serology if clinically suspicious and certainly if mutiple cysts seen on ultrasound.
  • Glucose (diabetics get fatty infiltration of gland usually symmetrical and of prolonged duration)
  • Ultrasound
    • to confirm whole gland swelling
    • to look for ductal dilatation +/- calculi
  • No ductal obstruction: if present for weeks/months and even if autoimmune then needs specialist review ?lymphoma, sarcoid.

parotid lump

neoplasm likely

  • FNA cytology.
    • benign neoplasm- then still need referral for surgical opinion. Beware that cytology not 100%
    • malignant neoplasm- refer.
    • benign cyst -may still be malignant e.g.necrosis within malignant node, or cystic adenocarcinoma
    • reactive node- could be lymphoma or metastatic node, if doesn't resolve 3 weeks refer for excision.
  • Ultrasound only if not sure if mass present or to differentiate from ductal obstruction

Neck Lumps


The aim of management is to diagnose every neck lump and therefore to determine which are detrimental to the patient and should be treated.

  • age of presentation is very important. Patients under 30 generally have inflammatory or congenital lesions while malignancy increases from the 4th decade.
  • aim to determine what tissue is involved eg skin, subcutaneous, node, salivary, thyroid.
  • midline lumps include benign lesions such as dermoid, thyroglossal cysts, plunging ranulae, and thyroid masses.....but malignancy is still possible eg. thyroid cancer, or metastases to midline nodes from skin, lip, oral cavity,
  • most lumps at the angle of the jaw are in the parotid. In younger patients they usually represent a benign parotid tumour (surgery required) but parotid nodal metastasis from a facial skin cancer is very common in this country and increases in incidence from the 5th decade onwards.

Multiple lumps of recent duration:

Blood tests

  • in young patients (
  • FBC ESR
  • serology for glandular fever (usually obvious)
  • toxoplasma titres - see toxoplasmosis in patient section. I see at least 5 of these each year presenting with nodes only.
  • CMV titres - I see 1-2 per year.
  • cat scratch titres - 1-2 per year
  • possibly rubella titres - seldom see
  • In older patients (>40) -malignancy increases yet the tests above may still be relevant.
    • multiple lumps when malignant may reflect lymphoma (ask re "B" symptoms), metastatic carcinoma from oral/throat/skin/thyroid primary. Ask re skin lesions, throat symptoms (soreness, otalgia, lump. hoarseness, dysphagia, blocked ear, blocked nose, epistaxis).

If blood tests do not indicate diagnosis then consider ultrasound to determine what tissue is involved and to determine whether FNA cytology required. However, also consider whether there is likely to be a delay and whether referral is preferable.

 

 

The aim of management is to diagnose every neck lump and therefore to determine which are detrimental to the patient and should be treated.

Ultrasound

Consider whether this is best imaging modality before referral. Public radiology departments inundated with requests. There must be value added to the working diagnosis. Unless showing a calculus or fluid collection it is seldom diagnostic.

  • confirms presence of lump
  • determines nature of tissue: node/salivary/thyroid
  • determines whether lump solid/ cystic/complex
  • describes the lump and may indicate likelihood of significant pathology
  • determines number of lesions
  • may be useful to guide FNA



The aim of management is to diagnose every neck lump and therefore to determine which are detrimental to the patient and should be treated.

FNA cytology

be careful here...there may be sampling error or may be secondary inflammation! If reactive cytology and lump persists then significant risk of false diagnosis. Always be prepared to reconsider working diagnosis.

if lump solid and clearly palpable US guidance not required. If difficult to palpate and/or cystic then consider US guided FNA

  • determines nature of tissue: node/salivary/thyroid
  • describes the cells involved and may indicate likelihood of significant pathology
  • may diagnose malignancy