Swelling in the neck in a 58-year-old man

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Problem 5 Swelling in the neck in a 58-year-old man

Jonathan W. Serpell

A 58-year-old man presents with a 6 month history of a swelling in the neck. This has been getting slowly bigger and is not painful. He has no other symptoms and the history is otherwise unremarkable. The swelling is shown in Figure 5.1. While taking the history you do, however, notice the swelling moves upwards on swallowing.

Figure 5.1

Q.1

Describe the abnormality in the photograph.

Q.2

What further information would you like from the history?

Q.3

What are the key features of a problem-oriented examination of a patient with suspected thyroid disease?

Q.4

What are the possible causes of this man’s thyroid lump?

Q.5

What investigations would you organize?

Q.6

What does the cytology of the aspirate reveal (Figure 5.2)?

Figure 5.2

Q.7

What does his ultrasound scan show (Figure 5.3)?

Figure 5.3

Q.8

What would you tell the patient at this stage?

Q.9

What do you tell this patient about the surgery?

The patient undergoes a right thyroid lobectomy and makes an uneventful recovery.

Q.10

What does the specimen (Figure 5.4) show?

Figure 5.4

Q.11

What advice will you now give the patient?

Answers

A.1 There is a smooth surfaced swelling at the base of the neck on the right side. You notice that the swelling elevates on swallowing. The swelling is in the anterior triangle of the neck and about 4 cm in maximal diameter. The trachea appears to be displaced to the left. The overlying skin is normal. This may well be a swelling arising in the right lobe of the thyroid gland, as it elevates on swallowing. Thyroid swellings elevate on swallowing because they are enveloped by the pretracheal fascia which attaches the thyroid to the laryngopharynx.

A.2 You will want to know about the following:

• Is there a goitre which has either increased or decreased in size, or perhaps increased in size rapidly, suggesting bleeding or malignancy?

• Are there any symptoms suggestive of local pressure effects on adjacent structures in the neck (local pressure is common and often manifests as the inability to lie flat in bed at night, dysphonia, dysphagia, dyspnoea, noisy breathing)?

• Are there any symptoms suggestive of excessive thyroid hormone production (thyrotoxicosis)? This may occur in cases of toxic adenoma or from a dominant nodule within a multinodular goitre which is toxic. Alternatively the thyroid mass may be incidental to underlying Graves’ disease, but the presence of thyrotoxicity may modify the treatment plan.

• Specific enquiry of overactivity will include symptoms related to the metabolic, cardiovascular, neuropsychiatric and ocular manifestations of thyrotoxicosis. These would include increased appetite, weight loss, palpitations, altered bowel habit, temperature sensitivity, tremor, nervousness, muscle weakness, tiredness, low efficiency, anxiety, irritability and excessive sweating.

• An ophthalmic history should make note of any deterioration in vision or any sense of grittiness and diplopia.

• Thyroid nodules may be associated with hypothyroidism in the setting of Hashimoto’s thyroiditis. Specific features of hypothyroidism, such as intolerance of cold, constipation, tiredness, poor appetite, weight gain, forgetfulness, dryness of the skin and hair, a general slowing down mentally and physically, menorrhagia, symptoms of carpal tunnel syndrome, and symptoms of anaemia may be present.

• Is there a family history of thyroid cancer (particularly medullary and papillary thyroid cancer)?

• Has there been any previous exposure to ionizing radiation (especially in childhood) to the neck to treat conditions such as acne, tonsillitis, thymic enlargement or excessive facial hair?

• Has the patient lived in an area of endemic goitre or does he have a family history of multinodular goitre.

• Pain in the goitre is uncommon but may suggest haemorrhage into a nodule or subacute thyroiditis or rarely malignancy.

• The patient is examined with adequate exposure, free of clothing in the region of the neck, and in the sitting position.

• Inspection and palpation are undertaken from the front, laterally and behind the patient.

• Previous thyroidectomy and other neck scars are noted.

• Does the swelling pulsate, and if so is there also a thrill and a bruit?

• Is any venous distension present?

• Is Pemberton’s sign positive?

• Does the swelling elevate on swallowing?

• Is the goitre diffuse, i.e. does it affect the whole gland, or is there an apparently solitary nodule within an otherwise normal thyroid gland?

• The specific features of the thyroid mass are noted and should include site, shape, surface, consistency and tenderness.

• Is the cervical trachea palpable and if so is it in the midline or deviated?

• Does the goitre extend retrosternally on the right and/or left sides?

• Is there any regional lymphadenopathy in the anterior or posterior triangles of the neck?

• Are there signs of hyper- or hypothyroidism?

• An assessment of the patient’s swallowing, cough and phonation is made.

A.4 The differential diagnosis of this thyroid mass – in order of most to least common – is:

• Dominant nodule in a multinodular goitre (colloid, hyperplastic or adenomatous nodule).

• True solitary nodule:

– cystic degeneration of a colloid nodule

– follicular adenoma

– thyroid carcinoma

– focal area of nodularity within Hashimoto’s thyroiditis.

Even when it is thought that the nodule is a true solitary nodule, further investigation will show that 50% of cases are in fact dominant nodules within a multinodular goitre. Around 8% of the population will have a palpable goitre, and of those subjected to ultrasound of the thyroid, by the age of 50, 50% of the population will have demonstrable ultrasound identified thyroid nodules. Of all these thyroid nodules, only 5% will be malignant. Overall, thyroid cancer is rare, representing only 1% of all malignancies.

• Thyroid function tests – T4 and TSH. If TSH is suppressed this may indicate thyrotoxicosis due to Graves’ disease, toxic adenoma or toxic multinodular goitre.

• Thyroid antibodies – thyroid peroxidase antibodies, anti-thyroglobulin antibodies.

• Calcium, and parathyroid hormone (PTH) as a baseline.

• TSH receptor antibodies will distinguish Graves’ disease from toxic adenoma or toxic multinodular goitre.

• Nuclear scanning of a thyroid nodule has a limited role except in the circumstances of thyrotoxicity where it is important to demonstrate that the thyroid gland itself is diffusely hot as in Graves’ disease or that there is a dominant nodule within the multinodular goitre or a toxic adenoma which is hot. Nuclear scanning is no longer routinely used to demonstrate whether or not a thyroid nodule is cold.

• Ultrasound of the neck, including the thyroid nodule, the thyroid and cervical lymph nodes:

– features suggesting malignancy on ultrasound include an irregular margin, micro-calcification or coarse calcification, a predominantly solid as opposed to cystic nodule, and vascularity within the nodule as opposed to peripheral vascularity which is a feature of benign nodules

– the shape, size and composition and vascularity of the swelling are noted

– definition of the remainder of the thyroid gland and whether other nodules are present

– cervical lymph nodes.

• A fine needle aspirate for cytology of the thyroid mass. Cytology obtained by fine needle aspiration (FNA) is the most specific, sensitive and cost-effective of all thyroid investigations. Fine needle cytology has a low false negative rate of 5% and its accuracy increases when samples are taken under ultrasound guidance compared to freehand. The aim of cytology is not necessarily to provide a specific diagnosis of an individual thyroid mass but rather categorize a mass into a diagnostic group, which in turn will dictate subsequent management, either observation or surgery. Accordingly a synoptic method of reporting cytology is utilized.

• Firstly the sample may be non-diagnostic in between 5% and 10% of cases and this will mandate repeating the cytological aspirate.

• Benign thyroid nodules will tend to show a large amount of colloid with a small number of bland follicular cells and these nodules are likely to be benign and can be observed.

• If the thyroid lump is predominantly a cystic structure, this can be aspirated to dryness at the time of obtaining cytology, thus eliminating the lump and providing immediate reassurance to the patient. Of all such cysts, 50% will not re-accumulate and the aspiration will have been definitive treatment.

• Where cytology demonstrates malignant cells (e.g. papillary or medullary carcinoma) or the cytology is suspicious for malignancy, this will indicate the need for thyroidectomy.

• For cases of cellular follicular lesions which are indeterminate, the cytology is unable to distinguish between a well-differentiated tumour such as a follicular adenoma or follicular carcinoma or a benign lesion such as a hyperplastic or adenomatous thyroid nodule. These indeterminate lesions on cytology will therefore require a diagnostic hemithyroidectomy to establish the histological diagnosis. Of these, between 10% and 20% will be malignant.

A.6 The cytological aspirate shows sheets of follicular cells with minimal colloid. There are many clusters of bland epithelial cells which form well-defined circular follicular structures in the centre and to the right of the picture. This is a typical microfollicular pattern. There is, however, no clear evidence of malignancy. When follicular structures are identified on a fine needle aspirate of a thyroid nodule, the differential diagnosis includes a hyperplastic (adenomatous or colloid nodule) follicular adenoma, or follicular carcinoma. A reliable distinction between these is not possible on cytological appearances from an FNA because the distinction between follicular adenoma and follicular carcinoma can only be made histologically by demonstrating invasion of the capsule of the tumour or by vascular invasion.

A.7 The ultrasound scan shows a well-circumscribed, solitary, solid lump in the lower pole of the right lobe of the thyroid gland. The remainder of the thyroid gland appears to be normal. This solid mass lesion, in the context of an otherwise normal thyroid gland, is therefore likely to be a tumour, but still most likely benign.

A.8 You should tell the patient that he has a growth in the thyroid gland. The gland appears to be functioning normally but the lump is solid and solitary and might be a cancer, although you favour a benign or innocent growth (80–90%). The only way you will be able to tell exactly what the lump is will be to perform an operation and remove the lump. This will involve removal of the right half of his thyroid gland. The pathologist will then assess the excised lump and provide a definitive diagnosis. This process will take at least 48 hours following surgery. Once a definitive diagnosis is reached, you will be able to discuss further treatment with the patient should it be required. At this stage it is probably unnecessary to have a detailed discussion on thyroid malignancy, since the lump is most likely benign.

A.9 A detailed process of consent is essential. The operation and the anaesthetic, the likely inpatient stay and the postoperative recovery phase should all be discussed in detail.

• The details of hemithyroidectomy will include a discussion of the incision in the lower part of the neck which will be expected to heal with a good cosmetic result.

• The right half of the thyroid gland is removed but the left side will not be touched. In 90% of cases one side alone will be sufficient to produce adequate thyroid hormone. In the remaining 10% of patients, the remaining half of the thyroid is not adequate to produce thyroid hormone and therefore these patients will need to go on to thyroid hormone replacement.

• The risks associated with hemithyroidectomy include:

– those associated with anaesthesia

– those related to any operation, such as wound infection and bleeding

– those specific to thyroid surgery.

• The specific risks associated with thyroid surgery include:

– bleeding into the neck (about 1 in 100 cases)

– voice changes (fewer than 1 in 10 cases). These may be due to laryngeal trauma during intubation; recurrent laryngeal nerve injury, temporary in about 5%, permanent in less than 1% and trauma to the external branch of the superior laryngeal nerve

– hypocalcemia is rare after hemithyroidectomy because there are usually two normally functioning glands on each side of the neck.

A.10 The right lobe of thyroid has been opened longitudinally, there is an encapsulated tumour 4 cm in diameter which occupies most of the lobe. The tumour is pinkish red and vascular with areas of haemorrhage. Gross examination does not show any evidence of capsular invasion. Histologically the lesion is shown to be composed of follicular cells and there is invasion through the capsule of the nodule. There is no evidence of invasion in the blood vessels. It was concluded the lesion was an invasive follicular carcinoma.

A.11 You will need to explain to the patient that an invasive follicular carcinoma has been found in the excised half of the thyroid. As a consequence further surgery, treatment and long-term follow-up are required. It is important to emphasize at the start that these tumours have an excellent prognosis (85% 10 year survival).

You therefore recommend to the patient the following measures:

• That the remaining half of the thyroid gland is removed (completion thyroidectomy) to facilitate further treatment and follow-up.

• That further treatment with radio iodine ablation, which is given orally, but requires an inpatient stay, will ablate any residual thyroid tissue in the neck.

• He will be on lifelong thyroxine (most differentiated thyroid cancers are TSH dependent and the thyroxine will suppress the secretion of TSH and therefore reduce the incidence of recurrence).

• A staging CT scan of the neck and chest will be undertaken as a baseline for metastatic disease, after the patient has had radioiodine.

• Long-term follow-up will be with serum thyroglobulin, neck ultrasound and radioiodine scanning.

Revision Points

Management of the Lump in the Thyroid

Aims

To establish if the lump is solitary and if the lump is malignant.

• Define the anatomy and morphology of the gland (history, clinical examination, and ultrasound).

• Measure thyroid function (T4 and TSH).

• Establish a cytological diagnosis which in turn will dictate subsequent management by fine needle aspiration cytology (FNAC has 95% accuracy).

• Exclude other pathology when indicated (e.g. thyroid peroxidase and anti-thyroglobulin antibodies for Hashimoto’s thyroiditis).

Issues to Consider

• How would your management differ if the FNAC reported a papillary carcinoma?

• What other thyroid malignancies exist and how are they treated?

• Why is there such a high incidence of thyroid cancer near to the Chernobyl nuclear plant?

• What is the risk of diagnostic imaging (particular CT scanning) to the development of radiation-related malignancies?

Further Information

, www.british-thyroid-association.org. The website of the British Thyroid Association, with a number of useful links

, www.endocrinesurgeons.org.au. The website of Australian Endocrine Surgeons

, www.aace.com. The website of the American Association of Clinical Endocrinologists, with clinical guidelines for the management of thyroid carcinoma

, www.thyroidmanager.org. A site covering all aspects of thyroid disease

Yeung M.J., Serpell J.W. Management of the solitary thyroid nodule. The Oncologist. 2008;13:105-122.

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