Case Presentation and Discussion
Neck Mass
Gemma Uy, MD Year III Surgery Resident GSI, Department of Surgery, Philippine General Hospital 1999
Notes from the Facilitator
Note 1: The surgical resident was asked to read the self-instructional program entitled "Management of a Surgical Patient" written by the undersigned and used it as a guide to present and discuss the case. This is her output. My comments are seen in the "text areas" within and at the end of the manuscript.
Note 2: I welcome reactions not only from Dr. Gemma Uy but also from readers. Forms are provided at the end of the manuscript for this purpose or email can be used.
Note 3: The same case was presented and discussed by another surgical resident, Dr. Liborio I. Soledad, Jr. You may want to read this too and compare.
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg Facilitator
Case Presentation
This is a case of a 36 year-old female with a chief complaint of neck mass. The mass was noted since 15years prior to consult and was gradually enlarging. No hoarseness, dysphagia, tremors, palpitations were noted.
On physical exam, pertinent findings were:
HR = 84/min (-) tremors
Case Discussion
With a chief complaint of a neck mass, considerations for the origin of the mass include:
Comments: The presence of a palpable neck mass on PE confirms the presence of a neck mass. Your illustration shows really the presence of a neck mass. MAINTAIN THE GOOD HABIT OF USING ILLUSTRATION! It is only after you have assured yourself of the presence of a neck mass that you start determining what it is. YOU ARE CORRECT IN FIRST DETERMINING THE ORGAN/TISSUE OF ORIGIN OF THE MASS BEFORE YOU THINK OF THE DISORDER, WHETHER MALIGNANT, NONMALIGNANT, OR A SPECIFIC DISEASE.[This is a common pitfall!] MAINTAIN THAT HABIT!
Based on the central location of the mass, paratracheal and medial to the left sternocleidomastoid muscle, the organ/tissue of origin of the neck mass will be the organs and tissues located in the specified area. ALL YOUR CONSIDERATIONS ARE CORRECT. QUESTION:Specifically, what or which cartilage were you referring to? Tracheal cartilage, cricoid, or thyroid cartilage?
On physical examination, the mass is unlikely to involve the skin since no break or skin lesions were noted.
Also, it does not originate from the cartilage because of its consistency and mobility.
What you are saying is that it does not feel like a cartilage! The "soft" consistency is not compatible for a cartilage consideration. If you consider the cartilaginous structures in the central neck, the thyroid, cricoid, and tracheal cartilages are movable. Thus, there is a flaw in using mobility as a basis for saying the mass is not cartilage. You can use the lateral location of the mass to say that the mass is most likely NOT the thyroid, cricoid, or tracheal cartilage.
A mass in the neck of this relatively large size (4x5cm) with no other masses noted on the head and neck area has a low possibility of being a metastatic lymph node when no obvious primary focus is seen.
A stronger reason why the neck mass is not a lymph node is the central location of the mass (paratracheal) and the mass moving with deglutition (which suggests a thyroid gland origin). A more lateral neck mass is most likely a lymph node. THE STRONGEST CUE THAT A NECK MASS IS A LYMPH NODE IS THE LATERAL LOCATION OF THE MASS, ON AND LATERAL TO THE STERNOCLEIDOMASTOID MUSCLE. Use the presence/absence of a related primary focus ONLY AFTER you have analyzed the location factor. NOTE WHAT I SAID EARLIER ON THE COMMON PITFALL TO JUMP ON THE SPECIFIC DISEASE/DISORDER BEFORE CONSIDERING THE ORGAN OR TISSUE OF ORIGIN BASED ON OBJECTIVE PARAMETERS! YOU WERE THINKING OF A METASTATIC LYMPH NODE ALREADY BEFORE YOU ARE THROUGH DECIDING THE ORGAN OR TISSUE OF ORIGIN!!!
On the other hand, parathyroid masses are uncommonly seen, and by prevalence, this consideration is not highly entertained.
The cues for parathyroid masses are a central mass which is most likely not a thyroid mass or a tracheal or esophageal mass (in other words, no alternative organ or tissue of origin) AND SYMPTOMS OF HYPERCALCEMIA. Use this pattern recognition process first before you use the prevalence process to demote consideration for parathyroid mass.
After taking into account those mentioned above, the considerations are narrowed down to either a soft tissue mass or a thyroid gland mass.
Furthermore, the characteristics of the mass, soft, moves with deglutition and location on the anterior neck below the thyroid cartilage plus the fact that a thyroid mass is more often seen than a soft tissue mass in the neck make the thyroid gland the most likely tissue of origin.
The cues for a thyroid mass are the central location of the mass on the neck (where it is normally located) and its movement with deglutition. The soft consistency of the mass is not a reliable cue for a thyroid gland mass. A thyroid mass can be hard. A soft tissue mass or other nonosseous or noncartilaginous masses on the same area can also feel soft. Again, put more priority on patttern recognition process than on prevalence. The cues for a soft tissue mass are that the mass is located below the skin level and above the thyroid level, nonosseous, noncartilaginous, and does not move with deglutition.
The next step is then to determine the nature of this thyroid mass - be it an inflammatory, benign or malignant type.
Because of its long duration (15 years) and no obvious signs of inflammation (redness, tenderness, etc) then its unlikely to be inflammatory.
Valid reasoning! Process the inflammatory factor first because it is the easiest thing to do. The algorithm is : Positive signs of inflammation - therefore inflammatory disorder! No signs of inflammation - consider malignant vs nonmalignant disorder! Betweeen the two, the malignant factor is easier to process. Thus, look for signs of malignancy first. Positive signs - malignant disorder. Negative signs - most likely nonmalignant.
Benign or Malignant?
Malignant masses in the neck are usually firm or hard, associated with cervical lymphadenopathy, and compressive symptoms- hoarseness, dysphagia.
SIGNS OF THYROID MALIGNANCY - signs of invasion - fixation, hoarseness, dysphagia signs of spread - cervical lymph nodes, distant masses hard consistency can be used but this is not as reliable as those mentioned above. SIGNS OF THYROID BENIGNITY - CYSTIC NATURE OF MASS
In this patient, a 36-year-old female with 15-year duration of a soft mass with no other symptoms, then it can be said that the neck mass is of thyroid gland origin most probably benign by pattern recognition and prevalence.
Primary clinical diagnosis: colloid adenomatous goiter
Processes used: - Pattern Recognition A left paratracheal mass which moves with deglutition is most likely a thyroid mass. In the absence of signs of inflammation and malignancy, chances are the mass is nonmalignant (benign). - Prevalence A nonmalignant thyroid mass with no signs of inflammation and malignancy can be a colloid adenomatous nodule or a follicular adenoma. Since colloid adenomatous nodule is more common, it is considered as the primary clinical diagnosis. Colloid adenomatous goiter is a very common thyroid disorder in the Philippines.
Secondary clinical diagnosis: thyroid cancer
Don't forget to mention the basis/bases for the secondary clinical diagnosis. You are definite that the neck mass is a thyroid mass. What you are not absolutely certain of is the nature of the thyroid mass. In the absence of signs of inflammation, you are definite the mass is not an inflammatory thyroid mass. If it were a non-inflammatory mass, it could be a malignant or nonmalignant mass. In the absence of signs of malignancy and based on prevalence, probability wise, the mass is more likely to be a nonmalignant one. However, it could still be a malignant one. Thus, your primary clinical diagnosis is a nonmalignant one (colloid adenomatous nodule being the most common) and the secondary clinical diagnosis is a malignant one.
Paraclinical Diagnostic Tests
Before you go to comparing and selection of the options for paraclinical diagnostic procedures, answer first the question whether a paraclinical diagnostic procedure is needed or not.
Options
Cost
Benefit
Risk
Availability
Fine needle aspiration biopsy
affordable
know nature of mass - cystic or solid, malignant or benign; may be therapeutic if mass is cystic - aspirate all fluid
low
available
Thyroid scan
expensive
know if hot or cold nodule (10% of cold nodules are malignant)
not always available
Ultrasound
relatively expensive
know if solid or cystic
You don't need this table if you do not need a paraclinical diagnostic procedure. At any rate, just supposing you need one. Your table shows a comparison of the options based on four parameters. You are correct in using the four parameters. However, the priority should be benefit - risk - cost - availability in the decreasing order. Cost is not the first priority. Under cost, I suggest you place the estimated cost in the community on a private setting. For example for needle biopsy, Php 1,500; for thyroid scan, PhP 1,000; and ultrasound, Php 1,000. Under benefit, you can add needle biopsy is a direct investigative method while scan and ultrasound are indirect methods. Under risk, don't just place low or high or moderate. Spell out the risk, such as pain and hematoma for needle biopsy and radiation for thyroid scan. Under availability, your entries will be dependent on the place of practice. So, please specify. For example, in Metro Manila, thyroid scan and ultrasound may be more readily available than needle biopsy. In the provinces, thyroid scan and ultrasound are not readily available.
Is a paraclinical diagnostic procedure needed for the patient?
See comments above. This question should come first before the comparison of the different options of paraclinical diagnostic procedures.
Will the management of the patient differ if the mass is proven to be benign vs malignant?
Since the contemplated treatment plan for the patient is surgical regardless of whether it is benign or malignant, then a paraclinical diagnostic procedure will not alter the treatment plan.
You are correct! This is one of the processes that you use to decide whether you need a paraclinical diagnostic procedure or not. However, there is another process and which is the first one that you should use. You omitted this. The first process is degree of certainty of your clinical diagnosis. DON'T OMIT THIS IN THE FUTURE! Based on what have been discussed so far, you can say that the degree of certainty of the primary clinical diagnosis of colloid adenomatous goiter is around 80 to 90%. You can understand how I got to the figures by asking the question: Given 100 female patients in the 4th decade of life and presenting with a solitary thyroid nodule which is non-hard and with no signs of inflammation and malignancy, how many of them will turn out to be benign colloid adenomatous goiter and how many will turn outto be malignant thyroid cancer? The general figures in the literature are 80:20 in favor of benign masses. Right? Since the primary basis for choosing colloid adenomatous nodule is prevalence, you can say the degree of certainty of your primary diagnosis is NOT quite certain, even if you have a 80-90% probability.The only time in which you can confidently say that you are quite certain of your diagnosis is when your primary basis is pattern recognition and which is based on signs or objective data. As a rule if you are not quite certain of your primary clinical diagnosis, you go for a paraclinical diagnostic procedure. After assessing the degree of certainty of your diagnosis, the next process you use is the treatment comparison process. As a rule, if the treatment will be the same or almost the same for both primary and secondary clinical diagnoses, you don't need a paraclinical diagnostic procedure. You were right in saying that "since the contemplated treatment plan for both is the same, you don't need a paraclinical diagnostic procedure." Your plan for the neck mass if it turns out to be colloid adenomatous nodule, as you said, is surgery. Question is: Why surgery? Why not nonoperative?
Treatment
Restate your pretreatment diagnosis before you state the goal. Assuming that the pretreatment diagnosis is Colloid Adenomatous Nodule. The goal will be to extirpate the mass in such a way that there will be no morbidity and mortality and patient is satisfied.
The goal of treatment for a benign thyroid mass is to remove as much of the mass without any complication or harm to the patient. This is usually done for cosmetic purposes in patients who are asymptomatic.
Medical treatment may sometimes decrease the size of the mass but it does not eradicate this size and require continued therapy.
The options will be explained to the patient.
Compare the two options: operative and nonoperative treatment based on your goal and using the four parameters of benefit-risk-cost-availability. Tabulate as you did in the paraclinical diagnostic procedures. See table below this text area.
Options of Tx
Operative
-The mass can be extirpated completely in one sitting -Definitive diagnosis
-Pain and scar -Hematoma, infection, risk of anesthesia (l%)
Private setting: PhP 40,000
Charity setting (no PF): PhP 5,000
There are surgeons and operating room facilities readily available in Metro Manila
Nonoperative (thyroid suppressive therapy)
-Probability of extirpation with thyroid suppressive therapy) is only about 1%
-Side effects of thyroid hormones (allergy, osteoporosis) - 1%
6-month course, at 2 tablets/day
PhP 3,000
Abundant supply
Nonoperative (observation-monitoring)
-Probability of the mass spontaneously disappearing is less than 1%
-The mass may turn out to be malignant resulting in delayed diagnosis.
Does not cost any centavos
Not dependent on availability of treatment equipment and resources
Preoperative Preparations
Treatment Plan : Left lobectomy, isthmusectomy, pyramidalectomy under general anesthesia
The assumption here is that the patient signs an informed consent for an operation.
Intraoperative management
Utilize a skin crease in the lower neck, if present, to promote cosmetic acceptability of scar.
What is the gross appearance of a colloid adenomatous nodule? In other words, intraoperatively, what are the gross features on the mass that will indicate that the mass is a colloid adenomatous nodule and not something else? Presence of colloid cysts with or without the fleshy adenomatous elements.
if mass is limited to the left lobe, then a left lobectomy with isthmusectomy and pyramidalectomy is done.
Is this a routine procedure? Can it be omitted? If yes, what are the indications for putting a drain or vice versa, for not putting a drain?
Penrose drain is brought out at the corner of the incision and anchored
Postop Care
Suppose the mass really turns out to be colloid adenomatous nodule based on intraoperative finding and microscopic exam. If the patient asks you, what is the cause of this condition and how do I avoid it - how do you answer these two questions? The patient asks you further - can there be a recurrence? how do we avoid the recurrence? Will you give hormonal suppressive therapy for life? Answer these questions. How will be the long-term follow-up of this patient?
Facilitator's Additional Comments
Summary of Case As Presented by Dr. Gemma Uy
A 36-year-old female presented with a left paratracheal neck mass of 15 years duration. The mass moves with deglutition. It is not hard, not fixed and not tender. There are no skin changes nor palpable lymph nodes on the neck. The pulse rate is 84/min.
Clinical Diagnosis
The paratracheal mass moves with deglutition. Thus, most likely, it is a thyroid mass.
With a pulse rate of 84/min and with the nature of the change in structure of the thyroid being a mass rather than an enlargement, most likely the patient is not hyperthyroid.
A nonhyperfunctioning thyroid nodule can be an inflammatory, malignant or nonmalignant nodule.
With no signs of inflammation and no signs of malignancy, the mass is most likely nonmalignant.
A nonmalignant nodule can be a colloid adenomatous nodule or follicular adenoma. There are no reliable clinical parameters that can differentiate the two. To get to the primary diagnosis, we just have to rely on prevalence. Between the two, colloid adenomatous nodule is more common. Thus, it is the primary clinical diagnosis for this patient.
My secondary diagnosis would be a thyroid malignancy. Although in the absence of frank or obvious signs of malignancy, a nonmalignant disorder is more probable, a malignancy is the alternative diagnosis.
Follicular adenoma is not the secondary diagnosis if we follow the guide in making a secondary diagnosis, that is, it should be derived from the "uncertain" areas when formulating a primary diagnosis. In this case, the "uncertain" area is located at the point where we were trying to decide whether the mass is malignant or not.
Thus, based on pattern recognition and prevalence,
Primary Clinical Diagnosis: Thyroid mass, left lobe, most likely colloid adenomatous goiter
Secondary Clinical Diagnosis: Thyroid cancer, left lobe, most likely papillary cancer, this being the most common among the cancers of the thyroid gland
Comments on Paraclinical Diagnostic Process, Treatment Process, and Health Maintenance Process were already made previously.
Suggestions to Dr. Gemma Uy on improvement of case presentation and discussion:
1. Refer to the format of a general case presentation and discussion.
2. Refer to the format used in "Management of Surgical Patient."
3. Use the Evaluation Form below as a guide.
4. Read the case presentation and discussion of Dr. Liborio Soledad Jr.
Case Presentation and Discussion Evaluation
Key:
A - Adequate, Acceptable I - Inadequate, Insufficient, Improvement Needed NA - Not applicable, Not assessed
1. Clinical Diagnostic Process
AINA
1.1
Rational Process Using Pattern Recognition and Prevalence
1.2
Specific Diagnosis
2. Paraclinical Diagnostic Process
2.1
Indication Using Degree of Certainty and Whether Management Will Change if the Real Diagnosis Turns Out to be the Secondary Diagnosis
2.2
Cost-effective Selection
2.3
Rational Interpretation
3. Nonsurgical Treatment - Rational
4. Surgical Treatment (Preop)
4.1
Psychosocial Preparations
4.2
Screening for Medical Problems
4.3
Optimizing Physical Conditions
4.4
Preparing for Operating Needs
5. Surgical Treatment (Intraop)
5.1
Rational Intraop Evaluation
5.2
Rational Operative Maneuvers
5.3
Adequate Operative Maneuvers
6. Surgical Treatment (Postop)
6.1
Adequate Postop Care
6.2
Rational Postop Diagnosis
6.3
Rational and Adequate Follow-up
7. Health Promotion and Maintenance
8. Medical Recording
7.1
Adequate and Relevant
7.2
Clear
7.3
Systematic and Organized
9. Discussion in General
8.1
Adequate
8.2
8.3
Reactions from Dr. Gemma Uy
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rjoson@pacific.net.ph
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