Case Presentation and Discussion

Neck Mass

Liborio I. Soledad, Jr., MD
Year I 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 his 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. Liborio Soledad Jr. 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. Gemma Uy. You may want to read this too and compare.

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Facilitator

Case Presentation

This is the case of M.S. , 36/F, from Cavite, admitted for the first time in Philippine General Hospital (PGH) for a neck mass.

15 years prior to admission (PTA), patient accidentally palpated a mass on the anterior neck area, described as non-hard, non-tender, and movable. No associated symptoms were observed. No consult was sought. No medications taken.

7 years PTA, there was note of persistence of the neck mass with slight enlargement. She consulted a private MD who prescribed Tapazole which she took every 8 hours for 4 months. No note of increase in mass size and patient was advised surgical intervention. Patient declined due to lack of finances.

1 year PTA, there was note of persistence of mass with further increase in size.

2 months PTA, patient consulted at PGH-Outpatient Department (OPD).

T4 = 109 (62-165 nmol/L)
TSH = 1.64 (0.1-4.5mIU/L)
Fine Needle Aspiration Biopsy = bloody smears

Patient was advised surgery.

Negative for fever, cough, easy fatigability, increasing appetite, dysphagia, diarrhea, difficulty in breathing, weight loss, hoarseness, vomiting, jaundice, tremors, palpitations, abnormal sweat patternsIf we go for efficiency in interviewing or history-taking and medical recording, you can omit this Review of System. You can put the pertinent negatives, that is, those related to the chief complaint of the patient, under history of present illness. Example: since the patient was prescribed antithyroid drugs, you may want to investigate during your history-taking whether the patient has symptoms of hyperthyroidism. Palpitations, tremors, and acute weight loss are important symptom-cues for hyperthyroidism. These are the pertinent negatives you should place in the history of present illness. The data on fever, cough, easy fatigability, increasing appetite, jaundice, vomiting, diarrhea, and abnormal sweat pattern are nonspecific and do not contribute to the diagnosis. You may omit these. In fact, you don't have to ask for them during the history-taking. Dysphagia, hoarseness, and difficulty in breathing as a result of the mass are pertinent data which you can include in the history of present illness.

Negative for hypertension, asthma, diabetes, TB

Negative for cancer, hypertension, diabetes, asthma, goiter

Menarche at 16 years of age; regular monthly intervals; no oral contraceptive use; last normal menstrual perior: 7/3/99 - 7/9/99; G9P9(7-0-2-7)

Nonsmoker, nonalcoholic beverage drinker, housewife

Fairly developed, fairly nourished, not in acute cardiorespiratory distress

BP = 120/70; HR = 84/min; RR = 18/min; T = afebrile

Pink conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy, no neck vein engorgement

(+)4x5 cm mass on anterior neck, non-hard, non-tender, non-erythematous, moves with deglutition

Always include an illustration of your PE findings. Anterior neck is too broad an area for the reader to decipher where the mass is exactly located.

Equal chest expansion, clear breath sounds

Adynamic precordium, distinct heart sounds, regular rhythm, no murmurs

Abdomen soft, nontender, normoactive bowel sounds, no masses, no organomegaly

Full pulses, pink nailbeds, no edema

You can omit the findings which have no bearing on the diagnosis of the patient's chief complaint. If you don't mention them, the assumption is that there is nothing unusual or abnormal about them. Focus on the more pertinent and important positive and negative signs that contribute to the diagnosis of the neck mass. Examples: Exact location of the neck mass, size, moves with deglutition - a cue for a thyroid disorder, therefore, you must include positive and negative signs of hyperthyroidism, signs of inflammation, signs of malignacy, and signs of benignity. Is the mass solid? Are there skin changes? Is there erythema? Is there a distant mass? etc.

In dealing with neck masses, one must first identify the exact location. History and PE would tell you that the mass is located in the anterior neck area. The next step is identify the tissue of origin. It may be any of the following: skin, thyroid gland, lymph node, soft tissue, or muscle.

If you have a specific location of the mass, you have fewer differentials as far as organ or tissue of origin is concerned. This contributes to efficiency in the diagnostic process. Example: If you start off with a left paratracheal mass rather than anterior neck mass, then the considerations will be fewer. Lymph node is possible but not likely probable in the paratracheal area. The cue for lymph node is a more lateral location on the neck.

Absence of skin changes or signs of skin invoolvement weakens the possibility that the lesion comes from the skin. Lymph node usually indicates secondary involvement. Further PE does not reveal any primary lesion from the face, head, or oral cavity. It is likely, therefore, that the lesion is not lymph node in origin. Investigating muscle as the probable source leads us to ask the patient to flex the different musculatures of the neck. The mass does not become prominent in any of these attempts, which lowers the likelihood of muscle as the source.

Take note of my comments earlier with regards to lymph nodes. The first cue should be the exact location of the mass. After this, you can use the associated primary lesion cue.

A particular finding in this patient is movement of mass upon swallowing. This is a strong indication that the mass is coming from the thyroid gland.

Having identified the source, we now determine whether the mass is malignant or not. Signs of malignancy would include hard, non-movable, single nodule, and presence of lymphadenopathies together with symptoms of compression. These are not found in the patient. It is highly likely that the mass is non-malignant.

Suggest categorizing masses into inflammatory, malignant and nonmalignant. I find this very practical and easy. With this categorization, look for signs for inflammation, because the inflammatory signs are easy to recognize. After this, look for signs of malignancy. These signs, if present, have greater degree of diagnostic reliability than signs of benignity. Signs of thyroid malignancy are signs of invasion (fixation, skin ulceration, hoarseness of voice, invasion of trachea and esophagus) and signs of spread (regional lymph nodes, distant mass suspicious for metastasis). In the absence of signs of invasion and spread, you can also use a hard solid consistency as a cue for thyroid cancer. Basis? Majority of thyroid cancers are papillary. Majority of papillary cancers are hard. Majority of benign thyroid nodules are not hard. Take note, however,ofthe subjectivity of determining consistency. Single nodule is not a reliable sign for malignancy.

Next, we need to look for signs of inflammation like tenderness, warmth, and redness of overlying skin. There are no such findings leading us to conclude that the mass is most likely not inflammatory.

Signs of benignity found in this patient include cystic consistency, non-hard, well-delineated borders, mobility, and history of gradual enlargement. Prevalence would also tell you that 70-80% of thyroid masses are benign. Other data in the history tells us that the patient is in the euthyroid state as evidenced by lack of signs of symptoms of tremors, tachycardia, palpitations, weight loss, easy fatigability, increased appetite, abnormal sweat patterns, and normal serum levels of T4 and TSH.

At this point, our primary clinical diagnosis is a thyroid mass, probably colloid adenomatous goiter.

Why colloid adenomatous goiter? Why not other benign thyroid neoplasm, like follicular adenoma?

Our secondary clinical diagnosis is a malignant thyroid tumor.What are your bases?

To confirm our primary diagnosis, we employ an additional diagnostic tool. Fine needle aspiration cytology is the most powerful tool available in the diagnosis of a thyroid nodule. It can differentiate a malignant lesion from a non-malignant one. Furthermore, one can identify if the mass is cystic or solid and if cystic, can be used to drain its contents. It is important to identify whether the mass is malignant or not as a malignant tumor warrants a surgical procedure for treatment.

Ultrasonography can also tell you if the mass is cystic or solid, but it could not differentiate a malignant from a benign lesion. Some malignant masses occasionally are cystic in consistency. This modality was not employed in our patient.

Note: A needle aspiration biopsy was already done. It showed bloody smears. Would you still recommend for another needle biopsy? In the paraclinical diagnostic process, the first question to answer is whether you need to do a paraclinical diagnostic procedure or not. If yes, why? If no, why? You use the certainty and change-in-management to factors to answer this question. If you have adequately supported your NO answer, then you proceed to treatment. If you go for a YES answer, that is the time you talk about options, then selection. After performing the procedure, you then interpret the results.

The most cost-effective treatment is to surgically remove the mass, without complications.

Support your statement. Why not nonoperative treatment? Or just monitoring-observation, since your diagnosis is colloid adenomatous goiter.

After having informed and explained to the patient and relatives the contemplated procedure, it is prudent to do the following: ask for consent, clear the patient of any medical condition that may affect outcome of operation, prescribe and prepared needed materials and equipment.

Plan the incision so as to have adequate exposure, with excellent cosmetic benefits. Create flaps that remain viable after the operation and with adequate extension to enable the surgeon to view and handle the mass. Once visualized, mass should be examined further to determine origin and whether mass is malignant or benign. Afterwards, one must decide on operative techniques to be employed.

The lone objective to satisfy here is to be able to remove the mass without sacrificing or compromising any anatomical structure such as nerve (recurrent laryngeal), or blood vessel, as the thyroid might be sharing nerves and blood with other anterior neck structures.

What is the most probable extent of thyroidectomy, if this were a colloid adenomatous nodule on the left lobe?

After removal of the tumor, several steps must be made prior to wound closure. One must check for bleeding and should employ hemostasis, either by suture ligation or electrocautery. A drain must also be kept in place to provide outlet for any unwanted fluid accumulation. Make sure to confirm instrument and sponge counts before closing.

Must a drain always be placed at the end of the thyroidectomy?

Closure should be done in layers using absorbable material to lessen pain experienced in suture removal. Also be wary of the suturing technique in order to provide an acceptable cosmetic appearance after the scar has healed. This can be achieved through proper wound edge approximation.

Immediate postop care should focus on patient monitoring so as to detect any untoward incidents. In addition, one should also address basic needs regarding pain management, wound care, nutritional support, and patient comfort.

In the succeeding days postop, one should check for wound healing and anticipate possible complications. A complete physical examination should be made prior to sending patient home. Patient should be instructed regarding home instructions and proper wound care and future visits.

Suppose the final diagnosis is colloid adenomatous nodule. The patient asks you what could have caused it? How can recurrence be prevented? Do I need to take medications? How do you answer these questions?

Summary of Case As Presented by Dr. Liborio Soledad

A 36-year-old female presented with an anterior neck mass of 15 years duration. There was no specific localization of the mass on the neck. 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 anterior neck 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. Liborio Soledad 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. Gemma Uy.

Reactions from Dr. Liborio Soledad, Jr.

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you can email me your reactions.)

rjoson@pacific.net.ph

Questions and Comments from Readers

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you can email me your questions and comments.)

rjoson@pacific.net.ph

Dr. Gemma Uy's Case Presentation and Discussion
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