Nonthyroidal Neck Masses Research Articles

Cytopathological Evaluation of Paediatric Non-Thyroidal Neck Swelling–Experience in a Tertiary Care Children Hospital

Background and Objective: Fine needle aspiration cytology (FNAC) is well accepted as a useful diagnostic technique in the management of adult patients with head and neck lumps. However, until recently, few reports have been obtained regarding the role of FNAC in non-thyroidal neck masses in children. Therefore, the objective of our study was to determine the diagnostic value of fine needle aspiration cytology in the diagnosis of pediatric non-thyroidal neck masses. Methods: This descriptive study was conducted at the Department of Pathology of Bangladesh Shishu (Children) Hospital & Institute January 2019 to December 2021. Hundred patients with non-thyroidal neck masses fulfilling the inclusion criteria were included in the study. Fine needle aspirations were performed, smears prepared and stained by Hematoxylin and Eosin stain. Results: The most common non-neoplastic neck swelling seen in children were an enlarged lymph node due to inflammation 38(42.2%), i.e., reactive lymphadenitis. Others were TB lymphadenitis 25 (27.8%), non-TB granulomatous lymphadenitis 2(2.22%), chronic sialadenitis 2(2.22%), branchial cyst 4(4.44%) and epidermal cyst 3(3.33%) cases. Overall sensitivity, specificity, positive predictive value and negative predictive value of FNAC in our cases are 93.06%, 72.22%, 93.06% and 72.22%. Conclusion: FNA is an important diagnostic tool in the management of childhood neck lesion with the clinical presentation. The procedure decreases the requirement for more invasive and costly procedures like surgical biopsy.

The Accuracy of Fine Needle Aspiration Cytology for the Diagnosis of Non-Thyroid Neck Masses

The Accuracy of Fine Needle Aspiration Cytology for the Diagnosis of Non-Thyroid Neck Masses

Ultrasound Evaluation for Assessing Non-Thyroid Neck Masses

Ultrasound Evaluation for Assessing Non-Thyroid Neck Masses

Importance of Sonoelastography in Assessing Non-Thyroid Neck Masses.

To evaluate the feasibility and value of sonoelastography in assessing non-thyroid neck masses. Non-thyroid neck masses requiring surgical interventions were evaluated using conventional B-mode ultrasonography (US) (size, short/long axis rate, shape, hilum, echogenity, calcification, necrosis, and peripheral edema) and sonoelastograpy (SE) with strain ratio (SR) and elasticity score (ES) before surgery. These parameters were compared with the histopathological examination. In total, 116 non-thyroid neck masses (66 lymph node, 35 parotid gland, eight submandibular gland, and seven cervical mass) of 89 patients (51 men, 38 women) with a mean age of 50.3±15.1 (19-79) years were evaluated. Thirty-seven malignant lymph nodes (23 metastatic and 14 lymphoma), seven malignant parotid tumors, two malignant submandibular tumors, 29 benign lymph nodes, 28 benign parotid lesions, and six benign submandibular lesions were evaluated. Mean SR and ES values of malignant masses were 6.3/3.2 for lymph nodes, 5.5/3.3 for the parotid gland, and 4.2/3 for the submandibular gland. Mean SR and ES values of benign lesions were 2.0/2.1 for lymph nodes, 4.4/3.2 for the parotid gland, and 3.2/3 for the submandibular gland. SR and ES were significantly higher for malignant masses compared with those for benign ones. SR was more predictive than ES in evaluating malignant lymph nodes. The area under the curve was 0.917(0.827-1.00) (p<0.05) for SR in differentiating benign-malignant lymph nodes, and the upper cut-off value was two. SR and ES were higher in the malign parotid and submandibular gland lesions than the benign ones, but the difference was not statistically significant. Strain ratio value could be a useful parameter in differentiating benign-malignant lymph nodes. More studies are necessary for differentiating benign-malignant parotid and submandibular lesions using SE.

Appraising the Role of Fine Needle Aspiration Cytology in Non-Thyroidal Head and Neck Masses: A Single Referral Institute Experience.

Background: Fine needle aspiration biopsy (FNAB) is a widely recognized and sensitive technique, in which a fine needle is introduced into a mass, cellular material is aspirated and a cytological diagnosis is made. It provides initial diagnosis for masses in the head and neck region, enables appropriate management plans for individual patients to be made and separates masses that are reactive or inflammatory in origin and do not require surgical intervention, from masses of neoplastic origin. Furthermore, FNAB can differentiate benign from malignant neoplasms. Objective: To study the value of fine needle aspiration biopsy (FNAB) in the diagnosis of palpable non-thyroidal neck masses in Dammam Medical Complex. Study design: Patients with palpable non-thyroidal neck masses, who had their FNAB during the three-year study period, were reviewed. The FNAB results were analyzed into two groups according to the tissue of origin, into lymph node and salivary gland in origins. The study groups were also classified based on the histopathology findings into; inflammatory, congenital and neoplastic. FNAB diagnoses were retrospectively correlated from patient’s file, with available histological findings or with the outcome of treatment. Accuracy, sensitivity and specificity of FNA were analyzed. Results: A total of 258 patients had FNAB during the study Period. All patients who lost follow-up, those who were referred from other hospitals so the full medical records could not be retrieved and those with inadequate FNAB specimens to make the diagnosis were excluded from our study. Out of the 178 FNABs included in our study, 159 FNAB were done in adult patients and only 19 FNAB were carried out in pediatric age group. For the masses from palpable lymph node, the most common diagnoses were reactive/nonspecific lymphadenitis in pediatric (73.7%) and in adult were reactive/nonspecific lymphadenitis and tuberculosis lymphadenitis (50.8% and 32.5%, respectively). The next most common masses were neoplasm (16.7%), of these 45% of the cases were metastatic in origin, while diagnosis of lymphoma made in 55% of the cases. FNA from major salivary glands were 12.6% of the cases, mainly parotid and submandibular gland (65% and 35%, respectively). In our experience, the overall FNA sensitivity was 96.77%, with specificity of 92.1% and accuracy of 95.68%. Conclusion: FNAB of head and neck masses is a simple and cost effective tool in reaching an initial diagnosis and road map the clinician’s management approach. It aids in separating inflammatory non-thyroidal neck masses from neoplastic lesions, enhances surgical planning for malignant diseases and allows rapid referral of lymphomas and cancer cases for a higher center for further management. FNAB carries a high sensitivity and specificity rate with high overall accuracy in both adult and pediatric patients if done by experienced physician and interpreted by experienced histopathologist. The complications of FNAB are negligible and the associated pain and discomfort is short lived and well tolerated by most patients. This advantage encourages the clinician to consider FNAB as first step in approaching non-resolving, non-vascular, non-thyroidal head and neck masses in both adult and pediatric population.

The role of fine needle aspiration in pediatric head and neck masses: does the yield justify the pain?

Abstract The aim of our study was to report our own experience with utilizing fine needle aspiration (FNA) as a primary diagnostic procedure in adolescent patients with head and neck masses, examining the utility, feasibility, and appropriateness of this technique. This is a retrospective, single-institute study that was conducted at Dammam Medical Complex from January 2004 to December 2006. All adolescent patients aged between 10 and 18 years with neck masses who underwent FNA as the primary diagnostic modality were included in our study. We excluded patients with neck masses of thyroid origin and those who were lost to follow-up. A total of 26 patients between 10 and 18 years of age were studied. All patients presented with nonthyroidal neck masses and underwent FNA. The study population was divided into three groups depending on the tissue of origin of the mass: lymph node origin (18 patients), salivary gland origin (five patients), and miscellaneous origin (three patients). FNA from lymph-node-related masses revealed lymphadenitis in about two third of the cases, whereas of the patients with masses of salivary gland origin, 60% had a diagnosis of pleomorphic adenoma. In the third group, the masses were of variable origin. There were no reported complications. The overall sensitivity and specificity were calculated and found to be more than 90%. We believe that FNA as an office-based procedure is well tolerated and has a high diagnostic potential in head and neck masses. FNA in the adolescent age group has not been studied separately in the literature. FNA, apart from reassuring benignity, helps in confirming malignancy and thus in initiating early treatment.

In Reply to: Fine Needle Aspiration

Dear Editor, In reply to the Letter to the Editor by Prof. Wiwanitki (1) concerning my recent study, we stated that “FNA is a useful atraumatic diagnostic technique with a high diagnostic accuracy which can provide a highly sensitive diagnosis with low false positive diagnoses in patients with nonthyroidal masses” (2). The author stated that FNA has 10.4% false negative results according to a recent study by Wharry et al.; however, this study was performed on thyroidal neck masses, while our study was conducted on nonthyroidal neck masses (3). As we demonstrated in Table 4 of the referred paper, we can see that the sensitivity and specificity of Fine Needle Aspiration (FNA) to diagnosis neck masses is high enough to consider it during the diagnostic process. Moreover, as we mentioned in our paper, the diagnostic properties of FNA depend on the properties of the mass. In masses suspicious for malignancy (such as larger masses, rapidly enlarged masses, masses in patients with history of malignancy or radiation, etc.) the cytology results and the FNA specimens should be more carefully interpreted (2). Also, as a limitation of our study we explained that pathologist experience can affect the cytology results. At our medical center, as a referral center in Iran, there is a group of pathologists who interpret the cytology results (4). There are two interesting comments that merit mentioning; the first is the rate of complications. Although many studies such as a review by Wu and Burstein declared that “FNA is used as one of the most cost-effective, complication-free, and rapid techniques for preoperative investigation of tumors and tumor-like conditions” (5, 6). Secondly, the role of radiologic modalities such as ultrasonography (US) in this paper is less discussed. Almost all studies conducted on the diagnostic accuracy of FNA, confirmed the role of Ultrasounds Imaging (US) to prepare a more useful specimen. Krishnappa et al. stated that “US-guided FNA provides a better representative sample and has a higher diagnostic rate in evaluation of thyroid lesions” (7). Also, some studies demonstrated that “the absence of suspicious US features did not reliably exclude malignancy”; others confirmed the usefulness of radiological properties to select a better site for FNA (8). For example, Moon et al. stated that “A taller-than-wide shape in either the transverse or longitudinal plane, was more accurate and sensitive in predicting thyroid malignancy” (9). Moreover, the size of the nodule is one of the most important US characteristics of a neck mass. There is a wide variety of size cut-off (between 1 to 4 cm) for neck masses suspicious for malignancy (3, 10). Moreover, US as a useful and safe radiologic modality can help find the largest, heterogeneous and more suspicious nodule for FNA.

Ultrasound Guided FNAC for Evaluation of Neck Lumps to Improve Inadequacy Rates; A Complete Audit Cycle

We present a completed audit cycle evaluating inadequacy rates in neck lump and thyroid fine needle aspiration cytology with and without ultrasound scan guidance. The first cycle of the audit was from January to July 2010 comparing free hand fine needle aspiration cytology (FNAC) with ultrasound guided fine needle aspiration cytology (USS+FNAC). Changes to practice were made, firstly all thyroid FNAC would be performed with USS+FNAC and a reduced threshold for referral for USS+FNAC for non-thyroid neck masses. The second audit cycle was completed sixteen months later to assess for an improvement in practice. 1st phase; 155 patients, 70 freehand, 85 USS+FNAC. 50% of the thyroid FNAC freehand were inadequate compared to 18% of the thyroid USS+FNAC. 2nd phase; 196 patients, USS+FNAC 134, freehand 62. Thyroid FNAC 105 (USS+FNAC-104, freehand-1). Inadequate USS+FNAC = 21/104 (20%). The completed audit cycle shows an increased proportion of thyroid FNACs performed by ultrasound guidance, improving from 82% to 99%, with an overall reduction of inadequate thyroid FNACs from 24% to 21%. There was a noticeable variability in the inadequacy rates from radiologist to radiologist with the head and neck senior radiologist demonstrating the lowest inadequacy rate at 9.6% in the second cycle. Although ultrasound guidance for FNAC is important for the reasons of increased sensitivity, specificity and accuracy, we have demonstrated that the operator experience and skill are just as important.

Gynecomastia Presenting as a Neck Mass

The differential diagnoses of neck mass may include a wide spectrum of lesions ranging from cysts, inflammatory processes, benign and malignant tumors arising from skin, soft tissue, lymph nodes, endocrine glands, salivary glands to metastatic tumors. In adults, malignant non-thyroid neck masses are often metastatic squamous cell carcinoma. Gynecomastia, presenting as a mass or enlargement in its typical subareolar location is usually a straightforward diagnosis. Enlargement due to gynecomastia in locations other than subareola can pose diagnostic challenge. We describe a unique case of gynecomastia presenting as a neck mass in a patient who was diagnosed and treated for squamous cell carcinoma of the floor of the mouth.

MAGNETIC RESONANCE IMAGING OF THE NORMAL CANINE THYROID GLAND

The magnetic resonance (MR) imaging features of the normal canine thyroid gland were retrospectively compiled from images acquired in 44 dogs presented for a variety of diseases unrelated to the thyroid gland. The appearance of the thyroid gland on different sequences, including pre- and postcontrast T1-weighted, T2-weighted, two-dimensional gradient echo, three-dimensional T2*-weighted gradient echo and proton density weighted images, were described in different image planes. The characteristic shape, location, and intensity of thyroid lobes compared with surrounding structures made them easily detectable in all dogs. The most common location of the thyroid lobes was dorsolateral to the trachea with the maximal cross-sectional area of the lobes located ventral to C2/3 or C3 in more than 85% of the dogs. The majority of the lobes were ovoid on transverse images. An isthmus was seen in one large dog and parathyroid glands could not be seen. The mean maximal thyroid lobe diameter on transverse images was 8.1 mm, being twice the mean diameter of the common carotid artery. Considering the excellent conspicuity and characteristic appearance of the canine thyroid gland, MR imaging can be beneficial in the diagnosis of diffuse thyroid diseases, in differentiating thyroid vs. nonthyroid neck masses and in staging and treatment planning of thyroid tumors in this species.

COMPUTED TOMOGRAPHIC FEATURES OF THE NORMAL CANINE THYROID GLAND

The computed tomographic (CT) features of the normal thyroid gland were compiled from images acquired in 25 client-owned dogs without thyroid gland disease. The mean pre- and postcontrast attenuation values were 107.5 and 169.0 Hounsfield Units, respectively. After injection of intravenous contrast medium (600 mg iodine/kg), the apparent thyroid gland volume (both lobes combined) increased from a mean value of 1148.0 nm3 to a mean value of 1188.9 mm3. All thyroid lobes were homogeneous on pre- and postcontrast images. In a craniocaudal direction, the gland spanned a region from the 1st to the 8th tracheal ring and the right lobe was often more cranial than the left. On transverse images the lobe shape was ovoid in 72%, and its location was dorsolateral to the trachea in 90% of dogs. Parathyroid glands could not be identified and an isthmus connecting both thyroid lobes was only seen in one dog. Considering the excellent visibility of the normal canine thyroid gland, CT can be beneficial in the differentiation of thyroidal versus nonthyroidal neck masses. CT also yields potential in the staging of thyroid carcinomas.

The usefulness of detecting thyroglobulin in fine‐needle aspirates from patients with neck lesions using a sensitive thyroglobulin assay

The aim of this study was to assess the diagnostic utility of thyroglobulin (Tg) in fine needle aspirates (Tg-FNAB) of nonthyroidal neck masses using a sensitive in-house method for detecting Tg in washout specimens. A total of 256 samples from 145 patients were evaluated for Tg in washout specimen from FNAB and compared to corresponding cytological smear and histology of 46 surgical specimens. Tg was measured by a sensitive in-house time-resolved immunofluorometric assay. The sensitivity for Tg-FNAB alone or in combination with cytological findings was found to be 100% in both the follow-up group and before primary surgery. In the follow-up group the specificity of Tg-FNAB was 100%. Fifty-nine of 60 follow-up specimens with malignant cytology were Tg-FNAB positive (n = 195). Histological examination of one lymph node with malignant cytology and negative Tg-FNAB showed metastasis from carcinoma of the salivary gland. Tg-FNAB was positive in 25 specimens with suspicious or cystic cytology. Tg-FNAB values were high (median 4557 microg/l, range 122-37200 microg/l) in washout specimen from cystic metastasis from which cytology did not confirm malignancy. Of the 20 lymph nodes with histology confirming metastasis from differentiated thyroid carcinoma (DTC), the Tg-FNAB was positive in 19 and intermediate in one. However, before primary surgery, two Tg-FNABs were false positive compared to the histology of the lymph nodes. TgAb in serum did not interfere with FNAB-Tg measurements. Tg-FNAB measurement is accurate with high sensitivity (100%) and of great importance in detecting cystic metastasis when cytology is not conclusive. Even metastases to small neck lymph nodes may be detected by using sensitive Tg-assay. Serum thyroglobulin antibodies appear to have ignorable effect on the clinical performance of Tg-FNAB.

Removal of nonthyroidal neck masses with improved cosmetic outcomes in skin-lifting surgery

To evaluate the cosmetic benefit of neck skin-lifting surgery for the removal of nonthyroidal neck masses. Fifty patients with neck masses were divided into the following 2 surgical groups that were matched in age, sex, and the size, location, and pathology of lesions: skin lifting (n = 25) and conventional (n = 25). The operation time, hospital stay, complications, and subjective satisfaction with the incision scar as assessed on a visual analogue scale (VAS) were compared between the 2 groups. All but 2 lesions (lymphomas) were benign and were removed completely, drained, or biopsied. The surgery time, hospital stay, and complication rates did not differ significantly between the groups. The mean satisfaction score of the patients was 8.2 +/- 1.1 in the skin-lifting surgery group and 4.8 +/- 2.5 in the controls (P < 0.001). The incision scars were commonly hidden by natural hair or collars in the patients who received skin-lifting surgery. This surgical technique can be safely applied to most benign masses in the entire neck excluding the thyroid region, especially in patients who prefer neck scars to be invisible. B-2b.

Efficacy of ‘two-man’ FNAB technique in the assessment of patients with non-thyroid neck masses

Objective: To show the superiority of ‘two-man’ FNAB technique comparing to the standard FNAB technique, in order to identify the cause of non-thyroid neck masses. Methods: Over an 18 months period, a consecutive paired study was conducted in the tertiary referral Venizelion General Hospital. Forty-four cytologic examinations were performed in patients with non-thyroid head and neck masses. The samples were taken from the same side using both techniques the standard FNAB technique and the ‘two-man’ FNAB technique (for which two persons carried out the procedure). The slides were seen by the pathologist and were defined as diagnostic, suggestive or inconclusive. The diagnosis was confirmed in any case by definite histology after surgical treatment or open biopsy. Results: From 44 samples taken with the ‘two-man’ technique, 34 were diagnostic (all true) verified by histopathology, seven suggestive (five true and two false) and three inconclusive (6.82%). The correct diagnosis was confirmed in 39 cases (88.64%). From 44 samples of standard technique, 22 were diagnostic (all true), 12 suggestive (five true and seven false) and 10 inconclusive (22.72%). The correct diagnosis was confirmed in 27 cases (61.36%). The accuracy of diagnosis with the standard FNAB technique was 0.79 (SE=0.07), while with the ‘two-man’ FNAB technique was 0.95 (SE=0.03), a significant statistical difference (Fischer exact test, P=0.041). Conclusions: ‘Two-man’ FNAB technique proved to be as safe and patient friendly as the standard FNAB, but more accurate and may be easier to perform than this. The ‘two-man’ FNAB technique could become the preferred method for fine-needle cytology, particularly for difficult to reach areas of the head and neck.

Detection of thyroglobulin in fine needle aspirates of nonthyroidal neck masses: a clue to the diagnosis of metastatic differentiated thyroid cancer.

We studied the feasibility of employing the measurement of thyroglobulin (Tg) in the washout of the needle used to perform the fine needle aspiration cytology (FNA-Tg) for the differential diagnosis of nonthyroidal neck masses of unknown etiology. We studied 35 patients presenting for 1 or more neck lumps outside the thyroid gland. A previous history of treated differentiated thyroid cancer (DTC) was given by 23 patients and of nonthyroidal malignancy by 3 patients. FNA-Tg was measured in the Tg-free serum used to wash out the needle employed for the cytology. Finally, all patients were treated by surgery. FNA-Tg was always detectable in 14 patients with thyroid cancer metastases demonstrated by histology, with a mean (+/- SD) of 27,087 +/- 37,622 ng/FNA (P less than 0.002) compared to patients without thyroid cancer metastases (mean +/- SD, 12.1 +/- 4.8 ng/FNA in 7 cases; undetectable in 14 cases). Assuming 21.7 ng/FNA (the mean +/- 2 SD of the negative patients) as the cut-off value, all patients with metastases from DTC were detected by FNA-Tg. FNA-Tg had better negative predictive value than cytology, since this last technique gave 10 inconclusive results, comprising 2 false negative results in patients with metastases from DTC. Our results indicate that elevated concentrations of FNA-Tg in nonthyroidal neck nodes strongly suggest the diagnosis of metastases from DTC.

Detection of thyroglobulin in fine needle aspirates of nonthyroidal neck masses: a clue to the diagnosis of metastatic differentiated thyroid cancer

Detection of thyroglobulin in fine needle aspirates of nonthyroidal neck masses: a clue to the diagnosis of metastatic differentiated thyroid cancer