Long-standing lateral neck mass as the initial manifestation of well-differentiated thyroid carcinoma

Objective: To analyze the presentation, evaluation, and treatment of a subset of patients with well-differentiated thyroid carcinoma who present with a lateral neck mass and no palpable disease in the thyroid gland. Study Design: A retrospective review of all patients undergoing thyroidectomy for malignancy, Methods: A database of all thyroidectomies performed for malignancy by the Vanderbilt University Department of Otolaryngology--Head and Neck Surgery from 1992 to 1997 was created, Patients who presented with an isolated neck mass without evidence of palpable disease in the thyroid were selected for the study population. Results: There were 60 cases of thyroid malignancy, with 14 cases (23.3%) that presented as isolated lateral neck mass. The characteristics of this group (compared with the population of all thyroid malignancies) include younger age at presentation (37.7 +/- 15.2 y vs. 49.8 +/- 15.6 y; Student ttest: P = .019) and long-standing presence of symptoms (27.4 +/- 39.6 mo vs. 3.6 +/- 3.9 mo; P = .023), These patients generally presented from a referring facility after having an excisional biopsy, which was 100% accurate. Fine-needle aspiration is becoming more useful and was 66.7% accurate. Histological examination revealed cancer in the thyroid gland in all patients, 11 cases of papillary carcinoma, 2 follicular carcinomas, and one medullary carcinoma. The mean size of the primary focus was 10.9 +/- 8.7 mm, with 29% demonstrating bilateral disease and 14% demonstrating multifocal disease in the ipsilateral gland, The neck specimens revealed an average of 5.3 +/- 3.2 metastatic nodes in levels II-TV and 3.9 +/- 4.6 metastatic nodes in the paratracheal region. Conclusion: Based on this patient population, the longstanding lateral neck mass in the young patient should raise the physician's index of suspicion for thyroid carcinoma. Fine needle aspiration should be used in conjunction with judicious excisional biopsy. The bilateral and multifocal nature of otherwise occult primary disease argues for total thyroidectomy in this setting.