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Note:
• 20%ofmetastaticsquamouscellcarcinomaisfromaerodigestive
tract.
• Sourceofprimaryfromheadandneckregionusuallyhavefrequency
likethis—nasopharynx,tonsil,baseoftongue,thyroid,larynx,floor
ofthe mouth, cheek,palate,pyriform fossa.Non-headandneck
sourceofprimaryarebronchus,oesophagus,breast,stomach.
• HistologicallyitisSCC(80%)ornon-SCC.Innon-SCCitmaybepoorly
differentiatedcarcinoma(10-15%),adenocarcinoma(5-10%)or
otherslikemelanoma,poorlydifferentiatedneoplasm(5%).
• Inpoorlydifferentiatedneoplasmimmunohistochemistry/immun-
operoxidase
areneededtoruleoutlymphoma,neuroendocrinetumours,undif-
ferentiated
SRB's Manual of Surgery
• 3yearsaftertreatmentofoneprimary,ifrecurrenceoccuritiscalled
asnew primaryinaerodigestivetract.
staining,electronmicroscopyandchromosomeanalysis
sarcomas.
• Lowerlip,tongue,softpalate andsupraglottiscancause bilateral
Fig. 5.37: Levels of neck nodes.
secondariesinneck.
• Softpalate,retromolarregion,nasopharynx,hypopharynxposterior
andlateraloropharynxcaninvolveretropharyngealnodes.
• NasopharyngealcarcinomaspreadstolevelII-V,retro andpara-
pharyngeal
nodes.
• 15%ofsecondariesare frominfraclavicular primaries—lung,
pancreas,oesophagus,stomach,breast,ovaries,testis,prostate.
• Nodalspreadbelowthelowerborderofcricoid(levelIVandV;Lower)
carriespoorprognosiscomparedtonodesabovecricoid(Upper).
A
C
Figs. 5.38A to D: Typical secondaries in the neck. Note the different
levels involved in different patients. Note the skin involvement and sinus
formation in few photos.
COMMON SITES OF PRIMARY
B
x Oral cavity, tongue, tonsils
x Salivary glands
x Pharynx—nasopharynx
x Larynx
B
D
x Oesophagus
x Lungs
x GIT
x Thyroid
Branchiogenic carcinoma
It is a primary squamous cell carcinoma which is uncommon,
arising from remnants of branchial cleft or arch. It is a differential diagnosis for secondaries in neck. It is common in men. It
is common near the area of carotid bifurcation. Histologically
it contains malignant squamous cells with lymphoid tissues
around. It spreads to lymph nodes and can infiltrate into adjacent
soft tissues. Treatment: Wide excision.
Features of Secondaries in Neck
Common in adult/elderly male (Male to female ratio is 4:1),
presents as painless rapidly increasing localised swelling in
the neck.
Nodular surface and hard in consistency, often fixed when it
is advanced. Fungation, ulceration, haemorrhage can occur
in advanced disease.
It is commonly from squamous cell carcinoma, but can also
be from adenocarcinoma or melanoma.
Squamous cell carcinoma is mainly from oral cavity, pharynx.
Adenocarcinoma is usually from GIT, commonly involving
left supraclavicular lymph nodes.
Breast, lungs, thyroid abdominal viscera are other areas
where primary may cause secondaries in neck which should
be examined when suspected.
A
Figs. 5.39A and B: (A) Typical secondaries in the neck—well localized,
hard swelling which is fixed to the sternocleidomastoid muscle;
(B) Secondaries in the neck nodes from laryngeal carcinoma.
B
Secondaries from papillary carcinoma of thyroid can be soft,
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cystic with brownish black fluid.
Secondaries can infiltrate into carotids, sterno mas toid,
posterior vertebral muscles, spinal accessory nerve (shrugging of shoulder is affected), hypo glossal nerve (tongue will
deviate towards the same side), cervical sympathetic chain
(Horner’s syndrome).
Secondaries spread into adjacent soft tissues and also to
the skin causing fungation and ulceration. Often because of
tumour necrosis, softer area develops in the hard node. Skin
fold prominence due to infiltration of the platysma is typical.
In advanced cases tumour may infiltrate into the major
vessels like carotids, or branches of external carotid artery
causing torrential haemorrhage.
Dysphagia, dyspnoea, haemoptysis, hoarseness of voice, ear
pain, deafness are other features depen ding on the primary site.
Secondaries, when mobile are treated by radical lymph node
block dissection in the neck.
BA
Figs. 5.41A and B: Advanced secondary carcinoma neck with
ulceration and fungation.
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CHAPTER 5 Neck
Fig. 5. 40: Fungating secondaries in the neck—terminal illness.
x Hoarseness—carcinoma larynx, thyroid
x Dysphagia—carcinoma posterior 1/3rd of the tongue, pharynx,
oesophagus
x Haemoptysis, cough, dyspnoea—carcinoma lung
x Ear pain, deafness—nasopharyngeal carcinoma
x Spinal accessory nerve—shrugging of shoulder is difficult
x Hypoglossal nerve—tongue deviates to same side with wasting
x Sympathetic chain—Horner’s syndrome with miosis, anhidrosis,
upper eyelid droop (pseudoptosis), enophthalmos, loss of spinociliary reflex
Types of Secondaries in the Neck
1. Secondaries in the neck with known primary
Here secondaries are present and primary has been identi-
fied clinically in the oral cavity, pharynx, larynx, thyroid or
other areas.
Biopsy from the primary and FNAC from the secondaries
are done.
Primary is treated accordingly either by curative radiotherapy
or by surgery (wide excision).
Fig. 5.42: Secondaries in neck with nodules and ulceration. Note
the deviation of tongue towards same side due to hypoglossal nerve
involvement.
2. Secondaries in the neck with clinically
unidentied primary
Hard neck lymph nodes are the secondaries, but primary has
not been identified clinically.
FNAC of the neck node is done and secondaries is confirmed.
Then search for the primary is done by various investigations.
They are:
a. Panendoscopy
¾
Nasopharyngoscopy.
¾
Direct laryngoscopy.
¾
Oesophagoscopy.
¾
Bronchoscopy—if needed only.
b. Blind biopsies are taken from fossa of Rosenmüller, lateral
wall of pharynx, pyriform fossa, tonsillar bed, base of tongue,
subglottic region (larynx). It is called as surveill ance biopsy
and is done to reveal unknown primary in 15% of cases of
secondaries in neck. If this surveillance biopsy is negative,
then ipsilateral tonsillectomy may be needed. Presently
bilateral tonsillectomy is recommended.
c. FNAC of thyroid and suspected areas.
d. CT scan.
Once the biopsy confirms the primary, it is treated either by
surgery or by curative radiotherapy.
Secondaries in the neck is treated by radical neck dissection.
Listen to the faintest sound; for opportunities knock only once.
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3. Secondaries in the neck with an occult (unknown)
primary
It is biopsy (FNAC) proven cancer of the neck node, which even
after a complete clinical and radiological workup (that includes
physical examination, CT scan, oesophgoscopy, laryngoscopy,
bronchoscopy and multiple surveillance biopsies) reveals or
yields no demonstrable primary lesion.
OCCULT PRIMARY SITES WHICH CAN CAUSE SECOND-
B
ARIES IN NECK
x Fossa of Rosenmüller
x Lateral wall of pharynx
SRB's Manual of Surgery
x Posterior third of the tongue
x Thyroid
Histologically secondaries in neck with occult primary may be
of squamous cell carcinoma or of nonsquamous cell carcinoma,
i.e. adenocarcinoma/poorly differentiated tumours (lymphoma/
sarcoma/melanoma). In upper and midcervical region 80%
are due to squamous cell carcinomas. In lower cervical and
supraclavicular region 40% can be adenocarcinomas. Common
sites of primary here (for adenocarcinoma) are thyroid, breast,
gastrointestinal tract, salivary glands, lungs, prostate and kidney.
Here secondaries in the neck lymph nodes are confirmed by
FNAC, but primary has not been revealed clinically and by
any available investigations.
When all the investigations mentioned above are done, do
not show any evidence of primary, only then it is called as
occult primary.
Primary tumor is not identified at the time when definitive
therapy has started.
70% of occult nodes occur in jugulodigastric group.
Differential diagnosis for secondary with occult primary is
lymphoma and primary branchiogenic carcinoma.
Reasons for primary lesion being occult—too small a
primary to detect; possibility of immunological spontaneous
regression of primary and inability of the present diagnostic
tools to detect the primary.
FNAC is the tool to confirm the occult secondary. If FNAC
is inconclusive, only then open biopsy (incision/excision)
is done to confirm. Open biopsy helps in high suspects of
lymphomas or poorly differentiated carcinomas. It facilitates
tissue study, immunohistochemistry, and special stains. Many
studies prove that risk of seedling, survival and prognosis will
not alter by open biopsy. But at present it is proposed only
when FNA
C fails or special methods are mandatory to type
the disease. After open biopsy, frozen section confirmation
and immediate neck dissection has to be done.
Immunoperoxidase staining can be done in FNAC specimen
or formalin fixed paraffin tissue using monoclonal or polyclonal antibodies. Immunoperoxidase is the most commonly
used tool. It is mainly useful in lymphomas/neuroendocrine
tumours. Electron microscopy is superior to immunohistochemistry as ultrastructure details can be assessed. But it is
x Paranasal sinuses
x Bronchus
x Oesophagus
costly. Chromosomal analysis for tumour specific genes is
used in B, T and germ cell lymphomas.
Initially the secondaries in the neck are treated by radical neck
dissection, then regular follow-up is done (at three monthly
intervals) until the primary reveals.
Once primary is revealed it is confirmed by biopsy and treated
accordingly, either by curative radio therapy or by wide exci-
sion depending on location of revealed primary.
This type is usually less aggressive and has got better
prognosis.
Fig. 5.43: Diagrammatic representation of neck lymph node staging
in secondaries.
NODAL STAGING IN SECONDARIES
B
N
– Nodes cannot be assessed.
x
N
– No regional lymph node spread.
0
N
– Regional single node <3 cm with ENE (-).
1
N
– N2a: Single ipsilateral node <3 cm with ENE (+); OR single
2
ipsilateral node 3–6 cm with ENE (–). N2b: Multiple ipsilateral nodes
<6 cm in size and ENE (–). N2c: Bilateral or contralateral nodes <6
cm with ENE (–).
N3 – N3a: Single ipsilateral node >6 cm with ENE (–). N3b: single ipsilateral node >3 cm with ENE (+) OR multiple ipsilateral or contralateral
or bilateral any sized nodes with ENE (+) OR single contralateral node
of any size with ENE (+).
Note: ENE means extranodal extension; ENEmi is microscopic metastases <2 mm; ENEma is macroscopic >2 mm. Suffix – sn is for SLN
biopsy; f is for FNAC or core biopsy; u is nodes above the lower
border of the cricoid; l is nodes below the lower border of cricoid.
BA
Figs. 5.44A and B: (A) Large secondaries in neck with nodularity, with
involvement of platysma below. (B) bilateral secondaries are observed.
Skin fold prominence is obvious.
Investigations for Secondaries in Neck
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FNAC of secondary: Open incision biopsy is not advised
here. It destroys the fascial barriers and causes the spread of
tumour faster and earlier into next level nodes or other soft
tissues. Eventual neck dissection technically becomes difficult. Recurrence rate in neck will be higher after open biopsy.
If FNAC of node and all investigations for primary become
negative, then open biopsy of node following confirmation
with frozen section and immediate neck dissection is undertaken. In such situation if neck dissection is delayed after
open biopsy confirmation, chances of cure will be reduced.
Nasopharyngoscopy, laryngoscopy, broncho scopy,
oesophagoscopy—panendoscopy with examination under
anaesthesia.
CT scan is to see the base of skull, paranasal sinuses, naso-
pharynx, extension of primary tumour/secondary deposits;
CT scan of chest and abdomen.
Chest X-ray to visualise primary or secondaries in case
melanomas or mediastinal nodes.
MRI scan or PET scan in conjunction with CT scan or MRI.
MRI identifies soft tissue extension/changes; guided primary
biopsy is possible; extension into bone is identified.
CT chest and abdomen in case of infraclavicular primaries
or to assess nodes.
Note:
• Testingforhuman papilloma virus(HPV) andEpstein-Barrvirus
(EBV)isusefulinprimarycarcinomaoftonsilorbaseofthetongue.
• Openincisionbiopsyisavoidedinsecondariesinnecknodes;done
onlyifFNACfailsorinsuspectedlymphomaorpoorlydifferentiated
carcinoma.
• Necksecondariesadenocarcinomaiscommoninlowerneck,where
primaryislocatedbelow theclavicle—breast,lungsor digestive
tract.Adenocarcinomainnodesofupperneckmaybefromsalivary
glands,thyroidorparathyroids.
• Tripleendoscopyincludesnasopharyngoscopy;directlaryngoscopy;
oesophagoscopy.
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CHAPTER 5 Neck
Fig. 5.45: FNAC of neck lymph node. It is very useful method in
secondaries in neck node and tuberculosis. Its use is equivocal in
lymphoma where open biopsy of the node is preferred method.
(Courtesy: Dr Krishna Upadhya, Pathologist, Nandikoor Laboratory,
Mangaluru).
Fig. 5.46:
Biopsy from primary: Incision biopsy is the choice here.
Blind biopsies from suspected areas.
CT neck showing secondaries.
DIFFERENTIAL DIAGNOSIS
B
x Lymphomas
x Tuberculous lymphadenitis
x Nonspecific lymphadenitis
IN SECONDARIES NECK WITH OCCULT PRIMARY
B
x FNAC of node/open biopsy to confirm
x Proper clinical methods to identify the location of primary
x CECT is the investigation of choice to look for primary
x Other methods are—MRI, triple endoscopy, examination under
anaesthesia, blind biopsies from fossa of Rosenmuller, pyriform
fossa, base of tongue, subglottic area and tonsils, FNAC of thyroid,
ipsilateral/bilateral tonsillectomy if surveillance biopsy and other
methods are negative
x Once occult primary is confirmed and if node is less than 3 cm in
size, it is treated as N
x Postoperative RT is essential if disease is N
nodes are positive); if 2 or more levels are involved; if extracapsular
spread is present
x In fixed lymph node/nodes, initially radiotherapy is given followed
by surgery (RND), if nodes become mobile and later adjuvant
chemotherapy
x In N
bilateral neck dissection (one side IJV preservation) with
2c
bilateral RT is given
x N
stage has got poor prognosis. RND and RT with later chemo-
3
therapy are used. In fixed nodes, RT and then chemotherapy is used
x Proper follow-up at regular intervals is essential with all diagnostic
tools to identify the possible site of primary which may get revealed
during follow-up period
disease with RND/MRND
1
x HIV
x Chronic lymphatic leukaemia
; N2b (more than 2
2a
‘Excellence’ is an outcome, of good intentions and the right ways to do a work.
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(SCC): It is treated with both radical neck dissection (RND)
and follow up for primary or often curative radiotherapy to
bilateral neck and follow up. (2) SCC which is poorly differ-
entiated: It is probably from nasopharynx. Radical RT to
bilateral neck with pharyngeal axis is the initial treatment with
bilateral RND later. (3) Adenocarcinoma occult secondaries:
It is treated by chemoradiotherapy as commonly it is aggres-
A
B
sive and advanced. (4) Undifferentiated occult secondaries:
It is very aggressive secondaries and is treated with chemo
RT and follow up.
SRB's Manual of Surgery
Types of Block Dissection (Academy’s
Classication)
1. Classic Radical Neck Dissection: It is resection of lymph
nodes (level I to V), fat, fascia, sternocleidomastoid muscle,
C
Figs. 5.47A to C: (A) Secondaries in neck but no skin involvement;
C) Secondaries with skin involvement is obvious.
(B and
Treatment of secondaries in the neck
N1 MRND/RND and RT, if capsular invasion
N2a Mobile node RND then RT
Fixed node RT to downstage then RND
N2b RT then RND
N2c Bilateral RND then bilateral RT
N3 Fixed—first RT then RND, if it becomes mobile (downstage)
followed by chemotherapy
Mobile—RND then RT, followed by chemotherapy
Note:
Chemoradiation (Chemo—RT) is also a good option either
before or after RND. IMRT (Intensity Modulated RT) is better.
Primary is treated depending on the site, either by wide
excision (surgery) or by curative radiotherapy. Then the
secondaries are treated.
Secondaries when mobile, are treated by radical neck dissec-
tion.
When fixed it is inoperable. Palliative external radiotherapy is
given to palliate pain and to prevent the anticipated bleeding.
Sometimes initially, external radiotherapy is given to down-
stage the disease so that it becomes operable and later classical block dissection can be done.
Postoperative RT is given after neck dissection when—more
than two lymph nodes are positive for metastases; nodes
show metastases at two or more levels; extracapsular spread
in lymph node. Suspected occult primary is included/covered
in the RT field. RT is also given to contralateral neck nodes in
nasopharyngeal carcinoma. Level II lymph node alone from
an occult is more likely to be from nasopharyngeal carcinoma
and RT is preferred in such situation covering nasopharyngeal
area; later RND is done.
In occult/unknown primary, secondaries are considered as
follows—(1) Squamous cell carcinoma occult secondaries
omohyoid muscle, internal jugular vein, external jugular vein,
accessory nerve, submandibular salivary gland, lower part of
parotid, prevertebral fascia—“en-block”(Criles’ operation). Incision that is commonly made are Fischel T or modified Criles’
or MacFee incisions which are two parallel incisions, one at
submandibular region, and another at supraclavicular region.
Blood supply of the flap remains intact and so healing will be
better without flap necrosis.
Fig. 5.48: MacFee incision for radical neck dissection. Upper incision
is from mastoid process along the line of digastric to hyoid bone point,
then upwards to chin. Lower incision is parallel to clavicle 2 cm above
from anterior margin of trapezius to midline.
2. Modified Radical Neck Dissection—MRND (Conserva-
tive Functional Block Dissection [After BoCCA Surgeon]):
It is done only in selected cases where tumour is very welldifferentiated and less aggressive. Here one or more nonlymphatic strictures are preserved. Medina classification is used
for MRND types.
Type I: Only spinal accessory nerve is preserved—MRND type
I (most important). N-Preserved.
Type II: Preservation of spinal accessory nerve and IJV. NV are
preserved.
BA
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Figs. 5.49A and B: Incisions/different approaches for radical (RND/
MRND) neck dissections. There are many incisions mentioned. Few of
them are shown in diagram.
Fig. 5.50: Radical neck dissection, on table.
Type III: Accessory nerve, sternomastoid and internal jugular
veins are preserved—MRND type III. NMV-Preserved. It is called
as functional neck dissection.
3. Selective Neck Node Dissection: Here one or more
nodal levels in the neck are retained unlike RND. It can be
supra-omohyoid, lateral neck (antero lateral), anterior (central)
or posterolateral neck dissections.
Supraomohyoid neck dissection (SOND): Removal of only fat,
fascia, lymph nodes, muscles, submandibular salivary gland,
with dissection above the omohyoid muscle is done. Done
only in selected individuals with well-differentiated tumour and
involvement of few submandibular lymph nodes (Levels I, II, III
are removed). It is also done in N0 lesions. Here ideally (done in
N0 cases) after dissection, frozen section biopsy should be done;
if nodes are positive, MRND/RND should be done depending on
grading of the primary.
Lateral neck Dissection (Anterolateral/jugular/ALND): It is done
in laryngeal and pharyngeal primaries with clinically negative
nodes. Levels II, III, IV are removed bilaterally.
Anterior (Central) Dissection: Level VI (pre, paratracheal) nodes
are removed. It is done in carcinoma of thyroid.
Posterolateral Dissection: Levels II, III, IV, with suboccipital
and postauricular or with level V are removed for cutaneous
malignancies.
4. Extended Radical Dissection: Removal of one or more addi-
tional groups of lymphatics or removal of nonlymphatic structures with RND is called as extended RND. Additional nodes in the
mediastinum are cleared (level VII). Nodes like level VI or parapharyngeal, retropharyngeal, external carotid artery, hypoglossal
nerve, vagus nerve, parotid gland, mastoid tip—are addressed.
Other types of neck dissections
Bilateral neck Dissection: Here internal jugular vein is preserved
on one side. Always the side where the vein is preserved, is operated first (If both the jugulars are ligated, cerebral congestion
occurs leading to cerebral oedema which is dangerous. Jugular
veins are ligated as an inevitable procedure during surgery, the
patient is kept in propped-up position; antibiotics, diuretics, steroids, mannitol infusion are given, repeated CSF taps are done to
control the cerebral oedema). Ligating one IJV increases the ICP
by 3 fold; both IJV ligations increase ICP by 5 fold. ICP gradually
falls over 8–10 days. For this reason pressure dressing should
be avoided over the wound of neck dissection after surgery.
Commando operation (Combined Mandibular Dissection and
neck Dissection): It is en-block removal, which includes wide
excision of primary tumour with hemimandibulectomy and neck
441
CHAPTER 5 Neck
Fig. 5.51: Radical neck dissection on table photo. Note the internal
jugular vein, digastric muscle, strap muscles, lower margin of the
mandible.
COMPLICATIONS OF BLOCK DISSECTION
B
x Haemorrhage; Infection
x Lymph ooze; Carotid blow out
x Seroma and flap necrosis
x Frozen shoulder is common
x Rarely pneumothorax and chylous fistula
x Drooping of shoulder due to paralysis of trapezius in radical neck
dissection
Peace is so hard to nd because it is under your nose.
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block dissection, Examples: It is done usually in carcinoma of
tongue or floor of the mouth; it is a composite resection of
primary tumour, mandible and radical neck dissection (RND).
Comprehensive Neck Dissection (Medina): It means either RND
or MRND types of neck node dissections.
Note:
• Tocontrolhaemorrhagein headandneckcancers andduring
headand necksurgeries(likeradical parotidectomy,commando
operation,maxillectomy)oftenligationofexternalcarotidarteryis
required.Ligation should be done distal to the origin of the superior
thyroid artery.
superiorthyroidarteryasthiswillleadtoformationofeddycurrent
andthrombusatthecarotidbifurcationandintracranialembolism.
SRB's Manual of Surgery
LigationofECAtocontrolbleedingisusuallydoneincontinuity.
• Middleoftheneck,laterallyoverCCAisthepoorlyvascularisedarea
ofskinwhichcanleadintoskinnecrosis.Soverticalincisionorthree
pointjunctionsatthispointshouldbeavoided.Horizontalincisions
arebetterinneck.
Itshould neverbeligatedbelow theoriginofthe
• Carotidarteryshouldbeprotectedbymuscle flap or free dermalgraft.
Levator scapulaemuscleflapiscommonlyused.
BA
Figs. 5.52A and B: (A) Ligation of external carotid artery should be
done when needed distal to the origin of the superior thyroid artery; (B)
Impending carotid blow out after radical neck dissection.
Carotid blow out is most dangerous complication. It is due to sepsis,
wound breakdown, stripping of arterial adventitia, necrosis and
drying of the artery. Ligation of the carotid is done to save the life
of the patient but procedure itself has got 20% mortality and 50%
morbidity (hemiplegia).
CHEMOTHERAPY FOR
HEAD AND NECK CANCERS
It may be used alone or as multimodality therapy.
Types
Adjuvant chemotherapy: Chemotherapy is used before, during
or after main therapeutic modality (surgery or radiotherapy).
When used before it is called as anterior/induction chemo-
therapy. It reduces the burden, downstages the tumour,
reduces the chance of micrometastasis that may occur during
surgery. When used with radiotherapy (concurrent) it is used
as radiosensitiser. When used after surgery/radiotherapy it
is called as posterior chemotherapy.
Palliative chemotherapy: It is used in advanced/recur-
rent/metastatic cancers to relieve symptoms like pain/
dysphagia/dyspnoea or to prevent chances of bleeding or
fungation.
It may be single drug therapy like methotrexate/bleomycin/
cisplatin/5-fluorouracil or multidrug combination chemotherapy.
Combination chemotherapy is more beneficial which increases
efficacy.
Methotrexate—40 mg/m2 IV weekly. It causes mucositis,
bone marrow suppression with liver and kidney toxicity.
Hydration and alkalisation of urine before and after therapy
is beneficial to reduce toxicity.
5–Fluorouracil—10–15 mg/m2 IV daily for 5 days. Compli-
cations are bone marrow suppression and gastrointestinal
symptoms.
Bleomycin—10–20 mg/m2 IV weekly. Pneumonitis and
pulmonary fibrosis are the complications.
Vincristine—1–2 mg/m2 IV monthly. Neurotoxicity (sensory
and motor neuropathy), constipation and alopecia are the
side effects.
Cisplatin—80–120 mg/m2 IV infusion once in 3 weeks.
Complications are neurotoxicity, bone marrow suppression,
renal toxicity, ototoxicity. Adequate hydration and mannitol
diuresis may be needed.
Cyclophosphamide—60–120 mg/m2 IV for 5 days at regular
3 weeks cycles. Alopecia, bone marrow suppression and
cystitis (haemorrhagic) are the toxicities (ABC). Barbiturates
should be avoided during therapy.
Adriamycin—60–90 mg/m2 IV. It is cardiotoxic and hence
cardiac monitoring is needed while infusion.
Paclitaxel and carboplatin as empiric chemotherapy are used
in neck secondaries with occult primary.
Mode of Administration
It can be given by intra-arterial route, through external carotid
artery (Never through internal carotid as it will cause cerebral
damage). Site of arterial catheter should be confirmed by
Doppler or angiogram. Drug is usually administered through
an arterial pump. Other method is to increase the height of
the drip stand to get a pressure above the level of the systolic
pressure of the patient (i.e. more than 13 ft).
Drugs can also be given intravenously or orally (metho-
trexate).
General toxicity of chemotherapeutic agents: Mucositis, alopecia,
stomatitis, nausea and vomiting, diarrhoea, bone marrow
suppression.
Often transfusions of blood/FFP/platelet are needed before or
after chemotherapy depending on parameters.
Monitoring the Patient on Chemotherapy
Clinical assessment—pulse, blood pressure, alopecia, urine
output, jaundice, skin changes like rashes, fever, pallor.
Biochemical parameters—total count, platelet count, blood
urea and serum creatinine, liver function tests.
Specific relevant tests—chest X-ray, endoscopy, CT scan,
tumour marker if specific in some types of carcinomas.
Chapter
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6
Thyroid
C hapter Outline
·
Development
·
Surgical Anatomy
·
Physiology
·
Congenital Anomalies
·
Thyroid Function Tests
·
FNAC of Thyroid
·
Classication of Goitre
·
Diffuse Hyperplastic
Goitre
·
Multinodular Goitre
·
Discrete Thyroid Nodule
·
Solitary Thyroid Nodule
·
Retrosternal Goitre
·
Thyrotoxicosis and
Hyperthyroidism
·
Radioactive Iodine
·
Thyroid Neoplasms
·
Papillary Carcinoma of
Thyroid
·
Follicular Carcinoma of
Thyroid
DEVELOPMENT
The thyroid gland develops from a median down growth of a
column of cells from the pharyngeal floor between the first and
second pharyngeal pouches (thyroid primordium; subsequently
marked by the foramen caecum of the tongue). The canalised
column becomes the thyroglossal duct which is displaced forward
by the developing hyoid bone and then below the hyoid, lies
slightly to one side, more commonly to the left. The duct bifurcates to form the thyroid lobes and a portion of the duct forms the
pyramidal lobe (origin → migration → differentiation). Parafollicular C cells arise from neural crest through ultimobranchial body.
·
Differentiated Thyroid
Carcinoma
·
Anaplastic Carcinoma of
Thyroid
·
Medullary Carcinoma of
Thyroid
·
Malignant Lymphoma
·
Hashimoto’s Thyroiditis
·
De-Quervain’s Subacute
Granulomatous
Thyroiditis
·
Riedel’s Thyroiditis
·
Thyroid Incidentaloma
·
Thyroidectomy
·
Emil Theodor Kocher
·
Kocher’s Test
·
Hypothyroidism
·
Recurrent Laryngeal
Nerve Palsy
SURGICAL ANATOMY (Thyroid Means—in Greek
“SH
IELD”)
It is located in the anterior triangle of the neck. It weighs about
20 grams. Gland lies against C5 to T1 vertebra.
Right and left lateral lobes located in a space (thyroid fossa)
between trachea and oesophagus medially and carotid sheath
laterally. Each lobe is 5 × 3 × 1.5 cm in size, extends from the
middle of thyroid cartilage to 6th tracheal ring. Right lobe is
larger than left. Gland is larger in females compared to males.
Lateral lobes are covered by sternohyoid, sternothyroid, superior
belly of omohyoid and partly by anterior margin of the sternocleidomastoid muscle.
Isthmus is the connecting part between two lateral lobes in
midline extending from 2nd to 4th tracheal rings. It is 1.5 cm X
1.5 cm in size. It is absent in 10% of individuals.
Pyramidal lobe is upward extension as fibrous strands or
muscular strands from the junction of the isthmus and left lateral
lobe. It is seen in 30% of individuals. It is often connected to
hyoid bone through levator glandulae thyroideae, fibrous tissue
from upper end of pyramidal lobe to body of hyoid bone.
Gland is invested by pretracheal fascia. Berry’s ligament is a
strong condensed vascular connective tissue between the lateral
lobe and cricoid cartilage on each side. True thyroid capsule is
peripheral condensed connective tissue and blood vessels are
deeper to it. True capsule is covered by false capsule which is
derived from pretracheal layer of deep cervical fascia. It is thin in
front; thick behind and forms Berry’s ligament above and behind.
Surgical avascular plane is located between true and false capsule.
(In prostate, surgical cleavage plane is located deep to true capsule).
Medial surface is related to trachea, oesophagus, thyroid,
cricoid, cricothyroid and inferior constrictor muscles; posterolaterally related to carotid sheath, ansa cervicalis, cervical sympathetic chain; posterior border is related to parathyroid glands
(superior [IV] and inferior [III]) and tubercle of Zuckerkandl.
Tubercle of Zuckerkandl arises from lateral analge of thyroid
which is located posteriorly; it is closely related posteriorly to
recurrent laryngeal nerve and superior parathyroid gland. It is
better developed on the right side. Often, it may be absent.
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Fig. 6.1: Relations of the thyroid.
Beahrs’ triangle (OH Beahrs) or Riddle’s triangle is formed by
common carotid artery as base; inferior thyroid artery above
as superior arm and recurrent laryngeal nerve as lower arm.
It is helpful in identifying and tracing the RLN. Joll’s triangle is
used to identify the external laryngeal nerve and is formed by
superior pole of the thyroid and superior thyroid vessels laterally, above by strap muscles, medially by midline, floor contains
cricothyroid muscle.
Blood Supply
Superior thyroid artery is first anterior branch of external
carotid artery enters the gland near superior pole as a larger
anterior superficial branch and a smaller posterior branch.
It supplies upper 1/3rd of lobe and upper half of isthmus.
Inferior thyroid artery, a branch of thyrocervical trunk of
subclavian artery passes behind the carotid sheath running
medially reaching the posterolateral aspect of the gland. It
supplies lower 2/3rd of the lobe and lower half of the isthmus.
Thyroidea ima artery, a branch of aorta or brachio cephalic
artery enters the isthmus or lower pole of one of the lateral
lobes (3%).
Tracheal and oesophageal branches serve blood supply to
retained thyroid gland after thyroidectomy.
Accessory thyroid arteries.
Lymphatic Drainage
Primary:
¾
Prelaryngeal or cricothyroid node also called as Delphian
node is a node (single node) located anterior to cricothy-
roid membrane between cricothyroid muscles and is the
most important node among level VI nodes. Delphian
node receives afferent lymphatics from larynx and from
upper anterior parts of the both lobes of the thyroid gland
and its isthmus. It has got two efferent lymphatics; one
towards paratracheal and lower jugular, other towards
pretracheal (sub-Deplhian), mediastinal and supraclavicular lymph nodes. R. Randall from Harvard coined
the term Delphian (formerly purpose of this node was
uncertain. Delphi is a place in Greece where Pythia, snake
women after inhaling sulphurous fumes uttered meaningless jargon, the purpose of which was unclear; it also
means that spread to this node predicts the outcome of
laryngeal and thyroid cancers in the same way prophecy
of Apollo at temple of Delphi foretold the future in the
ancient Greece).
¾
Paratracheal (located at lateral wall of the trachea and
tracheo-oesophageal groove) and pretracheal (subDelphian nodes are in front of trachea and isthmus)
receive afferents from remaining thyroid and from
Delphian node. Its efferents reach lower jugular and
mediastinal nodes.
¾
Perithyroidal nodes are nodes along the superior and
inferior thyroid veins which drain into pretracheal, paratracheal nodes.
¾
Mediastinal nodes up to the level of innominate (brachio-
cephalic) vessels get the afferent from pretracheal and
paratracheal nodes. Central nodal compartment includes
all nodes from trachea to carotids; nodes from hyoid
bone above to innominate artery below with pretracheal
nodes. It is level VI and mediastinal nodes above the level
of innominate artery.
Venous Drainage
Superior thyroid vein. It accompanies the superior thyroid
artery to join IJV or common facial vein.
Middle thyroid vein is short and stout; drains into the internal
jugular vein. It is first to be ligated in thyroi dectomy.
Inferior thyroid veins are many in number. They join the left
brachiocephalic vein.
Kocher’s 4th thyroid vein is found in between middle and
inferior thyroid veins which join the IJV.
Fig. 6.2: Lymphatic drainage of thyroid.
Fig. 6.3: Anatomy of thyroglossal duct showing its pathway.
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THYROID LYMPHATICS
B
x Ascending medial lymph vessels from the upper border of
isthmus drain to prelaryngeal node which are located in
the cricothyroid membrane.
x Ascending lateral vessels from the upper pole of the gland
along the superior thyroid artery drain into deep cervical
nodes.
x Descending medial vessels begin at lower part of the
isthmus to reach pretracheal lymph nodes.
x Descending lateral vessels run from the deep surface of
the thyroid to recurrent laryngeal chain nodes.
Secondary:
¾
Deep cervical nodes: Levels—IIA, III, IV, VB.
¾
Supraclavicular nodes; Occipital nodes.
IMPORTANT RELATIONS OF THYROID GLAND
B
x Recurrent laryngeal nerve lies in the tracheo -oesophageal
groove, in relation to Berry’s ligament.
x Superior laryngeal nerve which gives a branch, external
laryngeal nerve supplies cricothyroid muscle. It accompanies superior thyroid artery.
x Parathyroid glands—four in number, two on each side
embedded in thyroid.
PHYSIOLOGY
Thyroid gland has two secretory cells: 1. Follicular cells—
secretes thyroid hormones (Thyroxine (T4; 93%), Triiodothyronine (T3; 7%). 2. Parafollicular cells (‘C’ cells)—secretes
calcitonin. The thyroglobulin also is secreted into the follicle by
the cuboidal epithelial cells.
Iodine metabolism: Ninety per cent of body iodide uptake is in the
thyroid gland, whose uptake into the follicular cells is regulated
by TSH and follicular iodide content. Requirement of iodine is
50 mg/year or minimum 0.1 mg/day.
Thyroid hormone synthesis: Iodothyronines (MIT, DIT) are
formed in follicular cells by the coupling of inorganic iodide with
tyrosine (Iodide trapping → iodide oxidation by peroxidase into
inorganic iodine → iodine binding withy tyrosine to form MIT
or DIT and → so with coupling T3 and T4 which combines with
thyroglobulin → to form colloid). These are biologically inert
molecules. T4 (Thyroxine) is formed by coupling of two DIT
molecules and T3 (Tri-iodothyronine) is formed by coupling of
one MIT and one DIT molecules. Both are bound to thyroglobulin
which is the primary component of colloid matrix. When need
is there, T3 and T4 are broken down from thyroglobulin which
enter the circulation to bind with albumin (7%), thyroid binding
globulin (TBG, 75%), thyroid binding prealbumin (TBPA, 15%).
In periphery (liver), T4 is converted into T3; T3 is active form
and more physiologically important. T3 acts in hours quickly;
T4 acts in days slowly.
The hypothalamus-pituitary-thyroid axis regulates thyroid
hormone production and releases in a classic feedback system.
TRH is a regulatory hormone from hypothalamus and TSH is
a regulatory hormone from anterior pituitary. TSH stimulates
iodide trapping and thyroid hormone synthesis and release.
Thyroglobulin is a dimeric glycoprotein with m. wt of 6,60,000.
It gets synthesized in the follicular cells of thyroid and released
into the follicle to combine with T3 and T4 to form colloid.
FUNCTIONS OF THE THYROID GLAND
B
x Regulation of basal metabolic rate
x Required for normal psychosomatic growth
x Has chronotropic and ionotropic effect on heart
x Increases the sensitivity of receptors to catecholamines
and also increases the number of receptors
x Required for normal respiratory drive
x Required for normal haematopoiesis
x Thyroxine has opposite effect of insulin
x Increases the bone turnover
Note: Thyroid is the largest endocrine gland
CONGENITAL ANOMALIES
Athyreosis is total absence of lateral lobes and isthmus with
hypothyroidism.
Ectopic Thyroid
Ectopic thyroid refers to the presence of thyroid tissue in locations other than the normal anterior neck region. It is the most
frequent form of thyroid agenesis. It lies along the course of the
thyroglossal tract as entire gland or as residual thyroid tissue.
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CHAPTER 6 Thyroid
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