Patient with Neck Masses

A Patient with Neck Masses

Facilitating Learning Session
with

Participants (mostly surgical trainees with some certified general surgeons)
in the
Postgraduate Course of the Department of Surgery, Philippine General Hospital
Manila

September 7, 1999

9 Participants
Drs. Randy Abdulla, Janice Maddela, Marlo Rendon, Merceditha Althea Quinon,
Luis Serafin C. Dabao, Romulo Barrameda, Jr., Gemma Uy, Arlean, and others

(from Laguna, Polymedic Medical Center, Iloilo, Tondo Medical Center)

Facilitator: Reynaldo O. Joson, MD

Notes:

This was the second day of the postgraduate course.
A group of 9 participants was assigned to me in the preceptorial.
My residents prepared cases for discussion. One of the participants, Dr. Randy Abdulla, decided to present a patient of his.
I did not know the details of the problems of the patient nor did the participants.

How I Did It and What Transpired

I used the framework of a "Management of a (Surgical) Patient."
I focused on problem-solving and decision-making.
I used inquiry approach and promoted interactions.

Randy presented the initial data:

26 year old female

4 years prior to consult , noted a mass in the anterior neck (1st mass). No associated symptoms.
1 year prior to consult, noted another mass (2nd mass) in the anterior neck. No associated symptoms.

Rey Joson asked: Based on the data given by Randy, what is your primary and secondary diagnoses and why?

Answers:

Majority had thyroid cancer with neck node metastasis as the primary diagnosis (using pattern recognition process and the law of parsimony).

Some had colloid adenoma and TB lymph node as the primary diagnosis.

As to secondary diagnosis, those with thyroid cancer with neck node metastasis had colloid adenoma and TB lymph node as the secondary diagnosis.

Those with colloid adenoma with TB lymph node as the primary diagnosis had thyroid cancer with neck node metastasis as the secondary diagnosis.

Note: A few had MCAG as the secondary diagnosis suspecting that the 2nd mass is within the right thyroid lobe (despite the illustration given by Randy showing the 2nd mass distinctly separate from the 1st mass).

Rey Joson asked: How certain are you with your primary diagnosis?

All answered not certain mainly because of the cystic nature of the 2nd mass.

Since the treatment of the primary and secondary diagnoses are markedly different and since the diagnosis was not certain, all participants said they needed a paraclinical diagnostic procedure.

What diagnostic procedure?

All said they would do a needle evaluation because it is the direct way of investigation and is most cost-effective.

Randy was asked whether he did a needle evaluation on his patient. He answered affirmatively.

He aspirated the two masses. The 1st mass was really solid and microscopic exam showed "negative for malignant cells." The 2nd mass yielded chocolate brown fluid followed by complete disappearance after aspiration. He subjected the fluid for cell block and result was negative for malignant cells.

Rey Joson now asked: How do you interpret the needle aspiration and biopsy results? What is now your primary and secondary diagnosis?

There was a just a rearrangement of the initially cited primary and secondary diagnosis. The considerations were still the three diagnoses mentioned: thyroid cancer (most likely papillary) with neck node metastasis; multiple colloid adenomatous goiter (MCAG) in the right lobe; colloid adenoma with TB lymphadenopathy.

Rey Joson asked: What will you do now? All justified their decision to operate.

Rey Joson asked focusing on intraop diagnosis:

What intraoperative findings will tell you that the diagnosis is MCAG?

Answer: The two masses are within the right lobe and the masses are cystic and adenomas in nature.

What intraoperative findings will tell you that the diagnosis of the 1st mass is colloid adenomatous nodule?

Answer: Solitary nodule with cystic and adenomatous components.

What intraoperative findings will tell you that the 2nd mass is a TB lymph node?

Answer: Caseation necrosis.

What intraoperative findings will tell you that the 2nd mass is a metastatic lymph node, specifically, metastatic papillary carcinoma?

No answer. Rey Joson provided the answer. Black node.

Rey Joson asked Randy whether his patient was operated on. The answer was affirmative.

Intraoperative findings:

The two masses noted preoperatively were distinct separate mases.

There were actually two masses within the right lobe. Beside the one that was clinically palpated, there was another mass, 1 cm in size, in the medial aspect of the right lobe. This mass was hard and white. There was another mass, 1.5 cm in size, on the left lobe, about 2 cm. The mass on the left lobe was soft solid just like the one on the right lobe that was palpated preoperatively.

The 2nd mass was blackish in color.

Rey Joson asked the participants: How do you interpret the intraoperative findings? What is your primary diagnosis?

Unanimous: Papillary thyroid carcinoma with neck node metastasis.

Randy volunteered an information. He did a frozen section on the three masses on the thyroid gland after doing a right total lobectomy, isthmusectomy, pyramidalectomy, and left subtotal lobectomy. He also submitted the blackish mass for frozen section. All turned out to be negative for malignancy.

Rey Joson asked the participants. How do you interpret the frozen section results? What is now your primary diagnosis?

All participants changed their previous malignant diagnosis to a benign one - MCAG with nonspecific lymphadenopathy.

Rey Joson asked: Wouldn't you like to first challenge the diagnosis of the frozen section biopsy before accepting it hook line and sinker? Your intraoperative findings point strongly to a thyroid cancer diagnosis. If I were the one making the intraoperative diagnosis, the hard and white nodule and the black node are reliable cues for papillary carcinoma. The two other nodules on the thyroid gland are colloid adenomatous nodules. In other words, the thyroid pathologies consist of both MCAG and papillary cancer with neck node metastasis.

Let us ask Randy what was the paraffin-section or final histopathological report?

Randy: You are correct. The final histopathological report showed exactly what you said - Papillary thyroid carcinoma with MCAG.

Congratulation, Sir!

Postcript by Rey Joson

As a facilitator, I felt so excited with my analytical and diagnostic process, not to say, diagnostic acumen.

To everybody reading this, I recommend you master the "Management of a Patient " framework which I have developed over the years. It is applicable to all patients and to all situations. It promotes a rational, effective, efficient, and humane way of managing a patient.

You cannot find this in any foreign and local textbooks written by authors other than yours truly.

Email me to have a copy of the self-instructional program on the framework.

Questions and Comments from Readers

(You can use the text area below and then press the "submit" button or
you can email me your questions and comments.)

rjoson@pacific.net.ph

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