Head & neck cancers: What you’ll see, how to proceed
What physical findings should raise your suspicion? How are tumors treated and what follow-up care can you provide? Here’s what you need to know.
PRACTICE RECOMMENDATIONS
› Do not treat a neck mass with antibiotics unless it has features consistent with infection. C
› Order laryngoscopy for all patients with hoarseness that does not resolve after 3 months—or sooner, if malignancy is suspected. C
› Order ultrasonography-guided fine-needle aspiration for diagnostic evaluation of salivary gland masses. B
› Manage a thyroid nodule based on its sonographic features, including size, consistency, and the presence of concerning features. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Thyroid US is the study of choice for initial evaluation of the size and features of a nodule; findings are used to make recommendations for further workup. If further evaluation is indicated, FNA biopsy is the test of choice.29
In 2016, the American Thyroid Association released updated guidelines for evaluating thyroid nodules (TABLE).30 The US Preventive Services Task Force recommends against screening for thyroid cancer by neck palpation or US in asymptomatic patients because evidence of significant mortality benefit is lacking.31
How is it treated? Treatment of thyroid cancer focuses on local excision of the nodule by partial or total thyroidectomy (depending on the size and type of cancer) and surgical removal of involved lymph nodes. Differentiated thyroid cancer is categorized as high-, medium-, or low-risk, depending on tumor extension, incomplete tumor resection, size of lymph nodes > 3 cm, and distant metastases. Adjuvant treatment with radioactive iodine can be considered for intermediate-risk DTC and is recommended for high-risk DTC.32
Following surgical treatment, thyroid-stimulating hormone suppression is recommended using levothyroxine.33 Patients at higher risk of recurrence should have longer and more intense suppression of thyroid-stimulating hormone.30 Levels of serum thyroglobulin and anti-thyroglobulin antibody should be followed postoperatively; rising values can indicate recurrent disease. The calcitonin level should be followed in patients with a history of MTC. Thyroid US should be performed 6 to 12 months postoperatively, then periodically, depending on determination of recurrence risk and any change in the thyroglobulin level.30
(Note: Glucagon-like peptide-1 [GLP-1] receptor agonists, used to treat type 2 diabetes mellitus, carry a black-box warning for their risk of MTC and are contraindicated in patients who have a personal or family history of MTC, MEN2A, or MEN2B.34)
Continue to: Anaplastic thyroid cancer...
