Symptom: Neck, Lump in

Initial Grading Reminder

Note: Palpation of the gland with appropriate thyroid nodule workup is indicated. Grading criteria below are for neck swelling related to rapid thyroid enlargement and effects of compression (i.e., red-flag symptoms).

CTCAE Grading of Swollen Neck:

Grade 1: Asymptomatic localized neck edema
Grade 2: Moderate neck edema; slight obliteration of anatomic landmarks; limiting instrumental ADL
Grade 3: Generalized neck edema (e.g., difficulty in turning neck); limiting self-care ADL

Assessment and Grading

Assess for pre-existing causes of lumps in the neck, including thyroid nodules and cervical nodal metastases.

Characterize the symptom (onset, pace)

Ask the patient:

When did the you notice the lump? How big is it? Has it developed gradually or suddenly? Is your neck swollen? Have you had any swelling of your neck/thyroid gland in the past?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Is your neck swollen? Any changes in your voice? Do you have difficulty turning your neck? Any difficulty breathing?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients with thyroid nodules should be seen.

    Patients with any of the red-flag symptoms should be seen immediately.

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    Nursing Assessment of Potential Causes

    Thyroiditis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear unwell?
    • Changes in weight since last visit
      • Appear heavier? Thinner?
    • Changes in hair texture/thickness?
    • Appearing hot/cold?
    • Does the patient look fatigued?
    • Appetite/weight changes?
    • Hot or cold intolerance?
    • Change in energy, mood, or behavior?
    • Palpitations?
    • Increased fatigue?
    • Bowel-related changes?
      • Constipation/diarrhea
    • Skin-related changes?
      • Dry/oily
    • Ensure that patient undergoes thyroid function tests prior to first dose, every 12 weeks while on PD-1 therapy and q3 weeks with ipilimumab
    • High TSH with low free T4 consistent with primary hypothyroidism
    • DDX: secondary hypothyroidism due to hypophysitis, low TSH and low free T4
    • Occasionally thyroiditis with transient hyperthyroidism (low TSH and high free T4) may be followed by more longstanding hypothyroidism (high TSH and low free T4)
    • Other immune-related toxicity?
    • Prior thyroid dysfunction?

    Differential Diagnosis

    What do you suspect is the cause of the neck lump?