SIGNIFICANCE AND MANAGEMENT OF THYROID LESIONS IN LYMPH NODES AS AN INCIDENTAL FINDING DURING NECK DISSECTION Lawrence J. Fliegelman, MD, 1 Eric M. Genden, MD, 1 Margaret Brandwein, MD, 1,2 Jeffrey Mechanick, MD, 3 Mark L. Urken, MD 1 1 Department of Otolaryngology-Head and Neck Surgery, Mount Sinai School of Medicine, Box 1189, One Gustave L. Levy Place, New York, New York 10029 2 Department of Pathology, Mount Sinai School of Medicine, New York, New York 3 Department of Endocrinology, Mount Sinai School of Medicine, New York, New York Accepted 29 March 2001 Abstract: Background. The incidental discovery of thyroid le- sions in lymph nodes during a lymph node dissection performed for a separate primary head and neck tumor is an unusual clinical entity. Its discovery has led to controversy regarding its signifi- cance and management. Methods. We identified five patients over the years 1991– 1999 with this finding. All five patients were subsequently treated with a total thyroidectomy and a level VI lymph node dissection. Results. Pathological examination revealed three papillary carcinomas and level VI lymph node metastases in the two pa- tients who had carcinoma in their thyroid glands. All five patients are presently free of their primary and thyroid disease on follow- up examinations. Conclusions. These patients should be addressed with addi- tional work-up and surgery if metastatic thyroid cancer is docu- mented in the lymph node. We offer a diagnostic algorithm that may aid in further work-up and treatment in these unusual cases. © 2001 John Wiley & Sons, Inc. Head Neck 23: 885– 891, 2001. Keywords: thyroid; incidental; neck; dissection; lymph node Occult or incidental thyroid carcinoma is not an uncommon lesion and may occur in 1% to 10% of the population with a 6% to 35% prevalence rate found in autopsy studies. 1,2 Although these le- sions may become clinically significant, they are usually associated with an excellent long-term prognosis, and many head and neck surgeons rec- ommend conservative management including fre- quent physical examinations and follow-up diag- nostic studies. The clinical presentation of a metastatic thyroid lesion in a cervical lymph node is generally pursued more aggressively because these are advanced stage lesions. Standard therapy for well-differentiated thyroid carcinoma is warranted including appropriate biopsy, diag- nostic imaging, and surgical treatment. 3–5 The course of action is less clear when a well-differ- entiated thyroid carcinoma is found incidentally in cervical lymph nodes during lymph node dis- section performed for another primary head and neck lesion of non-thyroid origin. 6 This is made even more confusing when the thyroid lesion in the lymph node has a benign appearance on pathological examination. Thyroid tissue found in Correspondence to: L. J. Fliegelman Presented at the Annual Meeting of the American Head and Neck Society, Palm Desert, California, April 24, 1999. © 2001 John Wiley & Sons, Inc. Thyroid Lesions in Lymph Nodes HEAD & NECK October 2001 885