A forgotten lump
Miss T, a 15-year-old schoolgirl, consulted Dr F on several occasions about her recurrent sore eyes. During one consultation, she drew his attention to a small lump in the right anterior triangle of her neck that had appeared more than a month earlier.
Dr F arranged blood tests, including thyroid function tests, noting that he thought the lump may have been related to the thyroid gland.
He recorded his intention to refer Miss T to a surgeon for advice if the tests were normal. Miss T’s lump appeared to subside. Although the tests were reported as normal, Dr F did not, as he had intended, refer Miss T for surgical opinion. Neither he, nor Dr Y, another member of the practice, took the opportunity to examine the lump when Miss T consulted them on other matters.
Four years later Miss T saw Dr F again; she had enlarged neck glands and Dr F found bilateral non-tender rubbery cervical and axillary lymphadenopathy.
He referred her to a local ENT surgeon, who diagnosed metastatic thyroid carcinoma. Treatment took the form of thyroidectomy and radioiodine therapy, which left Miss T with keloid scarring and hypothyroidism requiring thyroxine-replacement therapy.
She also faced an uncertain prognosis, with a significant chance that the tumour would recur.
A legal claim against Dr F and Dr Y was held to be indefensible by GP experts. One noted, ‘ …No effort was made by Dr F, or by the doctor who next saw the patient – Dr Y – either to review the situation or to refer the patient … Due to the failure of the GPs to follow up their initial consultation … I believe that it would be very difficult to defend this case’. Another expert accepted that the diagnosis was rare in this age group but added, ‘ … a persistently enlarged lymph node is abnormal at all ages and all doctors should know that this should be followed up’.
According to an expert in pathology, the four-year delay in treatment had made a great difference to the outcome for Miss T, as the primary carcinoma had spread from the thyroid gland throughout the neck during that time and, by the time surgery was carried out, it was not possible to remove it all. Had a thyroidectomy been carried out when the tumour was contained in the thyroid gland, it would probably have cured her.
This case occurred in the UK in the early nineties. Since then, Department of Health guidelines have been issued advising on referrals for suspected cancer. These suggest referral where any neck mass persists for more than three weeks. A wall-chart outlining this guidance can be viewed at http://makeashorterlink.com/?B5DC25FB7
When patients present with neck lumps in primary care, it is essential to arrange concrete follow-up and to have a low threshold for surgical referral if the lump persists.