Alright, thanks for sticking with us. I'm gonna try to um go quickly through um some of the high points of these talks that I prepared for you guys. So um some some quick facts about work up of the adult neck mass. So um I think the key take home point is to think cancer, you know, I think cancer until proven otherwise. So a persistent neck mass in an adult is usually usually a neo plaza. And so uh it's malignant until proven otherwise. Uh and it's important to recognize, recognize that risk factors for head and neck cancer are changing and that there's been a decrease in smoking rates and a rising incidence of HPV related uh malignancy. So a lot of people with head neck cancer these days are younger, non smokers, higher education and socioeconomic levels and have never been sick in their life. Um and it's also important for the primary care doctor to realize that delays in diagnosis are quite common and unfortunately and do result in worse outcomes. Uh so some normal neck anatomy. This is just a reminder of kind of some of the ways that we communicate the level of the neck mass. And it's helpful in forming a differential and also an understanding the pathology reports on some of our cases. So I don't know if you can see my my mouth looks like you can. So, you know, level Two is kind of the high part of the neck level three is the mid part and level four it goes all the way down. Um Level five is the post your neck where a lot of skin cancers will metastasize to uh level six is the central neck where a lot of thyroid cancers uh we'll uh we'll produce nodes and level one is right underneath the chin, More likely to come from an oral cavity side, but the the kind of major drainage of the head and neck is kind of in levels 2, 3 and four. Uh So that is sort of where you know tumors from a lot of different areas can go because of so many lymph nodes being present. I'm going to quickly review some of the guidelines. Uh So this is probably the most important slide. So whenever a patient comes in with a painless and large neck mass, it's been there for a few weeks. Don't give an empirical trial of antibiotics. Uh This is the first point in the guidelines and it's something that you know, I hate to say that you'll see even E. N. T. S. Do. Sometimes someone comes in, I had a patient who uh came in with a fairly advanced tumor and they were upset because their first TNT gave them ciprofloxacin. Um and you know several weeks went by before they got an appropriate biopsy. Um but uh between 20-70% of patients in some studies report that delays caused by a trial of antibiotics. If you do give an antibiotic trial, you think it may be an infection do reassess them within two weeks. However, if a patient has reactive lymph lymphatic neuropathy you typically don't need to treat this with antibiotics. Um So we all should recognize a suspicion of what's called a standalone, suspicious history. The patient comes in, they tell you this, the alarm bells ring. So uh this has been going on for at least two weeks. Uh They've had no recent infection or dental problems. They have a significant smoking history and the masses not fluctuated in size or it's continued to grow. Um This standalone, suspicious physical exam is this if you're patient walks in with this and they need a cT scan. So you know, the mass appears to be greater than 1.5 centimeters. It's firm. Uh It may or may not be fixed to surrounding tissues, but if it is, that's very bad news. Uh and it's non tender. What should you do for these patients? Uh We're gonna go through the kind of next steps. So uh think of referrals in certain cases. So uh you know, uh any of us here can perform a bronchoscopy for your patients. This is particularly important if you think that if the patient has any hoarseness or throat symptoms or if you think there it could be a tongue based mass. This is the best way to assess for that or urgently same day if the patient is having any type of airway concerns, um you can perform or refer for a thorough oral cavity or or differential exam. Uh If you think it could be skin cancer related, they may need a dermatology look over and you can refer them for a thyroid ultrasound of uh the mass seems to be associated with thyroid mass. Another key slide is, and this is untimely because of our shortage of contrast. But uh the key study to get for most adults with the suspicious neck mass, suspicious for cancer is A. C. T. Or M. R. I. With contrast. Um The C. T. Is is usually what I go for because it's more expeditious and cheaper. Uh These days maybe not because of the contrast shortage. But this does a number of things that characterizes the neck mass and evaluates for possible primary spots. If you look in their mouth, you don't see anything, you at least get images of their throat all the way down. Uh And this is important for staging the patient as well. Uh Generally good to avoid non contrast studies during normal times. Um And if you do have to go non contrast and memorize a better study than the C. T. Um And then the other key step is if it is you can order an ultrasound sound guided F. And a uh in the head and neck. You know, we skip a lot of the labs and we go straight to a tissue diagnosis because the masses are accessible. So this can be either surgeon or radiologist performed. It's generally a low risk procedure with a high accuracy. We generally don't, you'll see we generally don't perform open biopsies for suspicious neck masses. Um The only real contraindications to an F. And A. Is if you think it could be the credit or um you know something like that which is pretty rare. Um Another key point is that in generations past a cystic neck mass was regarded as generally benign. Uh We talked a little bit about HPV tumors these days. They tend to produce cystic neck notes. So historically they said oh it's a you know isolated cystic mass on the lateral neck could be a bronchial cleft cyst. These days you have to be very suspicious. It could be an occult metastases from the tonsils. Uh So if a person comes in they have a fluctuating neck mass or a ct scan that shows that you can refer them for a focused focused exam. If they don't have one, they need a C. T. Neck with contrast and you can send them for an ultrasound guided fn. A biopsy. The ultrasound guided is important because they can target the capsule of the of the node and avoid the kind of necrotic middle part which will not give you a diagnosis. Um There are some ancillary tests that are useful when an F. N. A. Is not uh diagnostic and this is sort of the list of them. But the key point is really that uh the these ancillary tests uh you know, are not necessary in most cases and um are secondary to establishing a tissue diagnosis. Um that's the differential. I'm gonna skip through some of my slides about HPV because of time considerations and give you guys a quick update on thyroid cancer. So this is really going to be some just key take home points about uh thyroid cancer. So um the kind of watershed year and thyroid cancer came with the latest edition of the 88 American Thyroid Association guidelines for management of adult thyroid nodules where a lot of things changed. And the key points which probably have everyone is familiar with and have, you know, generally been assimilated assimilated into practice in the last seven years is is that they generally advised against biopsy of any suspicious thyroid nodules that were less than a centimeter in size. Um and the big shift for a surgeon was that they promoted a part a hemi thyroidectomy for low risk cancer. So previously someone came in with the one centimeter popular thyroid cancer. They get their whole thyroid out no questions asked. Uh these days, most of those patients are going to get a hemi thyroidectomy. Um It generally um brought about less liberal use of radioactive iodine and and and also required less intense surveillance surveillance from endocrinologist after surgery. Um the so again, key points, so another key point of what's new and you know, kind of what's new in thyroid cancer. The concept of active surveillance. Um and this is a paper that I wrote up in the last couple of years kind of summarizing this. But recently there's been what's considered an epidemic of small, lowest thyroid cancers because of the proliferation of Uh kind of ultrasound screening tests. And this is kind of uncovered this large subclinical reservoir of disease uh that generally doesn't advance or cause problems. Uh and this is a disease that has a 97% ten-year disease specific survival when treated with surgery. Um So active surveillance is basically a joint decision between a patient and clinician to closely monitor a known cancer that is thought to be low risk. And it's monitored every six months for growth um with the understanding and that you're choosing someone that were the nodule to grow or even if it were to spread uh to a central lymph node, that the outcome would be the same as if you were to treat that that lesion upfront with surgery. Um So it's um I've been studying a lot of clinical trials, which I'll get to. There's some advantages um and disadvantages. So the advantages is obviously avoid surgical risk of nerve paralysis, calcium problems, scarring um is a major consideration in many of the countries that did the clinical trials and um you know, the problems of having surgery. But um I think the last point is the most interesting is it addresses the fact that, you know, we believe there's a large subclinical reservoir of kind of low risk disease that's out there and never discovered. And it addresses the concerns that we're over treating thyroid cancers by operating on all the small harassment. The disadvantage are many. So there's, you know, the patient has to stick with the program and not forget about it. And there's uh, you know, long cost of, you know, follow up monitoring that's needed. Uh, there's a theoretical risk of cancer spread and that's closely related to the patient anxiety of having a small cancer that is in your neck that you're not going to treat. And so not all patients are appropriate uh, for active surveillance for this risk. And it's a less definitive way to deal with the problem. So, um, that is kind of in a nutshell. So, um, there's a lot of clinical trials that have been done mostly in ASia, some in North America. There was a recent meta analysis that looked at 4000 patients that have been enrolled and basically the, the results you could say are comparable to surgery. So in in in these studies, About 4.4% of the time the tumor grew and required intervention, about 1% of the time there was a lymph node metastasis that developed and a very small percent 10.4 developed metastatic disease. To my knowledge, there's been no deaths in any patient enrolled in active surveillance uh, trial, Um, switching gears again. So medullary thyroid carcinoma, a rare thyroid cancer, only 2% of thyroid cancers. But it accounts for about 15% of deaths from thyroid cancer. Things that we learned in medical school, 80% are sporadic, 20% are hereditary. And um 50-60% of sporadic tumors, which are going to be many of your adult patients that come in are going to carry a red mutation. Uh The M 1919 T mutation is the most common and also is associated with more aggressive disease. Uh And so all patients with thyroid carcinoma required germline testing to determine is this um hereditary condition or somatic sporadic mutation. And all patients uh receive calcitonin and see a as part of their kind of staging. And uh you know, if if the patient has very high levels of these, they can actually cause systemic symptoms of flushing and diarrhea. Many of these patients present with more advanced disease. As measured thyroid carcinoma has a tendency to spread to lymph nodes. Uh The work up is mostly similar to differentiated thyroid cancer except for it. Um They're gonna get an ultrasound of the next. You're gonna send them for an F and a biopsy but they're going to require serum calcitonin or and see a uh surgery is still the preferred treatment when the patient is curable for local and regional disease. Uh when a patient has a very high calcitonin level above 500 that should prompt metastatic work up. Uh And the the reason I'm talking about this today is that there's new systemic treatment options that are available. So uh these include multi target kinase inhibitors, or super selective red inhibitors, which are recently approved in which I'll talk more about. Um And so these are not for small curable tumors, but for very locally advanced or recurrent tumors with those with proven metastatic disease. Uh mentally theory, carcinoma is not a differentiated cancer. And so there's no role for radioactive iodine treatment and a very limited role for radiation. So, selective red inhibition. Um so there's there's two drugs that have been FDA approved sulphuric Attentive or pressing alternatives are both approved. Uh selective red inhibitors. Uh They have pretty good response rates. Um two thirds to 3/4 of patients will have a response. And the majority of them Our durable somewhere around 80% in the trials that have been published. Uh and these super selective inhibitors are better tolerated than the non selective multi target Canada's inhibitors. Um so that was fast and our next and final topic is in a plastic carcinoma. So we all know about this. It's a very aggressive thyroid cancer with a very poor prognosis. Um And these patients present with aggressive, fast growing uh central neck mass. And oftentimes they have trick you Asafa jewel invasion And they have a tendency to also have distant metastases historically. The survival was only about six months for these patients. Um but there's been a change in recent years. Many of them actually carry a baby raft mutation in about 50-60% of cases and be roughneck inhibition has resulted in dramatic change and in outcomes and the computer looks like it's about to die. So I don't know if there is a plug up here but we should probably get one. So the targeted there's new targeted therapy for so D. T. Or demographic tremendously has been FDA approved for only about two years. And so this requires the patient to have a V. 600 E. B. Raft mutation. So um the work out of these patients is now very multidisciplinary. It's no longer just a surgeon rushing off to surgery. The patient. Uh You know the airway evaluation they get a core thyroid biopsy. And the pathologists are in a rush to do immune history chemistry to confirm their mutation status. Um If they have a reputation unless they are you know, eminently respectable, then that's probably going to be uh their first step and it results and sometimes dramatic and sustained responses. And the current practice is to reassess them for surgery. If they have a significant response because not all of them will have a lasting response. Um So this is pretty much what we covered. I think the other key thing is is the trend away from performing a trick uh In these cases historically these patients would get a trick for retaliation. But, um, it's now generally avoided because it's considered, uh, to be, you know, to kind of prolong a death that's very unpleasant. And so most, uh, in most cases, I mean, you know, palliative care discussions are part of the work up, and usually that means avoiding a tracheostomy, so that was a bit rushed. But thanks everybody, if there's any questions happy to answer.