An evidence-based approach to the treatment of thyroid lymphoma

Efficacy of Chinese medicine in the adjuvant treatment of Hashimoto's thyroiditis with hypothyroidism: a systematic review and meta-analysis

The quality of the studies was assessed using the Cochrane risk bias assessment tool and the results were analyzed using Review Manager 5.3 software. The evidence was also evaluated for its strength using GRADE. A total of 18 randomized controlled trials were included in the study, involving 1247 patients. The primary outcomes of this study included overall efficacy, effectiveness in treating specific symptoms, and the Traditional Chinese Medicine symptom score. The secondary outcomes included the levels of FT3, FT4, and TSH, the size of the thyroid gland, and any adverse events. The results of the meta-analysis showed that CHM combined with WM has a better curative effect and a more effective reduction in clinical symptoms than WM alone: comprehensive efficacy [OR = 4.83; 95% CI (3.45, 6.76)], syndrome efficacy [OR = 5.95; 95% CI (3.94, 8.99)], TCM symptom score SMD = -1.49; 95% CI (-1.86, -1.11)], FT3 [SMD = 0.59; 95% CI (0.48, 0.71)], FT4 [SMD = 0.59; 95% CI (0.48, 0.71)], TSH SMD = -0.97; 95% CI (-1.35, -0.58)], and thyroid volume SMD = -0.25; 95% CI (-0.34, 0.15)]. The incidence of adverse events between the groups was not significantly different [OR = 1.00; 95% CI (0.14, 7.27)]. Because of the effectiveness of CHM, we support using CHM to improve clinical efficacy in the treatment of HTH. The results of our research suggest that the use of Chinese Herbal Medicine (CHM) in combination with Western Medicine (WM) may result in improved clinical efficacy in the treatment of hypothyroidism (HTH) compared to using WM alone.

Ultrasound scanning in diagnosing primary thyroid lymphoma

OBJECTIVE

This study aimed to summarize the clinical manifestations and ultrasound characteristics of primary thyroid lymphoma (PTL) and explore the key aspects in the process of diagnosing PTL.

METHODS

We conducted a retrospective analysis of the clinical and ultrasound features of 11 patients with PTL who were admitted to Shandong Provincial Third Hospital, China, between May 2009 and August 2023. The pathology was confirmed in all cases through an ultrasound-guided core needle biopsy or surgical resection.

RESULTS

The mean age of the 11 patients was 64.45±9.85 years. In six patients, the main clinical manifestation was a palpable mass in the neck, five of whom had a significant increase in the size of the mass within 3 months to 2 years. Eleven patients had coexisting Hashimoto's thyroiditis (HT). Three patients were diagnosed as having diffuse-type PTL, wherein the ultrasound showed enlargement of the affected thyroid gland with diffusely uneven hypoechoic parenchyma. In 7 patients with nodular type PTL and 1 case of mixed type PTL, the ultrasonographic features of the nodular lesions were of irregular morphology and yet had distinct borders, and only 1 case had gross calcification. There were 7 cases of hypoechoic lesions (7/11 cases, 63.6%), 9 cases where the lesions had linear echo chains (9/11 cases, 81.8%), and 10 cases (90.9%) where there was echogenic enhancement posterior to the lesion.

CONCLUSION

In elderly patients with HT, the thyroid volume increases significantly in a short period of time and symptoms associated with compression in the neck region appear. The ultrasound characteristics were extremely hypoechoic lesions in the thyroid parenchyma, with more linear echo chains visible inside, accompanied by posterior echo enhancement. When encountering such presentations, physicians must consider the possibility of PTL. Performing a core needle biopsy in cases that raise suspicion can reduce the incidence of misdiagnosis.

Primary thyroid lymphoma: A single-center experience

BACKGROUND

Primary thyroid lymphoma (PTL) is a very rare entity accounting for 5% of all thyroid malignancies and less than 2% of lymphomas. PTLs are classified as non-Hodgkin's B-cell lymphomas in the majority of cases, although Hodgkin's lymphoma of the thyroid has also been identified. This study aimed to identify the clinical, biochemical, and pathological features of primary thyroid lymphomas.

METHODS

From January 2008 to December 2020, data from patients diagnosed with PTL treated at the Gangnam Severance Hospital, including clinical, biochemical, and pathological features of thyroid lymphomas, were assessed.

RESULTS

Of 10 patients, nine women and one man, with a median age of 62 (range, 44-82) years were included. Fine needle aspiration biopsy was performed in nine patients and surgical resection was performed in one patient without biopsy. Excisional and surgical biopsies were performed in all patients, including five who underwent excisional biopsy and five who underwent thyroidectomy. Histological analyses revealed that all 10 lymphomas were non-Hodgkin B-cell lymphoma; six patients had diffuse large B-cell lymphoma, three had mucosa-associated lymphoid tissue lymphoma, and one had Burkitt lymphoma. Four patients received chemotherapy, two were treated with chemoradiation therapy, one received radiation therapy only, one did not require more treatment after surgery, one refused treatment, and one was transferred to another hospital.

CONCLUSIONS

Although PTLs are scarce, clinicians should be aware of this rare entity and evaluate and treat PTLs on an individual basis.

Development and validation of a nomogram to predict B-cell primary thyroid malignant lymphoma-specific survival: A population-based analysis

B cell primary thyroid malignant lymphoma (BC-PTML) accounts for 95% of all cases of PTML. However, development of effective treatment and management strategies for BC-PTML is challenging owing to the rarity of this disease. This study assessed data from 1,152 patients in the Surveillance, Epidemiology, and End Results (SEER) database who were diagnosed with BC-PTML during 2000-2015. Patients were randomly divided into a training group (n=806) and a test group (n=346) at a ratio of 7:3 using the hold-out method. Kaplan-Meier analysis and log-rank tests were used to calculate the survival rate of patients. Subsequently, a stepwise Cox regression model was established to screen the prognostic factors of patients with BC-PTML, and these variables were used to construct a nomogram to predict 5-, 10-, and 15-year BC-PTML cancer-specific survival (CSS). The discrimination and calibration of the new model were evaluated using the concordance index (C-index) and calibration curves, and the accuracy and benefits of the model were assessed through comparison with the traditional Ann Arbor staging system using decision curve analysis (DCA). After stepwise regression, the optimal model included radiotherapy, primary site surgery, Ann Arbor Stage, chemotherapy, histological subtype, and age at diagnosis. The C-index, area under the receiver operating characteristic curve, and DCA suggested that the nomogram had improved discriminatory ability and clinical benefit compared with the Ann Arbor staging system. In summary, this study established an effective nomogram to predict CSS in patients with BC-PTML and assist clinicians in developing effective individualized treatment strategies.

A diffuse large B-cell thyroid lymphoma presented as a compressive goiter in a young woman with no evidence of Hashimoto's thyroiditis

Thyroid lymphoma should be suspected in case of rapid enlargement of the thyroid gland even in a young patient with no history of Hashimoto thyroiditis. The confirmation is based on histopathology and immunohistochemistry.

Hashimoto's thyroiditis: An update on pathogenic mechanisms, diagnostic protocols, therapeutic strategies, and potential malignant transformation

Hashimoto's thyroiditis, characterized by thyroid-specific autoantibodies, is one of the commonest autoimmune disorders. Although the exact etiology has not been fully elucidated, Hashimoto's thyroiditis is related to an interaction among genetic elements, environmental factors and epigenetic influences. Cellular and humoral immunity play a key role in the development of the disease; thus, a T and B cells inflammatory infiltration is frequently found. Histopathologic features of the disease include lymphoplasmacytic infiltration, lymphoid follicle formation with germinal centers, and parenchymal atrophy. Moreover, the occurrence of large follicular cells and oxyphilic or Askanazy cells is frequently associated to Hashimoto's thyroiditis. Clinically, Hashimoto's thyroiditis is characterized mainly by systemic manifestations due to the damage of the thyroid gland, developing a primary hypothyroidism. Diagnosis of Hashimoto's thyroiditis is clinical and based on clinical characteristics, positivity to serum antibodies against thyroid antigens (thyroid peroxidase and thyroglobulin), and lymphocytic infiltration on cytological examination. The mainstream of treatment is based on the management of the hypothyroidism with a substitution therapy. A relationship between Hashimoto's thyroiditis and a possible malignant transformation has been proposed in several studies and involves immunological/hormonal pathogenic links although specific correlation is still debated and needs to be further investigated with prospective studies.

The diagnosis of primary thyroid lymphoma by fine-needle aspiration, cell block, and immunohistochemistry technique

AIM

Primary thyroid lymphoma (PTL) is a rare malignant disease. Its prognosis depends on early diagnosis. The role of fine-needle aspiration (FNA), including smear cytology, cell block (CB) techniques, and immunohistochemistry (IHC) sections in the diagnosis of PTL is still unclear. Here we reported 19 cases of PTL and literature review to evaluate the diagnostic accuracy for lymphoma by cytology.

METHODS

Our study retrospectively reviewed 19 patients diagnosed with PTL at the affiliated hospital of Southwest Medical University in China from June 2011 to May 2019. According to the Bethesda system for reporting thyroid cytopathology, the CB sections were evaluated for the presence of single tumor cells. IHC was performed on CB.

RESULTS

The diagnostic accuracy for PTL of FNA, CB with smears, and the joint application of the three methods (FNA + CB + IHC) of our study with 19 cases was 68.4% (13/19), 83.3% (15/18), and 100% (17/17), respectively.

CONCLUSION

The present study demonstrates that FNA has low sensitivity in diagnosing PTL, but the joint application of FNA, CB, and IHC might provide high diagnostic accuracy for lymphoma and should be applied in all cases where the clinical suspicion is high regardless of the FNA findings.

A Review of Primary Thyroid Lymphoma: Molecular Factors, Diagnosis and Management

Purpose/aim: To focus on current aspects of primary thyroid lymphoma (PTL), which is a rare clinical entity usually manifested by a rapidly growing mass in the neck that can cause pressure symptoms.

MATERIALS AND METHODS

Relevant papers in PubMed published through June 2017 were selected to track updated information about PTL with an emphasis on diagnosis and novel therapeutic management.

RESULTS

The most frequent cases include non-Hodgkin lymphoma derived from B-cells, mainly diffuse large B-cell lymphoma (DLBCL) followed by mucosa-associated lymphoid tissue (MALT) lymphoma or a mixed type. Other subtypes are less common. Lymphomas derived from T-cells and Hodgkin lymphomas are extremely rare. Hashimoto's autoimmune thyroiditis has been implicated as a risk factor for lymphoma. At the molecular level, the Wnt5a protein and its receptor Ror2 are involved in the course of the disease. Ultrasonography, fine needle aspiration (FNA) biopsy, and core or open biopsy combined with new diagnostic facilities contribute to an accurate diagnosis. An increased potential exists for a cure without the need for a radical surgical procedure. Modern chemoradiation therapy plus the monoclonal antibody rituximab, which acts against CD20, have limited the need for surgical interventions and provide an excellent outcome in most cases. However, some cases have resulted in treatment failure or recurrence.

CONCLUSIONS

A multidisciplinary approach must be used to define the management policy in each case. Future efforts by researchers are likely to be focused on the molecular level.

[A retrospective analysis of 12 cases of primary thyroid lymphoma]

OBJECTIVE

To discuss the clinical characteristics and diagnostic and therapeutic considerations of primary thyroid lymphoma (PTL) by reviewing PTL cases.

METHODS

In the study, 12 cases of PTL diagnosed and treated in Peking University First Hospital between January 1995 and September 2015 were identified. The clinical characteristics, management experiences and prognosis of these cases were reviewed retrospectively.

RESULTS

A total of 12 PTL patients (four males and eight females) were collected, with an average age of 63 years (42 to 81 years) at the time of diagnosis. The average time to clarify diagnosis was 5 months (0.5 to 24 months). Eleven patients presented with a rapidly growing neck mass and visited surgical department, except one complained of coughing and suffocated. Seven patients were hypothyroid, and four were euthyroid at the time of diagnosis. In sonography of 11 cases, nine showed bilateral nodules, with an average diameter of 3.87 cm. Pathologic diagnosis of non-Hodgkin's lymphoma was confirmed in all the 12 cases by means of partial thyroidectomy (four) or core needle biopsy (eight). The pathological subtypes were diffuse large B cell lymphoma in nine patients, mucosa-associated lymphoid tissue lymphoma (MALToma) in two, and small B cell lymphoma in the other one patient. Five patients were concomitant with Hashimoto's thyroiditis. Eleven patients received chemotherapy. Only one patient did not have any further treatment after operation due to an inertia type of tumor. The median overall survival time was 24 months (1-117 months), three patients died. Among the patients who survived, seven completed chemotherapy without disease progression, one MALToma case did not receive chemotherapy after thyroidectomy but was still alive with PTL, and one patient just finished his second course of chemotherapy.

CONCLUSION

The diagnosis of PTL should be considered when dealing with rapidly growing goiters in elder female Hashimoto's thyroiditis patients whose B ultrasound indicates hypoechogenicity in thyroid nodules or parenchyma, especially with lymphadenopathy and tracheal compressions. Timely use of coreneedle biopsy on suspicious cases can avoid unnecessary surgical trauma, and chemotherapy is the main treatment.

Clinicopathological characteristics and prognostic factors for primary thyroid lymphoma: report on 28 Chinese patients and results of a population-based study

Objectives

Few studies on prognostic indicators for primary thyroid lymphoma (PTL) have been presented due to the uncommon nature of the tumor. This is the first study to explore the independent prognostic factors in the 2 PTL subtypes.

Methods

We retrospectively reviewed 1,653 cases of PTL. The cases comprised 28 Chinese patients from a local cohort and 1,625 patients from the Surveillance, Epidemiology, and End Results database from 1973 to 2013. Statistical analysis was performed to determine the demographics and prognostic factors of PTL patients.

Results

The disease-specific survival (DSS) and prognostic indicators were significantly different between patients with extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) and patients with diffuse large B-cell lymphoma (DLBCL). Patients with MALT lymphoma were younger (P=0.011) and had lower clinical stage (P=0.014) compared to patients with DLBCL. Cox regression analysis revealed that age, treatment modalities employed, clinical stage, and number of other types of cancer were independent prognostic factors for DLBCL patients.

Conclusion

PTL demonstrates specific clinical features and is associated with a relatively good prognosis. Older age is associated with poor DSS in both MALT patients and DLBCL patients. Additionally, combination of different treatment modalities is associated with improved DSS in DLBCL patients.

Lymphomas and thyroid: Bridging the gap

The thyroid gland is often involved in the development of neoplastic diseases, including lymphoproliferative disorders. The aim of this paper is to provide a comprehensive overview of the multiple interactions between lymphoma and thyroid. Through an extensive research among the literature, the relationship between lymphomas and thyroid can be established at various levels, and the possible interconnections are here summarized in 5 points: (1) the greater risk of lymphoma development in some thyroid diseases; (2) the primary thyroid lymphoma, with focus on issues related to the diagnosis, differential diagnosis, and treatment; (3) the incidence of thyroid involvement in primitive nodal lymphomas or in extranodal lymphomas of the other sites; (4) thyroid changes after treatment of lymphoma, in relation to the effects of radiation therapy and immuno-chemotherapy; (5) the incidental findings of thyroid changes, on imaging, in patients with lymphoma, without a direct involvement of the gland in malignant disease. In conclusion, issues that until now have been dealt with separately will therefore be analyzed in a unique paper, allowing a global view of the topic and emphasizing the need of a multidisciplinary approach. Future learning areas in this topic mainly relate to rapidly increasing the knowledge of imaging studies together with expanding the armamentarium of novel biological and targeting agents in lymphoma patients.

Primary thyroid MALToma- a rare diagnosis of an unassuming thyroid nodule

Primary thyroid lymphoma, although a rare malignancy, can arise in common chronic inflammatory conditions such as Hashimoto's thyroiditis. Incidental finding of a thyroid nodule with chronic thyroid inflammation warrants further investigation. Early detection of malignancy can play a vital role in improved outcomes. We report a case of a 60-year-old male who presented to the clinic for a routine visit. An enlarged, firm, non-tender thyroid gland was appreciated on exam with high thyroid stimulating hormone (TSH) level. Fine needle aspiration of the mass revealed nonspecific atypical lymphocytes. The pathology and immunohistochemical stains were consistent with histologic impression of extra nodal marginal B-cell lymphoma (mucosa-associated lymphoid tissue [MALT] lymphoma) and Hashimoto's thyroiditis. Patient was treated with thyroxine after complete surgical excision of left thyroid lobe and remains in remission with close follow-up with his primary care provider. Primary thyroid MALT lymphoma follows an indolent process and remains asymptomatic in most patients. These are usually found to arise at sites of ongoing chronic inflammation with underlying autoimmune or infectious etiologies. Treatment modalities include surgical excision and/or radiation therapy for localized lesions, with both radiation and chemotherapy indicated for disseminated disease.

Surgical Treatment of Primitive Thyroid Lymphoma

Aims and Background

Primitive thyroid lymphoma, although rare, is becoming more frequent. Its incidence is increasing, from 0.5% in the sixties to 1-5% of all thyroid neoplasms today. The diagnosis of such neoplasms is not always straightforward. In fact, it is often the result of pathologic findings on a gland resected for an apparently benign disease. Surgical dissection may prove more complicated than in standard cases of thyroidectomy for the possible tight adhesions existing between the gland's capsule and the surrounding structures. In cases of capsular infiltration, postoperative external local radiotherapy is indicated.

Methods

A retrospective observational analysis was performed to establish whether patients with incidental thyroid lymphomas who underwent total thyroidectomy for another pathology had major surgical complications and worse prognostic results than patients with an accurate preoperative diagnosis.

Results

Six cases of thyroid lymphoma were retrospectively reviewed: 4 diffuse large B-cell lymphomas and 2 MALT lymphomas. Of these, 2 were correctly preoperatively identified by fine-needle aspiration biopsy and 4 were an unexpected finding at histology: 3 cases of total thyroidectomy carried out for huge hypothyroid goiter in patients affected by Hashimoto's thyroiditis and in 1 case of total thyroidectomy carried out for anaplastic carcinoma in a patient affected by Hashimoto's thyroiditis.

Conclusions

In our experience, a correct preoperative diagnosis was extremely difficult (33%). In patients who underwent fine-needle aspiration, a correct diagnosis was made in 66% of cases. All patients with stage IE lymphoma who underwent total thyroidectomy had equivalent surgical complications and prognosis.

Primary Thyroid Lymphoma: External Beam Radiation Therapy Induced Thyroiditis Mimics Residual Disease on Serial 18F-FDG PET/CT Imaging

A 67-year-old female patient with no prior history of benign thyroid disease was diagnosed with primary thyroid lymphoma and was staged with¹⁸F-fluoro-2-deoxy-D-glucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT). She was treated with chemotherapy and external beam radiation therapy, and a follow-up PET/CT showed significant reduction in the size of the thyroid lymphoma with persistent intense ¹⁸F-FDG uptake, which was interpreted as partial response to therapy. However, two subsequent PET/CT studies showed no change in the persistent intense ¹⁸F-FDG uptake in the thyroid and a biopsy confirmed the presence of thyroiditis with no evidence of residual lymphoma. Follow-up PET/CTs performed over the subsequent three years showed stable intensely ¹⁸F-FDG avid thyroiditis with no evidence of lymphoma recurrence. We present the imaging characteristics of a long term radiation treatment induced thyroiditis mimicking ¹⁸F-FDG avid residual disease on PET/CT.

Primary thyroid lymphoma: A case report and review of the literature

Introduction

A rapidly enlarging mass of the anterior compartment of the neck with compressive symptoms may represent, among other diagnosis, a neoplasm of the thyroid gland.

Presentation of case

We describe the case of a 59-year-old woman referred to the endocrine surgical unit because of compressive cervical symptoms for 3 months. The cervical ultrasound revealed a sub-sternal goiter with heterogeneous echo structure and the fine-needle aspirating cytology was inconclusive. Given the large impact of symptoms on life quality, she was submitted to a total thyroidectomy. Histological examination of the surgical specimen revealed the presence of a Diffuse Large B Cell Lymphoma of the thyroid.

Discussion

Primary thyroid lymphomas are rare and there are few randomized studies for diagnostic and therapeutic guidance. New immunohistochemical and molecular techniques have improved the diagnostic accuracy with corebiopsy limiting the role of surgery. The treatment should first include the control of local disease with radiotherapy and/or surgery combined with chemotherapy to control obscure or disseminated disease. Palliative surgery may be needed to relieve airway compression symptoms. Under these circumstances, surgery should be performed by a specialized surgeon to decrease the associated morbidity. The prognosis of patients depends on the histological classification of the tumor and the stage of the disease.

Conclusion

Due to the rarity of the disease, each case must be evaluated and treated individually, since there is not a consensual therapeutic approach.

•

Primary thyroid lymphomas are very rare.

•

New immunohistochemical and molecular techniques have improved the diagnostic accuracy with corebiopsy limiting surgery.

•

Surgery has a small role in PTL and when needed it should be performed by a specialized surgeon to decrease morbidity.

Primary thyroid lymphoma presenting as dermatomyositis: a first case and review of the literature

A 55-year-old woman presented with a 3-week history of weakness. On examination, she had a heliotrope rash, V-neck and shawl signs. There was symmetric proximal muscle weakness, and 2/5 strength in upper and lower extremities. Laboratory values showed CK 5836, CRP 14.9, erythrocyte sedimentation rate 49, lactate dehydrogenase 633, negative antinuclear antibodies and anti-Jo1 antibodies. Muscle biopsy and immunohistochemistry findings were consistent with dermatomyositis. Treatment with high-dose steroids, cyclophosphamide and intravenous immunoglobulin (IVIG) was started, without improvement of symptoms. She was found to have cold agglutinins with a cold screen titre of 1:256,256. Work up for malignancy ensued. Positron emission tomography-computed tomography (PET-CT) showed increased uptake in the thyroid. Fine-needle thyroid biopsy with flow cytometry studies revealed atypical lymphocytes consistent with diffuse large B-cell lymphoma. The patient underwent R-CHOP therapy, with remarkable improvement of her symptoms. Dermatomyositis associated with primary thyroid lymphoma has not been previously reported. This case reinforces the importance of cancer screening in dermatomyositis patients.

Clinicopathological characteristics and treatment outcomes of 38 cases of primary thyroid lymphoma: a multicenter study

Purpose

Primary thyroid lymphoma (PTL) is a rare disease and it has been investigated in a limited number of studies. The present multicenter study evaluated the clinical features and treatment outcomes of PTL.

Methods

The medical records of patients diagnosed with PTL between 2000 and 2013 in three centers were retrospectively reviewed.

Results

The study included 11 men and 27 women with a median age of 63.3 years (range, 42-83 years). The median follow-up was 56.0 months (range, 3-156 months). Of the 38 patients included, 16 had mucosa-associated lymphoid tissue (MALT) lymphoma, six had mixed MALT and diffuse large B-cell lymphoma (DLBCL), and 16 had DLBCL. Thirty-five patients (92.1%) had early stage (stage I/II) disease. Of the 16 MALT lymphoma patients, 14 were treated by surgery, and radiotherapy (RT) or chemotherapy was combined in five patients. Two patients received RT or chemotherapy alone. Of the six mixed MALT and DLBCL patients, three underwent surgery with chemotherapy and three underwent chemotherapy alone, RT alone, or surgery with RT. All of the 16 DLBCL patients received chemotherapy, and surgery and RT was combined in 4 and 1 patients, respectively. The 5-year survival was 100% for MALT lymphoma (7 of 7) and mixed MALT and DLBCL patients (5 of 5) and 87.5% for DLBCL patients (7 of 8).

Conclusion

Early stage PTL has an excellent prognosis when managed by single or combined treatment modalities. Clinicians should consider PTL in patients with underlying Hashimoto's thyroiditis presenting with an enlarging thyroid mass.

Thyroid lymphoma: A case report and literature review

Thyroid lymphoma is an unusual pathology. Different subtypes of lymphoma can present as primary thyroid lymphoma. This review illustrates via imaging, findings and treatment the need for accurate diagnosis and timely treatment. Patients and methods: patient’s chart, pathological findings and radiological images were reviewed in a retrospective analysis. Over several days, this 80 years old woman developed airway obstruction and rapid enlargement of her thyroid secondary to diffuse large B-cell lymphoma. She rapidly responded to her oncological protocol. Primary thyroid lymphoma is a rare disease. It is an important diagnosis to consider in patients presenting with rapidly enlarging neck masses. It is a treatable condition with fairly favorable overall survival even with the most aggressive histological subtypes.

Core needle biopsy could reduce diagnostic surgery in patients with anaplastic thyroid cancer or thyroid lymphoma

OBJECTIVE

To evaluate the diagnostic performance of fine needle aspiration (FNA) and core needle biopsy (CNB) in patients with anaplastic thyroid cancer (ATC) or thyroid lymphoma (TL).

METHODS

Between January 2000 and March 2012, 104 patients were diagnosed with ATC or TL by means of ultrasound (US)-guided FNA, CNB, or surgery. This study ultimately included 99 patients with ATC (n = 59) or TL (n = 40). We evaluated the sensitivity and positive predictive value of FNA and CNB for the diagnosis of ATC and TL, and compared the rates of diagnostic surgery between FNA and CNB.

RESULTS

FNA was used in 83 patients, and CNB was used in 32 patients initially (n = 16), after FNA results (n = 8), or simultaneously with FNA (n = 8). CNB achieved sensitivity of 87.5 % (28/32) and positive predictive value of 100.0 % (28/28) for the diagnosis of ATC and TL. The respective values for FNA were 50.6 % (40/79) and 90.9 % (40/44). The rate of diagnostic surgery was significantly lower after CNB (4/32, 12.5 %) than after FNA (28/79, 35.4 %) (p = 0.020).

CONCLUSIONS

CNB was able to reduce unnecessary diagnostic surgery in patients with ATC or TL by virtue of its superior diagnostic sensitivity and positive predictive value compared to FNA.

KEY POINTS

• Diagnostic sensitivity and PPV for CNB were 87.5 % and 100.0 %, respectively. • The respective values for FNA were 50.6 % and 91.0 % for ATC and TL. • Diagnostic surgery rates were reduced after CNB compared to FNA (p = 0.020).

Sonographic appearance of primary thyroid lymphoma-preliminary experience

Objective

Primary thyroid lymphoma (PTL) is an uncommon thyroid malignancy. Despite the rarity of PTL, it is important to recognize PTL promptly because its management differs from that of all the other thyroid neoplasms. This study was designed to investigate the sonographic features of PTL.

Methods

Twenty-seven pathologically confirmed PTLs were categorized into diffuse and non-diffuse type. Sonographic features including thyroid size, thyroid background echotexture, lesion size, echogenecity, calcification, vascularity, cervical lymphadenopathy of each type were retrospectively analyzed.

Results

All 27 PTLs were diffuse large B-cell lymphomas and were accompanied by diffuse Hashimoto's thyroiditis. Ten were diffuse type and seventeen were non-diffuse type sonographically. The observations in diffuse group included goiter (10/10, 100.0%), marked echogenesity (10/10, 100.0%), heterogeneous echotexture (10/10, 100.0%), and cervical lymphadenopathy (4/10, 40.0%). The observations in non-diffuse group included marked hypoechogenicity (17/17, 100.0%), heterogeneous background thyroid gland (17/17, 100.0%), goiter (15/17, 88.2%), increased vascularity (8/13, 61.5%), mulifocality (10/17, 58.8%), and cervical lymphadenopathy (7/17, 41.2%).

Conclusions

Although some common features were found, the sonographic appearance of PTL is unspecific, especially for the diffuse type. Therefore, interventional diagnostic procedures should be warranted in the clinical settings when PTL is suspected.

The effect of chronic lymphocytic thyroiditis on patients with thyroid cancer

Background

The purpose of this study was to investigate the association between chronic lymphocytic thyroiditis (CLT) and malignant tumors of the thyroid.

Methods

A retrospective review of 647 patients who underwent thyroid surgery at the Department of Breast and Thyroid Surgery in Anhui Provincial Hospital, China in 2012 was performed. The clinicopathological characteristics of patients with thyroid malignancies and CLT were collected. CLT was diagnosed by histopathological method.

Results

Among 647 patients, 144 patients had thyroid malignancies and 108 patients had been diagnosed with CLT. Moreover, in total, 44 patients had thyroid malignancies coexistent with CLT: forty-one (93.2%) patients had been diagnosed with the papillary thyroid cancer (PTC); two (4.5%) patients suffered from medullary carcinoma; and one (2.3%) patient suffered from lymphoma. The morbidity of thyroid malignancies in patients with CLT was significantly higher than that in patients without CLT (40.7% versus 18.6%; P <0.001). A female preponderance was observed in the patients with CLT compared with those without CLT (P <0.001). There was no statistically significant difference in the tumor size (P = 0.073), multifocality (P = 0.0871), neck lymph node metastasis (P = 0.350), age (P = 0.316), microcarcinoma (P = 0.983) and tumor-node-metastasis (TNM) stage (P = 0.949) between the patients of thyroid malignancies with CLT and without CLT.

Conclusions

Female predominance was observed in patients with CLT. CLT may have no effect on the progression of thyroid malignant tumor. Nevertheless, the influences of CLT on the prognosis of the thyroid carcinoma still need to be investigated with a larger sample size.

Rapidly enlarging neck masses of the thyroid with Horner's syndrome: a concise clinical review

BACKGROUND

Horner's syndrome (HS) presenting with a neck mass is a rare but challenging clinical scenario which may be caused by malignant thyroid disease.

METHODS

A concise review of the literature (PubMED database; 1990-2013) on the clinical management of neck masses with HS. An example case is also discussed.

RESULTS

1.3% of HS is caused by thyroid pathology. Thyroid pathology is the commonest cause of a neck mass associated with HS: the majority are caused by benign pathology; with carcinoma and lymphoma accounting for the remainder. Anaplastic thyroid carcinoma (ATC), thyroid lymphoma (TL) and thyroid sarcoma (TS) typically present with rapidly enlarging anterior neck masses in the elderly and are difficult to distinguish clinically. Although fine needle aspirate cytology (FNAC) is the diagnostic tool of choice for thyroid masses, core or incisional biopsy may be necessary when FNAC is inconclusive.

CONCLUSION

Differentiation between ATC, TL and TS is imperative as their treatment and prognoses differ greatly. Where feasible a combination of surgical debulking, radiotherapy and chemotherapy is the treatment of choice in ATC. Advanced cases benefit from 2 monthly endoscopic surveillance ± tracheostomy, stenting or Nd-YAG laser therapy. Aggressive oncological resection alone is recommended in TS. Treatment regimes in thyroid lymphoma (typically chemotherapy ± radiotherapy) differ for histological sub-types. 5-year failure-free survival is 90% in TL compared with a mean survival of 6-8 months in ATC and 10 months in TS.

Reactive lymphoid hyperplasia of the thyroid followed by systemic autoimmune diseases: a case report

Introduction

Reactive lymphoid hyperplasia is a benign nodular lesion characterized by marked proliferation of non-neoplastic, polyclonal lymphocytes forming follicles. The lesion is found in various organs such as skin, orbit, lung, gastrointestinal tract, and liver. However, reactive lymphoid hyperplasia in the thyroid gland is extremely rare. Here, we present an interesting case of reactive lymphoid hyperplasia in the thyroid, which suggests the nature of the disease.

Case presentation

A 74-year-old Japanese man was referred to our institute because of a growing well-demarcated irregular-shaped mass in the right lobe of the thyroid. Malignant lymphoma was suspected by cytology, and right lobectomy was conducted. A final diagnosis of reactive lymphoid hyperplasia was made by the intimate investigation of the surgical specimen, with evidence of polyclonal and non-neoplastic lymphatic proliferations forming follicles with an active germinal center. After an initial uneventful postoperative course, our patient developed severe symptoms of systemic rheumatic arthritis, and alterations in autoimmune reaction, including clinically overt chronic thyroiditis, were identified.

Conclusions

Our case demonstrated important clinical information on reactive lymphoid hyperplasia of the thyroid, and suggested the importance of differential diagnosis, and possible close correlation between systemic autoimmune disorder and the disease.

Co-occurrence of papillary thyroid cancer and MALT lymphoma of the thyroid with severe airway obstruction: A case report and review of the literature

INTRODUCTION

Co-occurrence of papillary thyroid carcinoma (PTC) and mucosa-associated lymphoid tissue (MALT) lymphoma resulting in severe airway obstruction is very rare.

PRESENTATION OF CASE

A 58-year-old woman visited our department because of enlargement of a neck mass. Computed tomography (CT) and ultrasonography showed 2 discrete hypoechoic nodules. Fine-needle aspiration biopsy revealed thyroid lymphoma in the left lobe and PTC in the right lobe. After 1 week, she returned to the emergency room at our hospital with shortness of breath and difficultly in swallowing. CT revealed enlargement of the left lobe, which was severely compressing the trachea. We performed emergency total thyroidectomy with lymphadenectomy. The postoperative course was uneventful, and the patient was discharged without any symptoms.

DISCUSSION

The most common treatment for PTC is surgery; however, the treatment for thyroid lymphoma remains controversial. We propose that surgery be performed in the cases of symptoms such as shortness of breath and difficulty in swallowing.

CONCLUSION

We performed emergency total thyroidectomy to relieve obstruction of the trachea and to remove the two malignant tumors. We suggest total thyroidectomy for a case of co-occurrence of two malignant tumors, causing severe airway obstruction.

Patterns of care and treatment outcomes for primary thyroid lymphoma: a single institution study

Purpose

The aim of this study was to analyze the patterns of care and treatment outcomes in patients with primary thyroid lymphoma (PTL) in a single institution.

Materials and Methods

Medical records of 29 patients with PTL treated between April 1994 and February 2012 were retrospectively reviewed. Diagnosis was confirmed by biopsy (n = 17) or thyroidectomy (n = 12). Treatment modality and outcome were analyzed according to lymphoma grade.

Results

The median follow-up was 43.2 months (range, 3.8 to 220.8 months). The median age at diagnosis was 57 years (range, 21 to 83 years) and 24 (82.8%) patients were female. Twenty-five (86.2%) patients had PTL with stage IEA and IIEA. There were 8 (27.6%) patients with mucosa-associated lymphoid tissue (MALT) lymphoma and the remaining patients had high-grade lymphoma. Patients were treated with surgery (n = 2), chemotherapy (n = 7), radiotherapy (n = 3) alone, or a combination of these methods (n = 17). Treatment modalities evolved over time and a combination of modalities was preferred, especially for the treatment of high-grade lymphoma in recent years. There was no death or relapse among MALT lymphoma patients. Among high-grade lymphoma patients, 5-year overall survival (OS) and 5-year progression-free survival (PFS) were 75.6% and 73.9%, respectively. Complete remission after initial treatment was the only significant prognostic factor for OS (p = 0.037) and PFS (p = 0.003).

Conclusion

Patients with PTL showed a favorable outcome, especially with MALT lymphoma. Radiotherapy alone for MALT lymphoma and chemotherapy followed by radiotherapy for high-grade lymphoma can be effective treatment options for PTL.

Co-occurrence of papillary thyroid carcinoma and mucosa-associated lymphoid tissue lymphoma in a patient with long-standing hashimoto thyroiditis

Papillary thyroid carcinoma (PTC) is a common affliction of the thyroid gland, accounting for 70% to 80% of all thyroid cancers, whereas mucosa-associated lymphoid tissue (MALT) lymphoma of the thyroid gland is uncommon. The simultaneous occurrence of both malignancies is extremely rare. We report the case of a patient with both PTC and MALT lymphoma in the setting of Hashimoto thyroiditis. An 81-year-old female patient was first admitted with goiter and hoarseness, which was attributed to an ultrasonographic thyroid nodule. Subsequent fine-needle aspirate, interpreted as suspicious of papillary thyroid cancer, prompted total thyroidectomy. MALT lymphoma was an incidental postsurgical finding, coexisting with PTC in the setting of Hashimoto thyroiditis. Although the development of MALT lymphoma is very rare, patients with longstanding Hashimoto thyroiditis should undergo careful surveillance for both malignancies.

Long-term outcome of primary endocrine non-Hodgkin lymphomas: does the site make the difference?

AIM

Primary lymphomas of endocrine glands are extremely rare. Our study adds more data to the few published series regarding the incidence, clinical characteristics, management and overall survival (OS) by comparing the various diffuse large B-cell endocrine lymphomas. Moreover, it contributes to a better understanding of these neoplasms and provides concepts for future research.

METHODS

We retrospectively evaluated the clinical profile and the patterns of outcome among patients who were treated in our center with the diagnosis of aggressive, B-cell, primary endocrine lymphoma.

RESULTS

Between May 1980 and December 2011, 450 patients were diagnosed as primary extranodal non-Hodgkin lymphomas. Among them, 18 cases (4%) were primary testicular lymphoma (PTL), 8 cases (2%) were primary thyroid lymphoma (PTHL) and 4 cases (1%) were primary adrenal lymphoma (PAL). The therapeutic approaches employed were variable, including mainly chemotherapy in combination with radiotherapy and surgery. The median OS for the patients with PTL and PAL was 27 and 6 months, respectively. Better outcome was observed in patients with PTHL for whom the median OS has not been reached yet, whereas the PAL group had the worst prognosis.

CONCLUSIONS

The discrepancies in the outcome among endocrine lymphomas could be partly attributed to their biologic variability, which might be determined by the initial site involved. We conclude that treatment decisions should be made according to a multi-disciplinary approach to avoid unnecessary surgery. Existing treatment strategies for PTL and PAL fail to provide long-term survival, rendering the application of novel therapeutic approaches essential.

German Association of Endocrine Surgeons practice guideline for the surgical management of malignant thyroid tumors

INTRODUCTION

Over the past years, the incidence of thyroid cancer has surged not only in Germany but also in other countries of the Western hemisphere. This surge was first and foremost due to an increase of prognostically favorable ("low risk") papillary thyroid microcarcinomas, for which limited surgical procedures are often sufficient without loss of oncological benefit. These developments called for an update of the previous practice guideline to detail the surgical treatment options that are available for the various disease entities and tumor stages.

METHODS

The present German Association of Endocrine Surgeons practice guideline was developed on the basis of clinical evidence considering current national and international treatment recommendations through a formal expert consensus process in collaboration with the German Societies of General and Visceral Surgery, Endocrinology, Nuclear Medicine, Pathology, Radiooncology, Oncological Hematology, and a German thyroid cancer patient support organization.

RESULTS

The practice guideline for the surgical management of malignant thyroid tumors includes recommendations regarding preoperative workup; classification of locoregional nodes and terminology of surgical procedures; frequency, clinical, and histopathological features of occult and clinically apparent papillary, follicular, poorly differentiated, undifferentiated, and sporadic and hereditary medullary thyroid cancers, thyroid lymphoma and thyroid metastases from primaries outside the thyroid gland; extent of thyroidectomy; extent of lymph node dissection; aerodigestive tract resection; postoperative follow-up and surgery for recurrence and distant metastases.

CONCLUSION

These evidence-based recommendations for surgical therapy reflect various "treatment corridors" that are best discussed within multidisciplinary teams and the patient considering tumor type, stage, progression, and inherent surgical risk.

Thyroid surgery

Diseases of the thyroid are common and surgical treatment is often the preferred option. Thyroid surgery is becoming subspecialised and falls within the repertoire of maxillofacial, and head and neck surgeons. Multidisciplinary management of most patients with diseases of the thyroid is key to providing the best care particularly for those with malignancies and retrosternal extension. To reduce postoperative complications a meticulous search for, and protection of the recurrent laryngeal nerve and parathyroid glands, with an incision along the skin crease in the lower neck, which can be extended for neck dissection, are paramount. Recent advances in thyroid surgery include ultrasound-guided cervical plexus block, use of the Harmonic Scalpel(®) (Ethicon Endo-Surgery, Inc., USA), intraoperative nerve stimulation to monitor the recurrent laryngeal nerve, use of TissuePatch™ 3 (Tissuemed Ltd., Leeds, UK) adhesive sealant, and minimal access surgery.

Concomitant thyroid Malt lymphoma and papillary thyroid carcinoma

The objective of this study was to describe the rare thyroid MALT lymphoma concomitant with papillary thyroid carcinoma in a male patient who was submitted to total thyroidectomy. Treatment and follow-up issues are addressed. Male patient complains of fast thyroid enlargement without lymphadenophaty and normal clinical exams. Total thyroidectomy was indicated and performed without any complications. The pathology showed multicentric papillary thyroid carcinoma, concomitant thyroid MALT lymphoma and Hashimoto's thyroiditis. The immunohistochemistry assay was positive for CD 20, CD 43, CD 79, AE1/AE3. The staging studies showed no evidence of both metastasis, Ann Harbor stage IE, without B symptoms. After RIT no further radiotherapy or chemotherapy was indicated. Nowadays the thyroglobulin is undetectable, without recurrences at two years of follow-up. It was concluded that primary thyroid MALT lymphoma is uncommon being the papillary thyroid carcinoma more frequent. Both occurring concomitantly is very rare and the treatment has to prioritize the tumor of worst prognosis at the discovery moment.

High response rate and improvement of long-term survival with combined treatment modalities in patients with poor-risk primary thyroid diffuse large B-cell lymphoma: an International Extranodal Lymphoma Study Group and Intergruppo Italiano Linfomi study

The impact of different treatment modalities and prognostic factors on the clinical course of primary thyroid diffuse large B-cell lymphoma (PTDLBCL) is still the subject of research. This study was conducted to clarify these clinical aspects of this disorder. The clinical parameters of 48 patients with PTDLBCL at time of diagnosis were comparable to those of previous studies. Patients underwent either radiotherapy (RT)  ±  surgery (SX), chemotherapy (CHT) alone or in combination with local treatments (RT or SX), or SX followed by CHT and RT. A 90% complete remission (CR) rate was observed among patients who underwent combined treatment modalities (CTM), compared to 76% among the others. The 5-year progression-free survival differed significantly between both groups (p = 0.028). Poor performance status and advanced age correlated with decreased survival. PTDLBCL is a curable disease prevalent in elderly patients. Combined treatment modalities were able to induce an elevated rate of CR, improving long-term survival in younger patients. However, the outcome in elderly patients still remains unsatisfactory.

A rare case of chronic lymphocytic leukemia/small lymphocytic lymphoma presenting in the thyroid gland

BACKGROUND

Lymphoma involving the thyroid gland is rare. Diffuse large B-cell lymphoma and mucosa-associated lymphoid tissue lymphoma are the two most common histologic subtypes of primary thyroid lymphoma. Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) presenting initially as a thyroid abnormality is extremely rare, with very few reported cases in the literature.

SUMMARY

We report a case of a patient with a long history of Hashimoto's thyroiditis and goiter who presented with a recent enlargement of her thyroid gland. The sonographic finding of a distinct thyroid nodule in the heterogeneous background of chronic lymphocytic thyroiditis led to the performance of a fine-needle aspiration biopsy and flow cytometry, with a high index of suspicion for thyroid lymphoma. Subsequent surgical removal of the thyroid gland, prompted by the patient's history of head and neck radiation, confirmed the diagnosis of CLL/SLL. The patient's systemic illness was recognized only after the management of her thyroid disease. Although thyroiditis has long been associated with lymphoma arising in the thyroid gland, CLL/SLL involving the thyroid has not been linked to chronic lymphocytic thyroiditis. Therefore, the patient also had coexisting thyroiditis.

CONCLUSIONS

Due to the rarity of thyroid lymphomas, our experience in the detection and management of this disease is limited. Primary thyroid lymphoma should be suspected in a patient with a history of chronic lymphocytic thyroiditis presenting with a rapidly enlarging neck mass. The initial diagnostic method for thyroid lymphoma should consist of a fine-needle aspiration biopsy with the use of ancillary techniques such as flow cytometry and immunohistochemistry for improved diagnostic accuracy. Although controversial, the treatment of thyroid lymphoma is typically guided by the histologic subtype and extent of disease. CLL/SLL is one of the rarest subtypes of lymphoma that can involve the thyroid gland. Diagnosis of this entity is difficult, particularly before the recognition of systemic involvement, requiring the expertise of a multidisciplinary team for early detection and optimal management.

Undifferentiated sarcoma of the thyroid in a child

The most common malignant tumor of the thyroid is papillary carcinoma. Sarcoma of the thyroid is encountered very rarely; its therapy is complex and poses significant problems due to the problematic location of the tumor. A 14-year-old female was diagnosed with undifferentiated sarcoma of the thyroid and received combined therapy comprising surgery, chemo- and radiotherapy without significant side effects. This case underlines the fact that undifferentiated thyroid sarcoma may be a diagnostic possibility in children with malignant masses of the neck and may be successfully treated with modern therapeutic strategies.

Rituximab plus dose-reduced cyclophosphamide, mitoxantrone, vincristine, and prednisolone are effective in elderly patients with diffuse large B-cell lymphoma of the thyroid

BACKGROUND

Primary thyroid lymphoma is a rare disease. Although many reports have dealt with surgery followed by chemotherapy or radiation as well as combined chemoradiation, little is known about the value of immunochemotherapy alone. We present the results of systemic treatment using rituximab plus dose reduced mitoxantrone, cyclophosphamide, vincristine, and prednisolone in three elderly patients with primary diffuse large B-cell lymphoma (DLBCL) of the thyroid.

PATIENTS AND METHODS

Three patients aged between 86 and 93 years were found to have DLBCL of the thyroid. Lymphoma was locally advanced and deemed unresectable in one patient, whereas the remaining two patients were judged unfit for surgery. All patients were given systemic therapy with R 375 mg/m(2) on day 1, mitoxantrone 8 mg intravenously, cyclophosphamide 750 mg intravenously, and vincristine 1 mg (all given on day 2), along with 100 mg oral prednisolone on days 1-5.

RESULTS

Two patients were given 6 cycles and one patient was given 8 courses of treatment, and all responded with complete remission of the lymphoma. All three patients are alive without evidence of disease recurrence 16, 19, and 25 months after initiation of therapy. Side effects were leukopenia grade III and anemia grade II in one patient each, nausea/emesis grade I in two patients, and lower urinary tract infection and bronchitis in one patient each.

CONCLUSION

These data suggest that R plus dose-reduced mitoxantrone, cyclophosphamide, vincristine, and prednisolone are feasible and highly effective in elderly patients with DLBCL of the thyroid.

Prognosis of primary thyroid lymphoma: demographic, clinical, and pathologic predictors of survival in 1,408 cases

BACKGROUND

There is a paucity of data regarding prognosis of primary thyroid lymphoma (PTL), with only case reports and institutional series reported. This is the first population-based study of PTL in the United States.

METHODS

PTL patients were identified in the SEER database. Bivariate (chi(2), Kaplan-Meier, and log rank) and multivariate (Cox proportional hazards) analyses were used to assess the associations between patient characteristics and survival.

RESULTS

A total of 1,408 patients were identified over 32 years of follow-up (median, 3.75 years). Mean age was 66 years; 75% were female and 93% white. Overall, 98% had non-Hodgkin's lymphoma; 68% had diffuse large B-cell, 10% follicular, 10% marginal zone, and 3% small lymphocytic. A total of 88% had stage I-II disease. Median survival was 9.3 years. On bivariate analysis, older age, single marital status, stage II-IV disease, histology (large B-cell, follicular, or other non-Hodgkin's), earlier year of diagnosis, lack of prior malignancies, and no radiation/surgery predicted worse survival. Age >or=80 years, advanced stage, no radiation/surgery, and large B-cell or follicular histology predicted worse prognosis in multivariate analysis.

CONCLUSION

Older age, advanced stage, histologic subtype, and lack of radiation/surgical treatment are associated with worse survival. Thyroid resection offers benefit only for patients with stage I disease. Management of PTL requires multidisciplinary collaboration.

Primary thyroid marginal zone B-cell lymphoma MALT-type in a patient with rheumatoid arthritis

Autoimmune diseases are defined as specific, adapted immune reactions against self antigens. Immune mechanism deficiency is a causal factor for B-cell lymphoma in primary Sjögren's syndrome and autoimmune thyroid disease. Thyroid mucosa-associated lymphoid tissue (MALT) lymphoma is a 67-fold and parotid lymphoma is a 44-fold increased risk in Sjögren's syndrome and thyroiditis. MALT lymphoma was not reported in rheumatoid arthritis. We herein report the case of a 56-year-old woman with maltoma of thyroid in rheumatoid arthritis patient.

Unusual tumors of the thyroid gland

Thyroid neoplasms are classified into three major categories: epithelial, nonepithelial, and secondary. Most primary epithelial tumors of thyroid are derived from follicular cells. These include follicular adenoma and carcinoma (Hürthle and non-Hürthle), and papillary carcinoma and its variants. Other primary epithelial tumors include medullary carcinoma, mixed medullary and follicular carcinomas, insular and poorly differentiated carcinoma, anaplastic carcinoma, and the least common squamous carcinoma and related tumors. The nonepithelial tumors are rare; the most common include malignant lymphoma and tumors arising from the mesenchymal elements. The secondary tumors represent metastatic tumors to the thyroid usually originating in lung, kidney, and breast. In this article, the authors review the unusual tumors of the thyroid, their morphologic features, and clinical and prognostic implications.