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González-Sánchez C, Salvador-Egea MP, Glückmann-Maldonado E, Ríos A, Martín-Fernández J, Pérez-García JI, García-Lorenzo F, Flores-Pastor B, Gómez-Ramírez J, Ortega-Serrano J, Ros-López S, Villar-Del-Moral J, Morales-García D, Gutiérrez-Rodríguez MT, Domènech-Calvet J, Nuño-Vázquez-Garza JM, Franch-Arcas G. Diagnosis and treatment of primary thyroid lymphoma from a surgical perspective: a multi-institutional study. Langenbecks Arch Surg 2023; 408:206. [PMID: 37221304 DOI: 10.1007/s00423-023-02945-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/14/2023] [Indexed: 05/25/2023]
Abstract
PURPOSE Surgery of primary thyroid lymphoma (PTL) has been mostly limited to diagnostic work-up. This study aimed to further study its potential role. METHODS This was a retrospective study from a multi-institutional registry of PTL patients. Clinical, diagnostic work-up (fine needle aspiration, FNA; core needle biopsy, CoreNB), contribution of surgery (open surgical biopsy, OpenSB; thyroidectomy), histology subtype, and outcome data were evaluated. RESULTS Some 54 patients were studied. Diagnostic work-up included FNA in 47 patients, CoreNB in 11, and OpenSB in 21. CoreNB yielded the best sensitivity (90.9%). Thyroidectomy was performed in 14 patients with other diagnosis (incidental PTL), in 4 for diagnosis and in 4 for elective treatment of PTL. Incidental PTL was associated with not performed FNA nor CoreNB (OR 52.5; P = 0.008), mucosa-associated lymphoid tissue (MALT) subtype (OR 24.3; P = 0.012), and Hashimoto's thyroiditis (OR 11.1; P = 0.032). Lymphoma-related death (10 cases) mostly occurred within the first year after diagnosis and was associated with diffuse large B-cell (DLBC) subtype (OR 10.3; P = 0.018) and older patients (OR 1.08 for every 1-year increase; P = 0.010). There was a trend towards lower mortality rate in patients receiving thyroidectomy (2/22 versus 8/32, P = 0.172). CONCLUSION Incidental PTL accounts for most of thyroid surgery cases and are associated with incomplete diagnostic work-up, Hashimoto's thyroiditis and MALT subtype. CoreNB appears to be the best tool for diagnosis. Most of PTL deaths occurred during the first year after diagnosis and mostly related to systemic treatment. Age and DLBC subtype are poor prognostic factors.
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Affiliation(s)
- C González-Sánchez
- Department of Surgery, Complejo Asistencial Universitario de Salamanca, Paseo de San Vicente, 88-132, 37007, Salamanca, Spain.
- Instituto de Investigación Biomédica de Salamanca IBSAL, Salamanca, Spain.
| | - M P Salvador-Egea
- Department of Surgery, Complejo Hospitalario de Navarra B, Pamplona, Spain
| | | | - A Ríos
- Department of Surgery, Hospital Clínico Universitario Arrixaca, Murcia, Spain
| | - J Martín-Fernández
- Department of Surgery, Complejo Hospitalario de Ciudad Real, Ciudad Real, Spain
| | - J I Pérez-García
- Department of Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - F García-Lorenzo
- Department of Surgery, Hospital Alvaro Cunqueiro de Vigo, Vigo, Spain
| | - B Flores-Pastor
- Department of Surgery, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - J Gómez-Ramírez
- Department of Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - J Ortega-Serrano
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - S Ros-López
- Department of Surgery, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - J Villar-Del-Moral
- Department of Surgery, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria IBS de Granada, Granada, Spain
| | - D Morales-García
- Department of Surgery, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | | | - J Domènech-Calvet
- Department of Surgery, Hospital Universitario Sant Joan de Reus, Reus, Spain
| | | | - G Franch-Arcas
- Department of Surgery, Complejo Asistencial Universitario de Salamanca, Paseo de San Vicente, 88-132, 37007, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca IBSAL, Salamanca, Spain
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Barroca H, Marques C. A Basic Approach to Lymph Node and Flow Cytometry Fine-Needle Cytology. Acta Cytol 2016; 60:284-301. [PMID: 27639613 DOI: 10.1159/000448679] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 07/22/2016] [Indexed: 12/21/2022]
Abstract
According to the World Health Organization (WHO), the new classification of lymphomas is mainly based on morphological, immunophenotypical, and molecular criteria. Consequently, this new approach has led from the substantial role that architecture played in the past to a secondary panel highlighting the role of fine-needle biopsy (FNB). Applied together with other ancillary techniques, such as flow cytometry (FC), FNB is a potential tool for the diagnosis of lymphomas, and enlarged lymph nodes represent an excellent target for the implementation of this technique. Despite the difficulties inherent in this technology, which might pose problems in differential diagnosis, in the majority of cases this joint work allows an accurate diagnosis of malignancy and even correct subcharacterization in routine lymphomas. Additionally, in selected cases, other molecular techniques like FISH and PCR can also be performed on FNB specimens, helping in the characterization and diagnosis of lymphomas. In this review, we discuss the basic aspects of the combination of FNB cytology and FC in the diagnosis and subclassification of lymphomas. The preanalytical phase is extensively discussed. The advantages, disadvantages, and technical limitations of this joint work are addressed in general and in terms of the accurate subclassification of lymphomas.
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Affiliation(s)
- Helena Barroca
- Laboratório de Anatomia Patológica, Centro Hospitalar de S. João, Porto, Portugal
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Povoski SP, Hall NC, Murrey DA, Wright CL, Martin EW. Feasibility of a multimodal (18)F-FDG-directed lymph node surgical excisional biopsy approach for appropriate diagnostic tissue sampling in patients with suspected lymphoma. BMC Cancer 2015; 15:378. [PMID: 25953144 PMCID: PMC4426183 DOI: 10.1186/s12885-015-1381-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 04/28/2015] [Indexed: 11/22/2022] Open
Abstract
Background 18F-FDG PET/CT imaging is widely utilized in the clinical evaluation of patients with suspected or documented lymphoma. The aim was to describe our cumulative experience with a multimodal 18F-FDG-directed lymph node surgical excisional biopsy approach in patients with suspected lymphoma. Methods Thirteen patients (mean age 51 (±16;22–76) years), with suspected new or suspected recurrent lymphoma suggested by 18F-FDG-avid lesions seen on prior diagnostic whole-body PET/CT imaging, were injected IV with 18F-FDG prior to undergoing same-day diagnostic lymph node surgical excisional biopsy in the operating room. Various 18F-FDG detection strategies were used on the day of surgery, including, (1) same-day pre-resection patient PET/CT; (2) intraoperative gamma probe assessment; (3) clinical scanner specimen PET/CT imaging of whole surgically excised tissue specimens; (4) specimen gamma well counts; and/or (5) same-day post-resection patient PET/CT. Results Same-day 18F-FDG injection dose was 14.8 (±2.4;12.5-20.6) millicuries or 548 (±89;463–762) megabecquerels. Sites of 18F-FDG-avid lesions were 4 inguinal, 3 cervical, 3 abdominal/retroperitoneal, 2 axillary, and 1 gluteal region subcutaneous tissue. Same-day pre-resection patient PET/CT was performed on 6 patients. Intraoperative gamma probe assessment was performed on 13 patients. Clinical scanner PET/CT imaging of whole surgically excised tissue specimens was performed in 10 cases. Specimen gamma well counts were performed in 6 cases. Same-day post-resection patient PET/CT imaging was performed on 8 patients. Time from 18F-FDG injection to same-day pre-resection patient PET/CT, intraoperative gamma probe assessment, and same-day post-resection patient PET/CT were 76 (±8;64–84), 240 (±63;168–304), and 487 (±104;331–599) minutes, respectively. Time from 18F-FDG injection to clinical scanner PET/CT of whole surgically excised tissue specimens was 363 (±60;272–446) minutes. Time from 18F-FDG injection to specimen gamma well counts was 591 (±96;420–689) minutes. Intraoperative gamma probe assessment successfully identified 18F-FDG-avid lesions in 12/13 patients. Histopathologic evaluation confirmed lymphoma in 12/13 patients and benign disease in 1/13 patients. Conclusions A multimodal approach to 18F-FDG-directed lymph node surgical excisional biopsy for suspected lymphoma is technically feasible for guiding appropriate diagnostic tissue sampling of lymph nodes seen as 18F-FDG-avid lesions on diagnostic 18F-FDG PET/CT imaging.
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Affiliation(s)
- Stephen P Povoski
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
| | - Nathan C Hall
- Division of Molecular Imaging and Nuclear Medicine, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA. .,Division of Nuclear Medicine and Clinical Molecular Imaging, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Douglas A Murrey
- Division of Molecular Imaging and Nuclear Medicine, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
| | - Chadwick L Wright
- Division of Molecular Imaging and Nuclear Medicine, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
| | - Edward W Martin
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
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Walsh S, Lowery AJ, Evoy D, McDermott EW, Prichard RS. Thyroid lymphoma: recent advances in diagnosis and optimal management strategies. Oncologist 2013; 18:994-1003. [PMID: 23881987 DOI: 10.1634/theoncologist.2013-0036] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Primary thyroid lymphoma is rare, composing approximately 5% of all thyroid malignancies and less than 3% of all extranodal lymphomas. It typically presents as a rapidly enlarging goiter with associated compressive symptoms. Thyroid ultrasound and fine needle aspiration cytology, using flow cytometry and immunohistochemistry, remain the main modalities used to confirm the presence of lymphoma. The increasing use of an ultrasound-guided core biopsy to achieve an accurate diagnosis has further limited the role of surgery. An open surgical biopsy may still be required not only for definitive diagnosis but also to confirm the subtype of lymphoma. There are limited numbers of randomized or prospective trials to guide management, and controversy remains over optimal treatment. Treatment and prognosis of this disease can be dichotomized into two separate groups: pure mucosa-associated lymphoid tissue (MALT) lymphoma and diffuse large B-cell lymphoma (DLBCL) or mixed subtypes. Early stage (stage IE) intrathyroidal MALT lymphomas typically have an indolent course and may be treated with single-modality surgery, radiotherapy, or a combination of both. DLBCLs are more aggressive, and survival outcomes are highest with multimodal therapy incorporating monoclonal antibodies, chemotherapy, and radiotherapy. The prognosis is generally excellent but can be varied because of the heterogeneous nature of thyroid lymphomas. The aim of this paper is to discuss the changes in diagnostic modalities and to focus on the recent alterations in the management of this rare disease, including targeted therapies as well as the more limited role of the endocrine surgeon.
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Affiliation(s)
- Siun Walsh
- Department of Endocrine Surgery, St. Vincent's University Hospital, Dublin, Ireland
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Revised diagnostic criteria and classification for the autoimmune lymphoproliferative syndrome (ALPS): report from the 2009 NIH International Workshop. Blood 2010; 116:e35-40. [PMID: 20538792 DOI: 10.1182/blood-2010-04-280347] [Citation(s) in RCA: 304] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Lymphadenopathy in children for which no infectious or malignant cause can be ascertained constitutes a challenging diagnostic dilemma. Autoimmune lymphoproliferative syndrome (ALPS) is a human genetic disorder of lymphocyte apoptosis resulting in an accumulation of lymphocytes and childhood onset chronic lymphadenopathy, splenomegaly, multilineage cytopenias, and an increased risk of B-cell lymphoma. In 1999, investigators at the National Institutes of Health (NIH) suggested criteria to establish the diagnosis of ALPS. Since then, with approximately 500 patients with ALPS studied worldwide, significant advances in our understanding of the disease have prompted the need for revisions to the existing diagnostic criteria and classification scheme. The rationale and recommendations outlined here stem from an international workshop held at NIH on September 21 and 22, 2009, attended by investigators from the United States, Europe, and Australia engaged in clinical and basic science research on ALPS and related disorders. It is hoped that harmonizing the diagnosis and classification of ALPS will foster collaborative research and better understanding of the pathogenesis of autoimmune cytopenias and B-cell lymphomas.
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Abstract
With the advances in molecular pathology, the cell as a morphological and functional unit has become essential in the diagnosis of lymphoma. Conventional staining, preparation, and interpretation of cells, as seen in fine needle aspiration cytology (FNAC), often used as a first line investigation of lymphadenopathy, is being supplemented with an array of immunocytochemical and molecular analyses, aimed not only at a more precise disease definition, but also at recognising factors that can predict prognosis and response to treatment. Accepting the pitfalls of conventional cytomorphology, this review looks at molecular changes characteristic to particular lymphomas and explores the currently available technology for their detection, with particular reference to cytological material. Future protocols for the diagnosis and management of patients with lymphadenopathy should include FNAC as an initial investigation, followed by immunocytochemistry and molecular investigations. Tissue biopsy, the conventional method of diagnosis, may be avoided in selected cases.
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