Thyroid lymphoma: recent advances in diagnosis and optimal management strategies

Diffuse large B-cell lymphoma associated with papillary thyroid carcinoma: a case report and systematic review on management and outcomes

Primary thyroid lymphoma is a rare thyroid cancer, comprising ˂5% of thyroid neoplasms. Most cases are diffuse large B-cell lymphoma (DLBCL). Coexistence with papillary thyroid cancer (PTC) is extremely rare. This study presents a case of a 55-year-old woman with DLBCL and micropapillary thyroid cancer who underwent lobectomy, chemotherapy, and radiotherapy. Additionally, we performed a systematic review of 10 cases, including the reported case. The risk of bias in case reports varied. DLBCL diagnoses were mainly made after surgery, with total thyroidectomy being the most common surgical procedure. Chemotherapy was administered in most cases, and radiotherapy was used in some cases. Long-term outcomes indicated a low recurrence rate. While some debate the role of surgery in thyroid lymphoma, this study suggests that surgery should be considered in selected cases. Further research is needed to determine optimal treatment strategies for DLBCL with PTC.

Thyroid B-Cell Lymphoma in the Background of Hashimoto's Thyroiditis: A Case Report and Literature Review

Primary thyroid lymphoma (PTL) is a rare type of thyroid cancer, comprising less than 5% of all thyroid cancer cases. PTL includes subtypes like diffuse large B-cell lymphoma (DLBCL) and mucosa-associated lymphoid tissue lymphoma (MALT). The connection between PTL and autoimmune diseases of the thyroid, particularly Hashimoto's thyroiditis, has gained recognition in recent years. Studies have indicated an increased incidence of PTL among individuals with Hashimoto's thyroiditis. However, effectively recognizing and managing PTL in the context of autoimmune thyroid diseases remains challenging. Further research and clinical experience are needed to develop comprehensive strategies for early detection and optimal management of this complex condition. In a case involving an 88-year-old female diagnosed with diffuse large B-cell lymphoma, she presented with a complaint of persistent neck swelling for five years. The patient also experienced symptoms such as dysphagia, hoarseness of voice, obstructive sleep apnea, and choking attacks. Surgical resection of the neck swelling was successfully performed, and the patient was referred to the oncology department for further treatment. Thyroid B-cell lymphoma is an exceedingly rare form of thyroid cancer, typically identified in individuals who have a history of Hashimoto's thyroiditis. The prognosis for thyroid B-cell lymphoma is generally unfavorable, and surgical intervention remains the primary treatment approach for such cases.

Primary thyroid lymphoma: a case series

INTRODUCTION

Primary Thyroid Lymphoma (PTL) is defined as lymphoma involving the thyroid gland alone or the thyroid gland and adjacent neck lymph nodes without contiguous spread or distant metastases at the time of diagnosis. Most thyroid lymphomas are B cell lymphomas, and 98% of all PTL cases are non-Hodgkin's lymphoma. It is a rare disease accounting for around 5% of the thyroid neoplasms and 2% of extranodal lymphomas. If properly diagnosed and treated, the prognosis is favorable.

CASE PRESENTATION

Five cases (three men and two women) of PTL were diagnosed and treated in our institute between January 2005 and September 2019. These are 5 cases of Caucasian origin. The mean age was 76.2 (range: 63-95 years); one patient had associated hypothyroid. One patient had a medical history of breast cancer; one was hypothyroid, and four were euthyroid at the diagnosis. In 4 of these patients, PTL started with compressive symptoms. No patients underwent fine needle aspiration cytology (FNAC) or biopsy for the diagnostic only. In sonography, two cases showed bilateral nodules with goiter; in the three cases it showed nodules in the lobe and isthmus. Technetium-99m scintigraphy was performed on only two patients. Bone Marrow Biopsy (BMB) showed normal cellularity in 4 cases and only one case showed tumor cells. LDH levels were increased in all cases. The extension was evaluated in all patients with cervical and thoracic CT scans, Bone Marrow Biopsy (BMB), beta-2 microglobulin, and serum lactate dehydrogenase (LDH) levels. Three cases were staged as IE and two cases as IIE. Three patients underwent total thyroidectomy; two of them underwent cervical lymph node dissection. Two patients underwent lobectomy. All were diagnosed with lymphoma postoperatively and all were diffuse large B cell lymphoma (DLBCL). One patient completed treatment with R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone), and two cases received adjuvant chemo-radiotherapy (30 Gy). Two patients died immediately after surgery.

CONCLUSION

PTL is a rare disease whose diagnosis should be considered in cases of rapidly growing goitres. Timely needle biopsy in suspected cases can avoid unnecessary surgery. Systemic treatment is required, depending on the stage of the tumour.

Overview of Thyroid and Parathyroid Disease-The Endocrinology Perspective

Thyroid and parathyroid disorders are quite common in the population and range from benign to malignant conditions that may be hormonally active or inactive. Select disorders of the thyroid and parathyroid can be managed medically, although there are a variety of circumstances that may require definitive management with surgery. Surgical intervention may be required for hormonal control, compressive symptoms, or for the removal and/or control of malignancy. The endocrinologist's perspective of the preoperative and postoperative management regarding thyroid and parathyroid surgeries will be discussed.

Surgery is a Viable Treatment Option for Stage IE Primary Thyroid Lymphoma

BACKGROUND

Stage IE primary thyroid lymphoma (PTL) has been diagnosed in approximately half of patients with PTL; however, the optimal treatment for stage IE PTL has not yet been established.

METHODS

Stage IE PTL patients were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 1998 and 2019. Thereafter, the disease-specific survival (DSS) and treatment modalities (surgery alone, surgery + radiotherapy (RT) and/or chemotherapy (CT), and RT and/or CT) of these patients were compared by Kaplan-Meier curves and log-rank test after propensity score matching (PSM). Additionally, patients with PTL from the Affiliated Sixth People's Hospital of the Shanghai Jiao Tong University and School of Medicine (Shanghai, China) between 2007 and 2022 were retrospectively analyzed as an external cohort.

RESULTS

Among the 1596 patients with PTL from the SEER database, 842 were identified as patients with stage IE PTL, with an average follow-up period of 7.8 years. Pairwise analysis after PSM revealed no significant difference between the DSS of the three treatment groups. A total of 38 patients with PTL were identified in the external cohort, with an average follow-up period of 3.4 years. Compared with the RT and/or CT group, the surgery-alone group showed no significant difference in the incidence of hypothyroidism (p = 0.161) but had significantly fewer treatment-related complications (p = 0.021), shorter treatment duration (p < 0.001), and lower treatment costs (p = 0.025).

CONCLUSIONS

The results of our study demonstrate that surgery is a viable treatment option for patients with stage IE PTL.

Primary Intrathyroidal Non-Hodgkin Lymphoma: A Case Report

Primary thyroid lymphoma (PTL) is a rare disease characterized by the appearance of a rapidly growing solid mass in the cervical region. A major risk factor is chronic autoimmune thyroiditis with lymphocytes infiltrating the thyroid gland. The lymphoproliferative disease is seen more frequently in the females. PTL usually develops in the sixth and seventh decades of life. We present a case of a 66-year-old woman with diffuse primary B-cell thyroid lymphoma with no prior evidence of underlying autoimmune thyroid pathology. The initial localization of the lymphoproliferative disease was in the thyroid gland, but the involvement of regional cervical lymph nodes was also found at the time of diagnosis. After histological verification with immunohistochemistry and staging by imaging, chemotherapy was initiated according to the R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride, Oncovin® (vincristine), prednisone) protocol. An excellent therapeutic response was achieved with lymphoma remission after six cycles under the mentioned protocol. Thyroid autoantibodies became positive 18 months after rituximab treatment, possibly reflecting the transient suppressive effects of the immunotherapy. The patient was subsequently kept followed up by a multidisciplinary team in the light of possible lymphoma recurrence and/or development of thyroid dysfunction. This case report demonstrates possible challenges for the diagnosis, treatment, and follow-up of this rare thyroid lesion. At the time of diagnosis, the clinical presentation of the disease, the ultrasound image, and the cytological result may be similar to other low-grade thyroid carcinomas or secondary metastatic involvement of the gland. The initial lack of underlying thyroid autoimmunity makes this distinction even more challenging. Furthermore, despite the rapid resolution, regular long-term monitoring for recurrence is required.

Targeting hnRNPC suppresses thyroid follicular epithelial cell apoptosis and necroptosis through m6A-modified ATF4 in autoimmune thyroid disease

Both environmental and genetic factors contribute to the etiology of autoimmune thyroid disease (AITD) including Graves' disease (GD) and Hashimoto's thyroiditis (HT). However, the exact pathogenesis and interactions that occur between environmental factors and genes remain unclear, and therapeutic targets require further investigation due to limited therapeutic options. To solve such problems, this study utilized single-cell transcriptome, whole transcriptome, full-length transcriptome (Oxford nanopore technology), and metabolome sequencing to examine thyroid lesion tissues from 2 HT patients and 2 GD patients as well as healthy thyroid tissue from 1 control subject. HT patients had increased ATF4-positive thyroid follicular epithelial (ThyFoEp) cells, which significantly increased endoplasmic reticulum stress. The enhanced sustained stress resulted in cell death mainly including apoptosis and necroptosis. The ATF4-based global gene regulatory network and experimental validation revealed that N6-methyladenosine (m6A) reader hnRNPC promoted the transcriptional activity, synthesis, and translation of ATF4 through mediating m6A modification of ATF4. Increased ATF4 expression initiated endoplasmic reticulum stress signaling, which when sustained, caused apoptosis and necroptosis in ThyFoEp cells, and mediated HT development. Targeting hnRNPC and ATF4 notably decreased ThyFoEp cell death, thus ameliorating disease progression. Collectively, this study reveals the mechanisms by which microenvironmental cells in HT and GD patients trigger and amplify the thyroid autoimmune cascade response. Furthermore, we identify new therapeutic targets for the treatment of autoimmune thyroid disease, hoping to provide a potential way for targeted therapy.

[Diffuse large B-cell lymphoma of thyroid invading the superior mediastinum with hashimoto's thyroiditis: a case report and literature review]

This article reports a case of primary thyroid diffuse large B-cell lymphoma involving the superior mediastinum with Hashimoto's thyroiditis admitted to the Department of Otolaryngology and Head and Neck Surgery, First Hospital of Jilin University. This patient underwent right thyroid lobectomy and was transferred to the Department of Hematology of the Oncology Center for 6 courses of chemotherapy with R-CHOP protocol. The postoperative recovery was good, and the patient was regularly followed up for 12 months after the operation. The patient's condition was stable, and CT showed no abnormally high metabolism in the operation area indicating the inhibition of tumor activity, superficial lymph nodes and peripheral blood cells were normal. The case encountered many difficulties in the diagnosis process, and the diagnosis was not confirmed after puncture in two Grade III Class A hospitals in China. There are few patients with primary thyroid diffuse large B-cell lymphoma complicated with Hashimoto's thyroiditis, and it is particularly rare to invade the mediastinum. There is no report in China and abroad in the literature we reviewed. Therefore, this article reports the case and retrospectively analyzes the etiology, clinical symptoms, diagnosis and treatment of primary thyroid lymphoma.

Primary Thyroid Lymphoma: How Molecular Biology and Ancillary Techniques Can Help the Cytopathologist Overcome This Diagnostic Challenge

Primary thyroid lymphoma (PTL) occurs rarely, its diagnosis is a challenge, and the prognosis of these patients depends on the time of diagnosis. Even though fine-needle aspiration cytology (FNAC) is recognized as the most accurate tool for detecting thyroid malignancies, its sensitivity for PTL is poor. Both clinical and ultrasound presentation of PTL can be atypical, and laboratory tests fail to furnish relevant data. Consequently, the reliability of a cytopathologist facing PTL can be poor, even when he is aware of its clinical information. In addition, the cases described in the literature are extremely rare and fragmentary, and consequently, the molecular data currently available for this neoplasm are practically negligible. Here, we present a case report in order to discuss the intrinsic limitations in achieving a final diagnosis of PTL and how using molecular diagnostics to identify potential mutational models can improve the evaluation of this neoplasm.

Mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) in the thyroid mimicking a painless subacute (De Quervain's) thyroiditis on presentation, fine needle aspiration and cytology, and ultrasound findings: A rare case report

INTRODUCTION

We report a rare case of mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) in the thyroid mimicking painless subacute (De Quervain's) thyroiditis.

PRESENTATION OF CASE

Patient with history of hypothyroidism presented with huge non-tender goiter, compression symptoms and choking, no lymphadenopathy. Ultrasound (US) showed large thyroid lobes. There was a small hypoechoic nodule, and nonspecific lymphadenopathy. Fine needle aspiration/cytology (FNAC) of right thyroid nodule showed scant follicular cells, abundant polymorphic lympocytes, epithelioid histiocytes, and tingible body macrophages, suggestive of De Quervain's (granulomatous) thyroiditis. Total thyroidectomy was decided due to compression symptoms and huge goiter.

DISCUSSION

Intraoperative, thyroid was huge with no adhesions to the strap muscles/trachea. Total thyroidectomy with lymph node biopsy was undertaken. There were no complications. Postoperatively, the patient's condition was stable, breathing normally, and neck wound was clean. PTH was 11 pg/mL and calcium was 2.16 mmol/L, suggesting impending transient hypocalcemia. Histopathology showed lymphoepithelial lesions as clusters of lymphocytes within the thyroid follicles epithelium (MALT Balls). Immunohistochemical staining showed that the neoplastic lymphocytes were B cells and stained positive with B-cell markers CD20 and PAX5, but were negative for Cyclin D1 and for T cell markers CD3, CD5 and CD43. The patient was discussed at the lymphoma MDT meeting and the decision was to start the patient on radiotherapy which the patient received.

CONCLUSION

Thyroid MALT lymphoma can mimic painless subacute thyroiditis. The triad of a large swelling of non-tender goiter with compression symptoms during a short period; FNAC findings suggestive of thyroiditis; and US showing enlarged thyroid lobes might cause confusion to the unsuspecting practitioner. Histopathology after excision provides definitive diagnosis.

Thyroid lymphoma

PURPOSE OF REVIEW

To highlight recent advances in our understanding of the epidemiology, incidence, evaluation, management and outcomes of primary thyroid lymphoma (PTL), and highlight the indications and limitations of surgery.

RECENT FINDINGS

The differential diagnosis of a rapidly enlarging thyroid mass with or without obstructive symptoms should include PTL and anaplastic thyroid cancer. When PTL is suspected, initial investigations should include blood tests and ultrasound-guided biopsy preferably core need biopsy to allow tissue typing and immunohistochemistry analysis. Systemic imaging with FDG PET-CT is required for staging. Surgery is not recommended for treatment purposes and should be reserved for diagnosis and airway management. Treatment includes chemotherapy and radiotherapy and offer an excellent prognosis.

SUMMARY

PTL is a rare malignancy making diagnosis and management challenging. Initial investigations of suspected PTL should include blood tests and ultrasound-guided biopsy, preferably core needle biopsy and systemic imaging is required for staging. Surgery is reserved for diagnosis and airway management. Chemotherapy and radiotherapy are the treatment of choice.

Adult-type rhabdomyoma of the thyroid: A case report

Adult-type rhabdomyoma (AR) is a benign myogenous neoplasm. It is rarely located in the thyroid. We present a case of a 61-year-old man, presenting with complaints of a mass found in his left neck for three years. Ultrasonography and computed tomography showed a mass in the left lobe of the thyroid. Subsequently, a fine-needle aspiration biopsy showed that the lesion was suspected to be an oncocytic neoplasm, and the patient underwent surgery. Finally, the lesion was confirmed to be an AR of the thyroid by postoperative pathological diagnosis. In conclusion, AR that occurs in the thyroid is remarkably rare. No case reports to date have described in detail the imaging findings of AR in the thyroid. This study demonstrates the imaging characteristics of a patient with AR of the thyroid, in order to provide more extensive insights to consider the differential diagnosis of thyroid lesions.

Cytological evaluation of thyroid nodules in children and young adults: a multi-institutional experience

PURPOSE

The utility of the Bethesda system for reporting thyroid cytopathology is debatable in determining the risk of malignancy in pediatric patients. Moreover, the upper age limit for defining the pediatric group has varied across different studies. The aim of this study is to compare the risk of malignancy (ROM) and risk of neoplasia (RON) across different Bethesda categories between the pediatric, young adult, and adult patients.

METHODS

This is a retrospective multi-institutional study performed in three Indian hospitals. ROM was calculated and compared across Bethesda categories in adult (>18 years) and pediatric age groups (≤18 years), with a subgroup analysis in young adults (19-21 years).

RESULTS

Thyroid nodules from a total of 5958 patients were subjected to fine needle aspiration. Of these 199 were pediatric (3.3%) and follow-up histology was available in 2276. The ROM and RON rates, including overall ROM/RON, were significantly higher in pediatric age group as compared to adults. Overall ROM of suspicious for malignancy and malignant categories was higher in children as compared to adults. The overall surgical resection rates were also higher in pediatric patients (45.2% vs. 35.7%; p < 0.01). The similar trend of increased ROM, RON and resection rates was seen among young adults as compared to adult age group.

CONCLUSION

Thyroid nodules presenting in children are more likely to be malignant than those in adults. Importantly, the young adult group behaved in a similar manner with regard to surgical resection rates, ROM and RON to pediatric.

Follicular lymphoma of the thyroid and the role of core needle biopsy

Summary

Primary thyroid lymphoma (PTL) is a rare malignancy, accounting for less than 5% of all thyroid neoplasms. The follicular subtype is even more rare, accounting for approximately 10% of all PTL cases. We report a case of a 64-year-old woman, who presented with a rapidly growing goitre with mass effect and B symptoms. She had a history of Hashimoto's thyroiditis and her thyroid ultrasound revealed diffuse goitre with a dominant nodule (56 × 63 × 60 mm) within the right thyroid lobe. Ultrasound-guided percutaneous fine-needle aspiration of the right thyroid nodule was classified as benign, according to Bethesda System, with lymphocytic thyroiditis. A CT scan of the neck showed diffuse enlargement of the thyroid gland extending towards the anterior mediastinum with tracheal deviation and lymphadenopathy within levels VII and right II-IV. The core needle biopsy of the right thyroid nodule revealed a follicular non-Hodgkin's B cell lymphoma with a Ki67 of 60%. According to the Ann Arbor staging system, she was at stage IIIE. She underwent chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) with remarkable clinical improvement and is currently in remission 2 years after the diagnosis. PTL is an extremely rare malignancy that usually arises in a lymphocytic thyroiditis background, presenting as a rapidly enlarging goitre, which can lead to compressive symptoms or airway comprise.

Learning points

Primary thyroid lymphoma (PTL) is a rare malignancy, accounting for less than 5% of thyroid neoplasms. PTL should be suspected when a patient presents with a rapidly enlarging goitre, especially in the setting of Hashimoto's thyroiditis. Fine-needle aspiration has a limited capacity for PTL diagnosis due to similar cytomorphological features of lymphoma with thyroiditis. Therefore, in case of clinical suspicion and if fine needle aspiration fails to diagnose PTL, a tissue biopsy should be performed. Treatment is dependent on both the stage and histology of PTL. Chemotherapy and local radiotherapy remain the mainstay treatment for PTL.

Thyroid Mucosa-associated Lymphoid Tissue Lymphoma Presenting as Intermediate-risk Thyroid Nodule with Positive KRAS Mutation

Background

/Objective: Little is known about the epidemiology, clinical presentation, and diagnosis of thyroid mucosa-associated lymphoid tissue (MALT) lymphoma.

Case Report

We report the case of a 67-year-old woman who presented with an intermediate-risk thyroid nodule 8 years after diagnosis of hypothyroidism due to Hashimoto's. She was found to have a well-circumscribed hypoechoic 2.6-cm right-sided thyroid nodule lobe, which was biopsied and returned atypia of undetermined significance with positive KRAS mutation on the Thyroseq V3 Genomic Classifier. She subsequently underwent right thyroid lobectomy and was found to have thyroid MALT lymphoma on histopathological sections. After the surgery, she was referred to oncology for further management of the thyroid MALT lymphoma. A positron emission tomography/computed tomography scan was performed for complete staging and revealed diffuse fluorodeoxyglucose uptake in the residual left thyroid lobe without evidence of extrathyroidal involvement. Her case was discussed in a multidisciplinary fashion among oncology, endocrine surgery, and endocrinology. Given the positron emission tomography scan findings, she ultimately underwent completion thyroidectomy 4 months after the initial surgery to rule out residual disease. The patient tolerated the operation well without complication.

Discussion

Our report adds to the literature that Hashimoto's thyroiditis may be a risk factor of thyroid MALT lymphoma. Localized thyroid MALT lymphoma may be managed with total thyroidectomy.

Conclusion

We report a patient with localized thyroid MALT lymphoma who presented with an intermediate-risk nodule with positive KRAS mutation and was treated with total thyroidectomy.

Multimodal Sonographic Appearance and Survival Outcomes of 69 Cases of Primary Thyroid Lymphoma Over 10 Years

OBJECTIVES

To investigate ultrasound appearance and the survival outcomes for patients with primary thyroid lymphoma (PTL).

METHODS

Ultrasonic images and clinical characteristics from pathologically confirmed 69 PTL patients (2008-2019) were retrospectively analyzed. The clinical characteristics, ultrasonic characters, and prognostic factors were analyzed. Survival curves were plotted using the Kaplan-Meier method. Univariate and multivariate analyses were performed.

RESULTS

Of the 69 study patients, 23 were indolent PTL and 46 were aggressive PTL. Age (>70 years old) and elevated lactate dehydrogenase levels were statistically different clinical features between aggressive and indolent PTL. From ultrasonic images, 34 cases were nodular, 11 diffuse, and 24 mixed pattern. Mixed types displayed high invasiveness (45.7%) while diffuse types displayed higher inertness (39.1%), with statistically significant differences (P = .000). Invaded thyroid capsule and increased chaotic vascularity also showed significant differences between aggressive and indolent PTL. We also observed statistical difference in overall survival rates between aggressive and indolent PTL (P = .032). Single factor K-M analyses showed that age >70 years, aggressive pathology, and Ki67 >30% were positively correlated with the risk of poor PTL survival (P < .05).

CONCLUSIONS

Multimodal ultrasound provides accurate ultrasonographic information and facilitates PTL invasiveness diagnostics for improved clinical treatment. In addition, PTL patients aged >70 years, with aggressive pathology, and Ki67 >30% were more likely to have a poor survival outcome.

Prognostic Nomogram and Competing Risk Analysis of Death for Primary Thyroid Lymphoma: A Long-term Survival Study of 1638 Patients

Primary thyroid lymphoma (PTL) is such a rare malignancy that there are no large-scale prognostic proofs to create a consensus on optimal management. This study aimed to determine the survival outcomes of PTL and specify associated factors by building a prognostic nomogram and to analyze competing risks of death to balance the hazards and benefits of different therapeutic approaches.

Method

A total of 1638 PTL patients from 2000 to 2018 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Cox proportional hazard regression and competing risk analysis were applied.

Results

We have identified through Cox analysis that age in years, diffuse large B-cell lymphoma (DLBCL) pathology, lymph node dissection, radiation, and chemotherapy were independent prognostic factors for disease-specific survival (DSS). Based on these findings, we built a nomogram for predicting 5- and 10-year DSS and analyzed the overall survival (OS) by calculating cumulative incidence of death. The overall cumulative incidences of the 5- and 10-year PTL-specific cumulative death probabilities were 14.0% (95% CI: 12.3%-15.9%) and 16.3% (95% CI: 14.4%-18.4%), respectively, while the 5- and 10-year cumulative death probabilities from other causes were 12.4% (95% CI: 10.6%-12.3%) and 24.7% (95% CI: 22.1%-27.4%). Results from the competing risk hazards regression analysis revealed that older age and Ann Arbor grading were associated with a greater probability of death from other causes and death from PTL. Radioactive therapy by external beam radiation was associated with death from other causes only. DLBCL histology, lymph node dissection, and chemotherapy were correlated with death from PTL. Cumulative incidence curves demonstrated that the pathological type of lymphoma is the factor determining the likelihood of dying from PTL versus other causes.

Conclusion

Patients' age, Ann Arbor stage, pathological type of lymphoma, and the use of specific therapy regimen should all be taken into consideration when devising individualized treatment strategies for PTL. Decision models based on our findings may help clinicians make better decisions by taking into account the competing risk of death from causes other than PTL.

B-cell to T-cell ratio as a novel indicator in flow cytometry in the diagnosis of thyroid lymphoma

Preoperative flow cytometry is recommended to prove the monoclonality and confirm the diagnosis of thyroid lymphoma. However, lymphoma cases without light chain restriction may also have monoclonality. The aim of our study was to identify a novel marker for thyroid lymphomas using aspirated materials for flow cytometry. We retrospectively analyzed 26 patients with primary thyroid lymphomas and 16 patients with benign lymphoproliferative lesions. The materials for flow cytometry were obtained by fine-needle aspiration cytology using a 22-gauge needle under ultrasound guidance. Light chain restriction was defined as a κ to λ ratio of less than 0.5 or more than 3.0. According to the light chain-positive rate, 25% or less and more than 25% were classified as the low and high light chain-positive rate groups, respectively. B-cell predominance was defined as a CD19 to CD4 ratio (B- to T-cell ratio) of more than 2.0. B-cell predominance was more frequently observed in lymphomas (88.5%) than in benign lymphoproliferative lesions (25.0%; p < 0.001). Light chain restriction based on the κ/λ ratio was detected in 69.2% of lymphomas, but not in benign lymphoproliferative lesions. Among lymphomas belonging to the low light chain-positive rate group, 88.9% did not exhibit light chain restriction and B-cell predominance was present. In contrast, benign lymphoproliferative lesions with B-cell predominance were not detected in the low light chain-positive rate group. B-cell predominance was a useful indicator for diagnosing thyroid lymphoma in the low light chain-positive rate group without light chain restriction.

Comparison of the clinical characteristics of primary thyroid lymphoma and diffuse sclerosing variant of papillary thyroid carcinoma

OBJECTIVE

Both primary thyroid lymphoma (PTL) and diffuse sclerosing variant of papillary thyroid carcinoma (DSVPTC) are two rare malignant tumours with different therapies and prognoses. This study compared their clinical features.

METHODS

From a retrospective review of the pathologic database at our institute between January 2015 and August 2020, 52 PTL patients and 40 DSVPTC patients were included. Demographic, clinical, laboratory and ultrasound data were extracted from electronic medical records. Statistical analyses were performed using GraphPad Prism 5.0.

RESULTS

Both PTL and DSVPTC were more likely to occur in women (83.7 and 67.5%, respectively), but DSVPTC patients were younger (median age: 36 vs 64.5), had fewer compressive symptoms, and more frequently had neck lymph node metastasis than PTL patients. The prevalence of Hashimoto's thyroiditis (HT) and hypothyroidism was significantly higher in PTL patients than in DSVPTC patients (31% vs 17.5%). Hyperthyroidism could only be found in DSVPTC patients, which accounted for 7.5%. Heterogeneous echogenicity and irregular edges were frequently observed in both PTL and DSVPTC. However, compared with PTL, DSVPTC exhibited smaller lesion sizes, higher frequencies of diffuse sonographic patterns and calcification and lower frequencies of hypoechoic features and internal blood flow signal. The overall survival rate with PTL was 77.23%, which was lower than that with DSVPTC (90.91%), but this difference was not significant (P = 0.096).

CONCLUSION

Clinical characteristics such as age, compression symptoms, and sonographic features such as a large mass with heterogeneous echogenicity, hypoechoic, irregular edges, and calcification are helpful for impression diagnosis of PTL and DSVPTC before surgery.

Different CT imaging findings between histological subtypes in patients with primary thyroid lymphoma

PURPOSE

This study evaluates the differences in CT imaging findings between diffuse large B cell lymphoma (DLBCL) and mucosa-associated lymphoid tissue (MALT) lymphoma of the thyroid gland.

METHODS

This study included 18 patients with histopathologically confirmed primary thyroid lymphoma (nine with DLBCL and nine with MALT lymphoma). All patients underwent pretreatment CT imaging. We retrospectively reviewed all images and compared the imaging findings between the two pathologies.

RESULTS

The maximum diameter was significantly greater in DLBCL than in MALT lymphoma (67.7 ± 17.0 mm vs. 41.0 ± 27.2 mm, p < 0.01). Diffuse type (78% vs. 11%, p < 0.01), thickening of the isthmus (78% vs. 22%, p < 0.05), invasion of surrounding tissues (78% vs. 0%, p < 0.01), and regional lymphadenopathy (44% vs. 0%, p < 0.05) were more frequent in DLBCL than in MALT lymphoma. However, preserved peripheral thyroid tissue was more frequent in MALT lymphoma than in DLBCL (78% vs. 22%, p < 0.05).

CONCLUSIONS

The maximum diameter, morphological patterns (diffuse or nodular type), thickening of the isthmus, invasion of surrounding tissues, regional lymphadenopathy, and preserved peripheral thyroid tissue were useful CT imaging features in differentiating DLBCL from MALT lymphoma of the thyroid gland.

Small-Cell Malignancies of Thyroid: Challenge Solved?

"Small-cell malignancies of thyroid" is an unsolved dilemma. This term represents an umbrella terminology in thyroid, encompassing for a small group of tumors in which some of them are well-recognized tumors like medullary thyroid carcinoma, poorly differentiated thyroid carcinoma, and primary thyroid lymphomas and teratoma, whereas the remaining are less known as primary neuroendocrine carcinoma of thyroid, primary extraskeletal Ewing family tumors, and adamantinoma-like Ewing sarcoma. When the issue comes to evaluate a cytological sample predominantly composed of small-cell morphology, metastatic small-cell carcinomas to thyroid also should be excluded. In this review, our group focused on the main cytomorphological and clinical clues of each entity that help to set up a correct differential diagnosis. The literature discussions were also included for the entities that are not yet recognized by the mother publication WHO. A key point of the issue's simple algorithm based on FNAC with small-cell morphology of thyroid was suggested by the authors.

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.

Effectiveness of core needle biopsy in the diagnosis of thyroid lymphoma and anaplastic thyroid carcinoma: A systematic review and meta-analysis

BACKGROUND

Both anaplastic thyroid carcinoma (ATC) and thyroid lymphoma (TL) clinically present as rapidly enlarging neck masses. Unfortunately, in this situation, like in any other thyroid swelling, a routine fine-needle aspiration (FNA) cytology is the first and only diagnostic test performed at the initial contact in the average thyroid practice. FNA, however, has a low sensitivity in diagnosing ATC and TL, and by the time the often "inconclusive" result is known, precious time has evolved, before going for core-needle biopsy (CNB) or incisional biopsy (IB) as the natural next diagnostic steps.

OBJECTIVES

To determine the diagnostic value of CNB in the clinical setting of a rapidly enlarging thyroid mass, via a systematic review and meta-analysis of the available data on CNB reliability in the differential diagnosis of ATC and TL.

METHODS

A PubMed, Embase and Web of Science database search was performed on June 23th 2021. Population of interest comprised patients who underwent CNB for clinical or ultrasonographical suspicion of ATC or TL, patients with a final diagnosis of ATC or TL after CNB, or after IB following CNB.

RESULTS

From a total of 17 studies, 166 patients were included. One hundred and thirty-six were diagnosed as TL and 14 as ATC following CNB. CNB, with a sensitivity and positive predictive value of 94,3% and 100% for TL and 80,1% and 100% for ATC respectively, proved to be superior to FNA (reported sensitivity for TL of 48% and for ATC of 61%). Furthermore, the need for additional diagnostic surgery after CNB was only 6.2% for TL and 17.6% for ATC.

CONCLUSIONS

Immediately performing CNB for a suspected diagnosis of ATC and TL in a rapidly enlarging thyroid mass is more appropriate and straightforward than a stepped diagnostic pathway using FNA first and awaiting the result before doing CNB.

The usefulness of serial ultrasound in thyroid mucosa-associated lymphoid tissue lymphoma

BACKGROUND

Mucosa-associated lymphoid tissue (MALT) lymphoma is an extranodal lymphoma with an indolent natural course. The thyroid gland is an uncommon site of involvement. We aimed to investigate serial ultrasound features and the disease progression during the clinical course of thyroid MALT lymphoma.

METHODS

We searched our hospital's pathology database (5,418 patients with thyroid malignancy) between January 2000 and July 2022. The medical records and serial ultrasounds of 11 patients with 12 thyroid MALT lymphoma foci were analyzed retrospectively.

RESULTS

An enlarging neck mass, dyspnea, B symptoms, and neck lymphadenopathy were seen at diagnosis in 9 (9/11, 81.8%), 3 (3/11, 27.3%), 2 (2/11, 18.2%), and 9 (9/11, 81.8%) cases, respectively. Eleven cases were concomitant Hashimoto thyroiditis. Common ultrasound features included bilateral or unilateral asymmetric goiter or large, solid, and very hypoechoic nodules (11/12, 91.7%) interspersed with linear, reticular hyperechoic, and enhanced posterior echoes (11/12, 91.7%), and neck lymph node involvement (10/11, 90.9%). The Thyroid Imaging and Reporting Data System (TIRADS) categories showed higher diagnostic accuracy (11/12, 91.7%) than real-time ultrasound (2/12, 16.7%) in evaluating thyroid lesions for recommendation of fine-needle aspiration (FNA). Serial ultrasound showed self-limiting changes in three cases, relapse in three cases after subtotal thyroidectomy and chemotherapy, large cell transformation (LCT) in one case after left lobectomy, partial remission in one case, and complete remission after chemo/radiation in four cases; progression to enlarged thyroid nodules occurred in three cases without treatment, with no obvious change observed after diagnosis. Three patients died during follow-up.

CONCLUSION

On sonograms, solid large thyroid nodules or goiter with very hypoechoic and enhanced posterior echoes in the setting of Hashimoto thyroiditis should raise suspicion for MALT lymphoma. TIRADS categories can improve the ultrasound diagnostic efficacy for malignancy. Serial ultrasound examinations demonstrated self-limiting and indolent natures of thyroid MALT lymphoma.

Diffuse Large B-Cell Lymphoma Germinal Center B-Cell Subtype of the Thyroid

Non-Hodgkin lymphoma is one of the most common hematological malignancies having both nodal and extranodal sites of involvement. The thyroid gland is one of the rarest primary sites. Most cases of primary thyroid lymphoma are diffuse large B-cell in nature; thus, aggressive and in extreme cases can rapidly lead to airway compromise, especially in patients who have been living with goiter for years. We present one such case of a 64-year-old female who presented with signs of airway compromise, requiring emergent airway intubation and surgical debulking. She was treated with emergent chemotherapy (DA-EPOCH-R regimen), without radiotherapy and this resulted in complete remission.

Is it Anaplastic Thyroid Cancer, Primary Thyroid Lymphoma, or Rosai Dorfman Disease? An Elusive Histopathologic Diagnosis of a Thyroid Mass

The aim of this study is to present an elusive case of primary thyroid lymphoma (PTL), initially thought to be anaplastic thyroid carcinoma, then Rosai Dorfman disease, before the final diagnosis of PTL was made. An elderly female with hypothyroidism presented with compressive airway symptoms secondary to an enlarging neck mass. Imaging was suggestive of undifferentiated thyroid cancer. The initial biopsy was unexpectedly consistent with a lymphoproliferative disorder such as Rosai-Dorfman disease. A repeat biopsy with immunohistochemical analysis yielded a diagnosis of diffuse large B-cell lymphoma of germinal center subtype. The patient was spared thyroid surgery and started on appropriate chemotherapy. PTL is within the differential diagnosis that physicians must consider in a patient with a rapidly-enlarging neck mass. A clinical index of suspicion and early accurate diagnosis may spare the patient from unnecessary surgery that is required of most other non-hematopoeitic thyroid malignancies.

Performance of Contrast-Enhanced Ultrasound in Thyroid Nodules: Review of Current State and Future Perspectives

Ultrasound has been established as a baseline imaging technique for thyroid nodules. The main advantage of adding CEUS is the ability to assess the sequence and intensity of vascular perfusion and hemodynamics in the thyroid nodule, thus providing real-time characterization of nodule features, considered a valuable new approach in the determination of benign vs. malignant nodules. Original studies, reviews and six meta-analyses were included in this article. A total of 624 studies were retrieved, and 107 were included in the study. As recognized for thyroid nodule malignancy risk stratification by US, for acceptable accuracy in malignancy a combination of several CEUS parameters should be applied: hypo-enhancement, heterogeneous, peripheral irregular enhancement in combination with internal enhancement patterns, and slow wash-in and wash-out curve lower than in normal thyroid tissue. In contrast, homogeneous, intense enhancement with smooth rim enhancement and "fast-in and slow-out" are indicative of the benignity of the thyroid nodule. Even though overlapping features require standardization, with further research, CEUS may achieve reliable performance in detecting or excluding thyroid cancer. It can also play an operative role in guiding ablation procedures of benign and malignant thyroid nodules and metastatic lymph nodes, and providing accurate follow-up imaging to assess treatment efficacy.

PET/Computed Tomography in Thyroid Cancer

Primary thyroid cancers demonstrate distinct biological behaviors depending on their histologic characteristics. The ability to accumulate radioiodine by differentiated thyroid cancer cells is lost in primary aggressive, poorly differentiated and dedifferentiated tumor cells. PET imaging comes into play in these challenging situations where it can provide additive information to radioiodine scintigraphy and conventional imaging. This review focuses on the current guidelines and future prospects of PET imaging in thyroid cancers.

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.

Incidence and prognostic factors of primary thyroid lymphoma and construction of prognostic models for post-chemotherapy and postoperative patients: a population-based study

BACKGROUND

Primary thyroid lymphoma (PTL) is a rare thyroid malignancy, there are few large sample studies on PTL and no standardized treatment regimen has been established due to the rarity. The aims of this study were to explore the incidence and prognostic factors of PTL and construct visual prognostic prediction models for post-chemotherapy and postoperative patients.

METHODS

The incidence of PTL in 1975-2017 was extracted from the US Surveillance, Epidemiology, and End Results (SEER) database, then assessed using joinpoint regression software. A total of 1616 eligible PTL patients diagnosed in 1998-2016 were brought into prognostic analysis. Multivariate Cox regression analyses were carried out to reveal independent prognostic elements for overall survival (OS) and cancer-specific survival (CSS).

RESULTS

PTL incidence showed a relatively steady increase in 1975-1994, which annual percent change (APC) was 4.0%, and steady decreasing in 1994-2017(APC - 2.4%). Age, marital status, lymphoma Ann Arbor stage, histological subtypes, surgery, chemotherapy, and radiation were significantly correlated to OS and CSS. Nomograms were constructed to predict OS and CSS in post-chemotherapy and postoperative PTL patients separately, and were verified to have good reliability.

CONCLUSIONS

The incidence of PTL increased and subsequently decreased. We revealed the prognostic implications and constructed reliable nomograms for post-chemotherapy and postoperative PTL patients.

DLBCL of bilateral submandibular glands and MALToma of thyroid-A rare coexistence

Involvement of the bilateral submandibular glands and thyroid by the same lymphoma simultaneously has been reported in the literature. However, two different types of lymphomas presenting simultaneously at different sites have never been reported. This case report highlights this rare occurrence. A 65-year-old female, a known case of Hashimoto's thyroiditis with raised anti-TPO antibodies, presented with thyroid swelling for 1 year and bilateral submandibular swelling for 3 years. FNAC and flow cytometry showed features of mucosa-associated lymphoid tissue lymphoma in the thyroid gland, whereas the bilateral submandibular glands showed features of diffuse large B cell lymphoma. Histopathology and immunohistochemistry from the submandibular swelling led to similar diagnoses as the flow cytometry.

Clinical prognosis and bioinformatic analysis of primary thyroid lymphoma

Primary thyroid lymphoma (PTL) is a rare malignant disease with the most common histological type of diffuse large B-cell lymphoma (DLBCL). Hashimoto's thyroiditis (HT) is closely related to the pathogenesis of PTL. The present study is to explore the clinical prognosis of PTL and analyze the gene correlations between PTL and HT.Thirty-nine patients diagnosed with PTL between 2010 and 2018 in our institute were retrospectively reviewed and clinical features were evaluated on PTL survival. Then, overlapping differentially expressed genes (DEGs) between PTL and HT were evaluated for gene ontology, pathways enrichment, protein-protein interaction network analysis. Furthermore, we used gene expression profiling interactive analysis to evaluate the differential expression of these hub genes.In this analysis, International Prognostic Index (IPI) score ≥3 and high β2-MG (>3 mg/L) were associated with worse prognosis in PTL. Notably, a total of 15 both upregulated DEGs in DLBCL and HT were identified and 10 hub genes with a high degree of connectivity were picked out. Among these 10 hub genes, IL6, IL10, CXCL10, and CXCR3 were higher expressed in DLBCL than the normal tissue but have no significant prognosis of DLBCL.High IPI score and high β2-MG level have a poor prognosis in PTL. Besides, IL6, IL10, CXCL10, and CXCR3 are associated with both DLBCL and HT and may be used for the early diagnosis of PTL.

Contrast-Enhanced Ultrasound in the Differential Diagnosis of Primary Thyroid Lymphoma and Nodular Hashimoto's Thyroiditis in a Background of Heterogeneous Parenchyma

Objective

To investigate the diagnostic performance of contrast-enhanced ultrasound (CEUS) in the differentiation of primary thyroid lymphoma (PTL) and nodular Hashimoto’s thyroiditis (NHT) in patients with background of heterogeneous diffuse Hashimoto’s thyroiditis (HT).

Methods

Sixty HT patients with 64 thyroid nodules (31 PTL and 33 NHT) who had undergone CEUS examination were included in this study. With histopathological results as the reference, we evaluated the imaging features of each nodule on both conventional ultrasonography (US) and CEUS. Quantitative CEUS parameters including peak intensity (PI), time to peak (TTP), and area under the time–intensity curve (AUC) were gathered in the nodule and background parenchyma. The ratio indexes of theses parameters were calculated by the ratio of the lesion and the corresponding thyroid parenchyma. Logistic regression and receiver operating characteristic (ROC) curves analyses of valuable US indicators were further preformed to evaluate the diagnostic capability of CEUS in discrimination of PTL and NHT.

Results

Among all the observed US imaging features and CEUS parameters, 10 indicators showed significant differences between PTL and NHT (all P < 0.05). All the significant indicators were ranked according to the odds ratios (ORs). Eight of them were CEUS associated including imaging features of enhancement pattern, degree, homogeneity, and quantification parameters of PI, AUC, ratios of PI, AUC, and TTP, while indicators on conventional US, including vascularity and size ranked the last two with ORs less than 3. The five single CEUS parameters showed good diagnostic performance in diagnosis of PTL with areas under ROC curves of 0.72–0.83 and accuracies of 70.3–75.0%. The combination of CEUS imaging features and the ratios of PI, AUC, and TTP demonstrated excellent diagnostic efficiency and achieved area under ROC curve of 0.92, which was significantly higher than any of the five single parameters (all P < 0.05), with a sensitivity of 83.9%, specificity of 87.9%, and accuracy of 85.9%.

Conclusions

CEUS is an efficient diagnostic tool in the differential diagnosis of PTL and NHT for patients with diffuse HT. Conjoint analysis of CEUS imaging features and quantification parameters could improve the diagnostic values.

Prevalence and diagnostic challenges of thyroid lymphoma: a multi-institutional study in non-Western countries

Research on the primary thyroid lymphoma (PTL) diagnosis is limited, with only a few large sample size studies, reported from Asian countries. The aim of the present study was to clarify the current prevalence and challenges in PTL diagnosis, and recommended ancillary studies for PTL in non-Western countries. PTL (n = 153) cases were retrieved from 10 institutions in non-Western countries and analyzed. Ultrasound examination (UE) and fine needle aspiration cytology (FNAC) were used as main preoperative diagnostic tools in all participating institutions. Flow cytometry (FCM) was performed in the 5 institutions (50%). Lobectomy was the most common histological procedure to confirm the PTL diagnosis. All institutions routinely performed immuno-histochemical analysis. PTL was 0.54% of malignant thyroid tumor cases, with mucosa-associated lymphoid tissue lymphoma (MALTL) and diffuse large B-cell lymphoma (DLBCL) being 54.9% and 38.6%, respectively. Kuma Hospital, where the frequency of MALTL was highest (83.7%), routinely performed FCM using the materials obtained by FNAC. UE and FNAC sensitivities were 62.5% and 57.8%, respectively. In both UE and FNAC, sensitivity of MALTL was lower than of DLBCL. The study elucidated that the prevalence of PTL in non-Western countries was lower than previously reported. We propose that FCM should be more actively used to improve the preoperative diagnosis of MALTL. Our data predicted that the MALTL proportion will increase with improved diagnostic tools, while observation of PTL-suspected nodules without histological examination remains a viable option.

Thyroid lymphoproliferative lesions in Asia

Primary thyroid lymphomas (PTLs) are rare and most commonly present as rapidly enlarging thyroid mass causing obstructive symptoms. Due to worldwide differences in clinical practices related to thyroid malignancy, this review was conducted to compare the clinicopathological and diagnostic modalities related to PTL and their similarities and differences between the Asian and Western countries. Using the search engine PubMed, published data on thyroid lymphomas was collected and reviewed. A total of 18 Asian and 22 Western studies were included. Most of PTLs were B-cell Non-Hodgkin lymphomas (NHL). While mucosa-associated lymphoid tissue (MALT) lymphoma was the commonest (41.1%) among Asians, diffuse large B cell lymphoma (DLBCL) (71.9%) predominated in the Western population. Some rare subtypes of PTL were also identified. Majority of all patients in Asian as well as Western studies presented with early stage (stage I/II) disease. Interestingly, when compared with Asian patients, a larger proportion of patients from the West presented with higher stage (stage III/IV) disease (12.2% vs. 3%). Ultrasonography (USG) and fine needle aspiration cytology (FNAC) in addition to histological examination usually by core needle biopsy and in some by open procedures were used for the diagnosis of PTL in both the cohorts. The various ancillary techniques used were immunocytochemistry (ICC), flowcytometry (FC), immunohistochemistry (IHC), and molecular testing. The use of ancillary techniques for PTL diagnosis was more common in the West compared to Asia and markedly increased the sensitivity of cytology to diagnose PTL. Treatment and prognosis largely depend upon the subtype of PTL and stage at presentation. To conclude, from the available published literature, there is an apparent difference between Asian and Western cohorts in the histological type and stage of presentation of PTL, but the results may be affected by publication and selection bias. Also, advanced ancillary techniques are more commonly adopted in the West.

Radical surgery for primary thyroid lymphoma in a Filipino female: Report of a case and review of literature

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Primary Thyroid Lymphomas are rare tumors that must be suspected in progressively enlarging thyroid masses in the background of Hashimoto’s thyroidits.

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Tissue diagnosis combined with appropriate radiologic imaging may lead to an accurate diagnosis.

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Preoperative diagnosis is ideal to avoid unnecessary surgery due to the availability of effective multimodal treatment with chemoradiotherapy.

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Surgery may be appropriate and effective in a select group of patients but must be combined with adjuvant chemoradiotherapy to achieve favorable outcomes.

Introduction

Primary thyroid lymphomas are rare. They constitute only 2% of all thyroid malignancies. It is important to distinguish it from other tumors of the thyroid due to the marked difference in approach to management. Preoperative diagnostic confirmation is ideal to allow for appropriate therapeutic management, which consists of chemotherapy with or without radiotherapy and to avoid unnecessary surgery. In a select group of patients, surgery may be of benefit to relieve obstructive symptoms and establish diagnosis.

Case presentation

Presented herein is a 48 year old female with a progressively enlarging neck mass previously being treated for Hashimoto’s thyroiditis. Obstructive symptoms and a preoperative diagnosis of anaplastic carcinoma prompted surgical intervention. The patient underwent resection of the tumor with a total thyroidectomy and bilateral neck dissection. Post -operative diagnosis of non Hodgkins diffuse large B cell type of lymphoma was made.

Discussion

Primary thyroid lymphomas are rare tumors that may present similarly with some types of thyroid malignancies. An accurate diagnosis is important because non-surgical treatment options like combination chemotherapy and radiotherapy may be effective while sparing the patient from unnecessary radical surgery.

Conclusion

Primary thyroid lymphoma must be a differential diagnosis in patients presenting with large thyroid tumors in the background of Hashimoto’s thyroiditis. Although chemoradiotherapy is the preferred treatment approach, there is a role for surgery in cases of tumor obstruction and uncertain diagnosis.

Diagnosis methods and treatment strategy for primary thyroid lymphoma: a retrospective analysis of 41 cases in China

Primary thyroid lymphoma (PTL) is a rare malignant tumor. It can manifest as a rapidly growing mass and produce various compression symptoms. However, PTL is easily missed or misdiagnosed for the lack of standardized diagnostic methods. Therefore, it is very necessary to analyze the diagnosis methods and treatment strategy of PTL to clarify the guide of diagnosis and treatment. In this study, we retrospectively analyzed PTL patients to determine their clinical, ultrasound and histological features. Forty-one PTL cases were analyzed. The pathological results of all cases were B-cell-derived non-Hodgkin's lymphoma. In these patients, 12 were mucosa-associated lymphoid tissue lymphomas, and 24 were diffuse large B-cell lymphomas. Through the analysis of the clinical, ultrasonographic and histological features of 41 patients with PTL, and the discussion of treatment strategies, we support that middle-aged women with a history of Hashimoto's thyroiditis should pay more attention to the possibility of PTL if they have a swelling neck. Thyroid function tests and neck ultrasound are routine examinations. Core biopsy is an important diagnostic method. PTL treatment is mainly based on radiotherapy and chemotherapy, and surgery is not the first choice.

[Comparisons of clinical characteristics and prognosis between patients with primary and secondary thyroid lymphoma]

Objective: To compare clinical characteristics and prognosis between patients with primary (PTL) and secondary thyroid lymphoma (STL) . Methods: A retrospective analysis was performed on 46 patients with thyroid lymphoma (PTL 19, STL 27) from January 2002 to October 2018. Results: ①PTL group included 4 males and 15 females, with a median age of 57 years. The STL group included 10 males and 17 females, with a median age of 61 years. Diffuse large B-cell lymphoma (DLBCL) was the main pathological subtype in both PTL and STL groups, with 14 cases (73.7%) and 20 cases (74.1%) respectively. In terms of clinical manifestations, goiter was the most common symptom in PTL patients 100.0% (19/19) , while 29.6% (8/27) STL had goiter (P<0.001) . The incidences of increased thyroglobulin antibody (TRAb) /thyroid peroxidase antibody (TPO) were 81.3% (13/16) in PTL group and 43.8% (7/16) in STL group (P=0.028) respectively. Concerning the clinical features of patients, only two PTL patients (10.5%) with advanced Ann Arbor stage (Ⅲ/Ⅳ) , while 21 (77.8%) STL experienced advanced Ann Arbor stage (P<0.001) . Elevated serum β(2)-MG were appeared in 1 (7.1%) PTL and 9 (47.4%) STL patients (P=0.013) , and advanced IPI score (3-5) was more common in STL than PTL (59.3% vs 5.3%, P<0.001) . ②Among the 17 PTL patients who received treatments, 15 (88.2%) achieved remission; as for STL patients received treatments, 23/25 (92.0%) were in remission. The 5-year overall survival (OS) rates of PTL (n=17) and STL groups (n=25) were (87.4±8.4) % and (70.0±13.1) % (P=0.433) respectively. ③The 5-year OS rate in 41 patients with B-cell thyroid lymphoma was (81.1±7.5) %. Univariate analysis showed that IPI score of 3-5 (P=0.040) and high level of serum IL-8 (P=0.022) were significantly associated with poor outcome. Conclusion: DLBCL was the most common subtype in both PTL and STL, and goiter was the major symptom in PTL. IPI score of 3-5 and high level of serum IL-8 were unfavorable prognostic factors for patients with B-cell thyroid lymphoma.

Progressively Enlarging Goiter: Case Reports of Primary Thyroid Lymphoma and Literature Review

Primary thyroid lymphoma (PTL) is an exceptionally rare and highly aggressive potentially curable malignant disease. We report three typical cases of PTL referred to our hospital. All three cases had long history of Hashimoto's thyroiditis, and presented with progressively enlarging neck mass. The first two cases were confirmed by surgical biopsy to be diffuse large B cell lymphoma, and received radiotherapy combined with chemotherapy, or received only chemotherapy. The third case was confirmed by core needle biopsy to be mucosa-associated lymphoid tissue lymphoma, and received radiotherapy. In summary, confirmation of PTL diagnosis is essential for further clinical decisions. Core biopsy should be one of the most important methods to make the diagnosis of PTL, while the use of fine needle aspiration cytology alone is still limited in diagnosing PTL.

Ultrasonography in the Diagnosis and Monitoring of Therapy for Primary Thyroid Lymphoma

This study aims to evaluate the value of ultrasonography in the diagnosis, treatment, and follow-up of primary thyroid lymphoma. The clinical data of 12 patients, who were pathologically confirmed with thyroid lymphoma and treated in our hospital, were retrospectively analyzed. Ultrasonography was performed on the thyroid and neck lymph nodes, and the sonographic features of the lesions were recorded. During the course of the diagnosis and treatment of lymphoma, the patients were monitored and followed up by ultrasonography. The sonographic features of 12 patients with 20 lesions revealed hypoechoic masses, within which "strip-shaped" and "grid-shaped" high echoes were observed, and echoes behind masses were not attenuated. Furthermore, a small amount of blood flow signals were observed. Six patients received thyroidectomy. Among these patients, one patient relapsed. Six patients underwent chemotherapy. Among these patients, 2 patients relapsed and received chemotherapy again. Ultrasound can guide the biopsy of suspicious lymphoma lesions and provide accurate information on treatment effects and tumor recurrence for patients with thyroid lymphoma after treatment, especially after chemotherapy.

Flow cytometric, gene rearrangement, and karyotypic analyses of 110 cases of primary thyroid lymphoma: a single-institutional experience in Japan

Ancillary studies for primary nodal lymphomas have been well documented; however, studies of primary thyroid lymphoma (PTL) are limited. Here, we aimed to clarify the clinicopathological, flow cytometric, gene rearrangement, and karyotypic characteristics of PTL by investigation of a large series at a single institute. We performed flow cytometric, IgH rearrangement, and karyotypic analyses of 110 PTL tissues surgically resected at Kuma Hospital between January 2012 and April 2017. All PTLs were of B-cell origin, including mucosa-associated lymphoid tissue lymphoma (MALTL; 89 patients, 80.9%), diffuse large B-cell lymphoma (DLBCL; 18 patients, 16.4%), and follicular lymphoma (FL; three patients, 2.7%). In 96 (87.3%) patients, anti-thyroid antibodies were positive. For flow cytometry using aspirated and resected materials, light chain restriction was observed in 73.7% and 69.2% of examined cases, respectively. Heavy chain JH DNA rearrangement was observed in 65.4% of PTLs (58.1% of MALTL cases, 100% of DLBCL cases, and 100% of FL cases). Chromosomal abnormalities were detected in 49.0% of PTLs, and translocation was most frequently detected (24.0%), followed by addition (20.8%) and trisomy (18.8%). The most frequent (9.4%) karyotype was t(3;14)(q27;q32). Both FLs harbored t(14;18)(q32;q21), and the karyotype was not detected in patients with MALTL and DLBCL. The negative rate for all three examinations was 3.8%. We concluded that thyroid MALTL was cytogenetically different from that in other organs. Our results suggested that pre-operative flow cytometry analysis using aspirated materials was as reliable as that using resected materials.

Extranodal lymphoma of the head and neck: a pictorial essay

Primary extranodal lymphoma is defined as a lymphoma at a solitary extranodal site, with or without involvement of the lymph nodes. The clinical and radiological features of extranodal lymphoma have been documented in recent studies. In this pictorial essay, we reviewed imaging findings of extranodal lymphoma in the head and neck region.

Down syndrome with primary thyroid diffuse large B-cell lymphoma and Hashimoto thyroiditis: A CARE compliant case report

RATIONALE

Adult patients with Down syndrome (DS) commonly develop Hashimoto thyroiditis (HT). However, primary diffuse large B-cell lymphoma (DLBCL) of the thyroid is uncommon, and its simultaneous occurrence with HT is very rare. To our knowledge, coexisting DLBCL and HT in a patient with DS has not been reported in the medical literature.

PATIENT CONCERNS

We present a 43-year-old woman with DS who reported progressive swelling of the neck on the right side and dyspnea over the previous 1 month, with associated neck ache, hoarseness, and dysphagia. Thyroid ultrasonography and computed tomography of the neck revealed a large mass in the right lobe compressing the surrounding tissues.

DIAGNOSES

Based on the clinical and histopathologic findings, the patient was diagnosed with coexisting primary thyroid DLBCL and HT.

INTERVENTIONS

A palliative unilateral thyroidectomy was performed; postoperative histopathology and immunohistochemistry revealed thyroid DLBCL and HT. The patient was scheduled for chemotherapy and targeted therapy after recovering from surgery.

OUTCOMES

The patient died 3 weeks after surgery due to asphyxia caused by uncontrollable growth of recurrent tumor.

LESSONS

The coexistence of DS, primary thyroid DLBCL, and HT is very rare. There is no standardized approach to the clinical identification of primary thyroid lymphoma (PTL), making early diagnosis difficult. A multidisciplinary approach and close follow-up are needed. The mechanisms of the link between DS and PTL are poorly understood and remain to be elucidated.