Treatment and survival of patients with thyroid lymphoma: a population-based study with clinical and pathologic reviews

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 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.

The Relationship Between Primary Thyroid Lymphoma and Various Types of Thyroid Autoimmunity: A Retrospective Cohort Study of 498 Cases, Including 9 Cases with Graves' Disease

Background: Primary thyroid lymphoma (PTL) is known to develop mostly in patients with Hashimoto's thyroiditis (HT), and it is rare for it to develop in patients with Graves' disease (GD). The objective of this study was to investigate the clinical features, pathological findings, and long-term outcomes of PTL patients, grouped according to the presence of GD, HT, or no autoimmune thyroid disease (AITDs). The GD group was of major interest due to limited knowledge of the relationship with PTL. Methods: In this single-center retrospective cohort study, we reviewed the medical records of all patients diagnosed with PTL between August 1979 and October 2021, and we characterized the patients according to the presence of HT, GD, or no AITDs. Pathological specimens were classified according to the World Health Organization classification. Staging was performed in accordance with the Ann Arbor classification. Results: During the 42-year period, 498 participants were diagnosed with PTL. The median age was 68 (interquartile range 61-76) years, and 221 patients were stage IE, whereas the remaining 277 patients were stage IIE. Of the PTL patients, 431 (86.6%) were diagnosed with HT, 9 (1.8%) were diagnosed with GD, and 58 (11.6%) did not have AITDs. All nine patients with GD were positive for anti-thyroglobulin antibody and/or anti-thyroid peroxidase antibody. All patients with GD were treated with anti-thyroid medication. There were no significant differences in the proportions of each subtype of PTL between the PTL patients with GD and all subjects with PTL (p = 0.51), PTL patients with HT (p = 0.51), or PTL patients without AITDs (p = 0.48). The median follow-up time was 6.2 (interquartile range 3.0-10.7) years after the diagnosis of PTL. The Kaplan-Meier curve analyses showed no significant differences in overall survival and event-free survival between PTL patients with GD and those with HT (p = 0.37), or between PTL patients with GD and those without AITDs (p = 0.43). Conclusions: The PTL was observed with HT in a majority of cases, and rarely with GD (1.8%). The proportions of each pathological subtype of PTL and the prognosis of PTL were not different between the patients with GD and those with HT or those without AITDs.

Mucosa-Associated Lymphoid Tissue Lymphoma of the Thyroid Gland: A Systematic Review of the Literature

OBJECTIVE

Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type of the thyroid gland is a rare indolent malignant disease encountered in approximately 0.5% of patients with Hashimoto thyroiditis (HT). The purpose of the present systematic review was to accumulate the current evidence in the field.

STUDY DESIGN

We searched the Medline, Scopus, EMBASE, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials CENTRAL databases from inception to May 2018. Statistical analysis was performed with SPSS version 22.0.

RESULTS

Fourteen case series and 20 case reports were finally included in the present systematic review. Analysis of the patient data included in the published case reports suggested that the age at diagnosis of MALT lymphoma does no differ among males and females (64 [52.5-73] vs. 67 [60.5-72] years, p = 0.442). HT was detected in 60% of patients, whereas coexisting carcinoma was evident in 17% of cases. The incidence of HT and thyroid cancer was comparable among males and females (p = 0.474 and p > 0.999, respectively). Among all patients included in the present systematic review there were two disease relapses and two deaths attributed to the disease.

CONCLUSION

MALT lymphoma of the thyroid gland is a rare malignancy with an indolent course. The scarce data available in the literature preclude safe conclusions concerning the mode of treatment and follow-up of these patients. However, the combination of minimally invasive surgery and adjuvant therapy seems feasible. Moreover, an extended follow-up period is recommended.

T(14;18)(q32;q21) involving MALT1 and IGH genes occurs in extranodal diffuse large B-cell lymphomas of the breast and testis

Primary B-cell lymphoma of the testis, breast and thyroid are rare and data concerning cytogenetic aberrations at these extranodal sites are scarce. We examined the presence of extranodal marginal zone lymphoma-associated translocations, t(11;18)(q21;q21), t(1;14)(p22;q32), t(14;18)(q32;q21), t(3;14)(p14.1;q32) and numerical aberrations of chromosomes 1, 3, 12 and 18 by fluorescence in situ hybridization in 6 extranodal marginal zone lymphomas and 24 diffuse large B-cell lymphomas with (n=9) or without (n=15) marginal zone lymphoma components, with primary localizations in the breast (n=15), testis (n=9) and thyroid (n=6). We found t(14;18)(q32;q21), with breakpoints in IGH and MALT1, in one testicular diffuse large B-cell lymphoma and in two diffuse large B-cell lymphomas of the breast. No other translocations, amplifications or deletions involving IGH, BCL-10, BCL-2, MALT1 and IAP2 were detected. Numerical aberrations occurred in 67% of the lymphomas, 67% of extranodal marginal zone lymphomas, 56% of diffuse large B-cell lymphomas with marginal zone lymphoma components and in 73% of 'de novo' diffuse large B-cell lymphomas. These included 78% of testis, 67% of thyroid and 60% of breast lymphomas, and included mainly trisomy 18 (n=16), trisomy 3 (n=8) and trisomy 1 (n=3). One testicular diffuse large B-cell lymphoma harbored both t(14;18)(q32;q21) and trisomy 3. Our results indicate that at least a few cases of diffuse large B-cell lymphoma of the testis and the breast belong to the spectrum of extranodal marginal zone lymphoma.

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.

An evidence-based approach to the treatment of thyroid lymphoma

BACKGROUND

Primary thyroid lymphoma is a rare tumor that makes up 1-5% of thyroid malignancies and less than 2% of extranodal lymphomas. The treatment and prognosis of thyroid lymphomas can be divided into two distinct clinicopathologic entities: pure mucosa-associated lymphoid tissue (MALT) lymphomas and diffuse large B-cell or mixed subtypes.

METHODS

An evidence-based review was performed to determine the role of fine-needle aspiration (FNA) biopsy and adjuncts as the first diagnostic test for thyroid lymphoma, the role of open surgical biopsy, the role of palliative surgery as well as the best treatment (combined chemoradiation versus single modality surgery or radiation) for thyroid lymphoma. The ideal treatment of thyroid lymphoma was further assessed for both diffuse B-cell and MALT histologic subtypes.

RESULTS

Although an evidence-based review was challenging primarily due to a lack of high-level evidence, several recommendations are possible and presented regarding the optimal diagnostic methods and treatment of thyroid lymphoma. FNA and adjuncts are recommended as the first test to diagnose thyroid lymphoma, but open surgical biopsy may still be required in many cases. Combined chemoradiation therapy is recommended for all diffuse B-cell or mixed lymphomas. Single modality therapy with surgery or radiation alone may be considered for early-stage (IE) intrathyroidal MALT lymphomas. No recommendations could be made regarding the role of palliative surgery.

CONCLUSION

Evidence-based recommendations can be applied to the individual patient with thyroid lymphoma with the involvement of an experienced multidisciplinary team consisting of an endocrine/oncology surgeon, radiation oncologist, and medical oncologist.