EBV-negative Fibrin-Associated Large B-Cell Lymphoma Arising in Thyroid Hyperplastic Nodule: Report of a Case and Literature Review

Fibrin-associated large B-cell lymphoma is a rare microscopic-sized tumor, typically representing an unexpected finding at sites rich in chronic fibrin deposition. It is associated with Epstein-Barr virus, and has been reported to occur in a wide variety of anatomic sites and clinical scenarios. We report a case arising in a thyroid hyperplastic nodule, only the second case reported in this location. Notably, this is only the fourth case of fibrin-associated large B-cell lymphoma that is not associated with Epstein-Barr virus. We provide a literature review on the clinico-pathological characteristics and outcome of this newly characterized indolent lymphoma type, which has only recently been separated out from the pathologically similar but highly aggressive large B-cell lymphoma associated with chronic inflammation.

Primary thyroid lymphoma: A single-center experience

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Core Needle Biopsy Can Early and Precisely Identify Large Thyroid Masses

Background

Large thyroid masses, particularly if rapidly growing, are often characterized by compression and infiltration of the vital structures of the neck. Therefore, an early and precise diagnosis, not only of malignancy but also of histotype, is mandatory to set up the right therapy. The aim of this study was to evaluate the diagnostic performance of fine needle aspiration cytology (FNAC) and core needle biopsy (CNB) in this setting.

Patients and Methods

We prospectively evaluated 95 patients with large and rapidly growing thyroid masses admitted to the University Hospital of Pisa between April 2014 and January 2020. All patients were submitted to FNAC and CNB in the same session. The ability of both procedures to diagnose the malignancy of the lesions, particularly the histotype, and to obtain sufficient material to perform molecular analysis was evaluated.

Results

FNAC obtained adequate tumor sample to reach a diagnosis in 76 of 95 (80%) patients, while a higher percentage was obtained with CNB (92/95, 96.8%). FNAC was able to identify the malignancy of the lesion in 74 of 95 (77.9%) cases, but only in 16 of 74 (21.6%) cases was it able to define the histotype. CNB was able to define the malignancy of the lesion in all but three cases (92/95, 96.8%), and in all specimens, the histotype was identified. Moreover, in all cases, the material extracted from CNB was optimal to perform molecular analysis. No surgery-related complications were experienced with both procedures.

Conclusions

CNB is a rapid and safe procedure with higher performance compared to FNAC in identifying the histotype of large and rapidly growing thyroid masses. Moreover, adequate material can be obtained to characterize the molecular profile for the treatment of potentially lethal cancers. In the era of precision medicine, CNB should be introduced in routine clinical practice as a key procedure for an early diagnosis and therapy of these diseases.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

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.

Mantle cell lymphoma involving the thyroid gland

Mantle cell lymphoma (MCL) rarely involves thyroid gland. Positron emission tomography-computed tomography (PET-CT) may be critical in identifying thyroid involvement by MCL and pursuing further work up of the suspicious thyroid lesions, irrespective of the thyroid function tests.

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.

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.

Primary Extra-Nodal DLBCL of Glands: Our Experiences outside Guidelines of Treatment

Lymphomas usually involve lymph nodes and other lymphoid tissues, but sometimes occur in non-lymphoid organs, called extra-nodal sites. Primary diffuse extra-lymph node large B-cell lymphoma (DLBCL) of the thyroid and parotid gland have been observed rarely. According to the most accredited guidelines, primary extra-nodal DLBCL of the parotid and thyroid glands should be treated with three cycles of R-CHOP followed by radiotherapy of the involved site (ISRT). Surgery alone is not enough to treat DLBCL. We describe two unusual cases of primary extra-nodal DLBCL in elderly patients treated exclusively with surgical resection, given the inability to apply chemotherapy. Both patients achieved clinical recovery, which was maintained after a follow-up of more than 18 months, despite not having performed the indicated chemotherapy protocol. The two cases presented here, and a few others reported in the literature, should be considered exceptions to the rule, and do not allow the conclusion that surgery alone might be sufficient for complete remission.

Tracheal stenosis and recurrent nerve paralysis due to thyroid malignant lymphoma with huge chronic thyroiditis

We experienced a case of huge chronic thyroiditis with malignant lymphoma that caused dyspnea with tracheal stenosis, dysphagia with esophagus stenosis and recurrent nerve paralysis. In this case, thyroidectomy was performed and, after the surgery, there was no sign of breathing or swallowing difficulties, and it was confirmed by the postoperative computed tomography that the tracheal stenosis had improved. We considered two possible explanations for the preoperative right recurrent nerve paralysis. In the first, the right recurrent nerve could have suffered from mechanical stimulation such as compression and traction to the recurrent nerve due to enlargement of the malignant lymphoma together with chronic thyroiditis. The second possible explanation was that malignant cells had invaded neurons. We could not distinguish between the two possibilities, since this right recurrent nerve was spared and could not be examined histopathologically.

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.

Esophageal perforation in case of thyroid lymphoma

Esophageal perforation is a rare and serious complication of thyroid lymphoma and should be taken under consideration in cases with rapid deterioration in their course. Clinical suspicion and prompt diagnosis are key factors for reducing mortality risks in these cases.

Primary Thyroid Lymphoma: An Analysis of the National Cancer Database

Introduction Primary thyroid lymphoma (PTL) is a rare malignancy, representing only 1% to 5% of thyroid malignancies and 2.5% to 7% of all extranodal lymphomas. Most cases of PTL are of B-cell origin, and 98% of all PTL cases are non-Hodgkin's lymphoma. Case series and case reports represent the majority of the available studies on PTL, with a paucity of large retrospective population studies available for this disease. This is the first National Cancer Database (NCDB) study completed on PTL and the only large retrospective study to examine the use of chemotherapy and immunotherapy in the treatment of this specific population. Methods The NCDB for non-Hodgkin's lymphoma was utilized to identify 3,466 patients diagnosed with PTL between 2004 and 2015. The database was used to examine demographic information including age, race, gender, histology, stage, and treatment modality. Bivariate Kaplan-Meier analysis with log-rank tests was used to analyze overall survival. Multivariate analysis was performed with Cox proportional hazards regression models to obtain hazard ratios to assess the association of patient characteristics and treatment methods with survival. Results The median all-cause survival for PTL was 11.6 years (95% confidence interval [CI]: 11.1 to 12.1 years). The majority of PTL patients were female (68%) and white (93%), with a mean age of 65.8 years. Histologically, 59.5% of cases were diffuse large B-cell lymphoma (DLBCL), 18.3% marginal zone lymphoma, 8% follicular lymphoma, and 1.9% Burkitt lymphoma. Regarding treatment, 40.6% received beam radiation, and 54% underwent surgical resection. Single-agent chemotherapy was used in only 3.5% of patients, where 60.7% received multiagent chemotherapy. Additionally, immunotherapy was used in 16.2% of patients. There was a significantly increased risk of mortality associated with increasing age, DLBCL histology, and higher disease stage. Multivariate analysis of treatment methods revealed that lobectomy (hazard ratio [HR]: 0.58, 95% CI: 0.47-0.73) and total or subtotal thyroidectomy (HR: 0.58, 95% CI: 0.47-0.71) had significantly improved survival rates over no surgical management (p < 0.001). Beam radiation (HR 0.67, 95% CI: 0.58-0.79) had a significant survival benefit over treatment regimens that did not include radiation therapy (p < 0.001). Multiagent (HR: 0.40, 95% CI: 0.33-0.49) and single-agent chemotherapy (HR: 0.43, 95% CI: 0.30-0.63) had significant improvement over treatment regimens that did not include chemotherapy (p < 0.001). Immunotherapy had a survival benefit (HR 0.87) although this was not found to be statistically significant (95% CI: 0.68-1.11). Other factors associated with decreased risk of mortality include treatment at academic medical centers (HR: 0.846) and integrated cancer centers (HR: 0.76) as compared to community centers (p < 0.05). Conclusion This is the largest study to date of PTL and the first to analyze the NCDB database. Patient characteristics, treatment modalities, and overall survival in PTL were examined to further characterize this rare disease. Beam radiation, chemotherapy, and surgical resection all reveal significant survival benefit, with multiagent chemotherapy having the greatest advantage.

Primary thyroid lymphoma has different sonographic and color Doppler features compared to nodular goiter

OBJECTIVES

The purpose of this study was to determine the specific sonographic features of primary thyroid lymphoma and its color Doppler pattern compared to nodular goiter.

METHODS

The sonographic findings for 13 surgically proven primary thyroid lymphomas were analyzed and compared to those for 27 nodular goiters.

RESULTS

In accordance with the suggested pathologic patterns, the sonographic patterns of primary thyroid lymphoma could be classified into diffuse and nodular or segmental types based on the distribution of hypoechoic and echogenic structures within the lesions. Some common sonographic characteristics suggesting thyroid malignancy could not facilitate differentiation of primary thyroid lymphoma from nodular goiter. However, a central blood flow pattern would favor the diagnosis of primary thyroid lymphoma, whereas a peripheral pattern would suggest the diagnosis of nodular goiter.

CONCLUSIONS

Primary thyroid lymphoma has characteristic sonographic and Doppler flow features. Along with several other parameters, a central blood flow pattern would highly suggest the diagnosis of primary thyroid lymphoma rather than nodular goiter.

Update on extranodal lymphomas. Conclusions of the Workshop held by the EAHP and the SH in Thessaloniki, Greece

Classification and proper treatment of extranodal lymphoma is hindered by the diversity of lymphoma types and the relative rarity of many of these tumour types. In order to review controversial issues in extranodal lymphoma diagnosis, a joint Workshop of the European Haematopathology Association (EAHP) and the Society for Hematopathology (SH) was held, where 99 selected cases were reviewed and discussed. This Workshop summary is focused on the most controversial aspect of cutaneous B-cell lymphoma, other extranodal B-cell lymphomas, plasmablastic lymphoma and anaplastic large-cell lymphoma in extranodal sites, and makes practical recommendations about diagnosis and therapeutic approaches.

Clonal B cell populations in a minority of patients with Hashimoto's thyroiditis

BACKGROUND

Hashimoto's thyroiditis (HT) is a risk factor for thyroid lymphoma, and clonal B cell populations in HT support this link. The literature on B cell clonality in HT is controversial.

AIMS

To identify clonal B cell populations in HT and to assess their usefulness in differentiating HT from mucosa associated lymphoid tissue (MALT) lymphoma and predicting future development of lymphoma.

METHODS

DNA from formalin fixed, paraffin wax embedded blocks of thyroid specimens from 10 patients with HT and two thyroid MALT lymphomas was analysed for B cell clonality by seminested polymerase chain reaction (PCR) using FRIII/LJH and FRIII/VLJH primers to amplify the IgH gene VDJ region. In one case, PCR products were sequenced. Immunohistochemistry was performed by labelled streptavidin-biotin technique using antibodies to: CD45, CD45RO, CD3, CD20, and cytokeratin.

RESULTS

The histopathological and clinical findings were characteristic of HT. Clonal bands were seen in three and a polyclonal smear pattern was seen in seven cases. The clonal bands in HT were associated with a background smear, and could not be reproduced from other blocks from the same case or from deeper sections of the same block. The clonal bands in thyroid lymphomas were not associated with a background smear and were reproducible. None of the patients with clonal B cells has developed malignant lymphoma during a follow up of 10-13 years.

CONCLUSIONS

B cell clonal bands in HT have different features from those in lymphoma (non-pure and non-reproducible) and do not predict future development of lymphoma.

DNA sequence of immunoglobulin heavy chain variable region gene in thyroid lymphoma

Patho-epidemiological studies have shown that thyroid lymphoma (TL) develops in thyroid affected by chronic lymphocytic thyroiditis (CLTH). CLTH is categorized as an organ-specific autoimmune disease, in which activated B-lymphocytes secrete a number of autoantibodies. Because antigenic stimulation might be involved in the pathogenesis of TL, the variable region in heavy chain (V(H)) genes was characterized in 13 cases with TL and 3 with CLTH. Clonal rearrangement of the V(H) gene was found in 11 cases of TL, and cloning study with sequencing of complimentary determining region (CDR) 3 revealed the presence of a major clone in 4. Three of the 4 cases used V(H) 3 gene, with the homologous germline gene of V3-30 in two cases and VH26 in one case. A biased usage of V(H) 3 and V(H) 4 genes with the homologous germline gene of VH26 in V(H) 3 gene was reported previously in cases with CLTH. A high level of somatic mutation (1-21%, average 12%) with non-random distribution of replacement and silent mutations was accumulated in all cases. The frequency of the occurrence of minor clones ranged from 29-44% per case, indicating the presence of on-going mutation. DNA sequencing of immunoglobulin V(H) gene suggests that TL develops among activated lymphoid cells in CLTH at the germinal center stage under antigen selection.

Lethal tracheal dissolution during treatment for thyroid lymphoma

Background - A case of primary thyroid T cell lymphoma leading to lethal tracheal perforation during chemotherapy is described.