Clinical Thyroid Case

Rodrigo Arrangoiz MS, MD, FACS, FSSO

A 61-year-old woman presented to the hospital with dysphagia to solid foods and dyspnea on exertion that has been worsening over the last 1-2 months. Past medical history includes hypothyroidism from Hashimoto’s thyroiditis on levothyroxine, and T2DM on metformin (well-controlled). Physical exam is notable for significant diffuse thyroid enlargement, not rock hard or tender thyroid, positive Pemberton’s sign, hoarse voice (but she is able to speak in full sentences). Biochemical testing revealed normal CBC, CMP, and a TSH of 5.02 uIU/mL (normal 0.5-5.7). Thyroid ultrasound and neck CT are shown below.

What Is the Most Likely Cause for This Finding?

  1. Anaplastic thyroid carcinoma
  2. Fibrous thyroiditis
  3. Subacute thyroiditis
  4. Diffuse large B-cell lymphoma
  5. Mucosa-associated lymphoid tissue (MALT) lymphoma

Correct Answer: Diffuse large B-cell lymphoma

This patient, with a history of Hashimoto’s thyroiditis, presents with a rapidly enlarging thyroid mass that has caused dysphagia and dyspnea on exertion. In that clinical context, the most likely etiology of her symptoms is thyroid lymphoma, and the most common type of primary thyroid lymphoma is diffuse large B-cell lymphoma (DLBCL). Thyroid lymphoma is a rare malignancy representing less than 5% of all thyroid cancers. Hashimoto’s thyroiditis is a well-established risk factor, as patients with Hashimoto’s thyroiditis have a 60 times higher risk of developing primary thyroid lymphoma, compared to the general population. On ultrasound, thyroid lymphoma will appear with diffuse enlargement of the thyroid in a uniform and very hypoechoic pattern, like the one presented here. Usually cross-sectional imaging will be needed, and in this case, there was the apparent narrowing of the upper trachea.

DLBCL usually appears malignant on cytology, while MALT lymphoma can be more subtle, which might result in an Atypia of Undetermined Significance (AUS) by the Bethesda classification. If lymphoma is clinically suspected, it is very important to obtain material for flow cytometry with the biopsy. Treatment of thyroid lymphomas depends on the subtype and staging of the tumor. Usually R-CHOP (rituximab- cyclophosphamide, doxorubicin, vincristine, prednisolone) is used, and no thyroidectomy is recommended.

This patient did not appear to demonstrate hyperthyroidism, nor had a tender thyroid gland, so subacute thyroiditis is unlikely. Fibrous thyroiditis (or Riedel’s thyroiditis) will present with a very hard, fixed goiter. Anaplastic thyroid carcinoma would usually present with asymmetric enlargement of the thyroid, as there is usually a dominant nodule that does not involve the thyroid gland in its entirety

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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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