|Year : 2013 | Volume
| Issue : 3 | Page : 188-190
A rare coexistence of thyroid lymphoma with papillary thyroid carcinoma
Murat Cakir1, Esin Celik2, Fatma Betul Tuncer1, Ahmet Tekin1
1 Department of General Surgery, Konya University, Meram Medical Faculty, Konya, Turkey
2 Department of Pathology, Konya University, Meram Medical Faculty, Konya, Turkey
|Date of Web Publication||5-Sep-2013|
Department of General Surgery, Konya University, Meram Medical Faculty, Postal Code: 42080, Konya
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Diseases of the thyroid gland are frequently seen in general practice. Lymphoma of the thyroid is one of the rarest tumors. Its coexistence with papillary thyroid carcinoma is even rarer. Here, we present a 50-year-old female patient, who presented to our clinic with complaints of a rapidly growing lump on her neck, aphagia, and shortness of breath. A total thyroidectomy was performed. Histopathological analysis revealed the concomitant existence of papillary tumor. It should be noted that tumors with different histopathological behavior may rarely coexist with lymphoma in the thyroid gland. Masses growing rapidly in the thyroid shall suggest lymphoma.
| Abstract in French|| |
Maladies de la glande thyroïde sont fréquemment observés en médecine générale. Lymphome de la thyroïde est l'une des tumeurs plus rares. Sa coexistence avec papillaire de la thyroïde est encore plus rare. Nous présentons ici une patiente de 50 ans, qui a présenté à notre clinique des plaintes d'une boule en pleine croissance sur son cou, aphagia et l'essoufflement. Une thyroïdectomie totale a été réalisée. Analyse histopathologique a révélé la existence concomitante des tumeurs papillaires. Il est à noter que les tumeurs avec un comportement différent histopathologique peuvent rarement coexistent avec un lymphome dans la glande thyroïde. Masses en plein essor dans la thyroïde suggère lymphome.
Mots clés: Lymphome, cancer papillaire, thyroïde
Keywords: Lymphoma, papillary cancer, thyroid
|How to cite this article:|
Cakir M, Celik E, Tuncer FB, Tekin A. A rare coexistence of thyroid lymphoma with papillary thyroid carcinoma. Ann Afr Med 2013;12:188-90
| Introduction|| |
Diseases of the thyroid gland are frequently seen today. Among the thyroid cancers, the most frequent type is the papillary thyroid cancer, accounting for approximately 80%-90% of all cases. This tumor, which tends to occur more frequently in the younger population, grows slowly and is associated with a very favorable prognosis. Papillary thyroid cancer originated from the follicular cells of the thyroid and 8%-13.8% of them are surrounded by a capsule. ,
Lymphoma is one of the rare tumors of the thyroid. Lymphoma of the thyroid accounts for 1%-2% of all thyroid cancers.  Lymphoma of the thyroid usually arises in a background of Hashimoto's thyroiditis. The type of treatment depends on the histological subtype and the stage of the disease. We believe that this case is worth to discuss since lymphoma of the thyroid is among the rarest tumors of the thyroid gland and its coexistence with papillary carcinoma is even rarer.
| Case Report|| |
A 50-year-old female patient presented to our clinic with dyspnea, difficulty swallowing, and a rapidly growing mass in the neck. Physical examination revealed a 6 × 4 cm, partially mobile, painless nodule in the right lobe of the thyroid. Serum T4 and TSH were within normal limits. The ultrasound of the thyroid showed a 6 × 3 cm nodule in the right lobe. A fine needle aspiration of the nodule was performed and it was consistent with thyroid lymphoma. An MRI was performed to evaluate if there was any neck involvement [Figure 1]. The whole body scan did not show involvement of any other organ. So, the patient was diagnosed as primary lymphoma of the thyroid. Because the lymphoma was limited to thyroid gland and no other focus of malignancy was detected, we proceeded with total thyroidectomy. The pathological examination of the surgical specimen revealed diffuse large B cell lymphoma in the right lobe [Figure 2]c and d, and papillary microcarcinoma in the left lobe of the thyroid gland [Figure 2]a and b. Immunohistochemical stains of the lymphoma were positive with CD20 [Figure 2]d. The patient was started on levothyroxin 150 mcg/day. She has been followed up for the last 2 years without any problems.
|Figure 2: (a) Papillary carcinoma developing in the background of Hashimoto's thyroiditis in the left lobe of the thyroid. (b) The positive staining of papillary carcinoma cells with CK19 in the left lobe of the thyroid. (c) Large lymphocytic cells in the right lobe suggestive of thyroid lymphoma. (d) The positive staining of lymphoma cells with CD20 in the right lobe of the thyroid.|
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| Discussion|| |
The incidence of thyroid cancers shows differences between geographical regions due to some environmental factors. The presence of thyroid cancer as an incidental finding in patients treated surgically for presumably benign thyroid diseases is partly responsible from the increase in the incidence of these cancers. Hashimoto's thyroiditis is the only known risk factor for primary thyroid lymphoma. If a patient with Hashimoto's thyroiditis, receiving thyroxine therapy, shows enlargement of the thyroid, then primary thyroid lymphoma should be suspected. In our case, the left lobe of the thyroid showed both Hashimoto's thyroiditis and papillary carcinoma, but no evidence of lymphoma. Only 1%-2% of all thyroid cancers are lymphomas.  Lymphomas of the thyroid gland are mostly non-Hodgkin type. While a large portion of malignant non-Hodgkin lymphomas (NHL) arises from lymph nodes, the primary sites of origin for 20% of NHL are other organs and tissues. Lymphomas of the thyroid account for 2%-3% of the extranodal lymphomas. Most patients with primary thyroid lymphoma are middle aged or older females. Physical examination usually reveals a hard, fixed, and frequently unilateral thyroid nodule. When analyzed by an experienced cytologist, a fine needle aspiration biopsy is usually sufficient for the diagnosis. However, lymphomas of the thyroid might be confused with small cell, medullary, follicular, or anaplastic cancer of the thyroid during the histopathological examination. In addition to the histopathological analysis of the thyroid tissue, an immunohistochemical staining with monoclonal antibodies should also be performed.  When the lymphoma is diagnosed, it should be differentiated from the systemic lymphoma that progresses with the secondary involvement of the thyroid gland. There are conflicting views about the surgical treatment of lymphomas of the thyroid. Currently, surgical treatment is recommended only for patients with lymphoma limited to the thyroid gland.  Two studies performed by Mayo and Lahey clinics report very high cure rate and disease-free survival rates in patients with lymphoma confined to the thyroid and treated with thyroidectomy and subsequent radiotherapy. , For patients with lymphoma confined to the thyroid, the primary treatment option is radiotherapy. When there is a spread outside of the thyroid gland, surgery is performed only for biopsy. , In case of a recurrence, chemotherapy should be preferred. Our case was a middle-aged female patient. Lymphoma was diagnosed with FNAB. We acknowledged it as the primary lymphoma of the thyroid, since we did not detect any other focus other than the thyroid in the body and we suggested surgery at first. Hard, fixed, and rapidly growing nodule found during the physical examination supported the pathological diagnosis. No chemotherapy and radiotherapy were needed in the postoperative period because there was no systemic spread and no lymph-node retention.
Prognosis in lymphomas of the thyroid depends on the spread of the disease and the grade of the tumor. In early diagnosed cases, 5-year survival rate is about 80% if the cancer is limited to the thyroid while the same rate decreases to 35% if there is a lymphatic spread in the neck, and if there is a case of widespread retention the rate even goes down to 5%.
Papillary cancer, which is the most frequent one among all the carcinomas of the thyroid, and its co-occurrence with lymphoma of the thyroid is a very rare case and only a few case presentations can be found in literature. Cancers with diameters less than 1 cm are called occult papillary cancers. Mortality rate of occult papillary cancers is very low.  Their prognosis is good and 10-year survival rate is 85%. Since the dimension of our case's papillary carcinoma, which was detected following the surgery, was smaller than 1 cm, we classified it as micropapillary thyroid carcinoma. It was decided that surgical treatment would suffice and TSH was suppressed for papillary cancer.
Consequently, lymphoma should also be taken into consideration with masses growing rapidly in the thyroid gland. Tumors of different pathological characteristics can be found in the thyroidectomy material although this is a rare case. Different treatment protocols might be followed.
| Acknowledgement|| |
We thank Dr. Adnan Kaynak for his help in the manuscript.
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[Figure 1], [Figure 2]
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