- Papillary Carcinoma
- Where's the Cancer?
- Importance of The Pyramidal Lobe
- A Two-Fer Sale
- Taking The Easy Way Out...
- The Trouble with Follicular Tumors
- It quacks like a duck, but it isn't.....
- Thyroid Lymphoma
- You Have Some Nerve!!
- A Big One
- Graves' Disease
- Size Does Matter
- Hurthle Cell Carcinoma of the Thyroid
- Hashimoto's Thyroiditis with Right Sided Aorta
- From Russia with love....
- "Subcentimeter Nodule" the Red-Headed Step-Child of Ultrasonography
CASE OF THE MONTH
THE THYROID SURGERY CENTER OF TEXAS, P.A.
1927 Lohmans Crossing Road, Suite 201, Austin, TX 78734
History/Findings: Patient A: This was a 43-year-old gentleman from Warsaw, Poland, who came to the center for a rapidly growing left sided thyroid mass. An ultrasound done at home described only a 5cm thyroid mass. No further testing was done. Physical examination here confirmed that a large firm mass had virtually replaced the left lobe of the gland. Its surface was irregular. Thyroidectomy was recommended. Patient B: This is a 77-year-old lady from North Royalton, Ohio, who was found to have a rapidly enlarging left sided thyroid mass and large left jugular mass. On examination here there was a baseball sized left mid-jugular mass almost confluent with an enlarged left thyroid lobe. The right lobe was firm to palpation, suggestive of chronic thyroiditis.
Lab/Imaging:Patient A: HGB was 16.4 and WBC’s were 7,000 with 70% neutrophils, 21% lymphocytes. No imaging performed. Patient B: CT scan performed in Ohio showed only enlargement of the left thyroid lobe and did not identify the cervical lymphadenopathy which was present. Fine needle aspiration of the left jugular mass was performed, but as is so often the case, this was of no value. The specimen was found to contain only “lymphoid cells”. Hemoglobin was 12.8, WBC’s 5,500 with a normal differential.
Clinical Course: Patient A: The patient underwent a subtotal thyroidectomy as an outpatient at Seton Southwest Hospital. On frozen section, the diagnosis was “poorly differentiated tumor”. Because of this, the remaining right lobe was then removed. Patient B: The patient was taken to the operating room where biopsy would be performed, continuing on with total thyroidectomy and neck dissection if indicated. Once the yellowish rubbery tumor was identified, a biopsy of both the jugular mass and the left lobe of the thyroid mass were performed. This time, frozen section diagnosis was “favor lymphoma”. The procedure was terminated.
Final Pathology: Patient A: The left lobe and isthmus were completely replaced with an infiltrative diffuse large B Cell lymphoma in a background of chronic thyroiditis. There was no tumor in the right lobe. One adjacent lymph node was negative. Patient B: Biopsies showed diffuse large B Cell lymphoma.
Comments: It is unusual to see thyroid lymphoma, and it is down right rare to see two thyroid lymphomas in the same month. Both patients have returned home and begun staging to document the extent of their disease. Both will be treated with chemotherapy, radiation, or a combination of both. Thyroid lymphomas are most often of the diffuse type. Nodal involvement and direct extension into the soft tissues are negative prognostic indicators. These tumors are usually firm, rubbery, and may have an irregular surface. They do not feel like the other more common thyroid tumors, and these special characteristics should raise a red flag to the examiner. Hashimoto’s thyroiditis is often found associated with thyroid lymphoma. As with other thyroid tumors, expensive preoperative CT scans, while nice to look at, are not usually helpful. FNA is of little value.
“…Thyroid surgery…it’s all we do…”