Malignant lymphoma of the thyroid. A 30-year clinicopathologic experience and an evaluation of the presence of Epstein-Barr virus

Worldwide Prevalence of Epstein-Barr Virus in Patients with Burkitt Lymphoma: A Systematic Review and Meta-Analysis

Burkitt lymphoma (BL) is a form of B-cell malignancy that progresses aggressively and is most often seen in children. While Epstein-Barr virus (EBV) is a double-stranded DNA virus that has been linked to a variety of cancers, it can transform B lymphocytes into immortalized cells, as shown in BL. Therefore, the estimated prevalence of EBV in a population may assist in the prediction of whether this population has a high risk of increased BL cases. This systematic review and meta-analysis aimed to estimate the prevalence of Epstein-Barr virus in patients with Burkitt lymphoma. Using the appropriate keywords, four electronic databases were searched. The quality of the included studies was assessed using the Joanna Briggs Institute's critical appraisal tool. The results were reported as percentages with a 95% confidence interval using a random-effects model (CI). PROSPERO was used to register the protocol (CRD42022372293), and 135 studies were included. The prevalence of Epstein-Barr virus in patients with Burkitt lymphoma was 57.5% (95% CI: 51.5 to 63.4, n = 4837). The sensitivity analyses demonstrated consistent results, and 65.2% of studies were of high quality. Egger's test revealed that there was a significant publication bias. EBV was found in a significantly high proportion of BL patients (more than 50% of BL patients). This study recommends EBV testing as an alternative for predictions and the assessment of the clinical disease status of BL.

Histopathological Assessment for Papillary Thyroid Carcinoma

Histologic assessments of papillary thyroid carcinoma are crucial for management of patients with the cancer as well as research on the cancer as papillary thyroid carcinoma has different histologic subtypes and many parameters which are essential in predicting the biological aggressiveness of the cancer. The histologic assessments should be guided by universally adopted protocols including World Health Organization (WHO) classification of endocrine tumors, International Collaboration on Cancer Reporting (ICCR) dataset, American Thyroid Association initial risk stratification for differentiated thyroid carcinomas and TNM stage groupings. The essential steps in histologic assessment involve the identification of characteristic features of papillary thyroid carcinoma, correct histologic subtyping, noting the number of carcinomas, measuring the size of the carcinoma, documenting the different aggressive histological parameters (mitotic activity, presence of tumor encapsulation/circumscription, lymphatic vessel invasion, blood vessel invasion, necrosis, extrathyroidal extension), resection margin status, associated pathology, presence of parathyroid gland, lymph node and distant metastases as well as synthesis of pathological stage based on the various clinical, macroscopic, and histological features.

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.

Anaplastic thyroid carcinoma: Updates on WHO classification, clinicopathological features and staging

Anaplastic thyroid carcinoma is an uncommon carcinoma representing 1 to 4% of all thyroid cancers. The carcinoma is most common in females of the eight decades. It is a locally advanced cancer with frequent infiltration of surrounding organs, blood vessels and skin of neck. Paraneoplastic manifestations could occur. Approximately half of the patients with anaplastic thyroid carcinoma had distant metastasis with lung and brain as the most frequent sites of metastasis. The median survival of patients with anaplastic thyroid carcinoma reported was from 1 to 6 months. The terminology of the cancer in World Health Organization is "anaplastic thyroid carcinoma" rather than "undifferentiated thyroid carcinoma". In the latest American Joint Committee on Cancer (AJCC) TNM staging system for anaplastic thyroid carcinoma, there are updates on T and N categories. To conclude, updated knowledge of clinicopathological features, classification, pathological staging will improve our understanding of the cancer and will help in the management of the patients with this aggressive cancer.

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.

Diagnosis of hairy cell leukaemia by fine needle aspiration cytology of lymph node

BACKGROUND

Hairy cell leukaemia (HCL) is a rare lymphoproliferative disorder of B cell origin, and uncommonly it affects the lymph node. Fine needle aspiration cytology (FNAC) of lymph node of HCL has rarely been described.

CASE DESCRIPTION AND DIAGNOSIS

A 41-year-old man presented with pallor, fever, tachycardia, generalized lymphadenopathy, and massive splenomegaly. The FNAC of the cervical lymph node was done. The smears showed many atypical lymphocytes with a plasmacytoid appearance. There were many large cells with round to reniform shaped nuclei having with hair-like cytoplasmic processes. Flow cytometry (FCM) revealed a clonal B cell population with light chain restriction and positive CD20, CD79b, CD22, CD11c, CD25, CD103, CD123, and CD200 markers.

CONCLUSION

The characteristic cytological features such as atypical lymphoid cells, large cells with hairy projections along with FCM findings, are helpful in the diagnosis of HCL.

The diagnosis of primary thyroid lymphoma by fine-needle aspiration, cell block, and immunohistochemistry technique

AIM

Primary thyroid lymphoma (PTL) is a rare malignant disease. Its prognosis depends on early diagnosis. The role of fine-needle aspiration (FNA), including smear cytology, cell block (CB) techniques, and immunohistochemistry (IHC) sections in the diagnosis of PTL is still unclear. Here we reported 19 cases of PTL and literature review to evaluate the diagnostic accuracy for lymphoma by cytology.

METHODS

Our study retrospectively reviewed 19 patients diagnosed with PTL at the affiliated hospital of Southwest Medical University in China from June 2011 to May 2019. According to the Bethesda system for reporting thyroid cytopathology, the CB sections were evaluated for the presence of single tumor cells. IHC was performed on CB.

RESULTS

The diagnostic accuracy for PTL of FNA, CB with smears, and the joint application of the three methods (FNA + CB + IHC) of our study with 19 cases was 68.4% (13/19), 83.3% (15/18), and 100% (17/17), respectively.

CONCLUSION

The present study demonstrates that FNA has low sensitivity in diagnosing PTL, but the joint application of FNA, CB, and IHC might provide high diagnostic accuracy for lymphoma and should be applied in all cases where the clinical suspicion is high regardless of the FNA findings.

Clinicopathological features of primary thyroid Burkitt's lymphoma: a systematic review and meta-analysis

Background

Primary thyroid Burkitt’s lymphoma (BL) is an extremely rare and highly aggressive form of non-Hodgkin’s lymphoma; only isolated case reports are available for patients with this disease.

Methods

We analyzed the clinicopathological features of thyroid BL by conducting a meta-analysis of 21 known patients (including ours) and compared them to those of extrathyroidal BL.

Results

There were 13 men and 8 women with a median age of 39.3 years (range, 6–75 years). The median follow-up was 46.5 months (range, 0.5–361 months). Six patients (28.6%) had stage I disease, 2 (9.5%) had stage II, 2 (9.5%) had stage III, and 11 (52.4%) had stage IV. Five of 7 tested patients with thyroid BL (71.4%) had histological evidence of underlying Hashimoto’s thyroiditis. Ki-67 labeling indices exceeding 90% in all 19 patients tested (100%). Fluorescence in situ hybridization performed on 12 patient samples revealed that all (100%) had MYC rearrangement. Among the 16 patients for whom follow-up data were available, 4 died of disease-related causes. Kaplan-Meier analysis revealed that the 12- and 60-month overall survival rates for patients with thyroid BL were 87.5 and 70.7%, respectively.

Conclusions

Ours was the largest study of thyroid BL and its detailed clinicopathological features to date. Thyroid BL is not associated with underlying Epstein-Barr virus infection but is closely linked to Hashimoto’s thyroiditis; patients generally have good overall survival and respond well to intensive chemotherapy. The correct pathological diagnosis is essential for treatment selection and outcome improvement.

Clinical features associated with high pathological grade in primary thyroid lymphoma

This study aimed to identify clinical features associated with high pathological grade (HG) in primary thyroid lymphoma (PTL), through a systematic review and meta-analysis. Electronic databases were searched for studies assessing PTL. Extracted data were age, sex, lymph node involvement, symptoms, lymphocytic thyroiditis, serum tumor markers; the association with HG was assessed by using odds ratio (OR), with a significant p-value<0.05. Twenty-four studies with 1916 PTLs were included. HG was significantly associated with age≤55 (OR = 0.54; p < 0.0001); female sex (OR = 1.31; p = 0.02), lymph node involvement (OR = 2.23; p < 0.00001), compressive symptoms (OR = 2.61; p < 0.0001), absence of lymphocytic thyroiditis (OR = 0.45; p = 0.0002), and increased LDH levels (OR = 4.90; p < 0.00001), but not with age>60 (OR = 0.74; p = 0.24), age>70 (OR = 1.16; p = 0.66), and B symptoms (OR = 1.30; p = 0.54). In conclusion, Age≤55, female sex, lymph node involvement, compressive symptoms and absence of lymphocytic thyroiditis may be predictive factors for HG in PTL. On the other hand, B symptoms does not seem to be associated with pathological grade.

Hashimoto Thyroiditis in Primary Thyroid Non-Hodgkin Lymphoma

OBJECTIVES

To assess the prevalence of Hashimoto thyroiditis (HT) in primary thyroid lymphoma (PTL) and whether it differs between mucosa-associated lymphoid tissue (MALT) lymphoma and diffuse large B-cell lymphoma (DLBCL).

METHODS

Electronic databases were searched for studies assessing HT prevalence in PTL, based on antithyroid antibodies, clinical history, or pathology. Pooled prevalence of HT and its association with histotype (MALT or DLBCL) were calculated.

RESULTS

Thirty-eight studies with 1,346 PTLs were included. Pooled prevalence results were 78.9% (any HT evidence), 65.3% (antithyroid antibodies), 41.7% (clinical history), and 64% (pathology). HT prevalence was significantly higher in MALT lymphoma than in DLBCL (P = .007) and in mixed DLBCL/MALT than in pure DLBCL (P = .002).

CONCLUSIONS

Overall, 78.9% of patients with PTL have any HT evidence, but only half of these had been clinically followed. The difference in HT prevalence suggests that a subset of DLBCL may not derive from MALT lymphoma.

Bilateral Cavernous Sinus Thrombosis as First Manifestation of Primary Burkitt Lymphoma of the Thyroid Gland

Cavernous sinus thrombosis (CST) is a rare condition that is usually associated with infections, pregnancy, vasculitis and some types of medication, such as the contraceptive pill and paraneoplastic. Primary Burkitt lymphoma (PBL) of the thyroid gland is very uncommon and the clinical description of such cases has been largely limited to case reports. In this paper, we present a case of CST as the first manifestation of PBL of the thyroid gland. To the best of our knowledge, our patient is the first case report of PBL of the thyroid gland that presents with bilateral CST.

A possible link between the Epstein-Barr virus infection and autoimmune thyroid disorders

The Epstein-Barr virus (EBV), also known as human herpesvirus 4, is a member of the Herpesviridae virus family. EBV infection can cause infectious mononucleosis (IM) in the lytic phase of EBV's life cycle. Past EBV infection is associated with lymphomas, and may also result in certain allergic and autoimmune diseases. Although potential mechanisms of autoimmune diseases have not been clearly elucidated, both genetic and environmental factors, such as infectious agents, are considered to be responsible for their development. In addition, EBV modifies the host immune response. The worldwide prevalence of autoimmune diseases shows how common this pathogen is. Normally, the virus stays in the body and remains dormant throughout life. However, this is not always the case, and a serious EBV-related illness may develop later in life. This explains the chronic course of autoimmune diseases that is often accompanied by exacerbations of symptoms. Based on the present studies, EBV infection can cause autoimmune diseases, such as systemic lupus erythematosus (SLE), multiple sclerosis (MS), rheumatoid arthritis (RA), Sjögren's syndrome, and autoimmune hepatitis. The EBV has also been reported in patients with autoimmune thyroid disorders. Although EBV is not the only agent responsible for the development of autoimmune thyroid diseases, it can be considered a contributory factor.

Herpes and polyoma family viruses in thyroid cancer

Thyroid cancer is considered the most common malignancy that affects the endocrine system. Generally, thyroid cancer derives from follicular epithelial cells, and thyroid cancer is divided into well-differentiated papillary (80% of cases) and follicular (15% of cases) carcinoma. Follicular thyroid cancer is further divided into the conventional and oncocytic (Hürthle cell) type, poorly differentiated carcinoma and anaplastic carcinoma. Both poorly differentiated and anaplastic carcinoma can arise either de novo, or secondarily from papillary and follicular thyroid cancer. The incidence of thyroid cancer has significantly increased for both males and females of all ages, particularly for females between 55–64 years of age, from 1999 through 2008. The increased rates refer to tumors of all stages, though they were mostly noted in localized disease. Recently, viruses have been implicated in the direct regulation of epithelial-mesenchymal transition (EMT) and the development of metastases. More specifically, Epstein-Barr virus (EBV) proteins may potentially lead to the development of metastasis through the regulation of the metastasis suppressor, Nm23, and the control of Twist expression. The significant enhancement of the metastatic potential, through the induction of angiogenesis and changes to the tumor microenvironment, subsequent to viral infection, has been documented, while EMT also contributes to cancer cell permissiveness to viruses. A number of viruses have been identified to be associated with carcinogenesis, and these include lymphotropic herpesviruses, namely EBV and Kaposi's sarcoma-associated herpesvirus [KSHV, also known as human herpesvirus type 8 (HHV8)]; two hepatitis viruses, hepatitis B virus (HBV) and hepatitis C virus (HCV); human papillomaviruses (HPVs); human T cell lymphoma virus (HTLV); and a new polyomavirus, Merkel cell polyomavirus identified in 2008. In this review, we examined the association between thyroid cancer and two oncogenic virus families, the herpes and polyoma family viruses, and we discuss their potential role as causative agents in thyroid carcinogenesis.

Investigation of BK virus, Epstein-Barr virus and human papillomavirus sequences in postoperative thyroid gland specimens

BACKGROUND

Although recent evidence has implicated viruses in the regulation of epithelial-to-mesenchymal transition and tumor progression, little is known regarding viral infections in thyroid malignancies. Thus the aim of this study was to detect sequences of 3 potentially oncogenic viruses - BK virus (BKV), Epstein-Barr virus (EBV) and human papillomavirus (HPV) - in a series of postoperative thyroid gland specimens.

METHODS

Thirty patients with thyroid nodules who underwent surgery for thyroid disease within a 3-year period were enrolled. Both nodular and adjacent normal thyroid tissue was surgically excised from each patient. Viral gene sequences of BKV (VP1), EBV (LMP1, EBNA2 and EBER1) and HPV were amplified by PCR. The PCR results were confirmed by direct sequencing analysis.

RESULTS

VP1 gene sequences were detected in 60% (18/30) of thyroid cancer or multinodular hyperplasia lesions compared with in 43.3% (13/30) of adjacent normal thyroid tissue specimens. Fifteen of thirty (50%) of thyroid cancer or multinodular hyperplasia samples revealed LMP1 sequences compared with 46.7% (14/30) of corresponding normal thyroid tissues. EBNA2 gene sequences were detected in 90% (27/30) of thyroid cancer or multinodular hyperplasia samples, compared with 90% (27/30) of adjacent normal thyroid tissue specimens. All samples were negative for EBER1 sequences, while HPV DNA was not detected in either nodular or normal thyroid tissue.

CONCLUSIONS

This study suggests that BKV and EBV "infection" is an early event, occurring within normal tissue. Our findings do not show a clear role for the viruses examined, instead they suggest an "endemicity" pattern rather than a causal effect.

Lymphoma development in patients with autoimmune and inflammatory disorders--what are the driving forces?

For decades, it has been known that patients with certain autoimmune and inflammatory disorders, such as rheumatoid arthritis (RA) and primary Sjögren's syndrome (pSS), have an increased risk of developing malignant lymphoma. Although the clinico-biological reasons for this association remain largely unknown, our knowledge has improved and new insights have been obtained. First, the direct link between autoimmunity and lymphomagenesis has been strengthened by large epidemiological studies showing a consistent risk increase of lymphoma associated with certain autoimmune/inflammatory conditions in independent cohorts from different countries. Second, a number of local and systemic disease-related risk factors in these diseases have been repeatedly linked to lymphoma development, with the prime examples being disease severity and the degree of inflammatory activity. Considering the key role of B- and T-cell activation in the pathogenesis of both autoimmunity and lymphoma, it is perhaps not surprising that longstanding chronic inflammation and/or antigen stimulation have emerged as major predisposing factors of lymphoma in patients with active autoimmune disease. Finally, increasing evidence suggests that lymphomas associated with autoimmunity constitute a different spectrum of entities compared to lymphomas arising in patients without any known autoimmune or inflammatory conditions, pointing to a different pathobiology. In this review, we summarize the recent literature that supports a direct or indirect link between immune-mediated disease and lymphoma and describe the characteristics of lymphomas developing in the different diseases. We also discuss molecular, genetic and microenvironmental factors that may come into play in the pathobiology of these disorders.

Thyroid lymphoma: recent advances in diagnosis and optimal management strategies

Primary thyroid lymphoma is rare, composing approximately 5% of all thyroid malignancies and less than 3% of all extranodal lymphomas. It typically presents as a rapidly enlarging goiter with associated compressive symptoms. Thyroid ultrasound and fine needle aspiration cytology, using flow cytometry and immunohistochemistry, remain the main modalities used to confirm the presence of lymphoma. The increasing use of an ultrasound-guided core biopsy to achieve an accurate diagnosis has further limited the role of surgery. An open surgical biopsy may still be required not only for definitive diagnosis but also to confirm the subtype of lymphoma. There are limited numbers of randomized or prospective trials to guide management, and controversy remains over optimal treatment. Treatment and prognosis of this disease can be dichotomized into two separate groups: pure mucosa-associated lymphoid tissue (MALT) lymphoma and diffuse large B-cell lymphoma (DLBCL) or mixed subtypes. Early stage (stage IE) intrathyroidal MALT lymphomas typically have an indolent course and may be treated with single-modality surgery, radiotherapy, or a combination of both. DLBCLs are more aggressive, and survival outcomes are highest with multimodal therapy incorporating monoclonal antibodies, chemotherapy, and radiotherapy. The prognosis is generally excellent but can be varied because of the heterogeneous nature of thyroid lymphomas. The aim of this paper is to discuss the changes in diagnostic modalities and to focus on the recent alterations in the management of this rare disease, including targeted therapies as well as the more limited role of the endocrine surgeon.

Primary mucosa-associated lymphoid tissue thyroid lymphoma: a rare thyroid neoplasm of extrathyroid origin

Primary thyroid lymphoma is a rare malignancy, representing 2–8% of all thyroid malignancies and 1–2% of all extranodal lymphomas. The majority of cases concern non-Hodgkin's lymphoma of B cell origin, following by Hodgkin's disease, T cell lymphomas and rarely marginal zone B-cell mucosa-associated lymphoid tissue (MALT) lymphomas. MALT lymphomas have been associated with long-standing autoimmune Hashimoto's thyroiditis. We present the case of a 44-years-old woman with thyroid MALT lymphoma in the background of multinodular goiter of autoimmune origin.

Concomitant thyroid Malt lymphoma and papillary thyroid carcinoma

The objective of this study was to describe the rare thyroid MALT lymphoma concomitant with papillary thyroid carcinoma in a male patient who was submitted to total thyroidectomy. Treatment and follow-up issues are addressed. Male patient complains of fast thyroid enlargement without lymphadenophaty and normal clinical exams. Total thyroidectomy was indicated and performed without any complications. The pathology showed multicentric papillary thyroid carcinoma, concomitant thyroid MALT lymphoma and Hashimoto's thyroiditis. The immunohistochemistry assay was positive for CD 20, CD 43, CD 79, AE1/AE3. The staging studies showed no evidence of both metastasis, Ann Harbor stage IE, without B symptoms. After RIT no further radiotherapy or chemotherapy was indicated. Nowadays the thyroglobulin is undetectable, without recurrences at two years of follow-up. It was concluded that primary thyroid MALT lymphoma is uncommon being the papillary thyroid carcinoma more frequent. Both occurring concomitantly is very rare and the treatment has to prioritize the tumor of worst prognosis at the discovery moment.

Burkitt-like lymphoma infiltrating a hyperfunctioning thyroid adenoma and presenting as a hot nodule

BACKGROUND

Most solitary hyperfunctiong regions on thyroid scan consist of benign tissue. Here we report a patient with a Burkitt-like lymphoma that was infilterated into a region containing a hyperfunctioning nodule.

SUMMARY

A 56-year-old man was referred to our Endocrine Unit in May 2009 due to the incidental discovery of a large left thyroid lobe nodule by a computed tomography study. This had been performed to search for a primitive tumor in a patient with bone metastasis. He was clinically and biochemically thyrotoxic with no evidence of humoral thyroid autoimmunity. The nodule had a dyshomogenous appearance at neck ultrasonography, with multiple hypoechogenic areas and calcifications. (99m)-Technetium thyroid scintiscan revealed a hot nodule with suppression of the contralateral lobe. Fine-needle aspiration cytology indicated the presence of neoplastic cells not of thyroid origin. Remission of hyperthyroidism was obtained with methimazole, and the patient was submitted to left lobe thyroidectomy and istmectomy. Histological analysis of the surgical specimen led to a diagnosis of Burkitt-like large B-cell lymphoma harbored within a thyroid adenoma. After further staging, the final diagnosis was stage IV E Burkitt-like lymphoma with the involvement of the bone and the thyroid. This is the first description of an aggressive Burkitt-like lymphoma that infiltrated an hyperfunctioning thyroid adenoma, thus presenting as a hot nodule at thyroid scintiscan. In our patient there was no humoral or histological evidence of thyroid autoimmunity, thus suggesting a metastatic seeding of the lymphoma within the hyperfunctioning thyroid nodule.

CONCLUSIONS

Involvement of the thyroid gland by Burkitt-like lymphoma is extremely rare as is close localization of malignancy and a hyperfunctioning thyroid nodule. As highlighted by the present report, performing fine-needle aspiration cytology should be always considered in the clinical context of a metastatic disease of unknown origin or when there are ultrasonography signs suggesting malignancy, even when the nodule is hyperfunctioning.

Detection of EBV infection and gene expression in oral cancer from patients in Taiwan by microarray analysis

Epstein-Barr virus is known to cause nasopharyngeal carcinoma. Although oral cavity is located close to the nasal pharynx, the pathogenetic role of Epstein-Barr virus (EBV) in oral cancers is unclear. This molecular epidemiology study uses EBV genomic microarray (EBV-chip) to simultaneously detect the prevalent rate and viral gene expression patterns in 57 oral squamous cell carcinoma biopsies (OSCC) collected from patients in Taiwan. The majority of the specimens (82.5%) were EBV-positive that probably expressed coincidently the genes for EBNAs, LMP2A and 2B, and certain structural proteins. Importantly, the genes fabricated at the spots 61 (BBRF1, BBRF2, and BBRF3) and 68 (BDLF4 and BDRF1) on EBV-chip were actively expressed in a significantly greater number of OSCC exhibiting exophytic morphology or ulceration than those tissues with deep invasive lesions (P = .0265 and .0141, resp.). The results may thus provide the lead information for understanding the role of EBV in oral cancer pathogenesis.

Follicular lymphoma of the thyroid gland

The majority of lymphomas arising in the thyroid gland are mucosa-associated lymphoid tissue lymphomas and diffuse large B-cell lymphomas, which arise from a background of chronic lymphocytic thyroiditis. Follicular lymphoma may also present in the thyroid gland, but its clinicopathologic features at this site are not well characterized, leading to difficulties in diagnosis and clinical management. We have addressed this problem by studying the clinical, morphologic, immunophenotypic, and genetic features of 22 such cases. All cases showed morphology characteristic of follicular lymphoma, however, in many the interfollicular neoplastic infiltrate was particularly prominent and all lymphomas contained readily identifiable and often striking lymphoepithelial lesions, features heretofore considered indicative of mucosa-associated lymphoid tissue lymphoma at this site. Furthermore, 13 of 18 cases for which sufficient evidence was available had clinical and/or histologic evidence of chronic lymphocytic thyroiditis. Analysis of genetic and immunohistochemical features identified 2 distinct groups. In 1 group, similar to typical adult follicular lymphoma, cases carried a t(14;18)/IGH-BCL2 and/or expressed Bcl-2, and were mostly CD10-positive and of World Health Organization (WHO) grade 1 to 2. Follicular lymphomas in the other group lacked IGH-BCL2 and Bcl-2 expression, were often of WHO grade 3 and were often CD10-negative, similar to the minority of follicular lymphomas previously described that are Bcl-2-negative and are often encountered at other extranodal sites. The 2 groups differed in clinical stage at presentation, 11 patients in the former group but none in the latter group having disease beyond the thyroid gland. Appreciation of the spectrum of morphologic, immunophenotypic, and genetic characteristics of follicular lymphoma presenting in the thyroid gland should aid both diagnosis and clinical management.

Viruses and thyroiditis: an update

Viral infections are frequently cited as a major environmental factor involved in subacute thyroiditis and autoimmune thyroid diseases This review examines the data related to the role of viruses in the development of thyroiditis.

Our research has been focused on human data. We have reviewed virological data for each type of thyroiditis at different levels of evidence; epidemiological data, serological data or research on circulating viruses, direct evidence of thyroid tissue infection. Interpretation of epidemiological and serological data must be cautious as they don't prove that this pathogen is responsible for the disease. However, direct evidence of the presence of viruses or their components in the organ are available for retroviruses (HFV) and mumps in subacute thyroiditis, for retroviruses (HTLV-1, HFV, HIV and SV40) in Graves's disease and for HTLV-1, enterovirus, rubella, mumps virus, HSV, EBV and parvovirus in Hashimoto's thyroiditis. However, it remains to determine whether they are responsible for thyroid diseases or whether they are just innocent bystanders. Further studies are needed to clarify the relationship between viruses and thyroid diseases, in order to develop new strategies for prevention and/or treatment.

Outcomes of primary thyroid non-Hodgkin’s Lymphoma

Primary non-Hodgkin's lymphoma (NHL) of the thyroid gland is a rare disease with an incidence of 0.5 per 100,000 population. Stages IE and IIE thyroid NHL have been traditionally treated by surgical resection; however, modern treatment consists of chemotherapy and local radiotherapy, and surgery is often reserved for tissue diagnosis and relief of airway compression. We retrospectively reviewed the management and outcomes of nine consecutive patients with thyroid NHL, eight females and one male (median age 63 yr, range 34-71 yr) treated between 1994 and 1999. Five patients had disease stage IE and 4 stage IIE. Median follow-up was 72 mo. Pathohistology and immunohistochemistry identified two patients with mucosa-associated lymphoid tissue (MALT), three follicular center cell lymphoma (FCC), two patients large B-cell lymphoma (BLCL), one a marginal zone lymphoma (MZL), and one patient a peripheral T-cell lymphoma (PTCL). Total thyroidectomy was performed in three patients and subtotal thyroidectomy in four. One (MALT) patient underwent surgery alone; three patients surgery, radiotherapy, and chemotherapy (two FCC, one PTCL); three patients surgery and chemotherapy (one MALT, one FCC, one LBCL); and two chemotherapy alone (one LBCL, one MZL). Median survival was 79 mo (range 13-124 mo). The PTCL patient, a 34-yr-old man, died from disseminated disease at 13 mo despite secondary chemotherapy, and one LBCL patient with extensively invasive local disease died from stroke 17 mo after diagnosis. The remaining seven patients remain in remission with no local or systemic relapse at a mean of 86 mo. With appropriate therapy primary thyroid NHL has a favorable course; however, prognosis depends on the histology, local spread, and the stage of the disease at presentation, as well as the patient's performance status. Surgery in combination with chemotherapy and/or radiotherapy is still warranted for intermediate and high-grade thyroid NHLs, with over 77% of patients achieving long-term remission. Peripheral T-cell lymphoma carries a poor prognosis.

Detection of Epstein–Barr virus infection and gene expression in human tumors by microarray analysis

Epstein-Barr virus (EBV) genome-chips are employed to determine the EBV infection rate and to reveal the gene expression patterns of EBV in tumor biopsies. These chips are produced with 71 consecutive PCR-amplified EBV DNA fragments of 1-3 kbp covering the entire EBV genome. The specificity of the EBV-chips is determined by hybridizing the DNA on the chips with biotin-labeled cDNA probes reverse transcribed from the mRNA of P3HR1 cells, which were B-cell infected latently by EBV. Hybridization results revealed only the expression of EBNA1, EBNA2, EBER1 and EBER2 in these cells. On the other hand, EBV lytic genes are expressed after the cells are treated with 12-O-tetradecanoylphorbol-13-acetate and sodium butyrate to induce the EBV lytic cycle. Fourty-four tumor biopsies from different organs are assayed with these chips, which showed many defined and interesting EBV gene expression patterns. This study demonstrates that the EBV-chip is useful for screening infection with EBV in tumors, which may lead to insights into tumorigenesis associated with this virus.

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.

Hairy cell leukemia: a diagnosis by endoscopic ultrasound guided fine needle aspiration

Background

Endosonography (EUS) guided FNA is a relatively new imaging modality which is increasingly used for sampling deep-seated lymph nodes in the diagnosis and staging of various malignancies, both primary as well as metastatic. It is also useful for staging of non-Hodgkin's lymphoma as well as diagnosing recurrence. The diagnosis of leukemia on FNA samples from deep-seated lymphadenopathy poses an even greater challenge. Hairy cell leukemia (HCL) is an uncommon, but distinct, lympho-proliferative disorder of B cell origin. It usually affects the spleen and bone marrow and uncommonly involves lymph nodes. There are only a few cases reported where HCL was diagnosed on FNA specimens.

Case presentation

We report the first case of HCL accurately rendered on EUS-FNA samples.

Conclusion

This report underscores the concept that the presence of a cytopathologist in the endoscopy suite plays an important role in providing accurate diagnoses of lymphoid lesions biopsied with EUS-FNA.

[Non-Hodgkin's lymphoma in the thyroid: case report]

The authors describe the case of a 33 year-old white female, without any clinical or laboratorial evidence of thyroiditis or clinical hypothyroidism, who presented with a rapidly enlarging anterior neck mass. Diagnosis of a follicular non-Hodgkin's lymphoma was made through histopathological and immunohistochemical analysis.

An unusual form of Riedel's thyroiditis: a case report and review of the literature

We report the case of a 36-year old woman with a history of long-term fever associated with a biologic inflammatory syndrome that was not corrected by several courses of corticosteroid treatment. The only remarkable result during previous investigations was the presence of a positive Epstein-Barr virus (EBV) serology. Clinical examination revealed an heterogenous thyroid with a nodule on the right lobe. Serum thyrotropin (TSH) concentration was normal. The levels of antiperoxidase antibodies and thyrocalcitonin were normal. Ultrasound examination of the neck showed a 3-cm hypoechogenous nodule in the right lobe of the thyroid. A total thyroidectomy was performed. Histopathologic findings led to the diagnosis of Riedel's thyroiditis. We observed a dramatic improvement after surgery with absence of fever and normalization of inflammatory parameters. The role of EBV infection in the process of this unusual form of Riedel's thyroiditis is discussed.

Outcome Analysis for Stage IE and IIE Thyroid Lymphoma

Previous reports have revealed modest results in the management of thyroid lymphoma with radiotherapy alone. This retrospective report evaluates the outcome of patients treated for thyroid lymphoma with radiotherapy alone and with combined modality therapy (chemotherapy and radiotherapy) at a single institution. Twenty-seven patients with stages IE and IIE non-Hodgkin's lymphoma of the thyroid gland were treated between 1960 and 1998 at Barnes-Jewish Hospital, of which 14 patients were stage IE and 13 patients were stage IIE. The median age at diagnosis was 67 years, and there were 21 females and 6 males evaluated. The median follow-up time was 38 months (range: 3-279 months). All patients had histologically proven non-Hodgkin's lymphoma, of which 22 patients (81%) were intermediate grade. Treatment consisted of radiotherapy alone in 19 patients and a combined modality therapy in 8 patients. The median radiation dose to the thyroid bed was 44 Gy, and most patients received a doxorubicin-containing regimen administered prior to radiotherapy. Patient, tumor, and treatment-related characteristics were evaluated using Cox regression analysis. Local-regional tumor control, disease-free survival (DFS), and overall survival (OS) were calculated using the Kaplan-Meier method. Four patients had local relapse in this series, with a crude local tumor control rate of 85%. No factor was determined to be significant for local tumor control. The actuarial 5-year DFS and OS for the entire cohort were 57%, and 56%, respectively. In terms of DFS, both age and stage were statistically significant. The 5-year actuarial DFS for patients less than age 65 years was 83% versus 37% for those more than this age (p = 0.024). Furthermore, the 5-year actuarial DFS for patients with stage I and II disease was 69% and 45%, respectively (p = 0.022). In multivariate analysis, age continued to be significant for DFS (p = 0.049). Overall survival analysis revealed age, local tumor control, and stage to be significant in univariate analysis. Multivariate analysis was further carried out using Cox proportional hazard model, and it revealed age (p = 0.006) and local tumor control (p = 0.007) to be significant. Primary thyroid gland lymphomas have a favorable outcome with appropriate therapy, but prognosis depends on both clinical stage and age at presentation. Because of the risk of both local-regional and distant failure, combined modality approaches that use chemotherapy with radiotherapy are warranted for intermediate- and high grade thyroid lymphoma.

Diagnostic fine-needle aspiration cytology and immunocytochemistry analysis of a primary thyroid lymphoma presenting as an anatomic emergency

The case of a 66-year-old woman with rapidly progressive respiratory distress caused by a massive anterior neck mass with tracheal compression is presented. Within 24 hours, fine-needle aspiration cytology (FNAC) and immunocytochemistry provided a diagnosis of high-grade B-cell lymphoma and the opportunity to institute a chemotherapeutic regimen resulting in a rapid volume reduction and airway expansion. One year after combined modality treatment the patient was in complete remission (with an estimated thyroid volume of 4 cm3). This case report illustrates the advantages of FNAC and immunocytochemistry in the diagnosis of thyroid lymphoma.

Concomitant presentation of Hashimoto's thyroiditis and maltoma of the thyroid in a twenty-year-old man with a rapidly growing mass in the neck

We report an uncommon case of a 20-year-old man, who noted a painless, growing mass in his neck, which appeared in a weekend, associated with moderate dysphagia and weakness. Laboratory examination revealed an elevated serum thyrotropin of 25 mU/L, normal serum triiodothyronine and thyroxine levels, and high titers of antithyroglobulin and antithyroid peroxidase antibodies. The neck lesion showed a depressed iodine uptake in the left thyroid lobe, which had an asymmetrical pseudocystic pattern associated with poor vascularization in the ultrasound scan. Cytologic examination showed a lymphocyte thyroiditis in association with lymphoma of large cell arising from mucosa-associated lymphoid tissue (MALT-lymphoma or maltoma). The patient underwent a left thyroid lobectomy while being treated with levothyroxine for Hashimoto's thyroiditis, and the surgical treatment was further complemented with chemotherapy using fludarabine. The histologic examination confirmed the cytologic findings and the immunohistochemistry showed a B-cell type maltoma. Additional investigation provided no evidence of disease in other tissues. The clinical course has been favorable in the first 2 years of follow-up, with no evidence of local or systemic recurrence of the disease.

Telomerase activity in pancreatic endocrine tumours: a potential marker for malignancy

AIMS

Telomerase activation is known to be a common event in human cancer and may be a useful marker for malignancy. In general, the histological features of pancreatic endocrine tumours cannot be used to determine their malignant potential. The aim of this study was to investigate the role of testing telomerase activity in pancreatic endocrine tumours.

METHODS

Prospectively collected fresh frozen tissue specimens from 10 patients with pancreatic endocrine tumours (nine insulinomas, one adrenocorticotrophin producing pancreatic endocrine tumour) were examined by a highly sensitive polymerase chain reaction (PCR) based telomerase repeat protocol (TRAP).

RESULTS

Of the 10 pancreatic endocrine tumours, three had telomerase activity. The positive cases included two frankly malignant tumours with liver metastases and one pancreatic endocrine tumour occurring in the setting of multiple endocrine neoplasia type 1. The latter had an infiltrative border. Vascular and perineural tumour infiltration was noted. In the two malignant pancreatic endocrine tumours with liver metastases, telomerase activity was noted in the tumour and the adjacent morphologically non-neoplastic pancreas.

CONCLUSION

To our knowledge, this is the first report of the role of telomerase activity in pancreatic endocrine tumours. Telomerase activity might be useful for distinguishing between benign and malignant pancreatic endocrine tumours.