A Multicenter Retrospective Study of 58 Patients With Primary Thyroid Diffuse Large B Cell Lymphoma

Uncovering Primary Extranodal Diffuse Large B Cell Lymphoma in the Adrenal and Thyroid Glands

BACKGROUND Primary extranodal diffuse large B-cell lymphoma (DLBCL) is a rare, yet highly aggressive and invasive malignancy that can masquerade as a solid organ tumor. Timely diagnosis is critical for improving prognosis; however, it is challenging to achieve. CASE REPORT We report 2 cases treated at Yale New Haven Hospital (New Haven, CT, USA) and the West Haven Veteran's Affairs Medical Center (West Haven, CT, USA) in 2023. Case 1 describes a 69-year-old woman who presented with a large left adrenal mass that was suspicious for adrenocortical carcinoma and was found to have primary adrenal DLBCL following surgical resection. Case 2 describes a 59-year-old woman with Hashimoto's thyroiditis and goiter who was found to have primary thyroid DLBCL following partial thyroidectomy. CONCLUSIONS Primary extranodal DLBCL should be included in the differential diagnosis of solid adrenal and thyroid tumors. The risks of biopsy, given currently available techniques, should be weighed against the benefits of achieving a definite diagnosis, allowing for timely initiation of systemic immunochemotherapy. When biopsy can be safely performed, techniques designed to evaluate for DLBCL should be incorporated.

Primary Thyroid Lymphoma: Clinical Factors Predicting the Possibility of Diffuse Large B-Cell Lymphoma

Aims: Among primary thyroid lymphomas (PTLs), diffuse large B-cell lymphoma (DLBCL) has a poorer prognosis than other indolent lymphomas such as mucosa-associated lymphoid tissue (MALT) or follicular lymphoma (FL). However, the clinical differences between DLBCL and indolent lymphoma remain unclear. Therefore, this retrospective study on PTL was aimed at investigating the clinical differences between DLBCL and indolent lymphomas and identifying the factors differentiating DLBCL from indolent lymphomas. Materials and Methods: Medical records of 28 patients diagnosed with PTL and treated at our institution between 2005 and 2022 were retrospectively analyzed. Data on the following clinical variables were extracted: sex, age, symptoms (pain and dysphagia), ultrasonographic appearance patterns, the presence of airway stenosis on computed tomography and laryngeal endoscopy, blood test results, disease stage, and pathological diagnosis. Results: In all, 13 patients were histologically diagnosed with DLBCL, 12 with MALT lymphoma, and 3 with FL. Significant differences in disease-specific survival rates were evident between the DLBCL and indolent lymphoma groups (68.2 vs 100%, P = .043). High lactate dehydrogenase levels (>230 U/mL) and airway stenosis were observed only in patients with DLBCL. Multivariate analysis identified that the presence of a linear echoic strand pattern and the absence of an echoic nodular pattern on ultrasound were independently associated with DLBCL (P = .0497 and .012, respectively). Conclusion: DLBCL can cause airway stenosis. The linear echogenic strand pattern and the absence of a nodular pattern should be recognized as predictive factors of DLBCL.

Primary Intrathyroidal Non-Hodgkin Lymphoma: A Case Report

Primary thyroid lymphoma (PTL) is a rare disease characterized by the appearance of a rapidly growing solid mass in the cervical region. A major risk factor is chronic autoimmune thyroiditis with lymphocytes infiltrating the thyroid gland. The lymphoproliferative disease is seen more frequently in the females. PTL usually develops in the sixth and seventh decades of life. We present a case of a 66-year-old woman with diffuse primary B-cell thyroid lymphoma with no prior evidence of underlying autoimmune thyroid pathology. The initial localization of the lymphoproliferative disease was in the thyroid gland, but the involvement of regional cervical lymph nodes was also found at the time of diagnosis. After histological verification with immunohistochemistry and staging by imaging, chemotherapy was initiated according to the R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride, Oncovin® (vincristine), prednisone) protocol. An excellent therapeutic response was achieved with lymphoma remission after six cycles under the mentioned protocol. Thyroid autoantibodies became positive 18 months after rituximab treatment, possibly reflecting the transient suppressive effects of the immunotherapy. The patient was subsequently kept followed up by a multidisciplinary team in the light of possible lymphoma recurrence and/or development of thyroid dysfunction. This case report demonstrates possible challenges for the diagnosis, treatment, and follow-up of this rare thyroid lesion. At the time of diagnosis, the clinical presentation of the disease, the ultrasound image, and the cytological result may be similar to other low-grade thyroid carcinomas or secondary metastatic involvement of the gland. The initial lack of underlying thyroid autoimmunity makes this distinction even more challenging. Furthermore, despite the rapid resolution, regular long-term monitoring for recurrence is required.

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.

Coexistence of tuberculosis and extranodal marginal zone lymphoma of the thyroid gland: Case report and literature review

Introduction

Primary thyroid tuberculosis (TB) is rare even in countries where TB disease is endemic, with the prevalence ranging from 0.1 to 1.15%. Primary thyroid lymphoma is uncommon, and the majority of lymphomas arising in the thyroid gland are non-Hodgkin's lymphomas of B-cell origin, of which about 25% is extranodal marginal zone B cell lymphoma (MALToma).

Case presentation

An 86-year- old Turkish female patient with thyroid nodules and cervical lymphadenopathies presented with large multinodular goiter and compressive symptoms. Total thyroidectomy and central lymph node dissection were performed. The revised histological and immunohistochemical revealed the coexistence of thyroid TB and MALToma. The patient received an anti-TB treatment for six months before a revised histopathological examination. About seven months after anti-TB treatment, the patient died due to an unknown cause.

Clinical discussion

Although six cases of thyroid TB and papillary thyroid cancer have been documented in the medical literature, no cases of TB and MALToma coexistence have been published so far, to our knowledge. Another essential feature of this study is that the initial pathological examination was reported as thyroid TB. A subsequent re-examination revealed that the patient had both TB and MALT lymphoma.

Conclusion

We discuss this rare association and the dilemma encountered in the diagnosis and management of this patient with a review of the literature.

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Primary thyroid tuberculosis (TB) is rare even in countries where TB disease is endemic, ranging from 0.1 to 1.15%.

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Primary thyroid lymphoma is distinctly uncommon, accounting for only 0.5%–5% of all thyroid malignancies.

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To the best of our knowledge, only six cases of thyroid TB and papillary thyroid cancer have been reported in the literature.

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No cases of coexistence of TB and Marginal zone B-cell lymphoma have been reported so far.

Diffuse Large B-Cell Lymphoma Germinal Center B-Cell Subtype of the Thyroid

Non-Hodgkin lymphoma is one of the most common hematological malignancies having both nodal and extranodal sites of involvement. The thyroid gland is one of the rarest primary sites. Most cases of primary thyroid lymphoma are diffuse large B-cell in nature; thus, aggressive and in extreme cases can rapidly lead to airway compromise, especially in patients who have been living with goiter for years. We present one such case of a 64-year-old female who presented with signs of airway compromise, requiring emergent airway intubation and surgical debulking. She was treated with emergent chemotherapy (DA-EPOCH-R regimen), without radiotherapy and this resulted in complete remission.