Endocrine Abstracts

Primary thyroid lymphoma (PTL) is a rare disorder, representing merely 1-5% of all thyroid malignancies, 1-2% of extranodal lymphomas and 3% of non-Hodgkin’s lymphomas. It affects mainly women. PTL incidence is low in individuals younger than 40 years old. The most common clinical presentation of PTL is a palpable mass in the neck. It may be accompanied by other symptoms: dysphagia, dyspnea, and hoarseness. Diffuse B-cell lymphoma (DLBCL), is the most common pathological subtype of PTL. Hashimoto thyroiditis (HT) is essential risk factor of PTL. In clinical practice, a rapidly enlarging neck mass, accompanied by compressive symptoms, in women with HT should prompt the exclusion of PTL. Core-needle biopsy is superior to fine-needle biopsy in this cases. A 40-year-old female patient with AIT, on substitution therapy with L-thyroxine, was admitted to the hospital due to increased dyspnea accompanied by stridor. She presented a history of upper respiratory tract infection symptoms for two weeks, a feeling of mild dyspnea and an enlargement of the neck circumference. On admission to the Emergency Department (ED), the patient was cardiovascularly and respiratorily stable, with neck oedema, palpable thyroid enlargement and an exacerbated alveolar murmur on physical examination. Laboratory tests on admission were as follows: WBC 5.97 10³ [4.00—10.00], CRP 24.00 mg/l [<5.00], PCT 0.11 ng/ml [<0.5], TSH 4.898 uIU/ml [0.350-4.940]. Chest X-ray demonstrated tracheal stenosis. In ED, a patient was treated with improvement with hydrocortisone intravenously. Ultrasound evaluation revealed a markedly enlarged thyroid gland (V=86, 1 cm³), with heterogeneous reduced echogenicity with focal/infiltrative changes and markedly enlarged pre-tracheal lymph nodes below the isthmus. In an examination performed five months earlier, the dimension of the thyroid gland was significantly smaller (V=22, 1 cm³⁾. The BACC performed at that time resulted in a category II in the Bethesda classification. In the following days, due to a massive goitre with associated increasing compression symptoms, she was qualified for a total thyroidectomy. The conditions of the procedure were challenging - numerous adhesions and problematic infiltration of the thyroid parenchyma with surrounding tissues. Postoperative wound healing was as expected, and ENT evaluation revealed no vocal fold mobility disorders. In the following days, due to a tetanic seizure, patient was treated with calcium chloride intravenously, with clinical improvement. Histopathological evaluation revealed a pattern suggestive of large B-cell lymphoma infiltration. Oncological treatment has been initiated. This case emphasizes the difficulties in the early diagnosis of thyroid lymphoma.