primary thyroid lymphoma - PowerPoint Presentation

1. primary thyroid lymphomaDr.Rahim Zahedi

2. Rapid enlargement of thyroid Acute infectious thyroiditis ( onset of pain, firmness, tenderness, redness or swelling in the anterior aspect of the neck, sudden fever, dysphagia and dysphonia, very rare 0.1–0.7% of all thyroiditis )subacute thyroiditis (pain, swollen and tender, fever, fatigue, weakness, difficulty swallowing)hemorrhage of thyroid adenoma or cystAnaplastic thyroid cancer (neck pain and tenderness, and compression or invasion of the upper aerodigestive tract, resulting in dyspnea about 35 percent , dysphagia 30 percent, hoarseness 25 percent, cough and sometimes hemoptysis, 25 percent)Thyroid lymphoma

3. Diagnostic approachHistory and physical examination : rapid growth of a neck mass , no history of irradiation, no family history of thyroid cancer, no history of hypothyroidism, dyspnea and dysphagia, there is a palpable firm mass in approximate size of 5*4cm in right lobe of thyroid and could be palpated over isthmus of thyroid which causes left trachea deviation Serum TSH : 1.1 mlu/mlThyroid ultrasonography : a hypoechoic 59*38 m.m mass in Rt lobe of thyroid with internal vascularity , without calcification , without hypoechoic rimFNA : Benign , Note : due to monomorphic pattern of lymphoid cells, lymphoma cannot be ruled outCOR NEEDLE BIOPSY :primary thyroid lymphomaTREATMENT : chemotherapy (R-CHOP)

4. Primary thyroid lymphomaThyroid lymphomas are nearly always of the non-Hodgkin typeOnly about 2 percent of extranodal lymphomas arise within the thyroid glandlymphomas represent no more than 2 percent of all malignant thyroid tumorsthe annual incidence rate was estimated to be 2.1 per million personswith a four to one female predominanceThe mean and median ages at diagnosis are between 65 and 75 years

5. ETIOLOGYPreexisting chronic autoimmune (Hashimoto's) thyroiditis is the only known risk factor for primary thyroid lymphoma and is present in about one-half of patientsAmong patients with Hashimoto's thyroiditis, the risk of thyroid lymphoma is at least 60 times higher than in patients without thyroiditisLymphoma may also occur more commonly after iodine supplementationThere appears to be no clear association between exposure to ionizing radiation and lymphomaChromosomal abnormalities are rare in thyroid lymphomas

6. CLASSIFICATIONPrimary thyroid lymphoma is almost always of B-cell lineageoften in areas endemic for HTLV-I-associated adult T-cell leukemia/lymphoma60 to 80 percent of thyroid lymphomas are diffuse large B-cell lymphomasThe next most common subtype (approximately 30 percent) is extranodal marginal zone lymphomaOther less common histologic subtypes include follicular lymphomasextranodal small lymphocytic lymphomas have also been described

7. CLINICAL PRESENTATIONIn more than 90 percent , the major symptom is a rapidly enlarging goiterMany patients have symptoms or signs of tracheal, esophageal or neck vein compression, including dysphagia, dyspnea, stridor, hoarseness, neck pain, and facial edemaOn examination, the thyroid is firm, even hard, may be slightly tender, and is often fixed to adjacent structures and immobile with swallowingSubsternal extension is commonAbout one-half of patients have enlarged cervical or supraclavicular lymph nodesup to 10 percent of patients have systemic ("B") symptoms of lymphoma

8. DIAGNOSTIC EVALUATIONAn ultrasound scan of the thyroid gland and needle biopsy or excisional biopsy are usually recommended as initial diagnostic proceduresAlthough the diagnosis of lymphoma may be suggested by the fine needle aspiration initially performed for suspicion of thyroid malignancy, fine needle aspiration cytology is often nondiagnostic for thyroid lymphomaThyroid lymphomas cannot be distinguished from carcinomas or Hashimoto's thyroiditis by radiographic or radionuclide imagingRadioiodine scanning has no diagnostic role in patients with thyroid lymphomas because the malignant cells lack iodine-concentrating abilityCT and MRI are superior to ultrasonography for evaluating local extent because of their greater ability to detect tracheal invasion, substernal extension, and involvement of cervical, mediastinal, or abdominal nodesMRI may be more sensitive for defining the extent of extrathyroidal invasion

9. TREATMENTSevere airway compromise may occur in up to 25 percent of an aggressive lymphoma variant (eg, DLBCL) Such tumors shrink within hours after initiation of combination chemotherapy (eg, CHOP), due to the rapid effect of the steroid component, potentially obviating the need for tracheotomyThere is little evidence that thyroidectomy is of value in patients with stage IIE or IIIE thyroid lymphomaIn patients with clinical stage IE disease (particularly MALT lymphomas), surgery may permit the distinction between intrathyroid tumor, which may be treatable by local therapy alone (surgery followed by postoperative radiation), and extrathyroid extension, which appears to require systemic chemotherapy Patients with diffuse large B-cell lymphoma (DLBCL) of the thyroid should be treated in the same manner as employed in patients with DLBCL of any other site or extent. Thus, patients with localized, early stage disease can be treated with either three courses of combination therapy (eg, CHOP plus rituximab , followed by radiation therapy to the thyroid bed or six to eight cycles of CHOP plus rituximab without radiation

10. PROGNOSISIn one series of 51 patients with localized (stage I or II) thyroid lymphoma, five-year failure-free survival rates were 76, 50, and 91 percent for patients treated with radiation, chemotherapy, or combined modality therapy, respectivelyIn another series of 171 patients with localized (stage IE or IIE) thyroid lymphoma, five-year event-free survival rates for aggressive (diffuse large B-cell lymphoma and diffuse large B-cell lymphoma with MALT) and indolent (MALT) lymphoma was 73 and 89 percent, respectively

11.

12. SurvivalsThe 5- and 10-yr probability of overall survival (OS) was, for all patients, 77% and 54%, respectivelyThe median survival was 10.9 yrOS was significantly influenced by age and performance status , and a complete response was achieved with the treatment

13. We included 13 consecutive patients with pathologically proven primary thyroid lymphoma at Xiangya Hospital from 2007 to 2013Another 27 patients were randomly chosen as controls who had pathologically proven nodular goiter at our hospital from 2012 to 2013

14. Comparison of Clinical and Sonographic FeaturesBetween Primary Thyroid Lymphoma and NodularGoiter

15.

16.

17.

18. Thank you for your attention