images and diagnosis

Hematol Oncol Stem Cell Ther 4(2) Second Quarter 2011 hemoncstem.edmgr.com 103

Untreated primary thyroid lymphoma in an elderly womanSaad Akhtar,a Nasir Bakshi,b Iman Janabi,a Sarah Samar,a Irfan Maghfoora

from the aoncology Center and bDepartment of Pathology and Laboratory medicine, King faisal specialist hospital and research Centre, riyadh, saudi arabia

Correspondence: saad akhtar, mD · oncology Center, mBC 64, King faisal specialist hospital & research Centre, P.o. Box 3354, riyadh 11211, Kingdom of saudi arabia · t: +966-1- 442-3935, f: +966-1-4423941 · sakhtar@kfshrc.edu.sa, akhtars18@hotmail.com · accepted: June 2011

hematol oncol stem Cell ther 2011; 4(2): 103-104

Doi: 10.5144/1658-3876.2011.103

Figure 1. Large thyroid mass: (A) front view, (B) lateral view.

Figure 2. Chest x-ray: (A) A big soft tissue mass in the neck extending to the upper mediastinum with significant narrowing of the upper part of the trachea. No obvious pulmonary consolidation seen. (B) Resolution of neck mass and development of pulmonary infiltrates after chemotherapy.

images and diagnosis PRIMARY THYROID LYMPHOMA

Hematol Oncol Stem Cell Ther 4(2) Second Quarter 2011 hemoncstem.edmgr.com104

Figure 3. (A) Large lymphoid cells with highly atypical nuclei and moderately abundant cytoplasm with few background small lymphocytes (Wright-Giemsa stain, x 500). (B) Small group of markedly atypical/malignant large lymphoma cells with hyperchromatic nuclei (Papanicolaou stain, x 500).

1. Graff-Baker A, Roman SA, Thomas DC, Udels--man R, Sosa JA. Prognosis of primary thyroid lymphoma: demographic, clinical, and pathologic predictors of survival in 1,408 cases. Surgery. 2009;146:1105-15. 2. Mian M, Gaidano G, Conconi A, Tsang R, Gos--podarowicz MK, Rambaldi A, Rossi A, Oldani E,

Federico M, Luminari S, Bellei M, Pgliani EM, Ros--sini F, Cabrera ME, Martelli M, Lopez-Guillermo A, Busetto M, Cavalli F, Zucca E, Cortelazzo S. High response rate and improvement of long-term sur--vival with combined treatment modalities in pa--tients with poor-risk primary thyroid diffuse large B-cell lymphoma: an International Extranodal

Lymphoma Study Group and Intergruppo Italiano Linfomi study. Leuk Lymphoma. 2011;52:823-32. 3. Onal C, Li YX, Miller RC, Poortmans P, Constan--tinou N, Weber DC, Atasoy BM, Igdem S, Ozsahin M, Ozyar E. Treatment results and prognostic fac--tors in primary thyroid lymphoma patients: a rare cancer network study. Ann Oncol. 2011;22:156-64.

REFERENCES

A 92t yeartold otherwise healthy female was dittagnosed in another institution with thyroid lymphoma on fine needle aspirate (FNA) five

years back. The patient repeatedly refused further manttagement. Due to the rapid increase in the size of her tumor, shortness of breath and stridor, she was transttferred to our institution and required intubation in the intensive care unit. She had 30×15 cm neck mass extttending bilaterally and to the upper chest with an enttgorged neck and chest veins (Figure 1, A and B; Figure 2A). Her thyroidtstimulating hormone was 11.09 mU/L (normal range, 0.27 to 4.2 mU/L). Flow immunophettnotyping from the thyroid FNA specimen confirmed a CD19, CD20, and CD22 expressing monoclonal Btcell population, high forward and side scatter showing surttface kappa light chain restriction. CD10 and CD5 were not cotexpressed. These features and morphology were consistent with a large Btcell lymphoma.

She received cyclophosphamide 500 mg intravenousttly and one dose of vincristine 2 mg intravenously and dexamethasone 40 mg intravenously for 5 days. Her tuttmor was reduced by 70% after five days. Her shortness

of breath and stridor increased and chest xtray showed infiltrates and then aspiration pneumonia (Figure 2B. She developed febrile neutropenia, Klebsiella pneumonirrae bacteremia, deteriorated rapidly, developed multiple organ system failure and died fourteen days after receivtting chemotherapy.

DISCUSSIONPrimary thyroid lymphoma is relatively rare, accounting for only 2% to 5% of all thyroid malignancies with a mettdian age of about 65 years and 60% to 70% of patients have diffuse large B cell lymphoma.1t3 Conventional treatment is chemotherapy followed by radiation therattpy with a good longtterm outcome of 70% to 90%. Poor prognostic factors are older age, advanced stage, diffuse large B cell lymphoma, and lack of radiation therapy.1,2 Our patient was an elderly female with an aggressive untreated and neglected lymphoma. The huge size of her tumor caused significant local compressive effects. Diagnostic material and efforts were limited due to her clinical condition. She responded nicely but died due to diseasetrelated complications.