Case Report
J Clin Ultrasound 20:142-145, February 1992 CCC 0091-2751/92/020142-04$04.00 0 1992 by John Wiley & Sons, Inc.
Nonpalpable Primary Thyroid Lymphoma Diagnosed Ultrasound-Guided Fine Needle Biopsy Shodayu Takashima, MD,* Noriyuki Tomiyama, MD,* Shizuo Morimoto, MD,* Takahiro Kozuka, MD,* and Kiyoshi Ichihara, MDt
Primary thyroid lymphoma accounts for 4% of all thyroid malignancies and predominantly afflicts elderly women.’ They often present with a rapidly enlarging neck mass and have symptoms of obstruction such as dyspnea, dysphagia, and Tumors are usually large in size a t the time of diagnosis and firm to palpation.”’ Nearly all patients have non-Hodgkin lymphoma.lP5 Patients with this disorder are treated with radiation therapy with or without chemotherapy, and surgery is not the treatment of choice.’ We report a case of nonpalpable primary lymphoma in the thyroid gland in which the tumor was discovered by routine neck sonography and histopathologic diagnosis was established successfully by ultrasound-guided fine needle biopsy.
nor calcification was seen in the tumor. No lymphadenopathy was detected. Aspiration biopsy with a 22-gauge needle and cutting biopsy with a 21-gauge Sure-cut needle (TSK Laboratory, Tokyo) under sonographic guidance with use of a 5-MHz linear array probe (Yokogawa Medical System, Tokyo) were performed (Figure 1B). Non-Hodgkin lymphoma of the thyroid gland was suspected as a result of findings of fine needle aspiration biopsy and a definite histologic diagnosis for thyroid lymphoma was established by cutting needle biopsy findings (Figure 2). The lymphoma was staged as IE disease on the basis of staging workup using computed tomography and magnetic resonance imaging.
CASE REPORT
DISCUSSION
A 58-year-old woman had been affected with Hashimoto’s thyroiditis for more than 5 years. Physical examination revealed a diffuse enlargement of the thyroid gland, with the gland having a hard consistency. However, localized tumor was not palpable. Routine neck sonography obtained with a real-time mechanical sector scanner equipped with a 7.5-MHz transducer (SSD125; Aloka, Tokyo) revealed a diffusely enlarged thyroid gland with a general decrease in echogenicity and a mass lesion within the gland measuring 2.2 cm in the greatest diameter with marked hypoechogenicity relative t o residual thyroid parenchyma (Figure 1A). Neither halo
Fine needle biopsy under sonographic guidance is widely used for neck masses because this technique is rapid and cost effective, and it can place the needle in the target precisely and protect the vascular structures that lie in close proximity to the m a ~ s e s .However, ~’~ to our knowledge, there is no reported case in which histopathologic diagnosis for nonpalpable primary thyroid lymphoma has been obtained by this technique, and in which the efficacy of the method in diagnosing this condition in early diseases is discussed. Many previous reports revealed that thyroid lymphoma has a strong association with Hashimoto’s thyroiditis and that nearly all patients with thyroid lymphoma have coexisting Hashimoto’s t h ~ r 0 i d i t i s .Thyroid l~~ glands with Hashimoto’s thyroiditis frequently show diffuse enlargement and are firm to palpation.’ The present patient had no symptoms, and no localized tumor was detected on physical examinations, even after the sonographic study that sug-
From the Departments of *Radiology and ?Laboratory Medicine, Osaka University Medical School, Fukushima-ku, Osaka, Japan For reprints contact Shodayu Takashima, MD, Department of Radiology, Osaka University Medical School, 1-1-50 Fukushima, Fukushima-ku, Osaka 553, Japan.
142
NONPALPABLE PRIMARY THYROID LYMPHOMA
FIGURE 1. (A) Transverse sonogram shows an enlarged thyroid gland with general decrease in echogenicity and a mass lesion (arrowheads) with marked hypoechogenicity in the left lobe of the thyroid gland. (T, trachea.) (B) Transverse sonogram obtained during ultrasound-guided biopsy clearly shows the needle position (arrowheads) within mass lesion (arrows).
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FIGURE 2. Histologic specimen obtained from cutting needle biopsy yielded a diagnosis of non-Hodgkin lymphoma. (H & E x50.)
gested the presence and location of the thyroid tumor. This must be the fact that the size of the tumor was relatively small at the time of diagnosis; therefore, it hid behind the Hashimito’s thyroiditis, which was also hard to palpation. On sonography, primary thyroid lymphoma appears as markedly hypoechoic areas relative to residual thyroid parenchyma, accompanied with neither halo nor ~alcification.~ The residual thyroid gland also appears unhomogeneously hypoechoic because of superimposed Hashimoto’s t h y r ~ i d i t i s .However, ~ discrimination between these two conditions is usually possible in sonographic i r n a g e ~ The . ~ sonographic picture in the present case was compatible with that reported in the literature. It is true that these sonographic appearances are characteristic of thyroid lymphoma, but biopsy procedures are indispensable for establishing a histopathologic diagnosis. The 5-year survival rate for patients with stage IE lymphoma of the thyroid gland is high, reaching 89% and the 5-year survival rate for those with stage IIE disease falls to 27%.2When the disease becomes widely disseminated, the 5-year survival rate decreases to less than 5%.1°
Because prognosis for cases of the disorder depends much on the stage of the lymphoma, early diagnosis is vitally important. Thus, we think it clinically efficacious to detect thyroid lymphoma with sonography in the stage of nonpalpable tumor and to determine a histopathologic diagnosis under sonographic guidance, because invariably coexistent Hashimoto’s thyroiditis can prevent discovery of the tumor by palpation.
ACKNOWLEDGMENTS
We thank Chieko Watanabe for secretarial assistance and Reina Takashima for encouragement.
REFERENCES 1 Souhami L, Simpson WJ, Carruthers JS: Malignant lymphoma of the thyroid gland. Int J Radiat Oncol Biol Ph.ys 6:1143, 1980. 2. Burke JS, Butler JJ, Fuller LM: Malignant lymphoma of the thyroid: A clinical pathologic study of 35 patients including ultrsatructural observations. Cancer 39:1587, 1977. 3. Compagno J, Oertel JE: Malignant lymphoma and JOURNAL OF CLINICAL ULTRASOUND
NONPALPABLE PRIMARY THYROID LYMPHOMA other lymphoproliferative disorders of the thyroid gland: A clinicopathologic study of 245 cases. Am J Clin Pathol 74:1, 1980. 4. Anscombe AM, Wright DH: Primary malignant lymphoma of the thyroid. A tumor of mucosa-associated lymphoid tissue: Review of seventy-six cases. Histopathology 9231, 1985. 5. Takashima S, Ikezoe J, Morimoto S, et al: Primary thyroid lymphoma: Evaluation with CT. Radiology 168:765, 1988. 6. Rizzatto G, Solbiati L, Croce F, et al: Aspiration biopsy of superficial lesions: Ultrasonic guidance with a linear-array probe. AJR 148:623, 1987.
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7. Sutton RT, Reading CC, Charboneau J W , et al: US-guided biopsy of neck masses in postoperative management of patients with thyroid cancer. Radiology 168:769, 1988. 8. Volpe R: Autoimmune thyroiditis, in The Thyroid, Ingbar SH, Braverman LE (eds). Lippincott, Philadelphia, PA, 1986, p 1266. 9. Takashima S, Morimoto S, Ikezoe J , e t al: Primary thyroid lymphoma: Comparison of CT and US assessment. Radiology 171:439, 1989. 10. Billie J D , Wetzel WJ, Suen JY: Thyroid lymphoma with adjacent nerve paralysis. Arch Otolaryngol 108517, 1982.
J Clin Ultrasound 20:142-145, February 1992 CCC 0091-2751/92/020142-04$04.00 0 1992 by John Wiley & Sons, Inc.
Nonpalpable Primary Thyroid Lymphoma Diagnosed Ultrasound-Guided Fine Needle Biopsy Shodayu Takashima, MD,* Noriyuki Tomiyama, MD,* Shizuo Morimoto, MD,* Takahiro Kozuka, MD,* and Kiyoshi Ichihara, MDt
Primary thyroid lymphoma accounts for 4% of all thyroid malignancies and predominantly afflicts elderly women.’ They often present with a rapidly enlarging neck mass and have symptoms of obstruction such as dyspnea, dysphagia, and Tumors are usually large in size a t the time of diagnosis and firm to palpation.”’ Nearly all patients have non-Hodgkin lymphoma.lP5 Patients with this disorder are treated with radiation therapy with or without chemotherapy, and surgery is not the treatment of choice.’ We report a case of nonpalpable primary lymphoma in the thyroid gland in which the tumor was discovered by routine neck sonography and histopathologic diagnosis was established successfully by ultrasound-guided fine needle biopsy.
nor calcification was seen in the tumor. No lymphadenopathy was detected. Aspiration biopsy with a 22-gauge needle and cutting biopsy with a 21-gauge Sure-cut needle (TSK Laboratory, Tokyo) under sonographic guidance with use of a 5-MHz linear array probe (Yokogawa Medical System, Tokyo) were performed (Figure 1B). Non-Hodgkin lymphoma of the thyroid gland was suspected as a result of findings of fine needle aspiration biopsy and a definite histologic diagnosis for thyroid lymphoma was established by cutting needle biopsy findings (Figure 2). The lymphoma was staged as IE disease on the basis of staging workup using computed tomography and magnetic resonance imaging.
CASE REPORT
DISCUSSION
A 58-year-old woman had been affected with Hashimoto’s thyroiditis for more than 5 years. Physical examination revealed a diffuse enlargement of the thyroid gland, with the gland having a hard consistency. However, localized tumor was not palpable. Routine neck sonography obtained with a real-time mechanical sector scanner equipped with a 7.5-MHz transducer (SSD125; Aloka, Tokyo) revealed a diffusely enlarged thyroid gland with a general decrease in echogenicity and a mass lesion within the gland measuring 2.2 cm in the greatest diameter with marked hypoechogenicity relative t o residual thyroid parenchyma (Figure 1A). Neither halo
Fine needle biopsy under sonographic guidance is widely used for neck masses because this technique is rapid and cost effective, and it can place the needle in the target precisely and protect the vascular structures that lie in close proximity to the m a ~ s e s .However, ~’~ to our knowledge, there is no reported case in which histopathologic diagnosis for nonpalpable primary thyroid lymphoma has been obtained by this technique, and in which the efficacy of the method in diagnosing this condition in early diseases is discussed. Many previous reports revealed that thyroid lymphoma has a strong association with Hashimoto’s thyroiditis and that nearly all patients with thyroid lymphoma have coexisting Hashimoto’s t h ~ r 0 i d i t i s .Thyroid l~~ glands with Hashimoto’s thyroiditis frequently show diffuse enlargement and are firm to palpation.’ The present patient had no symptoms, and no localized tumor was detected on physical examinations, even after the sonographic study that sug-
From the Departments of *Radiology and ?Laboratory Medicine, Osaka University Medical School, Fukushima-ku, Osaka, Japan For reprints contact Shodayu Takashima, MD, Department of Radiology, Osaka University Medical School, 1-1-50 Fukushima, Fukushima-ku, Osaka 553, Japan.
142
NONPALPABLE PRIMARY THYROID LYMPHOMA
FIGURE 1. (A) Transverse sonogram shows an enlarged thyroid gland with general decrease in echogenicity and a mass lesion (arrowheads) with marked hypoechogenicity in the left lobe of the thyroid gland. (T, trachea.) (B) Transverse sonogram obtained during ultrasound-guided biopsy clearly shows the needle position (arrowheads) within mass lesion (arrows).
VOL. 20, NO. 2, FEBRUARY 1992
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144
CASE REPORT: TAKASHIMA ET AL.
FIGURE 2. Histologic specimen obtained from cutting needle biopsy yielded a diagnosis of non-Hodgkin lymphoma. (H & E x50.)
gested the presence and location of the thyroid tumor. This must be the fact that the size of the tumor was relatively small at the time of diagnosis; therefore, it hid behind the Hashimito’s thyroiditis, which was also hard to palpation. On sonography, primary thyroid lymphoma appears as markedly hypoechoic areas relative to residual thyroid parenchyma, accompanied with neither halo nor ~alcification.~ The residual thyroid gland also appears unhomogeneously hypoechoic because of superimposed Hashimoto’s t h y r ~ i d i t i s .However, ~ discrimination between these two conditions is usually possible in sonographic i r n a g e ~ The . ~ sonographic picture in the present case was compatible with that reported in the literature. It is true that these sonographic appearances are characteristic of thyroid lymphoma, but biopsy procedures are indispensable for establishing a histopathologic diagnosis. The 5-year survival rate for patients with stage IE lymphoma of the thyroid gland is high, reaching 89% and the 5-year survival rate for those with stage IIE disease falls to 27%.2When the disease becomes widely disseminated, the 5-year survival rate decreases to less than 5%.1°
Because prognosis for cases of the disorder depends much on the stage of the lymphoma, early diagnosis is vitally important. Thus, we think it clinically efficacious to detect thyroid lymphoma with sonography in the stage of nonpalpable tumor and to determine a histopathologic diagnosis under sonographic guidance, because invariably coexistent Hashimoto’s thyroiditis can prevent discovery of the tumor by palpation.
ACKNOWLEDGMENTS
We thank Chieko Watanabe for secretarial assistance and Reina Takashima for encouragement.
REFERENCES 1 Souhami L, Simpson WJ, Carruthers JS: Malignant lymphoma of the thyroid gland. Int J Radiat Oncol Biol Ph.ys 6:1143, 1980. 2. Burke JS, Butler JJ, Fuller LM: Malignant lymphoma of the thyroid: A clinical pathologic study of 35 patients including ultrsatructural observations. Cancer 39:1587, 1977. 3. Compagno J, Oertel JE: Malignant lymphoma and JOURNAL OF CLINICAL ULTRASOUND
NONPALPABLE PRIMARY THYROID LYMPHOMA other lymphoproliferative disorders of the thyroid gland: A clinicopathologic study of 245 cases. Am J Clin Pathol 74:1, 1980. 4. Anscombe AM, Wright DH: Primary malignant lymphoma of the thyroid. A tumor of mucosa-associated lymphoid tissue: Review of seventy-six cases. Histopathology 9231, 1985. 5. Takashima S, Ikezoe J, Morimoto S, et al: Primary thyroid lymphoma: Evaluation with CT. Radiology 168:765, 1988. 6. Rizzatto G, Solbiati L, Croce F, et al: Aspiration biopsy of superficial lesions: Ultrasonic guidance with a linear-array probe. AJR 148:623, 1987.
'OL.20, NO. 2, FEBRUARY
1992
145
7. Sutton RT, Reading CC, Charboneau J W , et al: US-guided biopsy of neck masses in postoperative management of patients with thyroid cancer. Radiology 168:769, 1988. 8. Volpe R: Autoimmune thyroiditis, in The Thyroid, Ingbar SH, Braverman LE (eds). Lippincott, Philadelphia, PA, 1986, p 1266. 9. Takashima S, Morimoto S, Ikezoe J , e t al: Primary thyroid lymphoma: Comparison of CT and US assessment. Radiology 171:439, 1989. 10. Billie J D , Wetzel WJ, Suen JY: Thyroid lymphoma with adjacent nerve paralysis. Arch Otolaryngol 108517, 1982.
