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Zorluk: OrtaBreast and Endocrine Surgery

A 68-year-old woman is evaluated in the surgical clinic for a rapidly enlarging mass in the anterior neck that she first noticed 4 weeks ago. She reports a recent onset of hoarseness and difficulty swallowing solid foods. The patient has a 15-year history of Hashimoto thyroiditis but admits she stopped taking her prescribed levothyroxine 8 months ago because she "felt fine." Her temperature is 37.0°C (98.6°F), blood pressure is 132/82 mm Hg, pulse is 60/min, and respirations are 16/min. Physical examination reveals a massive, firm, fixed, and non-tender goiter. There is no palpable cervical lymphadenopathy.

Laboratory studies are as follows:

Laboratory TestResultReference Range
Thyroid-stimulating hormone (TSH)14.5 mU/L0.4 - 4.0 mU/L
Free T40.6 ng/dL0.9 - 1.7 ng/dL

Ultrasound of the neck demonstrates severe, diffuse enlargement of the thyroid gland with marked hypoechogenicity and several irregular, solid areas. Which of the following is the most appropriate next step in the management of this patient?

  1. Ultrasound-guided core needle biopsy of the thyroid massCevap
  2. B
    Resumption of levothyroxine and follow-up ultrasound in 6 weeks
  3. C
    Radionuclide thyroid scintigraphy
  4. D
    Immediate total thyroidectomy
  5. E
    Empiric administration of intravenous glucocorticoids

Cevap

Ultrasound-guided core needle biopsy of the thyroid mass
This patient's presentation of a rapidly enlarging, fixed thyroid mass causing hoarseness and dysphagia, particularly in the setting of long-standing Hashimoto thyroiditis, is the classic presentation of primary thyroid lymphoma. The most crucial next step is to establish a tissue diagnosis. While ultrasound-guided fine-needle aspiration (FNA) is the initial step for most thyroid nodules, a core needle biopsy is frequently required when thyroid lymphoma is suspected. This is because FNA often cannot distinguish between the dense lymphocytic infiltrates of severe Hashimoto thyroiditis and a true lymphoma. Core biopsy preserves the tissue architecture, allowing for definitive immunohistochemistry and flow cytometry. Once diagnosed, thyroid lymphoma is typically treated with chemotherapy (e.g., CHOP regimen) and radiation, avoiding radical surgery.

Adım Adım Çözüm

1
Analyze the patient's clinical presentation and history.
The patient has an older age, a history of Hashimoto thyroiditis, and a rapidly expanding, fixed neck mass causing compressive symptoms (dysphagia, hoarseness).
Identifying red flag symptoms is critical to differentiating a benign goiter from an aggressive malignancy.
2
Evaluate the laboratory and imaging findings in context.
Labs show primary hypothyroidism (high TSH, low free T4). Ultrasound shows a diffusely enlarged, heterogenous, hypoechoic gland.
Although the patient is hypothyroid from medication non-adherence, a simple hypothyroid goiter does not grow massively over 4 weeks or invade local structures.
3
Formulate the most likely diagnosis and select the appropriate next step.
The clinical picture is highly suspicious for primary thyroid lymphoma. A core needle biopsy is selected.
Core needle biopsy is preferred over fine-needle aspiration (FNA) in suspected thyroid lymphoma because evaluating the tissue architecture and performing flow cytometry are necessary to distinguish lymphoma from the heavy lymphocytic infiltrate of severe Hashimoto thyroiditis.

Anahtar Kavram

Primary thyroid lymphoma typically presents as a rapidly enlarging, firm goiter with compressive symptoms in an older patient with preexisting Hashimoto thyroiditis; it requires tissue diagnosis (often via core needle biopsy) rather than empiric medical or surgical intervention.
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