Thyroid B-Cell Lymphoma Presenting With Hornerís Syndrome, Dysphasia And Dysphagia
Lynch J1, Rajeev P1, Booth F2
1Department of Surgery, St Maryís Hospital, Newport, Isle of Wight
2Department of Haematology, St Maryís Hospital, Newport, Isle of Wight.
Lymphoma of the thyroid is a rare entity constituting 2-8% of thyroid malignancies. We discuss the diagnosis and management of a rapidly growing B-cell thyroid lymphoma presenting with Hornerís syndrome and pressure symptoms.
A 68-year-old man presented to the endocrine surgery clinic with a rapidly growing painless mass arising from the right lobe of the thyroid. This was accompanied with dysphagia, ipsilateral ptosis and meiosis of the right pupil, and hoarseness of the voice. He had a past medical history of autoimmune liver disease for which he was taking azathioprine. The initial clinical impression was that of anaplastic thyroid cancer with the differential diagnosis of lymphoma. Routine blood tests, including FBC, renal function, calcium and PTH levels, were within normal limits. Two ultrasound guided fine needle aspirates were inconclusive so he proceeded to have a core biopsy of the thyroid which revealed diffuse B-cell lymphoma. Treatment with dexamethasone was immediately commenced in view of his significant pressure symptoms. A CT head/neck/chest/abdomen/pelvis revealed an 8◊5.5◊5.5 cm mass arising from the right lobe of the thyroid, displacing the trachea to the left, with associated cervical lymphadenopathy, and no distal spread of disease. Fibreoptic nasoendoscopy confirmed right vocal cord paresis. His case was discussed at the regional multidisciplinary meeting (thyroid and haematology). He was reviewed in the haematology oncology clinic and started on R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone, allopurinol, lansoprazole, and ciprofloxacin). Follow up at 6 months with a CT demonstrated excellent response to chemotherapy, with shrinkage of the tumour to 1.5cm in diameter. His ocular symptoms and vocal symptoms have also improved significantly.
Lymphoma must always be considered in the differential diagnosis of rapidly enlarging masses of the thyroid. Early distinction from anaplastic thyroid cancer is imperative as lymphomas respond well to chemotherapy whereas the mortality of anaplastic carcinoma is very high. Hornerís syndrome is a very unusual presentation of this disease. Excellent results may be achieved using chemotherapy alone.