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LETTER TO EDITOR  
Year : 2012  |  Volume : 55  |  Issue : 1  |  Page : 122-124
Hodgkin's lymphoma presenting as an abscess in thyroid gland


Department of Pathology, Medical Trust Hospital, Kochi, India

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Date of Web Publication11-Apr-2012
 

How to cite this article:
Thomas RM. Hodgkin's lymphoma presenting as an abscess in thyroid gland. Indian J Pathol Microbiol 2012;55:122-4

How to cite this URL:
Thomas RM. Hodgkin's lymphoma presenting as an abscess in thyroid gland. Indian J Pathol Microbiol [serial online] 2012 [cited 2020 Oct 30];55:122-4. Available from: https://www.ijpmonline.org/text.asp?2012/55/1/122/94885


Sir,

Primary thyroid lymphoma is a rare disease, representing approximately 1-5% of all thyroid malignancies and 2.5-3% of all extra nodal lymphomas. A wide spectrum of malignant lymphoma subtypes are reported in the thyroid, the majority being non-Hodgkin`s lymphoma (NHL) of B cell origin. [1] Primary involvement of thyroid gland by Hodgkin`s lymphoma (HL) is rare and only very few convincing cases are reported in the literature. To our knowledge, we report here the first case of primary HL presenting as a thyroid abscess. A 62-year-old woman was admitted to our surgical department with complaints of a swelling in the anterior aspect of neck associated with difficulty and pain in swallowing of two months duration. According to the patient, the swelling had increased in size over the past few weeks. She also complained of losing six kg weight over four months. A history of hypothyroidism was elicited for which she was on treatment since seven years. Physical examination revealed a mildly tender swelling in the anterior lower region of neck which was not moving with deglutition or respiration. Basic laboratory investigations were within normal limits. Thyroid function test was normal. A chest X-ray revealed superior mediastinal widening. Computed tomography (CT) imaging of thorax showed a lobulated necrotic mass of approximately 58 × 45 mm arising from the right lobe of thyroid with retrosternal extension up to the aortic arch displacing vascular structures in the superior mediastinum laterally [Figure 1]. Mass was seen extending to the thyroid isthmus leaving the left lobe normal. No evidence of mediastinal or hilar lymphadenopathy was seen. Visualized lung parenchyma on both sides were normal. There was no evidence of any enlarged cervical lymph nodes. The patient was taken up for surgery with a provisional diagnosis of a malignant thyroid mass. At surgery, a mass was found involving the isthmus of thyroid and extending retrosternally into the superior mediastinum. The mass had a thick capsule and drained pus like material which led to a presumptive diagnosis of thyroid abscess. Pus was sent for microbiological studies and a biopsy was taken from the abscess wall for histopathological examination.
Figure 1: CT image of thorax showing a lobulated necrotic mass within the thyroid gland

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Biopsy tissue consisted of an oval soft tissue piece 45 × 30 × 10 mm with a fleshy pale grey appearance and adhering purulent material. Microscopic examination showed an abscess surrounded by acutely inflamed granulation tissue with a fibro connective capsule. Thyroid tissue was present peripherally. Within the abscess and the granulation tissue, sheets of inflammatory cells, predominantly neutrophil polymorphs were seen. Eosinophils were also conspicuously present. Scattered within these inflammatory cells, several large atypical cells, many showing nuclear binucleation and multilobations with prominent nucleoli were seen [Figure 2]. Immunohistochemical studies were performed and these cells stained positive for CD30 [Figure 3]. CD15 stained the granulocytes, but the atypical cells were interpreted as negative. CD45, CD3, CD20, EMA, cytokeratin and Alk 1 were negative in the atypical cells. Ki 67 showed a high proliferation index in these large cells. Based on these findings, a diagnosis of classical HL, mixed cellularity type was made. Uninvolved thyroid tissue at the periphery showed features of Hashimoto`s thyroiditis, composed of atrophic follicles lined by Hurthle cells and the stroma infiltrated by lymphoplasma cells and lymphoid follicles [Figure 4]. Culture studies on the aspirated pus grew coagulase positive Staphylococcus aureus.
Figure 2: High power view showing scattered mononuclear and multilobated Hodgkin`s cells in a background of neutrophil polymorhs (H and E, ×200)

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Figure 3: Immunohistochemical staining for CD 30 antibody staining scattered Hodgkin`s cells (IHC, ×400)

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Figure 4: High power view of background thyroid showing features of Hashimoto`s thyroiditis (H and E, ×200)

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Primary thyroid lymphomas are almost always NHL of B cell origin, derived from mucosa associated lymphoid tissue. HL presenting in the thyroid is rare. In a review article by Wang et al., [2] the authors describe five cases of HL presenting as thyroid lesions and their review of English literature between 1962 and 2005 reveal 16 additional cases. All cases were classical HL, nodular sclerosing subtype. However, majority of these patients presented with stage II E disease with mediastinal or regional lymphnode involvement raising the question as to whether these cases represent primary thyroid tumors or reflect secondary involvement by nodal or thymic HL. Present case had no associated lymph node or mediastinal mass either on imaging studies or per-operatively, therefore, confirming origin of the tumor in the thyroid. In addition, residual thyroid tissue showed evidence of Hashimoto`s thyroiditis, an autoimmune disease, which is a well recognized precursor lesion for the development of lymphoma in extranodal sites. HL presenting as an abscess is only infrequently reported. Three reports with histological confirmation describe HL presenting as chest wall abscesses, [3],[4] one in association with old tuberculosis. [5] In all three cases, cultures failed to grow any organisms. A case of primary thyroid HL is presented here, which in addition to its occurrence at a rare site is interesting for its presentation as an abscess. This report also highlights the importance of submitting all surgical specimens for histology, even when it is surgically not indicated, which may not be the practice in primary hospitals. The patient was treated with chemotherapy, and at one year of follow up, the patient is well and free of disease.

 
   References Top

1.Thieblemont C, Mayer A, Dumontet C, Barbier Y, Callet Bauchu E, Felman P, et al. Primary thyroid lymphoma is a heterogenous disease. J clin Endocrinol Metab 2002;87:105-11.  Back to cited text no. 1
    
2.Wang SA, Rahemtullah A, Faquin WC, Roepke J, Harris NL, Hasserjian RP. Hodgkin`s lymphoma of the thyroid: A clinicopathologic study of five cases and review of the literature. Mod Pathol 2005;18:1577-84.  Back to cited text no. 2
    
3.Stolk MF, Van der Lee I, Biesma DH, Geers TA, Seldenrijk CA. Hodgkin`s disease presenting as a parasternal chest wall mass. Noth J Med 1999;54:239-41.  Back to cited text no. 3
    
4.Khalbuss WE, Grigorian S, Mignone J, D`Agostino HJ. Chest wall abscess: An unusual presentation of Hodgkin`s lymphoma. Diagn cytopathol 2005;33:33-5.  Back to cited text no. 4
    
5.Karimi S, Mohammadi F, Pejhan S, Zahirifard S, Azari PA. An unusual presentation of Hodgkin`s lymphoma as a chest wall abscess in association with old TB. Tanaffos 2007;6:71-4.  Back to cited text no. 5
    

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Correspondence Address:
Renu M Thomas
Department of Pathology, Medical Trust Hospital, MG Road, Kochi - 682 016
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.94885

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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