Primer Tiroid Lenfoması
Özet
Primer tiroid lenfoması (PTL), tiroid bezini veya ilişkili bölgesel lenf nodlarını etkileyen, metastatik özellik göstermeyen nadir bir malignitedir. Tüm tiroid malignitelerinin %5’inden azını oluşturan bu hastalık, kadınlarda erkeklere oranla 4 kat daha fazla görülür ve ortalama tanı yaşı 65’tir. Normal tiroid bezinde lenfoid doku bulunmasa da, Hashimoto tiroiditi varlığı PTL riskini 40 ila 80 kat artıran tek önemli faktördür. Neredeyse tüm vakalar B hücresi kökenli Non-Hodgkin lenfoma olup, en sık Diffüz Büyük B Hücreli Lenfoma (DLBCL) ve MALT lenfoma görülür. Klinik olarak genellikle hızla büyüyen, ağrısız bir guatr ve nefes darlığı, disfaji veya ses kısıklığı gibi obstrüktif semptomlarla ortaya çıkar. Tanıda ilk adım ultrasonografi olsa da, kesin tanı ve immünohistokimyasal çalışmalar için ince iğne aspirasyonu yerine daha duyarlı olan core (tıraşlama) biyopsi önerilir. Ayırıcı tanıda, benzer şekilde hızlı büyüme gösteren anaplastik tiroid karsinomu kritiktir. Evrelemede Lugano sistemi kullanılır ve hastaların %80’i erken evrededir. Günümüzde cerrahi yerine kemoterapi ve radyoterapi ana tedavi haline gelmiştir. DLBCL alt tipinde R-CHOP rejimiyle uygulanan kombine tedavi beş yıllık sağkalımı artırırken, prednizolon sayesinde obstrüktif semptomları hızla gerileterek trakeostomi ihtiyacını önler. Lokalize yavaş seyirli MALT lenfomada ise öncelikle cerrahi veya radyoterapi gibi lokorejyonel tedaviler tercih edilmektedir.
Primary thyroid lymphoma (PTL) is a rare, localized lymphoproliferative malignancy affecting the thyroid gland or regional lymph nodes, accounting for less than 5% of all thyroid malignancies. It is four times more common in women, with a median diagnosis age of 65. Although the normal thyroid lacks lymphoid tissue, Hashimoto's thyroiditis is the single major risk factor, increasing PTL risk by 40 to 80 times. Almost all cases are B-cell origin Non-Hodgkin lymphomas, predominantly Diffuse Large B-cell Lymphoma (DLBCL) and MALT lymphoma. The typical presentation is a rapidly enlarging, painless goiter accompanied by obstructive symptoms such as dyspnea, dysphagia, or hoarseness due to compression. Ultrasound is the initial imaging modality, but core biopsy is recommended over fine-needle aspiration for definitive diagnosis and immunohistochemical studies due to higher sensitivity. Anaplastic thyroid carcinoma is the primary differential diagnosis due to similar rapid growth. Staging is based on the Lugano system, with 80% of patients presenting with limited-stage disease. Management has shifted from surgery to chemotherapy and radiotherapy as primary treatments. For DLBCL, combined modality therapy using the R-CHOP regimen improves five-year survival and rapidly relieves airway obstruction via steroids, avoiding tracheostomy. Conversely, localized indolent MALT lymphoma is managed primarily through locoregional surgery or radiotherapy.
Referanslar
Peixoto R, Correia Pinto J, Soares V, Koch P, Taveira Gomes A. Primary thyroid lymphoma: A case report and review of the literature. Ann Med Surg (Lond). 2016;13:29-33. Published 2016 Dec 21. doi:10.1016/j.amsu.2016.12.023
Sakorafas GH, Kokkoris P, Farley DR. Primary thyroid lymphoma: Diagnostic and therapeutic dilemmas. Surg Oncol 2010;19:e124-9.
Walsh S, Lowery AJ, Evoy D, McDermott EW & Prichard RS. Thyroid lymphoma: recent advances in diagnosis and optimal management strategies. Oncologist 2013 18 994–1003. (https://doi.org/10.1634/ theoncologist.2013-0036)
Stein SA & Wartofsky L. Primary thyroid lymphoma: a clinical review. Journal of Clinical Endocrinology and Metabolism 2013 98 3131–3138. (https://doi.org/10.1210/jc.2013-1428)
G. Sangalli, G. Serio, C. Zampatti, G. Lomuscio, and L. Colombo, “Fine needle aspiration cytology of primary lymphoma of the thyroid: a report of 17 cases,” Cytopathology, vol. 12, no. 4, pp. 257–263, 2001.
Ahmed T, Kayani N, Ahmad Z & Haque MN. Non-Hodgkin’s thyroid lymphoma associated with Hashimoto’s thyroiditis. Journal of the Pakistan Medical Association 2014 64 342–344.
Kim NR, Ko YH & Lee YD. Primary T-cell lymphoma of the thyroid associated with Hashimoto’s thyroiditis, histologically mimicking MALT-lymphoma. Journal of Korean Medical Science 2010 25 481–484. (https://doi.org/10.3346/jkms.2010.25.3.481)
Levy-Blitchtein S, Plasencia-Rebata S, Morales Luna D & Del Valle Mendoza J. Coexistence of papillary thyroid microcarcinoma and mucosa-associated lymphoid tissue lymphoma in a context of Hashimoto’s thyroiditis. Asian Pacific Journal of Tropical Medicine 2016 9 812–814. (https://doi.org/10.1016/j.apjtm.2016.06.017)
Roldan-Valadez E, Ortega-Lopez N, Cervera-Ceballos E, ValdiviesoCardenas G, Vega-Gonzalez I & Granados-Garcia M. Whole-body (18)F-FDG PET/CT in primary non-Hodgkin’s lymphoma of the thyroid associated with Hashimoto’s thyroiditis and bilateral kidney infiltration. Revista Española de Medicina Nuclear 2008 27 34–39. (https://doi.org/10.1157/13114368)
Mizokami T, Hamada K, Maruta T, Higashi K, Yamashita H, et al. (2016) Development of primary thyroid lymphoma during an ultrasonographic follow-up of Hashimoto’s thyroiditis: a report of 9 cases. Intern Med 55: 943-948
Zhang L, Castellana M, Virili C, et al. Fine-needle aspiration to diagnose primary thyroid lymphomas: A systematic review and meta-analysis. Eur J Endocrinol 2019;180:177-87.
Calandra DB, Shah KH, Lawrence AM, Paloyan E. Total thyroidectomy in irradiated patients. A twenty-year experience in 206 patients. Ann Surg. 1985;202(3):356-360. doi:10.1097/00000658-198509000-00013
Pedersen RK, Pedersen NT. Primary non-Hodgkin's lymphoma of the thyroid gland: a population based study. Histopathology. 1996;28(1):25-32. doi:10.1046/j.1365-2559.1996.268311.x
E. S. Jaffe, “)e 2008 WHO classification of lymphomas: implications for clinical practice and translational research,” Hematology, vol. 2009, no. 1, pp. 523–531, 2009
Graff-Baker A, Roman SA, Thomas DC, et al. Prognosis of primary thyroid lymphoma: Demographic, clinical, and pathologic predictors of survival in 1,408 cases. Surgery 2009;146:1105-15.
Ohsawa M, Noguchi S, Aozasa K. Immunologic type of thyroid lymphoma in an adult T-cell leukemia endemic area in Japan. Leuk Lymphoma. 1995;17(3-4):341-344. doi:10.3109/10428199509056842
Skarsgard ED, Connors JM, Robins RE. A current analysis of primary lymphoma of the thyroid. Arch Surg. 1991;126(10):1199-1204. doi:10.1001/archsurg.1991.01410340037006
Treglia G, Del Ciello A, Di Franco D. Recurrent lymphoma in the thyroid gland detected by fluorine-18-fluorodeoxyglucose PET/CT. Endocrine. 2013;43(1):242-243. doi:10.1007/s12020-012-9782-0
Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol. 2014;32(27):3059-3068. doi:10.1200/JCO.2013.54.8800
Tsang RW, Gospodarowicz MK, Sutcliffe SB, Sturgeon JF, Panzarella T, Patterson BJ. Non-Hodgkin's lymphoma of the thyroid gland: prognostic factors and treatment outcome. The Princess Margaret Hospital Lymphoma Group. Int J Radiat Oncol Biol Phys. 1993;27(3):599-604. doi:10.1016/0360-3016(93)90385-9
Matsuzuka F, Miyauchi A, Katayama S, et al. Clinical aspects of primary thyroid lymphoma: diagnosis and treatment based on our experience of 119 cases. Thyroid. 1993;3(2):93-99. doi:10.1089/thy.1993.3.93
Pyke CM, Grant CS, Habermann TM, Kurtin PJ, van Heerden JA, Bergstralh EJ, et al. Non-hodgkin’s lymphoma of the thyroid: is more than biopsy necessary? World J. Surg. (1992) 16:604–9; discussion 609–10. doi: 10.1007/BF02067333
Udelsman R, Chen H. The current management of thyroid cancer. Adv Surg. 1999;33:1-27.
Doria R, Jekel JF, Cooper DL. Thyroid lymphoma. The case for combined modality therapy. Cancer. 1994;73(1):200-206. doi:10.1002/1097-0142(19940101)73:1<200::aid-cncr2820730135>3.0.co;2-#
Ha CS, Shadle KM, Medeiros LJ, et al. Localized non-Hodgkin lymphoma involving the thyroid gland. Cancer. 2001;91(4):629-635.
Cha H, Kim JW, Suh CO, et al. Patterns of care and treatment outcomes for primary thyroid lymphoma: a single institution study. Radiat Oncol J. 2013;31(4):177-184. doi:10.3857/roj.2013.31.4.177
Vitolo U, Seymour JF, Martelli M, et al.: Extranodal diffuse large B-cell lymphoma (DLBCL) and primary mediastinal B-cell lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2016, 27:v91-v102. 10.1093/annonc/mdw175
Graff-Baker A, Sosa JA, Roman SA. Primary thyroid lymphoma: A review of recent developments in diagnosis and histology-driven treatment. Curr Opin Oncol 2010;22:17-22
