10.14639/0392-100X-N2286
Objectives. Primary thyroid lymphoma (PTL) is a rare malignant tumour. Prompt and accurate diagnosis and optimal airway management are crucial for PTL, especially when complicated with dyspnoea. Methods. Eight patients with PTL and dyspnoea treated in Beijing Friendship Hospital from January 2015 to December 2021 were retrospectively reviewed. Results. Three of four patients complicated with mild to moderate dyspnoea underwent chemotherapy after prompt diagnosis by fine needle aspiration cytology (FNAC) combined with cell block immunocytochemistry (CB-ICC) and flow cytometric immunophenotyping (FCI) or core needle biopsy (CNB) combined with immunohistochemistry (IHC) without open surgery. Total thyroidectomy was performed in one patient without other diagnostic methods because the FNAC result was inconclusive. Four patients with moderate to severe dyspnoea underwent tracheostomy and incisional biopsy without severe complications after tracheal intubation under the guidance of a fibreoptic bronchoscope performed without general anaesthesia. Conclusions. For patients with mild to moderate dyspnoea suspected of PTL, FNAC along with FCI and CB-ICC or CNB along with IHC are recommended, in addition to prompt chemotherapy to avoid prophylactic tracheostomy. Patients with moderate to severe dyspnoea suspected of PTL should undergo tracheal intubation under the guidance of a fibreoptic bronchoscope without general anaesthesia, followed by tracheostomy with simultaneous thyroid incisional biopsy to reduce the risk of asphyxia during treatment.
text/xml
1827-675X
2286
en
Liangfa liu
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
airway management
Prompt diagnosis and airway management for primary thyroid lymphoma with compromised upper airway: a single-institution case series
Text.Serial.Journal
https://www.actaitalica.it/
43
Thyroid
2023-04-26
2022-08-21
2023-04-27
2023-04-27
108-113
1
Liangfa liu
2023/04/26
10.14639/0392-100X-N2286
108
Department of Otolaryngology-Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
1827-675X
airway management
en
113
Prompt diagnosis and airway management for primary thyroid lymphoma with compromised upper airway: a single-institution case series
https://www.actaitalica.it/article/download/2286/956
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:108-113; doi: 10.14639/0392-100X-N2286




Thyroid


Prompt diagnosis and airway management for primary
thyroid lymphoma with compromised upper airway:
a single-institution case series
Diagnosi tempestiva e gestione delle vie aeree nel linfoma primario della tiroide con
compromissione delle vie aeree superiori: casistica di una singola istituzione
Aobo Zhang, Mingzhen Zhao, Yanbo Dong, Shuoqing Yuan, Liangfa Liu
Department of Otolaryngology-Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China



SUMMARY
Objectives. Primary thyroid lymphoma (PTL) is a rare malignant tumour. Prompt and ac-
curate diagnosis and optimal airway management are crucial for PTL, especially when
complicated with dyspnoea.
Methods. Eight patients with PTL and dyspnoea treated in Beijing Friendship Hospital
from January 2015 to December 2021 were retrospectively reviewed.
Results. Three of four patients complicated with mild to moderate dyspnoea underwent chemo-
therapy after prompt diagnosis by fine needle aspiration cytology (FNAC) combined with cell
block immunocytochemistry (CB-ICC) and flow cytometric immunophenotyping (FCI) or core
needle biopsy (CNB) combined with immunohistochemistry (IHC) without open surgery. To-
tal thyroidectomy was performed in one patient without other diagnostic methods because the
FNAC result was inconclusive. Four patients with moderate to severe dyspnoea underwent tra-
cheostomy and incisional biopsy without severe complications after tracheal intubation under
the guidance of a fibreoptic bronchoscope performed without general anaesthesia.
Conclusions. For patients with mild to moderate dyspnoea suspected of PTL, FNAC along
with FCI and CB-ICC or CNB along with IHC are recommended, in addition to prompt
                                                                                                 Received: August 21, 2022
chemotherapy to avoid prophylactic tracheostomy. Patients with moderate to severe dysp-          Accepted: December 30, 2022
noea suspected of PTL should undergo tracheal intubation under the guidance of a fibreop-
tic bronchoscope without general anaesthesia, followed by tracheostomy with simultaneous         Correspondence
thyroid incisional biopsy to reduce the risk of asphyxia during treatment.                       Liangfa Liu
KEY WORDS: primary thyroid lymphoma, dyspnea, diagnosis, airway management                       Beijing Friendship Hospital, Capital Medical
                                                                                                 University, No. 95 Yong’an Road, Xicheng District,
                                                                                                 100050 Beijing, China
RIASSUNTO                                                                                        Tel. +86 13126606616
Obiettivo. Il linfoma tiroideo primitivo (PTL) è un tumore maligno raro. Una diagnosi            E-mail: liuliangfa301@263.net
accurata e tempestiva e una gestione appropriate delle vie aeree sono cruciali, specie in
caso di dispnea.                                                                                   How to cite this article: Zhang A, Zhao M, Dong
Metodi. Otto pazienti affetti da PTL e dispnea trattati presso il Beijing Friendship Hospital      Y, et al. Prompt diagnosis and airway manage-
da gennaio 2015 a dicembre 2021 sono stati retrospettivamente analizzati.                          ment for primary thyroid lymphoma with com-
Risultati. Tre dei quattro pazienti che presentavano dispnea lieve-moderata sono stati sotto-      promised upper airway: a single-institution case
posti a chemioterapia dopo diagnosi ottenuta tramite esame citologico su agoaspirato com-          series. Acta Otorhinolaryngol Ital 2023;43:108-
binato con immunoistochimica e immunofenotipizzazione con citometria di flusso, oppure             113. https://doi.org/10.14639/0392-100X-N2286
tramite esame istologico da agobiopsia (senza biopsia a cielo aperto). La tiroidectomia totale
è stata eseguita in un paziente perché l’agoaspirato era non dirimente. Quattro pazienti con     © Società Italiana di Otorinolaringoiatria
                                                                                                 e Chirurgia Cervico-Facciale
dispnea moderata-severa sono stati sottoposti a tracheotomia e biopsia senza complicanze
gravi dopo intubazione tracheale eseguita sotto guida fibroscopica col paziente sveglio.
                                                                                                                OPEN ACCESS
Conclusioni. Nei pazienti con dispnea lieve-moderata in cui vi è il sospetto clinico di PTL,
sono indicati l’agoaspirato o l’agobiopsia con rapido inizio della chemioterapia per evita-      This is an open access article distributed in accordance with
                                                                                                 the CC-BY-NC-ND (Creative Commons Attribution-Non-
re la tracheotomia. I pazienti con dispnea moderata-grave dovrebbero essere intubati sotto       Commercial-NoDerivatives 4.0 International) license. The
guida fibroscopica e successivamente sottoposti a tracheotomia e biopsia, al fine di evitare     article can be used by giving appropriate credit and mentio-
il rischio di asfissia durante la terapia.                                                       ning the license, but only for non-commercial purposes and
                                                                                                 only in the original version. For further information: https://
PAROLE CHIAVE: linfoma primario della tiroide, dispnea, diagnosi, gestione delle vie aeree       creativecommons.org/licenses/by-nc-nd/4.0/deed.en




108
                                                                                                                       Primary thyroid lymphoma with compromised upper airway




Introduction                                                                                       University, China. The electronic medical records database
                                                                                                   was searched with the keywords thyroid lymphoma and dysp-
Primary thyroid lymphoma (PTL) is a form of lymphoma in                                            nea. The exclusion criteria were: 1) a history of lymphoma in
the thyroid gland. It is a rare malignant disease and accounts                                     other parts of the body; 2) suspicious non-primary focus of
for 0.6%-5% of thyroid malignancies and approximately 2% of                                        thyroid when lymphoma was found; 3) dyspnoea not caused
extranodal lymphomas 1,2. Patients usually present with a pal-                                     by PTL; 4) incomplete data on diagnosis and treatment pro-
pable nodule in the thyroid or a rapidly enlarging neck mass,                                      cess. Eight patient files were retrieved. We analysed the clin-
causing local obstruction and infiltrative symptoms in more                                        icopathological data, especially the diagnostic process and
aggressive disease forms, including dysphagia, dyspnoea, stri-                                     airway management, and summarised our experience (Tab. I).
dor, hoarseness. 1-3. It can be difficult to distinguish PTL from
anaplastic thyroid carcinoma or Hashimoto thyroiditis (HT),                                        Results
even by ultrasonography or histomorphology 1,4,5. However, the
treatment and prognosis of the three conditions are quite dif-                                     All eight patients complained of a painless enlarged neck mass
ferent. Moreover, as PTL occurs relatively rarely, its accurate                                    with local compression symptoms, including dyspnoea, stridor,
diagnosis is usually made after surgical resection, increasing                                     hoarseness and dysphagia. Among these, four had pre-existing
the burden on patients and delaying optimal treatment 1-5.                                         nodules. The course of sudden enlargement of the neck mass
When PTL is complicated with dyspnoea, a rapidly enlarg-                                           was 4-8 weeks, and symptoms of dyspnoea occurred from
ing neck mass can even cause asphyxia. In such cases, prompt                                       several days to three weeks before hospital admission. Among
                                                                                                   the eight patients enrolled, seven were females (85.7%), with
and accurate diagnosis is crucial, and airway management can
                                                                                                   a median age of 72.5 years (range: 50-83 years); the median
be particularly difficult. Currently, no standard diagnostic and
                                                                                                   follow-up time was 33 months (range: 2-78 months). Seven pa-
treatment protocols are available for PTL. There are only a few
                                                                                                   tients (85.7%) had a history of HT, and the remaining had not
literature reports on such a condition, especially when compli-
                                                                                                   undergone HT-related laboratory tests. All the cases were non-
cated with dyspnoea. We, therefore, retrospectively analysed
                                                                                                   Hodgkin lymphoma (NHL): the histologic subtype of six cases
eight PTL patients with dyspnoea at our institution to summa-
                                                                                                   (75%) was diffuse large B-cell lymphoma (DLBCL), one was
rise our experience in its diagnosis and airway management.
                                                                                                   mucosa-associated lymphoid tissue (MALT) lymphoma with
                                                                                                   30% transformation to DLBCL and one was angioimmuno-
Materials and methods                                                                              blastic T-cell lymphoma (AITL). According to the Ann Arbor
We retrospectively reviewed the medical records of patients                                        Staging Classification, five cases (62.5%) were staged as IE-
diagnosed with PTL and dyspnoea from January 2015 to De-                                           IIE and three (37.5%) as IIIE-IVE. Mild dyspnoea was defined
cember 2021 at Beijing Friendship Hospital, Capital Medical                                        as tachypnea and shortness of breath, including failure to com-

Table I. Clinicopathological data of eight patients with a primary thyroid lymphoma.
 No.      Age/sex       Degree of        Stage       HT        Diagnostic        Histology                                  Therapy                 Follow-up         Recurrence/death
                        dyspnoea                              procedures                                                                            (months)
 1             77/F           Moderate             IIE        Yes         FNAC+FCI                DLBCL               Methylprednisolone                 52                   No/no
                                                                           +CB-ICC                                         R-COP*7
 2             63/F           Moderate             IE         Yes         FNAC+FCI                DLBCL               Methylprednisolone                 78                   No/no
                                                                           +CB-ICC                                        R-CHOP*6
 3             82/F              Mild             IVE         Yes         CNB+IHC                 DLBCL               Methylprednisolone                  8                    -/yes
                                                                                                                           R-COP*2
 4             59/F              Mild              IIE        Yes            FNAC;                DLBCL                       TT                         61                   No/no
                                                                              SE                                          R-CHOP*6
 5             83/F            Severe              IIE          -           IB+IHC                DLBCL                 Tracheostomy                     26                  Yes/yes
                                                                                                                           R-COP*4
 6             68/F         Moderate to            IIE        Yes            IB;                  MALT                  Tracheostomy                     40                   No/no
                              Severe                                       SE+IHC            lymphoma, 30%                   UTL;
                                                                                            transformation to             R-CHOP*8
                                                                                                 DLBCL
 7             50/F            Severe             IIIE        Yes           IB+IHC               DLBCL                   Tracheostomy                     2                    -/yes
 8             83/M           Moderate            IIIE        Yes           IB+IHC                 AITL                  Tracheostomy;                    3                    -/yes
                              To Severe                                                                                     CHOP*2
F: female; M: male; HT: Hashimoto thyroiditis; FNAC: fine needle aspiration cytology; CB-ICC: cell block immunocytochemistry; FCI: flow cytometric immunophenotyping; SE: surgical excision; IB:
incisional biopsy; TT: total thyroidectomy; UTL: unilateral thyroid lobectomy; DLBCL: diffuse large B-cell lymphoma; MALT: mucosa-associated lymphoid tissue; AITL: angioimmunoblastic T cell
lymphoma; R-CHOP: rituximab combined with cyclophosphamide, doxorubicin, vincristine, and prednisolone; R-COP: rituximab combined with cyclophosphamide, vincristine, and prednisolone.




                                                                                                                                                                                         109
A. Zhang et al.




plete sentences. Moderate dyspnoea was defined as stridor and     mide, doxorubicin, vincristine and prednisolone) combined
orthopnoea with intercostal, suprasternal and supraclavicular     with rituximab and/or radiotherapy was the standard chemo-
retractions. Severe dyspnoea was defined as restlessness and      therapy regimen. COP (cyclophosphamide, vincristine and
even cyanosis. Four cases (50%) had mild to moderate dysp-        prednisolone) combined with rituximab and/or radiotherapy
noea, and four (50%) had moderate to severe dyspnoea.             was administered to some elderly patients with heart diseases
                                                                  (No. 1, 3 and 5). The standard chemotherapy regimen was 6-8
Diagnostic process                                                cycles, except for two elderly patients (patients No. 3 and 5)
Fine needle aspiration cytology (FNAC) was the most com-          who could not endure the whole course of chemotherapy be-
monly used initial diagnostic method for thyroid nodules in       cause of adverse reactions. Patient No. 3 succumbed to the
the clinic. However, concerning patients highly suspected         disease due to a local invasion of the airway after 8 months;
of PTL only with mild dyspnoea, if routine blood evalua-          patient No. 5 died due to local and systemic relapse after 26
tion and coagulation tests were normal without receiving          months. The remaining four patients remain in remission with
antiplatelet or anticoagulation therapy, core needle biopsy       no local or systemic relapse, with a follow-up of 40-78 months.
(CNB) was preferred to obtain more tissues for diagnosis.         Regarding the AITL patient (No. 8), he succumbed due to lo-
For the four cases with mild to moderate dyspnoea, FNAC was       cal and systemic dissemination of the disease 3 months after
performed in three patients, which indicated a high suspicion     the final diagnosis, despite two courses of CHOP.
of thyroid lymphoma in two patients (No. 1 and 2). Cell-block
immunocytochemistry (CB-ICC) and flow cytometric immu-            Discussion
nophenotyping (FCI) of FNAC specimens were performed,
resulting in a final diagnosis of DLBCL. FNAC results were        PTL is a rare malignant disease that commonly occurs in
inconclusive, and total thyroidectomy was performed for the       middle-aged and elderly women, typically presenting with a
remaining one, for whom the diagnosis of PTL was unsus-           rapidly enlarging neck mass leading to compressive symp-
pected pre-operatively. CNB was performed in one of the four      toms 1-3,6. Most thyroid lymphomas are of B-cell origin and
cases (No. 3), and the final diagnosis was DLBCL based on         predominantly of the diffuse large-cell type. The second most
morphology and immunohistochemistry (IHC).                        common histologic type is MALT lymphoma. T-cell lympho-
The four cases with moderate to severe dyspnoea under-            ma is extremely rare and has a relatively poor prognosis 6-8.
went an incisional biopsy simultaneous with tracheostomy.         The risk of developing thyroid lymphoma is 67 times greater
Three patients were diagnosed with DLBCL or AITL based            in patients with HT than those with colloid goiter 9, and as
on morphology and IHC; the remaining one (No. 6) was              high as 90% of subjects with PTL have a positive history of
misdiagnosed with lymphocytic thyroiditis based on mor-           HT 10,11. In our cohort, similar to the previously reported litera-
phology. Unilateral thyroid lobectomy was then performed          ture, the median age was 72.5 years (range: 50-83 years); sev-
to obtain sufficient tissue from the central part of the le-      en of eight cases (85.7%) were females, with seven (85.7%)
sion. The final diagnosis was MALT lymphoma with 30%              having a history of HT. Histologic subtypes included DLBCL
transformation to DLBCL based on morphology and IHC.              (75%), MALT lymphoma (12.5%), and AITL (12.5%). PTL
                                                                  should always be suspected in elderly women with a history of
Airway management and treatment                                   HT complaining of a rapidly enlarging thyroid mass.
All patients were treated with supplemental oxygen during         Recent onset of symptoms or rapid enlargement of a painless
hospitalisation. Regarding the four cases with mild to moderate   pre-existing thyroid mass is the hallmark of PTL and anaplas-
dyspnoea, three patients with suspected lymphoma were given       tic thyroid carcinoma 2,3,6,7,11. It can be difficult to distinguish
intravenous methylprednisolone (40 mg daily) while awaiting       PTL from anaplastic thyroid carcinoma, even by ultrasonog-
biopsy results to avoid prophylactic tracheostomy (No. 1, 2,      raphy or histomorphology. As PTL occurs relatively rarely, the
and 3). All four cases with moderate to severe dyspnoea under-    diagnosis is often overlooked 1-5. In our cohort, the course of
went tracheostomy to prevent asphyxia. Before surgery, trache-    sudden enlargement of the neck mass was 4-8 weeks, and the
al intubation was performed under the guidance of a fibreoptic    symptoms of dyspnoea occurred from several days to three
bronchoscope without general anaesthesia (Fig. 1). The tumour     weeks before hospital admission. Four patients were com-
was significantly reduced after two rounds of chemotherapy,       plicated with mild to moderate dyspnoea and the others with
and partial remission was achieved. In addition, decannulation    moderate to severe dyspnoea. Since the treatment and progno-
and primary closure of tracheocutaneous fistulae (TCF) were       sis of PTL and anaplastic thyroid carcinoma are quite differ-
performed in two cases (No. 5 and 6).                             ent, and the upper airway obstruction can be life-threatening,
Chemotherapy was undertaken immediately after the final           prompt and accurate diagnosis is crucial.
diagnosis based on histology, clinical stage, performance sta-    Airway management is a primary concern for patients with
tus, etc., except for one patient who refused further treatment   moderate to severe dyspnoea in whom thyroid lymphoma is
(No. 7) and succumbed to the disease two months after trache-     suspected. Incisional biopsy is performed for the diagnosis si-
ostomy. For the CD20+ B-cell NHL, CHOP (cyclophospha-             multaneous with tracheostomy. FNAC is usually performed



110
                                                                                                  Primary thyroid lymphoma with compromised upper airway




Figure 1. Airway management of primary thyroid lymphoma with moderate to severe dyspnoea (patient No. 7). A. Coronal view of CT scan showing the entire
upper airway (arrow) compressed by the huge neck mass. B. Axial view of CT scan showing huge neck mass compression of the upper airway, resulting in signifi-
cant airway stenosis. The transverse diameter of the narrowest upper airway is only 3 mm (arrow). C. The appearance of the patient showing obvious swelling in
the anterior neck and left supraclavicular fossa.


for the initial diagnostic workup of a thyroid nodule, espe-                     suspected cases of NHL, especially when an open biopsy is
cially in patients with mild to moderate dyspnoea suspected of                   not possible. NHL can be sub-classified in most cases 4,12-15.
having thyroid lymphoma, due to its advantages since it is less                  However, this is not a routine procedure, and the yield from
invasive and does not tend to aggravate dyspnoea. However,                       FNAC may not be representative or insufficient for further
cytology has limitations in diagnosing thyroid lymphoma. It is                   diagnosis 6,16. CNB could obtain more tissue for thyroid lym-
difficult to differentiate thyroid lymphoma from lymphocytic                     phoma, with a higher diagnostic sensitivity than FNA (93%
thyroiditis and anaplastic carcinoma, especially in patients                     vs 71%, p = 0.006) 2. However, several potential complica-
with a history of HT 2,4,5. Cases of high-grade thyroid lym-                     tions have been reported, such as haematoma, voice change,
phoma can be confused with anaplastic carcinoma 4,6, but for                     infection, oedema, vasovagal reaction, haemoptysis and dys-
low-grade (MALT) thyroid lymphoma, cytology and histol-                          phagia 16. When PTL is associated with airway compromise,
ogy may be insufficient for diagnosis 2,5. This happened, for                    CNB may exacerbate dyspnoea or even cause asphyxia due
example, in case No. 6 of our series, in which an incisional                     to secondary haemorrhage and airway oedema. Based on the
biopsy was performed simultaneous with tracheostomy, and                         above factors, we need to weigh the pros and cons in real-time
it was still misdiagnosed as HT by histology. She had to un-                     in clinical practice. It is imperative to fully communicate with
dergo unilateral thyroid lobectomy, and the final diagnosis                      patients about the possible risks and benefits of diagnostic
was MALT lymphoma by IHC. Obtaining specimens only                               methods. In our unit, FNAC is a routine diagnostic method for
from the superficial surface of the thyroid without IHC at the                   thyroid nodules without the need for coagulation screening,
same time may lead to misdiagnosis. In recent years, FCI and                     as the most commonly used initial diagnosis method in the
CB-ICC have been gradually applied in clinical practice be-                      clinic. For patients who were clinically highly suspected of
cause they are feasible on FNA specimens and very useful in                      PTL only with mild dyspnoea, if routine blood evaluation and



                                                                                                                                                        111
A. Zhang et al.




coagulation tests were normal without receiving antiplatelet        (as observed in patient No. 6). At the same time, thyroidec-
or anticoagulation therapy, CNB would be preferred to obtain        tomy may have a therapeutic value for high-risk patients with
more tissues for diagnosis. In our cohort, three patients un-       lymphoma showing low-grade malignancy, who are unlikely
derwent FNAC, with two suspected of thyroid lymphoma; the           to endure chemotherapy or radiation therapy 1. Patients who
third was inconclusive. Using FCI along with CB-ICC, two            have undergone complete resection of the lymphoma often
patients (No. 1 and 2) were diagnosed with DLBCL. Redo bi-          have a better course than those without resection 18. A study
opsy was avoided, and appropriate chemotherapy was admin-           of 62 patients from the Mayo Clinic concluded that thyroidec-
istered in time without prophylactic tracheostomy. Case No. 3       tomy with adjuvant chemotherapy provided a long-term cure
of our series was promptly diagnosed with DLBCL by CNB              for PTL within the thyroid capsule 19. The opponents argue
along with IHC. Regarding patients with moderate to severe          that the role of surgery for thyroid PTL in stages IE and IIE
dyspnoea, it is necessary to perform an incisional biopsy from      is still unclear, as survival rates do not seem to improve when
the centre of the lesion and combine several diagnostic meth-       radical surgery is added to other treatment modalities 7. Based
ods to avoid misdiagnosis. Multidisciplinary cooperation with       on our experience, most PTL cases complicated with dysp-
a pathologist is also important to reach an accurate diagnosis.     noea have relatively high-grade histology and advanced stage,
Appropriate glucocorticoids can be administered for patients        and thyroidectomy may increase the risk of laryngeal nerve
suspected of PTL, pending final diagnosis. Glucocorticoid ad-       paralysis and post-operative hypoparathyroidism due to the
ministration can rapidly improve symptoms, which may be an          infiltration of local tissues. Therefore, as therapy surgery may
important clinical finding, aiding in the diagnosis of PTL 17.      not be very beneficial. Meyer-Rochow et al. 20 demonstrated a
It is possible to avoid prophylactic tracheostomy, especially       clear transition from excisional surgery to surgery as a diag-
in patients with mild to moderate dyspnoea (patients No. 1,         nostic procedure during the 1980s due to the impact of FNAC.
2, and 3). Tracheostomy under local anaesthesia or routine          Graff-Baker et al. 19 reported that the use of excisional surgery
tracheal intubation is risky when a considerable thyroid mass       for PTL has declined from 81% of patients in 1973-1987 to
compresses the upper airway. In patients with moderate to           61% in 1997-2005 in the United States. Hyejung-Cha et al. 21
severe dyspnoea suspected of PTL, we suggest that tracheal          reported that surgery was not the main treatment option after
intubation should be carried out under the guidance of a fibre-     2006, and non-surgical treatment, including chemotherapy
optic bronchoscope without general anaesthesia. After general       and/or RT, has become the mainstay of treatment in recent
anaesthesia, tracheostomy should be performed with thyroid          years, depending on the histologic subtype.
incisional biopsy simultaneously to reduce the risk of asphyx-      Therefore, nowadays, the mainstay treatment for PTL is
ia during treatment. Usually, DLBCL responds relatively well        considered to be chemotherapy and/or radiotherapy, with the
to chemotherapy, and the tumour size can be reduced dramati-        outcomes depending on the stage of disease, infiltration of
cally after several courses 17. In our cohort, four patients with   local organs, histology and the patient’s performance 18,19,22.
moderate to severe dyspnoea underwent tracheostomy with-            Treatment combinations should be tailored to each patient
out severe complications. Except for one case of abandonment        with adjustments for these prognostic factors. In our cohort,
of chemotherapy and one case of AITL with poor response to          those patients who underwent the whole course of chemo-
chemotherapy, the other two patients underwent decannula-           therapy (patients No. 1, 2, 4, and 6) achieved complete re-
tion and primary closure of TCF under local anaesthesia after       mission without relapse after 40-78 months. Those patients
two courses of chemotherapy. The benefits of tracheostomy           who failed to complete the whole course of chemotherapy or
obviously outweighed the possible risk of asphyxia during           had no further treatment (patients No. 3, 5, and 7) suffered
treatment and the economic burden. It should be emphasised          relapses or rapid progression and death. However, regarding
that the large cervical mass can increase the distance between      AITL (patient No. 8), he succumbed to the disease 3 months
the cervical skin and the anterior tracheal wall, increasing the    after the final diagnosis, despite undergoing chemotherapy.
risk of post-operative tube displacement or accidental extuba-
tion. Therefore, we recommend tracheostomy instead of rou-          Conclusions
tine tracheotomy. The isthmus of the thyroid should be excised      PTL should always be suspected in elderly women with a
and the surrounding skin defatted and sutured to the tracheos-      history of HT, complaining of a rapidly enlarging thyroid
toma circumferentially, making reintubation safer in the event      mass. For patients with mild to moderate dyspnoea sus-
of accidental extubation, with less susceptibility to maceration    pected of PTL, FNAC along with FCI and CB-ICC or CNB
and infection around the tracheostoma.                              along with IHC are recommended as the preferred diagnostic
The value of surgery in diagnosis and treatment is contro-          tools. Chemotherapy should be instituted promptly to avoid
versial. Those favouring surgery conclude that lobectomy            prophylactic tracheostomy. For patients with moderate to se-
or total thyroidectomy facilitates obtaining a large amount         vere dyspnoea suspected of PTL, tracheal intubation should
of tissue from the central part of the lesion, contributing to a    be performed without general anaesthesia under the guid-
more accurate diagnosis, especially in low-grade lymphomas          ance of a fibreoptic bronchoscope. Tracheotomy should then



112
                                                                                                   Primary thyroid lymphoma with compromised upper airway




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                                                                                      Watanabe N, Noh JY, Narimatsu H, et al. Clinicopathological features
project (grant number YJKYYQ20180039) and Digestive                                   of 171 cases of primary thyroid lymphoma: a long-term study involving
Medical Coordinated Development Center of Beijing Munic-                              24,553 patients with Hashimoto’s disease. Br J Haematol 2011;153:236-
ipal Administration of Hospitals (grant number XXZ0604).                              243. https://doi.org/10.1111/j.1365-2141.2011.08606.x
                                                                                 12
                                                                                      Suzuki A, Hirokawa M, Kanematsu R, et al. B-cell to T-cell ratio as a
Author contributions                                                                  novel indicator in flow cytometry in the diagnosis of thyroid lymphoma.
                                                                                      Endocr J 2022;69:291-297. https://doi.org/10.1507/endocrj.EJ21-0451
AZ, LL: conceived and designed the research; AZ, MZ: re-                         13
                                                                                      Barrena S, Almeida J, Del Carmen García-Macias M, et al. Flow cytom-
trieved patients’ data; AZ, YD, SY: prepared figures and                              etry immunophenotyping of fine-needle aspiration specimens: utility in
tables; AZ, LL: drafted, edited, and revised the manuscript.                          the diagnosis and classification of non-Hodgkin lymphomas. Histopathol-
All Authors read and approved the manuscript and agree to                             ogy 2011;58:906-918. https://doi.org/10.1111/j.1365-2559.2011.03804.x
be accountable for all aspects of the research in ensuring                       14
                                                                                      Oh EJ, Hong SW, Jeong H-J, et al. The diagnostic approach to fine-needle
                                                                                      aspiration of malignant lymphoma: using cytomorphology and immuno-
that the accuracy or integrity of any part of the work are                            cytochemistry with cell transfer method. Diagn Cytopathol 2014;42:671-
appropriately investigated and resolved.                                              679. https://doi.org/10.1002/dc.23110
                                                                                 15
                                                                                      Tuhin P, Upasana G, Arvind R, et al. Flow cytometric immunopheno-
Ethical consideration                                                                 typing and cell block immunocytochemistry in the diagnosis of pri-
This study was approved by the Institutional Ethics Com-                              mary Non-Hodgkin’s Lymphoma by fine-needle aspiration: experi-
mittee of Beijing Friendship Hospital, Capital Medical Uni-                           ence from a tertiary care center. J Cytol 2014;31:123-130. https://doi.
                                                                                      org/10.4103/0970-9371.145577
versity. The research was conducted ethically, with all study                    16
                                                                                      Matrone A, De Napoli L, Torregrossa L, et al. Core needle biopsy can early
procedures being performed in accordance with the require-                            and precisely identify large thyroid masses. Front Oncol 2022;12:854755.
ments of the World Medical Association’s Declaration of                               https://doi.org/10.3389/fonc.2022.854755
Helsinki. Written informed consent was obtained from each                        17
                                                                                      Eng OS, Lesniak S, Davidov TZ, et al. Diagnosing thyroid lymphoma:
patient for study participation and data publication.                                 steroid administration may result in rapid improvement of dyspnea : a
                                                                                      report of two cases. Int J Endocrinol Metab 2014;12:e11463. https://doi.
                                                                                      org/10.5812/ijem.11463
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