UNUSUAL MANIFESTATION OF MALIGNANCY Primary Thyroid Lymphoma Presenting With Stridor Sudha Sinha, MD, Leo Aish, MD, and Thein Hlaing Oo, MD, FRCP Key Words: thyroid lymphoma, stridor, non-Hodgkin lymphoma (Am J Clin Oncol 2005;28: 531–533) A 76-year-old white man with a history of hypothyroidism presented with hoarseness of voice, difficulty swallow- ing, and weight loss. He denied fevers or night sweats. Physical examination revealed a large, firm mass on the right side of the neck. Magnetic resonance imaging and computed tomographic scans of the neck revealed a 9.2  4.3  4.6-cm thyroid mass with extension into the pharynx, and mild airway obstruction below the vocal cords and in the trachea (Fig. 1). Within 2 weeks, the patient developed stridor and underwent an emergency tracheostomy and an open biopsy. Biopsy revealed diffuse, large B-cell lymphoma (Fig. 2). Staging procedures confirmed stage IE disease. He was treated with 6 cycles of chemotherapy with rituximab, cyclophosphamide, Adriamycin, vincristine, and prednisone (RCHOP), and involved field radiotherapy, achieving a com- plete remission. He has remained in remission for 18 months. Primary thyroid lymphoma constitutes 5% of all thy- roid malignancies and less than 1% of all cases of non- Hodgkin lymphoma (NHL). 1 Twelve cases of thyroid lym- phoma complicated by stridor have been previously reported in detail in the English literature. Table 1 provides a summary of these patients. Nine patients required a surgical procedure to relieve the stridor. Of note, 2 patients required a cardio- pulmonary bypass due to severe supraglottic edema preclud- ing an endotracheal intubation. Ten patients had associated Hashimoto thyroiditis or hypothyroidism. 2 The most com- mon presentation of primary thyroid lymphoma is a rapidly growing mass in the thyroid gland. Obstructive symptoms such as hoarseness, dysphagia, dyspnea, stridor, and superior vena cava syndrome are not uncommon. 3 Thyroid lymphoma should be considered in the differential diagnosis of any patient with a history of thyroiditis, hypothyroidism, a rapidly growing neck mass, and stridor. Early diagnosis may prevent the need for debulking surgery and tracheotomy and its related morbidities. There is no randomized data available on the optimal treatment of localized thyroid lymphoma. The Southwest Oncology Group study has clearly established that 3 cycles of CHOP followed by involved field radiotherapy are superior to 8 cycles of CHOP alone in the treatment of localized nonbulky aggressive NHL. 4 Although there are no data on the number of patients with thyroid lymphoma in this study, the results are likely applicable to patients with local- ized primary thyroid lymphoma. Given the bulky tumor in our patient, we elected to treat him with 6 cycles of RCHOP and radiotherapy. REFERENCES 1. Ansell SM, Grant CS, Habermann TM. Primary thyroid lymphoma. Semin Oncol. 1999;26:316 –323. 2. Sinha S, Natarajan N, Aish L, et al. Primary thyroid lymphoma should be considered as a differential diagnosis in patients with a rapidly growing neck mass and stridor. Blood. 2003;102:263b. 3. Van Ruiswyk J, Cunnigham C, Cerletty J. Obstructive manifestations of thyroid lymphoma. Arch Intern Med. 1989;149:1575–1577. 4. Miller TP, Dahlberg S, Cassady JR, et al. Chemotherapy alone compared to chemotherapy plus radiotherapy for localized intermediate- and high- grade non-Hodgkin’s lymphoma. N Engl J Med. 1198;339:21–26. From the Caritas St Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, Massachusetts. Presented as a published abstract at the 45th annual meeting of the American Society of Hematology. Reprints: Thein H. Oo, MD, Caritas St Elizabeth’s Medical Center, 736 Cambridge Street, Boston, MA 02135. E-mail: theinoo@pol.net. Copyright © 2005 by Lippincott Williams & Wilkins ISSN: 0277-3732/05/2805-0531 DOI: 10.1097/01.coc.0000160066.97299.a6 American Journal of Clinical Oncology • Volume 28, Number 5, October 2005 531