
==== Front
Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00790-9
10.1016/j.ijscr.2024.110009
110009
Case Report
Concurrent identification of follicular lymphoma and papillary thyroid carcinoma
Alzelfawi Lama A. a1
ALhumaidan Norah a2
Alageel Abrar H. b
Yahya Buthaina J. c3
Alrasheedi Saud D. d4
Alqahtani Adel S. adil4470@gmail.com
d⁎
a College of Medicine, Princess Noura Bint Abdulrahman University, Riyadh, Saudi Arabia
b General Surgery Department, Security Forces Hospital, Riyadh, Saudi Arabia
c Otolaryngology-Head and Neck Surgery Department, King Fahad Medical City, Riyadh, Saudi Arabia
d Breast and Endocrine Surgery Department, Security Forces Hospital, Riyadh, Saudi Arabia
⁎ Corresponding author at: Breast and Endocrine Surgery Consultant, General Surgery Department, Security Forces Hospital, Riyadh, Saudi Arabia. adil4470@gmail.com
1 Authors details: Lama A.Alzelfawi, Medical Student at Princess Noura bint Abdulrahman University, Riyadh, Saudi Arabia.

2 Authors details: Norah ALhumaidan, Medical Student at Princess Noura bint Abdulrahman University, Riyadh, Saudi Arabia.

3 Authors details: Buthaina J. Yahya, Otolaryngology-Head and Neck Surgery Resident, At King Fahad Medical City, Riyadh, Saudi Arabia.

4 Authors details: Saud D. Alrasheedi, Breast and Endocrine Surgery Consultant, General surgery Department at Security forces Hospital, Riyadh, Saudi Arabia.

06 7 2024
9 2024
06 7 2024
122 11000916 5 2024
30 6 2024
4 7 2024
© 2024 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

PTC has high lymph node metastasis, affecting central and lateral lymph nodes. On the other hand, follicular lymphoma is the second most frequent non-Hodgkin lymphoma in the West and affects cervical lymph nodes.

Case presentation

A 66-year-old Saudi man with type 2 diabetes and hypertension presented with neck lumps on both sides of his neck. The swelling was progressive, with no apparent cause, no history of hypothyroidism or hyperthyroidism, and no constitutional symptoms. Physical examination revealed multiple lymph node enlargements and a hard, firm mass on his thyroid gland.

Clinical discussion

Multiple malignant neoplasms are rare, but secondary primary cancers have been documented in patients with PTC. The occurrence of both cancers is commonly detected during follow-up and aided by modern imaging techniques. The main treatment for PTC is surgery, usually with a good prognosis.

Conclusion

A 66-year-old male was diagnosed with follicular lymphoma during a papillary thyroid carcinoma workup, emphasizing the importance of careful lymph node dissection and microscopic examination for rare cases.

Highlights

• A case report that shows incidental follicular carcinoma during the workup for papillary thyroid carcinoma.

• The importance of careful lymph node dissection and microscopic examination of the lymph nodes helped with the diagnosis of follicular carcinoma that was through lymph node dissection for papillary thyroid carcinoma.

Keywords

Papillary thyroid carcinoma
Follicular lymphoma
Lymph node tumor
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pmc1 Introduction

Currently, thyroid cancer (TC) is the most common endocrine cancer [1]. Papillary thyroid carcinoma (PTC) is considered the most common type of thyroid malignancy, representing 80 % of thyroid cancers [2], and its rate of lymph node metastasis is high [3]. This metastasis initially affects the central lymph node, then the lateral lymph nodes [4]. On the other hand, follicular lymphoma (FL) is a lymphoproliferative disease characterized by altered follicular center B lymphocytes [5] and it is the most frequent non-Hodgkin lymphoma (NHL) of the indolent B-cell type, making for around 25 % of all instances [6]. The most affected regions are cervical and inguinal lymph nodes [7]. The presence of synchronous tumors in patients suffering from PTC has been detected in previous literature [8]. Nonetheless, the cases of lymphoma diagnosed through lymph node dissection in patients with PTC are few [9]. Here we present an example of the two synchronous cancers in a 66-year-old gentleman.

2 Case presentation

2.1 Chief complaint

A case of 66-year-old Saudi man, a known case of type 2 diabetes mellitus and hypertension presented to the clinic with a history of neck lumps for a few months (less than 6 months) on both sides of his neck.

This case report has been reported in line with the SCARE criteria [10].

2.2 History of present illness

The neck swellings were multiple and beads-like swellings, progressive with no apparent cause, and no other swellings were noted on his body. The swelling was associated with dull aching, not radiated, and no reliving or aggravating factors. However, the swelling was not associated with trauma. No history of exposure to radiation or smoking, and no history of compressive symptoms such as no dysphagia or dyspnea. Additionally, the patient was not complaining of clinical presentation of hypothyroidism or hyperthyroidism such as no loss or gain weight, no palpitation, no sweating, and no heat or cold intolerance. Moreover, the patient denied any presence of constitutional symptoms such as weight changes, change in appetite, fever, night sweats, or fatigue. Also, unremarkable systemic review.

2.3 History of past illness

He was only on oral hypoglycemic medication and HTN medication. Also, he has no allergies to medications or food.

2.4 Personal and family history

He had tonsillectomy 40 years back with no complications. The patient denied any thyroid cancer or other type of cancer in his family.

2.5 Physical examination

His physical condition was generally well, vitally stable, with no visible neck swelling on inspection. Local physical examination of the lumps showed multiple lymph node enlargements bilaterally, along with a hard, firm palpable mass on the right thyroid gland about 2 cm each, firm in consistency, not mobile, with no skin changes or tenderness over it and multiple cervical lymphadenopathies on Rt side.

2.6 Laboratory examinations

The results of routine blood tests and thyroid hormone levels were negative.

2.7 Imaging examinations

Fig. 1 shows a US that revealed a bulky thyroid gland with heterogeneous nodular parenchymal echotexture. Multiple nodules are seen, bilateral, variable in size, and in echogenicity. The most pronounced nodule on the right lobe appears hypoechoic and ill-defined with peripheral rim of calcification measuring about 14 × 13 mm, consistent with TR-4. However, the most pronounced one on the left lobe appears well-defined and heterogeneous, taller than wider with no apparent calcification measuring about 11 × 8 mm, consistent with TR-4. Multiple bilateral enlarged cervical lymph nodes are seen which are suspicious. The largest on the right-side measures about 30 × 10 mm while the largest on the left side measures about 23 × 5 mm.Fig. 1 Ultrasound of the thyroid (A),(B),(C),(D). All images revealed a bulky thyroid gland with heterogeneous nodular parenchymal echotexture.

Fig. 1

2.7.1 Fine needle aspiration (FNA)

FNA from the right lobe showed papillary thyroid carcinoma (BETHESDA VI).

2.7.2 Computed tomography (CT)

Fig. 2 is a CT scan of chest abdomen and pelvis showed heterogeneous thyroid with multiple calcified and hypovascular nodules. Multiple enlarged right cervical lymph nodes in Ib, IIb and Va levels. Multiple enlarged upper abdominal, para-aortic and inguinal lymph nodes concerning for lymphoma or less likely metastatic lymph nodes.Fig. 2 CT scan of the Neck and thyroid with multiple calcified and hypovascular nodules.

Fig. 2

2.8 Treatment

Patient was seen and advised to go for surgery, and he underwent total thyroidectomy with bilateral modified radical neck dissection. He tolerated the procedure well with no intra-operative or post-operative complications. Until he became in good condition, he was discharged few days post-operatively. Two weeks after the surgery, he presented to the clinic, and we discussed with him the final histopathology results.

2.9 Primary diagnosis

2.9.1 Final histopathology report

Histopathology conveyed the following results.

Right and left thyroid lobes with isthmus showed papillary thyroid carcinoma, the classic type, multifocal, tumor size 2.5 cm. Two out of three lymph nodes in Level II showed metastatic papillary thyroid carcinoma. On the other hand, the right neck lymph node, right and left internal jugular lymph nodes all reveled follicular lymphoma, grade 3 A, negative for metastasis. Tracheal lymph node reveled follicular lymphoma and the largest lymph node was 3 cm. Extra nodal extension was not identified. Papillary thyroid cancer in one out of 35 lymph nodes at the right lateral level V and the size of the largest lymph node involved was 3 cm (Fig. 3, Fig. 4).Fig. 3 These two images show thyroid nodules that were showing papillary proliferation (A), and closer in (B) it shows typical features of papillary carcinoma, mainly nuclear clearing.

(A) image show thyroid nodules that were showing papillary proliferation.

(B) image shows thyroid nodules that were showing papillary proliferation. Closer in.

Fig. 3

Fig. 4 These 2 images from follicular lymphoma, (A) Low-power image showing loss of architecture and nodular proliferation of lymphoid cells. (B) These cells are mainly composed of centrocyctic type.

(A) Low-power image showing loss of architecture and nodular proliferation of lymphoid cells.

(B) These cells which are mainly composed of centrocyctic type.

Fig. 4

2.10 Outcome and follow-up

Diagnosis was made up by ultrasound of the thyroid gland, FNAC, or diagnostic lobectomy in the case of follicular neoplasia, with normal TSH and ‘cold’ appearance at thyroid scan.

Post-operative follow-up was referral to oncology clinic, hematology clinic for lymphoma treatment options, endocrinology clinic, and regular follow up in breast and endocrine surgery clinic.

3 Discussion

It is rare to find case reports describing patients with multiple malignant neoplasms, and many questions about their pathogenesis remain unanswered [11]. Nonetheless, secondary primary cancers have been documented increasingly in several studies in patients who suffer from PTC [12]. Additionally, although it has been suggested in these studies that first-degree family history of neoplasia and younger age at PTC diagnosis are factors influencing these synchronous malignancies, the common factor found to be associated with increased risk of cooccurring of PTC and FL is radiotherapy [13] [14]. Yet very few numbers of patients have been reported to have both with no history of exposure to radiotherapy [15].

Furthermore, the occurrence of papillary thyroid cancer and follicular cancers together is commonly detected during follow-up and aided by the increased use of modern imaging techniques for diagnosis [16]. Moreover, a biopsy of lymph node or other affected tissue typically determines the diagnosis of FL [17], though interestingly in this case, it has been initially detected through lymph node dissection like a previous case report which diagnosed a Hodgkin lymphoma the same way [10]. This highlights the importance of careful dissection for both treatment and diagnosis of other malignancies.

The mainstay treatment for PTC is surgery which can be total thyroidectomy or lobectomy [18], and the prognosis of patients who underwent surgery is considered good generally [19]. In the early stages of FL (I and II), it is recommended to use radiotherapy in combination with an anti-CD 20 antibody which can potentially be curative, whilst in the late stages (III and IV), treatment aims to alleviate disease-related symptoms and prolong survival rather than cure it [20].

Currently, there is no consensus regarding the treatment of concomitant PTC and FL due to the limited number of reported cases and the lack of data for post-treatment outcomes. In this case, the treatment for PTC was initiated first by performing a total thyroidectomy as the diagnosis for FL was not yet established, then he was referred to an oncology clinic for treatment of lymphoma.

4 Conclusion

We presented the case of a 66-year-old male who was incidentally diagnosed with follicular lymphoma during the workup for papillary thyroid carcinoma. This case underlines the importance of careful lymph node dissection and microscopic examination of the lymph nodes. The diagnosis of follicular lymphoma was through lymph node dissection for papillary thyroid carcinoma is extremely rare. This underlines the singularity and the importance of our case.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical clearance was not required in SFH for the single case being reported. We usually submit proposals to SFH for ethical clearance of research projects (case-series, cross-sectional or any study design that includes many patients).

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Lama A.Alzelfawi: Data collection, data interpretation, revision, writing the paper, drafting, approval of final manuscript.

Norah ALhumaidan: Data collection, data interpretation and analysis, drafting, revision, writing the paper, approval of final manuscript.

Abrar H. Alageel: Data collection, approval of final manuscript.

Buthaina J. Yahya: Data collection, approval of final manuscript.

Saud D. Alrasheedi: Concept and design of study,revision, approval of final manuscript.

Adel S. Alqahtani: Concept and design of study, revision, approval of final manuscript.

Guarantor

None.

Research registration number

NA, Not applicable.

Declaration of generative AI and AI-assisted technologies in the writing process

All authors disclose any use of generative AI and AI-assisted technologies.

Conflict of interest statement

All authors declare that there are no competing financial interests.

Data availability

The datasets in the current study are available from the corresponding author upon reasonable request.
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