An 81-year-old woman with moderate cognitive impairment due to Alzheimer's disease and a history of previous cervical node researched 3 months prior to admission, who grew rapidly in the last three weeks, consulting for dyspnea at rest, ortopnea.
He was studied in another center, with cervical ultrasound showing increased thyroid volume, TSH of 32.4 mIU/ml and anti-TPO antibodies (++).
Four thyroid punctures were performed, three of them with insufficient sample and the last one was informed as chronic thyroiditis.
Cervical computed tomography (CT) reported a large mass replacing the thyroid gland, muscles and adjacent skin and surrounding the right cervical vascular package.
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In October 2004, the patient presented to our hospital with a two-week history of dyspnea that progressed to dyspnea at rest.
On physical examination, the patient was anxious, wet and multiple aphthous, tachypneic, with traction, laryngeal stridor and an increase in the right lateral cervical adnexal volume of 10 cm.
Normal oxygen saturation
Laboratory tests showed sedimentation rate (SSR) of 78 mm/h and LDH of 436 U/L. Blood count, biochemical profile, renal function and coagulation tests within normal ranges.
The patient was hospitalized with a diagnosis of anterior cervical tumor, possibly anaplastic thyroid cancer and secondary airway obstruction.
Tumor resection was proposed for management of the obstructive emergency.
In the operating room, a nasopharyngeal tube without pathological findings was performed and fibrobronchoscopy (FBC) showed a thyroid level of severe fibrobronchoscope, guided intubation guided by endotracheal stenosis or obstruction of the trachea.
During the surgical procedure, it was observed the presence of nonsteroidal musculature secondary to an underlying tumor, which was large, encephaloid, highly vascularized and poorly defined.
Thyroid isthmectomy was performed in order to locate the airway and establish the stenosis.
The trachea was markedly deviated to the left and very deep, 12 cm under the skin plane, and it was impossible to install a tracheostomy tube, so an orotracheal tube N° 5.5 was used.
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The anatomopathological examination reported "lymphoid cell proliferation, arranged in medium and large sheets, irregular nuclei and hypercalcified plasmatic tissue, eosinophilic nucleoplasma associated with little prominent infiltrate and scarce neoplasia
Immunohistochemistry revealed common leukocyte antigen (+), CD20 (+) focally, vimentin (+), keratin (-), BCL2 (-), CD10 (-), CICLINA DI.
Definitive diagnosis: diffuse large B-cell non-Hodgkin lymphoma of the thyroid.
The patient recovered well in the postoperative period, except for purulent bronchorrhea due to multisensitive Pseudomona aeruginosa that was treated with antibiotics.
A nasojejunal tube was installed to start progressive feeding.
Evaluated by pathology, they requested a staging study that ruled out other tumor foci, confirming the primary thyroid origin of lymphoma.
Chest CT showed a remaining tumor partially surrounding the trachea and right paratracheal lymph nodes 1-2 cm in diameter.
Definitive treatment with CHOP scheme was started at 20 days post-op, with complete response after the first cycle, which allowed replacement of orotracheal tube 7.
Home discharge was given at the end of the second cycle.
After the third cycle of chemotherapy, she abandoned treatment.
Family members arrived at a clinic for the elderly, where he died in December 2004, apparently due to acute respiratory failure.
