A 54-year-old woman, morbidly obese and hypertensive, who consulted in August 2007 for dyspnea and intermittent dysphagia of 1 year duration, which was later associated with increased cervical volume of rapid growth and orthopnea.
Chest X-ray was normal.
Cervical ultrasound showed goiter with a large left solid nodule (4.3 x 5.7 x 4.5 cm), hypoechogenic, poorly vascularized and with bilateral cervical lymphadenopathies of reactive aspect.
Laboratory tests revealed elevated TSH and decreased T4.
Thyroid cancer was diagnosed, levothyroxine was initiated and surgical resection was programmed.
During surgery, the left prethyroid muscles were dissected to facilitate the exploration, which were adhered to the lesion.
The large white nodule projected into the cervical esophagus.
Total thyroidectomy was performed.
Rapid biopsy of the surgical specimen revealed lymphoid proliferation suggestive of lymphoma.
The patient developed symptomatic hypocalcaemia, which resolved with oral calcium.
She was discharged on the third postoperative day.
The definitive biopsy concluded "large cell lymphoid infiltrate with Hürtle cell metaplasia, which compromised the thyroid capsule and focally the perithyroid muscle tissue.
Immunohistochemistry: diffuse CD20 (+), focal CD3 (+) in small lymphocytes, diffuse CD10 (+), BCL2 (-)".
Compatible with NHL large cell thyroid strain B, Hammoto's thyroiditis and metaplasia with Hürtle cells.
Chemotherapy was indicated but the patient refused it for religious reasons.
Six months later, she consulted for local recurrence with obstructive airway symptoms.
She was referred to pathology where she lost control.
