An 80-year-old woman with no relevant past medical history presented in June 2007 with a clinical picture suggestive of pneumonia.
A chest X-ray revealed an anterosuperior mediastinal mass displacing the airway to the right and a cervical ultrasound confirmed an endothoracic goiter.
She was treated for her pneumonia and started goiter treatment with 50 mcg/day of levothyroxine.
In July 2007, an endocrinologist consulted due to rapid growth of the cervical tumor and progressive dyspnea for two weeks.
Cervical CT reported a large thyroid endothoracic mass, which fixed the right cervical vascular bundle, dislocated the airway to the right and surrounded the trachea and esophagus, being referred to the emergency room for surgical treatment.
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On admission, she presented dyspnea at rest, without blood gas compromise and an anterior cervical mass of 12 x 8 cm, poorly delimited and hard, projected to the anterosuperior mediastinum and without palpable lymph nodes.
The patient was hospitalized with a diagnosis of obstructive endothoracic goiter.
Anaplastic cancer? ~~~ Thyroid lymphoma?
Preoperative evaluation with nasofibroscopy ruled out endotracheal intubation.
The patient developed dyspnea, intermittent desaturations and signs of respiratory exhaustion, requiring emergency surgery.
In the operating room, the patient was intubated on the first attempt with a No. 4.5 tube with a driver.
A wide cervicotomy and section of pretlroid muscles, which were infiltrated, were performed.
Under them, the thyroid gland was replaced by a 15 x 10 cm tumor, which included the right cervical vascular-nerve bundle.
An intraoperative incisional biopsy suggested thyroid lymphoma.
Total resection of the tumour was achieved, with both recurrent nerves and at least 2 parathyroid glands.
The trachea was placed in an adequate lumen without macroscopic tumoral compromise or deformities; therefore, a tracheostomy was not performed.
The orotracheal tube was changed to No 8.
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In the immediate postoperative period she presented global respiratory failure and distributive shock secondary to a non-infectious systemic inflammatory response syndrome requiring management in the Intensive Care Unit (ICU) with mechanical ventilation (MV) and vasoactive drugs.
No postoperative hypocalcemia.
Definitive biopsy revealed diffuse type B large cell thyroid NHL.
Extensive acquisition of perithyroid tissues
Residual parenchyma with Hampto's thyroiditis".
Large lymphoid cells with intense CD20 (+), CD3(), CD30() and pancytokeratin (-).
On the ninth day she presented upper gastrointestinal bleeding (UGIB) with sudden drop in hematocrit and hemoglobin.
Digestive endoscopy showed multiple gastric ulcers without active bleeding, which were biopsied.
Pathologic Pathologic Pathological Assessment confirmed the onset of specific therapy.
Extubated on day 14, the patient was on spontaneous ventilation for four days, but then underwent torpidotomy, requiring non-invasive, long-term support, so at the end of August.
The biopsy of the gastric mucosa reported "accumulae of lymphoid cells with irregular nuclei.
CD20 (+), CD3 (-) and keratin (-)", compatible with high-grade NHL, strain B.
She presented multiple inflammatory lesions with infectious foci pulmonary and urinary, several episodes of massive UGIB, extensive peripheral venous thrombosis that required vena cava filter and acute interstitial nephritis secondary to drugs.
He received therapy with monoclonal antibodies anti CD20 (Rituximab), with partial and intermittent clinical improvement, dying 50 days after admission due to multiple organ failure.
