Patient information: A 60-year-old woman, with no history including no previous cervical irradiation, who consulted for recent-onset left supraclavicular and right lateralized basi-cervical swelling with no other associated signs.
Clinical findings:
Presence of a mass of firm consistency on the right side of the thyroid lodge that ascends on swallowing without inflammatory signs opposite, and presence of a firm left supra-clavicular mass fixed to the deep plane.
The rest of the clinical examination was normal.
Chronology: in view of this clinical examination, pre-therapeutic and iconographic assessments were requested.
Diagnostic approach: ultrasound revealed an enlarged thyroid gland at the expense of its right lobe, which was the site of two contiguous nodules with the same characteristics: oval with regular contours, well defined, predominantly tissue echostructure, partially hypoechoic and surrounded by a thin hypoechoic halo, the larger measuring 14 x 22 mm, both classified as EU-TIRADS IV.
The ultrasound revealed a left supraclavicular adenopathy, roughly oval in shape, with regular contours, a mixed echostructure, predominantly cystic with a hypoechoic fleshy portion, and an eccentric hilum measuring 19 mm in minor axis.
Cytopuncture was performed on the largest nodule, showing a dense, undifferentiated cell population consisting of diffuse sheets of cells with ill-defined cytoplasms and anisokaryotic, hyperchromatic nuclei with dense, finely nucleolated chromatin, and a necrotic-hemorrhagic background. According to the Bethesda classification: Cytology classified as "suspicious of malignancy" category V.
Therapeutic intervention:
The patient underwent total thyroidectomy with central bilateral and left laterocervical lymph node dissection in view of several left jugulocarotid adenopathies (Figure 1) and excision of the left supra-clavicular adenopathy (Figure 2).
Histological study of the right thyroid lobe revealed a nodule well bounded by a thin capsule made up of vesicles of variable size with areas of round thyroidocyte nuclei displaying the nuclear criteria of papillary carcinoma, interstitial fibrosis and foci of calcifications, concluding in the presence of a non-invasive vesicular thyroid tumour with papillary-type nuclei (NIFT-P according to WHO 2022 terminology) measuring 3.7 cm in long axis.
As for adenopathy, a smooth-surfaced nodule measuring 4.5x4x2.5 cm was found, with a pinkish-white <<fish flesh>> cross-section. Microscopically, a lymph node parenchyma of effaced architecture is revealed by the presence of a proliferation of medium to large lymphoid round cells with rounded nuclei equipped with one or more nucleoli. Mitotic activity is high, with the presence of apoptotic bodies, suggesting in the first instance a high-grade non-Hodgkin's lymphoma. Immunohistochemistry confirmed the diagnosis of a diffuse large-cell B lymphoma of Centro-germinative type.
Follow-up and results of surgery:
Following a multidisciplinary consultation meeting, the patient was first referred to medical oncology, where she received six cycles of chemotherapy.
R-CHOP, this protocol includes the administration of 04 molecules Rituximab - Cyclophosphamide -. Hydroxy Doxorubicin - Vincristine
R-CHOP is based on immunochemotherapy, i.e. the combination of chemotherapy and immunotherapy to stimulate the body's immune defenses.The treatment combines a monoclonal antibody (R on day 1, D1), chemotherapy (CHO on D1) and corticosteroids (Prednisolone from D1 to D5).
She was then referred to endocrinology and nuclear medicine for iratherapy followed by hormone replacement therapy.
One year after surgery, the patient was in good general condition, with no haematological or other signs, and complete disappearance of cervical adenopathy with hormonal stabilization,