Experimental and Clinical Endocrinology & Diabetes Reports 2016; 3(01): e1-e7
DOI: 10.1055/s-0035-1569376
Case Report
© Georg Thieme Verlag KG Stuttgart · New York

What makes Lymphadenopathy in Patients with Autoimmune Thyroiditis Suspicious for Malignancy?

C. Bouter
1   Depatment of Nuclear Medicine, Universitiy Medical Center (UMG) Goettingen, Goettingen, Germany
B. Meller
1   Depatment of Nuclear Medicine, Universitiy Medical Center (UMG) Goettingen, Goettingen, Germany
J. Meller
1   Depatment of Nuclear Medicine, Universitiy Medical Center (UMG) Goettingen, Goettingen, Germany
C. O. Sahlmann
1   Depatment of Nuclear Medicine, Universitiy Medical Center (UMG) Goettingen, Goettingen, Germany
› Author Affiliations
Further Information

Publication History

received 20 July 2015
first decision 09 October 2015

accepted 17 November 2015

Publication Date:
06 April 2016 (online)


Lymphadenopathy in Robbins level II-IV and VI is common in autoimmune thyroiditis but the diagnostic strategy of a distinct lymphadenopathy exceeding the known features in autoimmune thyroiditis patients is unknown. The aim of this study was to determine how the extent of cervical lymphadenopathy in autoimmune thyroiditis affects the diagnostic management.

The study comprises one index-patient with autoimmune thyroiditis and distinct suspicious lymphadenopathy in all cervical levels as well as retroclavicular. In addition 10 patients with autoimmune thyroiditis and distinct suspicious lymphadenopathy limited to level VI were evaluated.

Findings of high resolution ultrasound, fine-needle aspiration cytology, serological testing and clonal analysis are reported here. Further diagnostics of the index-patient included histology, immunohistochemistry, bcl-2-expression analysis and PET/CT.

The index-patient showed distinct lymphadenopathy in level I-VI and retroclavicular. Lymph nodes did not display any sonographic malignancy criteria. Molecular analysis and immunohistochemistry revealed monoclonal CD10- and CD20-positive, Bcl-2 expressing follicular B-cells confirming the diagnosis of a follicular B-cell Non-Hodgkin lymphoma.

10 additional patients with limited lymphadenopathy showed typical features of autoimmune thyroiditis and lymph nodes did not display sonographic malignancy criteria in all cases. Further tests excluded lymph node malignancies.

Extensive diagnostics in autoimmune thyroiditis and distinct cervical lymphadenopathy is crucial. Whereas limited lymphadenopathy in AIT was proven benign, extensive lymphadenopathy exceeding the known amount and/or spreading to retroclavicular/mediastinal compartments is suspicious for malignancy. Even in the absence of sonographic malignancy criteria further tests have to be performed.

  • References

  • 1 Wang C, Crapo LM. The epidemiology of thyroid disease and implications for screening. Endocrinol Metab Clin North Am 1997; 26: 189-218
  • 2 Chistiakov DA. Immunogenetics of Hashimoto’s thyroiditis. J Autoimmune Dis 2005; 2: 1
  • 3 Sahlmann CO, Meller J, Siggelkow H, Homayounfar K, Ozerden M, Braune I. Patients with autoimmune thyroiditis. Prevalence of benign lymphadenopathy. Nuklearmedizin 2012; 51: 223-227
  • 4 Serres-Créixams X, Castells-Fusté I, Pruna-Comella X, Yetano-Laguna V, Garriga-Farriol V, Gallardo-Agromayor E. Paratracheal lymph nodes: a new sonographic finding in autoimmune thyroiditis. J Clin Ultrasound 2008; 36: 418-421
  • 5 Brancato D. Neck lymph nodes in chronic autoimmune thyroiditis: the sonographic pattern. Thyroid 2013; 173-177
  • 6 Jones MR. The presentation of lymph nodes in Hashimoto’s thyroiditis on ultrasound. Gland Surg 2015; 301-306
  • 7 Akbaba G. Changes in the Charactersitics of Paratracheal Lymph Nodes in Patients with Chronic Autoimmune Thyroiditis for Five Years Follow- up. Endocrine Society’s 96th Annual Meeting and Expo, June 21–24, 2014 – Chicago. Chicago, USA 2014;
  • 8 Lindsay S, Dailey ME. Malignant lymphoma of the thyroid gland and its relation to Hashimoto disease: a clinical and pathologic study of 8 patients. J Clin Endocrinol Metab 1955; 15: 1332-1353
  • 9 Girardi FM, Barra MB, Zettler CG. Papillary thyroid carcinoma: does the association with Hashimoto’s thyroiditis affect the clinical-pathological characteristics of the disease? Braz J Otorhinolaryngol 2014
  • 10 Kim ES, Lim DJ, Baek KH, Lee JM, Kim MK, Kwon HS. Thyroglobulin antibody is associated with increased cancer risk in thyroid nodules. Thyroid 2010; 20: 885-891
  • 11 Guarino V, Castellone MD, Avilla E, Melillo RM. Thyroid cancer and inflammation. Mol Cell Endocrinol 2010; 321: 94-102
  • 12 Santoro M, Melillo RM, Carlomagno F, Fusco A, Vecchio G. Molecular mechanisms of RET activation in human cancer. Ann N Y Acad Sci 2002; 963: 116-121
  • 13 Shaha AR, Shah JP, Loree TR. Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid. Am J Surg 1996; 172: 692-694
  • 14 Wada N, Duh Q, Sugino K, Iwasaki H, Kameyama K, Mimura T. Lymph node metastasis from 259 papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection. Ann Surg 2003; 237: 399-407
  • 15 Henry JF, Gramatica L, Denizot A, Kvachenyuk A, Puccini M, Defechereux T. Morbidity of prophylactic lymph node dissection in the central neck area in patients with papillary thyroid carcinoma. Langenbecks Arch Surg 1998; 383: 167-169
  • 16 Raijmakers PGHM, Paul MA, Lips P. Sentinel node detection in patients with thyroid carcinoma: a meta-analysis. World J Surg 2008; 32: 1961-1967
  • 17 Dzodic R, Markovic I, Inic M, Jokic N, Djurisic I, Zegarac M. Sentinel lymph node biopsy may be used to support the decision to perform modified radical neck dissection in differentiated thyroid carcinoma. World J Surg 2006; 30: 841-846
  • 18 Dudea SM, Lenghel M, Botar-Jid C, Vasilescu D, Duma M. Ultrasonography of superficial lymph nodes: benign vs. malignant. Med Ultrason 2012; 14: 294-306
  • 19 Ahuja AT, Ying M, Ho SY, Antonio G, Lee YP, King AD. Ultrasound of malignant cervical lymph nodes. Cancer Imaging 2008; 8: 48-56 10.1102/1470-7330.2008.0006
  • 20 Gritzmann N, Koischwitz D. Ultrasound of the neck. J Otolaryngol 1993; 22: 315-320
  • 21 Sakorafas GH, Kokkoris P, Farley DR. Primary thyroid lymphoma (correction of lympoma): diagnostic and therapeutic dilemmas. Surg Oncol 2010; 19: e124-e129
  • 22 Hyjek E, Isaacson PG. Primary B cell lymphoma of the thyroid and its relationship to Hashimoto’s thyroiditis. Hum Pathol 1988; 19: 1315-1326
  • 23 Scholefield JH, Quayle AR, Harris SC, Talbot CH. Primary lymphoma of the thyroid, the association with Hashimoto’s thyroiditis. Eur J Surg Oncol 1992; 18: 89-92
  • 24 Anscombe AM, Wright DH. Primary malignant lymphoma of the thyroid – a tumour of mucosa-associated lymphoid tissue: review of seventy-six cases. Histopathology 1985; 9: 81-97
  • 25 Matsuzuka F, Miyauchi A, Katayama S, Narabayashi I, Ikeda H, Kuma K. Clinical aspects of primary thyroid lymphoma: diagnosis and treatment based on our experience of 119 cases. Thyroid 1993; 3: 93-99
  • 26 Kato I, Tajima K, Suchi T, Aozasa K, Matsuzuka F, Kuma K. Chronic thyroiditis as a risk factor of B-cell lymphoma in the thyroid gland. Jpn J Cancer Res 1985; 76: 1085-1090
  • 27 Pedersen RK, Pedersen NT. Primary non-Hodgkin’s lymphoma of the thyroid gland: a population based study. Histopathology 1996; 28: 25-32
  • 28 Bacon CM, Diss TC, Ye H, Liu H, Goatly A, Hamoudi R. Follicular lymphoma of the thyroid gland. Am J Surg Pathol 2009; 33: 22-34 10.1097/PAS.0b013e31817d7470
  • 29 Chuang S, Lin C, Shen F, Liao P, Liao Y, Chang JH. Detecting clonal rearrangement in non-Hodgkin’s lymphomas in Taiwan by polymerase chain reaction. Leuk Lymphoma 2003; 44: 117-121
  • 30 Taheri ZM, Ziazi LM, Dorudinia A, Nadji SA, Mohammadi F. Clonality of the immunoglobulin heavy chain genes in B cell non-hodgkin lymphoma using semi-nested PCR. Tanaffos 2011; 10: 25-31
  • 31 Medeiros LJ, Carr J. Overview of the role of molecular methods in the diagnosis of malignant lymphomas. Arch Pathol Lab Med 1999; 123: 1189-1207
  • 32 Theriault C, Galoin S, Valmary S, Selves J, Lamant L, Roda D. PCR analysis of immunoglobulin heavy chain (IgH) and TcR-gamma chain gene rearrangements in the diagnosis of lymphoproliferative disorders: results of a study of 525 cases. Mod Pathol 2000; 13: 1269-1279
  • 33 Saxena A, Alport EC, Moshynska O, Kanthan R, Boctor MA. Clonal B cell populations in a minority of patients with Hashimoto’s thyroiditis. J Clin Pathol 2004; 57: 1258-1263
  • 34 Matsubayashi S, Tamai H, Morita T, Fukata S, Matsuzuka F, Suzuki T. Hashimoto’s thyroiditis manifesting monoclonal lymphocytic infiltration. Clin Exp Immunol 1990; 79: 170-174
  • 35 [No authors listed]. Effect of age on the characteristics and clinical behavior of non-Hodgkin’s lymphoma patients. The Non-Hodgkin’s Lymphoma Classification Project. Ann Oncol 1997; 8: 973-978
  • 36 Ott G, Rosenwald A. Molecular pathogenesis of follicular lymphoma. Haematologica 2008; 93: 1773-1776
  • 37 Freedman AS. Biology and management of histologic transformation of indolent lymphoma. Hematology Am Soc Hematol Educ Program 2005; 314-320
  • 38 Zeppa P, Cozzolino I, Peluso AL, Troncone G, Lucariello A, Picardi M. Cytologic, flow cytometry, and molecular assessment of lymphoid infiltrate in fine-needle cytology samples of Hashimoto thyroiditis. Cancer 2009; 117: 174-184 10.1002/cncy.20022
  • 39 Freedman A. Follicular lymphoma: 2014 update on diagnosis and management. Am J Hematol 2014; 89: 429-436
  • 40 Ferlito A, Robbins KT, Silver CE, Hasegawa Y, Rinaldo A. Classification of neck dissections: An evolving system. Auris Nasus Larynx 2009; 36: 127-134