Thyroid mass as the presenting sign of hodgkin lymphoma in an adolescent

Lymphoma involves the thyroid rarely, but may present as a thyroid mass, goiter or thyroid fibrosis. Most are B-cell non-Hodgkin lymphomas. We present an unusual case of classic Hodgkin lymphoma presenting as goiter in an adolescent female. A 15 year old female presented with a painless, firm goiter associated with vocal hoarseness. Fever, fatigue, weight loss, and night sweats were absent. Examination demonstrated diffuse thyroid enlargement and tissue firmness, especially in the right lobe. Multiple enlarged lymph nodes, including supraclavicular, were palpated. The patient was clinically and biochemically euthyroid at presentation. Ultrasound demonstrated a 6.8 by 2.5 cm mass predominantly in the right lobe with extension into the isthmus and left lobe. The mass was mostly solid and hypoechoic with some cystic areas and calcifications. Multiple enlarged lymph nodes with cortical hypertrophy and calcifications were identified raising suspicion for metastatic papillary thyroid carcinoma (PTC). Fine needle aspiration (FNA) of a suspected metastatic lymph node demonstrated atypical B-cell proliferation which stained diffusely positive for CD20, and negative for antigens associated with PTC (BRAF, PAX8, TTF, and cytokeratin AE1,3). Excision of an axillary lymph node was required for definitive diagnosis. Histology showed predominantly small lymphocytes with few interspersed large atypical cells with prominent nucleoli (Reed-Sternberg cells), traversed by paucicellular fibrosclerotic septae imparting a nodular pattern. Final diagnosis was classic Hodgkin lymphoma, nodular sclerosing subtype, stage IIA. She initiated therapy with ABVE-PC (doxorubicin, bleomycin, vincristine, etoposide, prednisone, and cyclophosphamide) and had excellent response. She was changed to doxorubicin, vinblastine, and dacarbazine to reduce toxicities, omitting bleomycin to reduce pulmonary risks in the setting of the COVID-19 pandemic. Eleven months after therapy completion, she has no evidence of disease. She did not require thyroid surgery or radiotherapy. While PTC is strongly suspected with this presentation, lymphoma should be a diagnostic consideration in patients with a thyroid mass. In this case, FNA was valuable in raising the possibility of a lymphoproliferative disorder, which led to excisional lymph node biopsy to confirm the diagnosis. Initiation of chemotherapy in this chemo-sensitive tumor averted unnecessary thyroid surgery and extensive lymph node dissection.