Surgery MCQs Q12

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SURGERY • ENDOCRINE

A 74-year-old woman with a long-standing history of Hashimoto’s thyroiditis presents with a rapidly enlarging thyroid swelling (goiter) over the past few weeks.

What is the most likely diagnosis?

A Follicular carcinoma

B Papillary carcinoma

C Lymphoma

D Sarcoma

E Medullary carcinoma

Primary thyroid lymphoma is strongly associated with Hashimoto's thyroiditis. The chronic inflammation leads to lymphoid tissue proliferation that can transform into malignancy, most commonly Diffuse Large B-cell Lymphoma (DLBCL).

Decoding Clue

1

CLUE "Rapidly enlarging goiter"

TRANS Points away from slow-growing differentiated cancers (Papillary/Follicular) and toward aggressive entities (Anaplastic or Lymphoma).

2

CLUE "History of Hashimoto’s"

TRANS The specific risk factor that predisposes to MALToma or DLBCL transformation within the thyroid gland.

3

CLUE "74-year-old woman"

TRANS Typical demographic for both Hashimoto's and its malignant complications. High suspicion needed in this age group.

Differential Breakdown

A. Follicular carcinoma: Typically presents as a slow-growing solitary nodule. Associated with hematogenous spread (bone, lung), not rapid enlargement.

B. Papillary carcinoma: Most common thyroid cancer. Presents as a slow-growing nodule with lymphatic spread to nodes, not rapid goiter enlargement.

D. Sarcoma: Extremely rare in the thyroid and has no association with Hashimoto's thyroiditis.

E. Medullary carcinoma: Arises from parafollicular C-cells. Often associated with MEN 2 syndrome and high calcitonin levels.

High-yield

"In an elderly patient with Hashimoto’s thyroiditis, a rapidly enlarging goiter should be considered primary thyroid lymphoma until proven otherwise. Core biopsy is usually required for definitive histological diagnosis."

Relevant High-Yield Challenges

Challenge #1: Specific Subtype

What is the most common histological subtype of primary thyroid lymphoma?

Answer: Diffuse Large B-cell Lymphoma (DLBCL).

Challenge #2: Compressive Symptoms

What are the three most common compressive symptoms caused by rapid thyroid enlargement in lymphoma?

Answer: Dysphagia (difficulty swallowing), dyspnea (difficulty breathing), and hoarseness (recurrent laryngeal nerve pressure).

Challenge #3: Diagnostic Strategy

Is Fine Needle Aspiration (FNA) always sufficient for diagnosing thyroid lymphoma?

Answer: No. While FNA may suggest it, a core biopsy or open biopsy is often required to assess tissue architecture and confirm the specific lymphoma subtype.

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