Goitre, lymphoma and the doughnut sign

Description 

A 65-year-old woman, with a known case of Hashimoto's thyroiditis on eltroxin for 15 years, presented with progressive diffuse swelling neck for 2 months. She also gave a history of difficulty in swallowing and breathing for 1 week. On examination, she had respiratory distress, low oxygen saturation (85% on pulse oximeter) and cyanosed tongue. Systemic examination was unremarkable except for goitre (grade 2) and stridor. As the saturation was not improving with supplemental oxygen, she underwent an emergency tracheostomy. Subsequently, a contrast-enhanced CT scan of the neck showed large lobulated heterogeneously enhancing lesion in the region of thyroid gland encasing all major structure of neck including trachea (figure 1). Core biopsy and immunohistochemistry (CD45, CD20, CD10 and BCL6 positive) confirmed the diagnosis as diffuse large B cell lymphoma (DLBCL). The patient received R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone). After 1 month, she was asymptomatic with >50% decreased swelling,...

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