#Echo's Tgs Theories

[echooefrost]

HERE WE GO - Last Minute Thoughts about the Upcoming Chapter 

These are some Things Sage has stated about Chapter 15: 

We are heading towards the climax of the story, (it’s going to be a lot)

A lot of Frankenstein and Jekyll stuff 

The Background (and possibly the lighthouse) reflects an important moment in the chapter 

The foreshadowing [on the chapter cover] is heavy 

Personal predictions and Final Theory time: 

We are getting a Frankenstein Character (redemption of sorts) arc. Frankie was never a direct morally wrong character but she was an antagonist to Jekyll, and that’s what counts. With this new found ‘revelation’ I think we'll be getting lots of Frnakenstein and Jekyll having to work together. I don’t think that they’ll be “best friends! Let’s bury the hatchet, all good, no problems.” But more of a comfortable and slightly awkward acceptance for one another, where Frankenstein isn’t such a hypocrite and directly against Jeykll who is just trying to keep everything going, and for Jekyll to not care so much about others opinions and his own reputation, hopefully delving back into more arcane sciences himself. (not immediately change but the start of it at least) 

We are still yet to deal with the protestors out the front of the building so I think that’s the problem that Jekyll/Hyde and Frankenstein are going to have to tackle together because neither of them benefit from this rowdy and conservative victorian mob. I’m hoping we’ll get to see Jasper and possibly some other Lodgers come into play here, in trying to also help and stop the mob, to show Jekyll that he doesn’t have to try and fix everything himself. 

NOW, More onto the topic of the Chapter cover, As I have previously stated (on other mediums) Jekyll will go off the rails, this man is not okay, he is not mentally stable and he is about to absolutely snap. Though I would have already predicted this as we are heading towards the climax of the story and that Jekyll’s Character arc seemed to be heading in that general direction, the Chapter Cover really just confirms all of this (Just look at that guy's face! Evil!!!) 

To add onto the cover, we are yet to decipher exactly what the Shoreline/cliff and Lighthouse represent: 

a.) This could be a flashback or some sort of memory within the mindscape. I can see this happening in terms of everything (both Jekyll/hyde’s physical and shared body membrane) starting to collapse and as a desperate attempt to gain control the mind/body starts to freak out and start relaying old memories/places from the past as it tries to make sense of everything.

b.) This is an Actual Location that some of the Cast will go and visit within the Chapter. I’m not too sure about this one as the entirety of the comic has been set in London so far but it’s always a possibility! It looks as if the shoreline is somewhere in the U.K. I’m more inclined to believe it’s in Scotland, as Jekyll/Hyde are Scottish and would relate to their past etc. I’m not sure why they would go outside of London, but maybe it’s a frankenstein-related decision… 

c.) IT’S ALL A BIG METAPHOR!!! (so this is what I personally believe it to be.)  Knowing Sage’s Tendencies, they love to foreshadow shit in the Chapter covers. They even said so themselves: The Background reflects an important moment in the chapter AND The foreshadowing [on the chapter cover] is heavy. Ok but, What is it foreshadowing exactly? I think the Cliff is symbolic of falling, Jekyll’s fall from sanity, security of self and control. And because he’s falling Hyde has to go down too (because this is all his fault! - says Jekyll probably) The lighthouse I’m not exactly sure of yet but I think that it’s probably a person (either Jasper or Lanyon) Lighthouses symbolise, guidance, hope and safety. I think this person will help pull Jekyll/Hyde out of their spiral and help ground them back to reality (when we get an inevitable breakdown of sorts) The other possibility is that the lighthouse symbolsies an event (kind of what sage stated) but I like the person theory a bit more,,, Lastly the outfits, I don’t think they are really symbolic of anything but purely there to serve aesthetic purposes (similar to Jekyll and Lanyon’s outfits from Chapter 13) BUT If we are theorising, it could show the difference of how Hyde is is turing less ‘Hyde’ opposed to Jekyll because he’s wearing a fancier outfit than normal. But Jekyll does look slightly like a sailor here, adding to the theory that we will go to the ocean (and or) a Lighthouse. 

Alright this is getting kind of big so I’ll leave it here. Before the Page drops I think it’ll pick up where we left off (with Frankestien and Hyde) ALSO First Hyde/Frankenstein interaction incoming!!! Suffice to say I am extremely excited and worried at the same time. Oh boy here comes the Angst… Anyway, This is just me rambling, Let me know what you think! I love theorising and this Chapter has got me all types of pumped : O

[randomthoughtpatterns]

I was recently rereading the penisman, and seeing you bringing it up again is a pleasant coincidence to see! Sorry to ask whats likely an obscure question, but have you got any opinions/theories about the Hero's union? Things were just getting juicy about them with the flashback of Braveheartman & Wizardman, and ofc the entire thing with Sachika and Magi...

Oh! Has it been translated in full by now? I remember years ago someone tried to translate it but the result was let’s just say full of mistranslations. (although the translator did improve some in later chapters) Ishida’s writing is not easily decipherable.

To be honest, anon, I read the Penisman in, gods, 2014? Or was it earlier... The point is, it’s been a while. I don’t remember any theories I might have had. What I do remember is that I teared up reading a webcomic about a literal dickhead because friendship really was magic in Fleshlight’s arc. And all Ishida drew was a blob looking at a badly scribbled photo.

Judging by what I’ve seen of Choujin X so far, I think we might see an echo of The Penisman there as well, although obviously not as direct an adaptation as TG.

For a fun trivia tidbit, on his now-deleted blog Ishida said both The Penisman and ONE’s OnePunchMan were a result of the same challenge that top BNFs of their forum did, so if you’ve ever wondered why TP and OPM have basically the same plot, this is why.

[comicsnas]

showtime

WARNING: eye gore!!, violence Disclaimer: this is..... an au where guy fieri isnt a cool and chill dude that just likes food. i am very sorry for what i do to him in this. i dont mean it and if the cops knock at my door i will blame it on hussie word count: about 3.7k. i am so sorry

context john gets kidnapped by his mom dave doesnt panic

Los Angeles, CA, Wednesday

“No matter what happens, nobody cancels the premiere,” you say. “Okay? No matter what’s in the news. No matter how bad it gets. The movie drops on Thursday, and people are gonna watch it. Got it? This is a scare tactic and we’re not falling for it. Even if the world is ending, we are premiering this movie and going through with the promo. With or without me.”

Catalena, your manager, has been with you for too long to think that you’re joking. She was who flew you in from Houston to LA back when you were twenty, who let you sleep on your couch until you made enough money to get an apartment, who thought that the message you had for the world was one worthy of her help. She knows that all of this is real, and that she can’t stop you.

Her face says, Dave, you’re scaring me. Her mouth says, “You got it. Could you at least tell me… what you think is going to be in the news that would make us not premiere it?”

“Something bad,” you say. “Hopefully, anyway.”

She tilts her head. “Are you faking your death?”

“Lalonde and I are gonna disappear for a sec,” you say. “How people interpret that is gonna be up to them.”

“Not like you to leave things up to chance,” Catalena says. “Some will think it’s elaborate PR.”

“That’s why I’m only telling you. Lalonde and I are gonna frame this to look serious, and no one else is gonna know what’s going on. You keep your cool, but don’t let anyone know that you’re in on it.”

“I mean, I barely am.” She gives you a Look, a capital L Look, then sighs and nods. “Fine. So if I hear about your presumed death tomorrow, I won’t freak out. At what point am I allowed to assume you are actually dead, and freak out a little bit?”

“If you don’t hear from me in a week,” you say, “then Lalonde and I have been killed by Betty Crocker.”

Houston, TX, twelve years ago

You’re blind.

That’s not true. You’re not blind. You don’t think you are going to be blind. There is no way that you’re fully blind, because the assassin only got your right eye, so it doesn’t make sense for you to be blind, but you’re blind.

The pain might originate from your right eye, but it’s engulfing your entire head by now, and there is something sticky in your left eye and you can’t open it anymore and it burns, and you’re going to go blind, and then you’re going to die in a ditch, in a pool of your own blood, and this is it. It’s over. You and your half sister fucked around on the internet a bunch, got really deep into some conspiracy theories, and barely two weeks after you made the discovery that Betty Crocker definitely, undoubtedly, literally is an actual alien, someone was sent to kill you.

They didn’t manage, so far. They got your eye, and they broke your glasses, leaving a cut on your nose, and a bunch of cuts everywhere else, and you think you cracked your head open when you fell. But you cut their knife hand off, good and clean off, watched it fall to the ground right in front of you. By the time it hit the pavement, the assassin had already turned around and ran away, leaving you to crumple and suffer here by yourself.

This is it.

“Strider?” Rose says. Before the blood trickling into your good eye ruined your vision, you managed to dial her number and call her up, and now you’re lying on your side with your phone pressed to your ear, imagining her in her college dorm room in New York. You were going to visit her there, years ago, after you ran away from your parents. It never worked out. Neither of you has the money. You really wish you could have seen her at least once.

“Yeah,” you croak. “You at home?”

“At the dorm, yes. What’s going on?”

“You gotta go. She sent someone after me, she’s gonna come for you too. If she knows that I know, she’ll know that you know.”

One of the most comfortable parts of friendship with Rose, you’ve found, is that she never asks you to clarify what the fuck you’re talking about. Either she just lets you ramble, or she knows exactly what you mean. “Shit,” she hisses, and you can hear rustling on her side of the line, hopefully from her getting ready. She probably has a getaway bag somewhere, you think. You have one, but not on you right now. It’s too late for that.

“They’ve already hit me, so whoever she sent to you can’t be far,” you say. You try to blink your eye open, but then it hurts the other more, and it burns. You can’t even tell where exactly. It just burns. “Hurry up, Lalonde.”

“They’ve hit you?” she echoes, still rustling, breathing into the phone. On the move. Good. “Are you okay?”

“No,” you say. “Gonna call an ambulance after this. Just get the fuck out and text me later, yeah?”

Rose pauses. You can hear her pause, you can hear everything go very silent for a second. She says, “You called me before you called for help?”

“Yeah,” you say. She told you, once, that there is a quick and easy way out the window of her second-storey dorm room, that lets her balance over to her girlfriend’s room only a few windows ahead. She can’t hide there, it’s too close, but it’s a start. She’ll figure it out, she always will. She was the first person to ever have your back. “Of course I did.”

On a plane, Thursday morning

“What’s on your mind?” Rose asks.

You’re leaned back, staring out the window, listening to the clicking of her knitting needles next to you. The pilot here doesn’t know who he’s dealing with, just that he is flying two rich people and their car to Washington, DC. Your Mustang is in the cargo part of the plane, a vital part of the plan. You’ll torch it later. It was the first car you bought with your own money, after SBaHJ had become big and you had finally paid off your hospital debt.

Rose’s apartment isn’t that old, she got it after Roxy was born and she decided to move to Los Angeles, so you could help each other babysit. Trashing it still felt wrong. A home is a home, but you wanted it to look broken into, to make sure that people put two and two together. This isn’t a Dave Strider marketing scheme, you both got hit. After all the work that you’ve done, at least some of the public should understand what that means.

“Us,” you say.

“That’s very sentimental,” she says. “Are you sure you aren’t mourning your car again?”

“Shut up,” you say, and blindly swat at her, hitting her elbow. She hits you back, hand slapping your shoulder. “It’s a good car.”

Rose hums. When you look at her, she’s already back to knitting. You have no idea what she’s making, but it looks like a onesie for an octopus. “We will be fine,” she says. “We have to.”

You nod, and go back to staring out the window, thinking about what Alma said. “It’s just,” you say quietly. “We gotta start thinking about the endgame, here, don’t we.”

“Start?” Rose echoes. “Dave, we know the endgame to this. We’ve known for a while. The second you landed in the hospital with a cut inside your eyeball, you and I both knew that this would end in death.”

You don’t say anything. She’s right, of course she is. You knew then, and she knew, as soon as you texted her from your hospital bed, and she texted you back from a Greyhound bus. And you tried to forget, you both did, for a very long time. You almost managed, for a whole decade, until last year, someone made you scared and angry enough to ram a sword through his throat. Until Rose came and disassembled the body on your rooftop, and then helped you burn it. Reality has caught up with you, and someone is going to die.

The clicking of her needles has stopped again. You turn your head to look at her, and she’s looking back at you, and her face seems younger than it should be. She is just as scared as you are. Neither of you ever wanted it to go this far. Neither of you wanted to kill.

“I don’t like it either,” Rose says. “But someone is going to wind up dead, and it sure as shit isn’t gonna be us.”

Washington, DC, now

)(IC: u comin or what TG: yeah about that

You’re on the hood of your car. The children -- and Sally, John’s pet hedgehog -- are with the one sitter you still trust. Rose is in position, which means she is at a remote location outside the city holding Guy Fieri hostage. She has sent you a picture of him tied to a chair and gagged, which means that it’s go time.

All according to plan.

TG: how about you come kill me somewhere else instead of home sweet home )(IC: why would i do that TG: dying mans last request? )(IC: stfu lol this is so obviously a trap TG: wow ok so is yours )(IC: fair TG: just thought that you know TG: john means something to both of us and dont try to tell me no because i know he does TG: so like can we maybe duke it out somewhere where i wont accidentally blow him to smithereens TG: innuendo intended )(IC: UG)( )(IC: gross TG: lmao TG: anyway bethany you know me and you know im comin with c4 in my backpack if im comin TG: do you really want that around your son or can you just get off your ass and meet me here so john stays safe )(IC: u reely think ya have a fighting chance to even get that far )(IC: buoy you set one foot in my house and ya get spearfished TG: yeah not really making a great point for me to come there rn TG: just thought maybe youd wanna be with your guy guy )(IC: who TG: you know TG: guy the guy )(IC: tf

You text her the picture that Rose sent, just Guy Fieri looking miserable, no indication of whether or not you or Rose are with him.

)(IC: )(-EY )(IC: motherglubber what do u think yoar doin TG: yoar??? TG: thats literally not a word. wym you oar?? what TG: anyway im gonna dismember this asshole if you dont agree to keep john safe and come here and im gonna start with the frosted tips )(IC: FIN--E )(IC: cant effin wait to be done with you )(IC: ill come krill ya if its so shrimportant just gimme the location TG: ok shrimportant is actually pretty funny TG: [coordinates] TG: see you soon

She drives a fuchsia Jaguar that looks like Xzibit threw up all over it, because of course she does. You watch it leave from your perch on your Mustang, then slide off the hood. shes gone, you text Rose. get ready to bounce

Before you leave, you turn back toward you car, and gently pat the roof. “See you soon,” you repeat, “for one last ride.”

Look, it’s a good car, alright.

Later on in the plan, once you’ve convinced John to come with you, and Rose has joined you in the no doubt brutal course out of the house littered with security guards, the three of you will pack into this car, and you will drive. You will be tailed, you know you will. Rose and you estimate two to three SUVs with more security personnel that will follow you, and sooner or later, you won’t stand a chance against them.

So, you’ll call the cops. You don’t usually do this -- even during all these years, neither you nor Crocker ever called the police on each other, and technically, you still won’t, today. You will just anonymously call authorities, and tell them about a burning car by the side of the road. Then you will hang up, and you and Rose and John will hop out of a moving vehicle as you crash your beloved Mustang and have it go up in flames. Authorities will come and find Dave Strider’s infamous car, and hopefully that’ll get people talking.

Crocker’s guys will hopefully exit their cars and go looking for you, or at least for John. It’s an easy con from there -- while they look, you will steal their SUVs and drive off toward your safehouses. Simple. No sweat.

“This better work,” you mutter to yourself, then leave your car behind and start climbing the fence around Crocker manor.

You’ve been here once before, while she was out and John was showing you around. You weren’t actively trying to case the place back then, just spending time with your boyfriend and checking out where he grew up, but you couldn’t help how curious you were. You still remember the most important spots, and you did your best to paint a proper picture of them to Rose (you drew a map in MS Paint), so now you have a pretty good idea of where you need to go.

The guard posts, of course, are randomized. You’ll have to take these as they come, and you feel prepared enough, with just your sword and a handful of knives. You’re wearing the kevlar you wore to the Oscars. You’re gonna be fine.

It’s a race against time now, knowing that there is no guarantee when Crocker will be catching on and returning to her house, and knowing that you stand no chance actually fighting her face to face. You climbed in toward the side of the house, because it’s the shortest distance between fence and wall. The front and back yards are ridiculously huge and opulent, and while you would have plenty of gaudy statues to hide behind, you’re not looking to make your way through there.

The first guard spots you right as you hop down off the fence, and your knife is in his shoulder before he even finishes drawing his gun on you. He’s also wearing a vest, but those don’t stop blades, and you take offense in knowing that she made them dress up like that. As if either you or Rose were going to show up with guns. She really doesn’t know you at all. You knock out the guard with a hit of the knife grip against his temple. Maybe you can get through this without deaths.

One of them you comfortably take out from behind a useless fountain placed in this part of the garden for some reason, appreciating how quiet and low-key you can be about it so far. The bigger the ruckus, the sooner she’ll return, so having them all go down in silence is your best case scenario.

It’s the third guard that ruins your track record. You’re almost at the house wall, and you know you’re under the right window, which means all you have to do is scale it and climb right into John’s room, but for that to work you need to have a clean path behind you. Which you don’t, you realize the second a bullet hits your back.

Your vest catches it, but the momentum still knocks you down, and you scrape both of your palms open on the weird break between lawn and pavement. You hate this fucking garden. Who lives like this? You’re gasping for breath and trying not to inhale any grass, dealing with the reality that this is the first time someone has shot at you and actually hit you, and the bullet might not have penetrated skin at all, but Jesus Fucking Christ it still feels awful. Like someone kicked you in the spine, only with a bullet instead of a foot.

Onward. You hear footsteps behind you, and now it’s your turn to kick, hitting them in the face with your boot in the same motion that you’re pushing yourself up from the ground. As they curse and stumble, you draw your sword, but they catch their footing quickly, and you know you only have a split second to act. That gun is pointing at you, again, or still, and they’re going for your head this time, and if you don’t fight now, the journey ends for you here. Someone is going to die, and it sure as shit can’t be you. Your arm darts forward.

The sword goes through their vest, their ribs, and their heart -- you wouldn’t call it smoothly, you really wouldn’t. You can feel resistance with every inch, you feel it right up to your shoulder, and you hate it, and it makes you want to throw up, but you can’t, now. You shove them off your blade and watch them crumple to the ground, and turn right back toward the wall. They are not getting up again. That’s on you, and you can deal with that later. You have to get moving.

Your phone vibrates.

You manage to pull yourself up on a balcony and crouch there, hiding from whatever is going on in the yard now. Other guards must have heard the shot being fired, so you really need to get the fuck out of sight, but this has to do, for now. If Crocker is messaging you, you have to respond, so she doesn’t think you’re in her goddamn garden.

)(IC: yo )(IC: send me proof yoar still with him )(IC: almost there this betta be worth it TG: one sec

As expected. All according to plan, so far. You hope the blood on your sword won’t make the sheath sticky. You’ll have to clean it, later. You don’t want to.

TG: shes asking for proof TG: go ahead. sorry TT: No worries. TT: I know we don’t endorse violence, but honestly, Dawon, after being in a room with him for this long, I am quite happy to do this.

She sends you a picture, and you grimace at your phone. It takes a lot to make you grimace, as a Strider born and raised -- at the same time, you’re not easily shocked or grossed out, but this isn’t great to look at. Fieri’s eye has been pulled from its socket, dangling down his cheek suspended from the nerve, a hole in the eyeball. You hope Crocker won’t be able to tell that this was done with a knitting needle, and forward the photo to her.

TG: hows this )(IC: )(--EY FUCK OFF )(IC: stop i reely like guy 38( TG: yeah well i really like john TG: eye for an eye TG: hurry it up im waiting and theres a second eye to gauge out )(IC: ten minutes )(IC: ur gonna be so sorry buoy

TG: 10 mins TT: On my way.

Okay. Crocker is on her way to a location where there will only be Guy Fieri and a set of elaborate boobytraps which you know won’t kill her, but hopefully slow her down. Rose is on her way here, to help you and John get out of here. That’s plenty of time you still have. Things are going suspiciously well, you think, before you remember the ache in your back and the fact that you killed someone.

You have to get to John.

He’s another two floors up, but you are right in front of a balcony door. For a second, you wonder if you could get into the house from here and do the rest from inside, so you don’t present yourself to the mob of people with guns in the garden. Unfortunately, before you can do that, another person with a gun appears on the other side of that door, mouths an angry what the fuck at you, and draws an assault rifle. Alright, well.

The thing that has mostly kept you from becoming too violent in the past is the fact that you’re fast, and you’re a great climber, so when you hop backward onto the banister of the balcony and pull yourself up to the next one above you, it happens so fast that nobody in the garden reacts. It’s after you’re already crouching behind the balcony, thankfully made of robust concrete, that the shots start hitting it. You do nothing, count the bullets, wait for them to get rid of half of their magazines down there. Then you pull a knife, peek over the balcony, and throw it right into someone’s bicep.

More shots. More ducking and counting. You have two more knives to throw, and you do, rinse and repeat. The people down there are very angry with you now, and very much still able to shoot, but you figure at least their aim will be off, and they’ll be slower. You hope. You haven’t held a gun yourself in fucking forever.

You take a breath, and jump up to grab the balcony you know belongs to John.

As soon as you’re in the open, another bullet hits your back, further toward your side this time, and you almost let go. You let out an undignified noise instead, and hold on harder, focusing all you have into your arms to pull yourself up. Shots are ringing in your ears, and one hits the concrete right next to your head at almost the same time that another one grazes your leg. You hiss in pain, grunt in exertion, pull, pull, and roll yourself onto John’s balcony.

Someone in the garden yells, “Motherfucker!”

You sit, curled up, and pull apart the tear in your pants with your aching fingers to check the wound. It’s not deep, certainly not as bad as the chunk of missing flesh you have in your arm from being shot at last year. It’s fine. You’ll forget about it in a second, when your newest problem will be telling your amnesiac boyfriend that he needs to come with you.

You pull yourself up into a crouch, not more. You don’t want to risk getting shot in the head as you finally face him, so you just do it like this. Hunkered down, disheveled and bloody, you lean forward and knock on John’s window.

[midnight-in-town]

Hello, a few weeks ago you posted an omake of a younger Tsuneyoshi Washuu fighting Roma. He referred to her as a "special third degree" which a note below states was terminology used before 1945. So, this was at least 1944, and assuming TG takes places in our current decade then it's been over 70 years. This is strange because Roma's backstory said she was 51. This age was given after showing a picture of her as a child. So, could this be the age she was in the picture, and is now much older?

Hi Anon! Oh, I’ve seen a debate on that actually between @echo-from-the-void and @eto-when-and-where [x] and I meant to try and help, but I was so very busy last week that I thought I would leave the matter alone until I had enough time to try and solve whether this is a little plot hole or not. ;_;

Anyway, I gave it some thinking after receiving your ask, so here’s the thing: I don’t think there is any plot hole, it’s just that we all made the mistake to assume that…

…Roma was approximately 51 years at the time of ch135. So actually, I think the omake you’re talking about(credit goes to @randomthoughtpatterns for the translation)…

is a hint to the very complicated timeline about the remaining Clowns that we still know almost nothing about.

Basically, I think Roma was 51 years old at the time she was thrown into Cochlea (that panel of ch135 indeed), but what’s left is for us to determine when exactly that was and that’s when it gets tricky, since we’re currently in 2015-2017. 

(crack theory under read more)

Considering the omake with Tsuneyoshi though, my theory is as follows:

Roma lost to Tsuneyoshi just before 1945 and was thrown into Cochlea back then, which would explain why…

…there are several hints that apparently a long time passed between the moment she was locked up and then freed by Aogiri.

Besides that, there are other little hints that make me think that Roma was locked up a (very?) long time ago actually:

Because “Gypsy” being a name from an old past would explain why we never heard about her special reputation before: ghouls in their 20s/30s probably don’t know about her, because Roma was locked up so long ago in Cochlea. 

Also…

Roma herself told us that she knew about when “the King of the Underground” was rampaging around, which is to say she knew or met…

…”the Nagaraj” that led to the creation of the predecessor organization to the CCG in 1890 (more details for the general timeline here). 

So, assuming that Tsuneyoshi is the one who threw her in jail when she was 51: 1944(~) - 51 => if Roma was born around 1890…

…it would fit with the timeline and her being around when the Washuus were trying to deal with the Nagaraj.

TL;DR At the age of 51, Roma was thrown in Cochlea by Tsuneyoshi who defeated her apparently around 1945, which means that…

the “Clowns’ annihilation” that the CCG led only 10+ years ago had no direct link to Roma who was already in jail. In fact, Roma apparently was the founder of a gang that lasted several decades, which is why “even the Clowns [who were defeated by the CCG 10 years ago] didn’t know who their leader was”. 

Sorry for all the pictures, it’s supposed to be helpful. xD 

That’s my take on it but I’m still waiting for more hints about the Clowns’ gang and the part of the timeline that’s dedicated to them, since the more the story goes, the more hints we get that they are definitely older than they look (and thus they make everything more complicated). :3

Take with a big grain of salt though! And have a nice day. :))

EDIT: Additional relevant info here. :))

[juniperpublishersoa]

JuniperPublishers-Primary Lymphoma of Thyroid: A Diagnostic Dilemma

Journal of Surgery-JuniperPublishers

Abstract

Primary Lymphoma of Thyroid is a rarely encountered clinical entity that occurs in late age intrinsically associated with Hashimotos thyroiditis, comprising of 0.6 to 5 per cent of thyroid cancers in most series. We present a case of B-cell origin thyroid lymphoma. The diagnosis was made by combined histology and immunochemistry. A 60-year-old woman presented with an enlarging neck mass with odynophagia. On admission, the sonogram of the thyroid gland showed an enlarged mass and CT scan demonstrated diffuse enlargement of the thyroid. The histological investigation revealed the presence of a diffuse large B-cell non-Hodgkin’s lymphoma. The patient underwent chemotherapy. Clinicians should include primary thyroid lymphoma in the differential diagnosis of a rapidly enlarging thyroid mass. Thyroid ultrasound and fine needle aspiration cytology, using flow cytometry and Immunohistochemistry, remain the main modalities used to confirm the presence of lymphoma. The prognosis is generally excellent but can be varied because of the heterogeneous nature of thyroid lymphomas. Despite its rarity, PTL should be promptly recognized because its management is quite different from the treatment of other neoplasms of the thyroid gland.

Keywords: Primary Thyroid Lymphoma; Lymphocytic thyroiditis; Non-Hodgkin Lymphoma Thyroid Cancer

Abbreviations: PTL: Primary Thyroid Lymphoma; MALT: Mucosa-Associated Lymphoid Tissue; HT: Hashimoto’s Thyroiditis; DLBCL: Diffuse Large B-Cell Lymphoma; IHC: Immunohistochemistry; RCHOP: Rituximab-Cyclophosphamide-Doxorubicine-Vincristine-Prednisone; FDG-PET: Fluorine-18-Fluorodeoxyglucose Positron Emission Tomography; FNAC: Fine Needle Aspiration Cytology

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Introduction

Primary thyroid lymphoma (PTL) is a rare disease that continues to produce diagnostic and therapeutic dilemmas. PTL are very rare and account for only 5% of all thyroid malignancies and approximately 3% of all non-Hodgkin’s lymphoma. The annual incidence of PTL is one or two cases per million [1]. It is more prevalent in females, in the sixth to seventh decade of life with female to male ratio of 3:1 [2].

Most thyroid lymphomas are of B-cell origin. There appear to be two distinct clinical and prognostic groups of these rare tumors. The more common subtype, comprising of up to 70% of cases, is a diffuse large B-cell lymphoma. This subtype appears to have the most aggressive clinical course with almost 60% of these tumors diagnosed with disseminated disease. The other subtype is mucosa-associated lymphoid tissue (MALT) lymphomas comprising of approximately 6% to 27% of thyroid lymphomas. These have a relatively indolent course [3].

The most common presentation of thyroid lymphoma is a rapidly enlarging, painless goiter. Other symptoms such as dyspnea, dysphasia, and hoarseness may arise as a result of the pressure effects of the mass. Rarely, stridor or superior vena cava obstruction can occur. Cervical lymphadenopathy is present in the majority of cases [4]. Classic B-type symptoms such as weight loss and night sweats occur less commonly and have been reported in approximately 20% of patients. The majority of patients (30%-60%) are biochemically euthyroid at presentation [5].

The underlying pathogenesis of PTL remains obscure. The major risk factor for PTL is the presence of Hashimoto’s thyroiditis (HT). Interestingly, although the incidence of HT in patients with PTL approaches 80%, only 0.6% with HT will go on to develop PTL [6]. The association is postulated to result from the development of intrathyroidal lymphoid tissue in HT. It has also been postulated that the stimulation of antigens that are specific to the thyroid microenvironment are necessary for the development of PTL [7]. This theory is supported by the fact that more than half of thyroid lymphoma patients have a previous or concurrent diagnosis of chronic lymphocytic thyroiditis,suggesting that chronic antigenic stimulation may play a role in pathogenesis [8].

The overall prognosis of thyroid lymphoma has been described by the British Thyroid Association guidelines as “generally excellent”; however, prognosis is subtype dependent, and 5-year survival rates can be as low at 45% [9]. The management and prognosis of PTL has changed with the advent of multimodal adjuvant therapy and increasing interest in and research into targeted therapies. Here, we report a case of diffuse large B-cell lymphoma (DLBCL) manifesting as a primary disorder of the thyroid gland. The importance of recognizing primary thyroid lymphoma lies in the fact that this disease is quite curable without the need for extensive surgery if recognized early and treated appropriately.

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Case Report

A 60 years old woman presented to surgery outpatient department with a rapidly growing (2 weeks) thyroid enlargement along with mild odynophagia. The patient had no history of fever, night sweats or weight loss. She was a non-smoker and had no previous neck radiation exposure. The remaining medical and family history was unremarkable. Hormonal evaluation revealed increased thyrotrophic levels [TSH 32.32ΙU/ml, NR 0.3-4.5], normal thyroxine [123 μg/dl, NR 66-181] and normal tri-iodothyronine levels [1.81 nmol/L, NR 1.1-3.1]. The antithyroglobulin antibodies were markedly increased (anti-Tg 1300 IU/ ml, NR<60). The initial sonogram indicated enlargement of bilateral lobes with altered echo texture and micro calcification. Bilateral cervical lymph nodes were mildly enlarged. Patient was advised FNAC thyroid swelling which revealed degenerated and intact follicular cells and large number of lymphoid cells with prominent immature component (Figure 1). Diagnosis of florid lymphocytic thyroiditis with suspected lymphomatous transformation was rendered. Patient was given steroids and L-thyroxine, 50μg replacement therapy daily. She responded well initially. But after 3 months, she came back with history of fever, weight loss, malaise and bilateral cervical swellings.

The patient underwent imaging of the neck for further evaluation. CECT Cervical region demonstrated diffusely enlarged thyroid, isotense on noncontract and showed enhancement on contrast scan. Multiple enlarged lymph nodes bilateral cervical and axillary region were also noted (Figure 2). CECT abdomen and thorax revealed abdominal, mediastinal, cervical, axillary and inguinal lymphadenopathy along with hepatosplenomegaly possibility of Koch’s or Lymphoma were suggested (Figure 3).

Cervical lymph node biopsy was received three months after initial FNAC. Biopsy showed Non Hodgkin’s Lymphoma; Diffuse Large B-Cell Lymphoma with marked necrosis and extra nodal extension (Figure 4 A & B). On Immunohistochemistry (IHC) lymphoma cells were: CD20 and CD10 positive (Figure 5A & 5B). According to Ann Arbor guidelines for Primary Thyroid Lymphoma the patient now had stage IV E disease. Patient underwent 6 cycles of chemotherapy with RCHOP (Rituximab- Cyclophosphamide-doxorubicine-vincristine-prednisone). She is now on regular follow up and is doing well.

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Discussion

Primary Thyroid Lymphoma (PTL) is a lymphomatous process involving the thyroid gland without contiguous spread or distant metastases from other areas of involvement at diagnosis. It is a rare tumor constituting about 1-5% of all thyroid malignancies and 1-2% of all extra nodal lymphomas, with an annual incidence of two per million [1]. Most patients present in the 7th decade of life (average age 67 years) [2]. Preexisting chronic autoimmune (Hashimoto’s) thyroiditis is a wellrecognized risk factor predisposing to the development of PTL. The risk of PTL among patients with autoimmune thyroiditis is 40 times greater as compared to that of the general population. It takes a long time (20-30 years) to develop PTL after the onset of lymphocytic thyroiditis [6]. Normally, the thyroid gland does not contain native lymphoid tissue. Intra-thyroid lymphoid tissue develops under pathological conditions, and mainly in patients with autoimmune thyroiditis, probably as a result of chronic antigenic stimulation. PTLs are classified based on pathological subtypes, with each carrying a different prognosis. The two most common subtypes are diffuse large B-cell lymphoma (DLBCL) and MALT lymphoma. DLBCL accounts for up to 70% of all PTLs [3].

DLBCLs are typically positive for MS4A1 (CD20), with 75% also positive for the BCL6 ontogeny and up to 50% positive for the BCL2. DLBCL itself has now been divided into two major cell-of-origin phenotypes with differing prognoses: a favourable germinal center B-cell-like lymphoma and a more aggressive activated B-cell like subgroup with over expression of the activated B-cell immunophenotype markers IRF4 (MUM1) and FOXP1 [10]. This group of patients, those who over expressed IRF4 (MUM1) are associated with high expression of NM23-H1 had a poorer prognosis. MALT lymphoma of the thyroid follows a relatively benign indolent clinical course and thus is more likely to present at an earlier stage and, historically, demonstrate a better response to treatment [3].

A rapidly growing (usually within 1-3 months), painless thyroid enlargement, either in the form of goiter or discrete nodule, is the most common clinical presentation in PTL. Pressure symptoms are often present. This clinical presentation can be confused with a plastic thyroid carcinoma. Because of the frequent coexistence of Hashimoto’s thyroiditis, many patients are hypothyroid or under thyroid hormone replacement therapy and circulating antibodies to thyroid peroxidise are positive in these patients (60%) [6]. Classic B-type symptoms of fever, night sweats and weight loss are less common.

Ultrasonography is the imaging modality of choice and can typically show one of three patterns: nodular, diffuse, or mixed. When presenting as a solitary mass, the radiological appearance can resemble that of anapaestic thyroid carcinoma but can be distinguished by its homogenous appearance as well as thelack of calcification, necrosis, and cystic degeneration within the nodule .When diffuse lymphoma is identified, it appears as a heterogeneous hypoechoic parenchyma with the presence of structures resembling septae. Magnetic resonance imaging may be more sensitive than computed tomography in the detection of extrathyroidal involvement. Fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) can be useful in staging and restaging or in assessing response to treatment in PTL [11]. Once the diagnosis of PTL has been established, imaging of the entire body is necessary in order to stage the patient accurately. The Ann Arbor criteria, similar to staging of lymphoma at other sites, are used for the staging of PTL.

Fine needle aspiration cytology (FNAC) is the initial technique of choice for pathological assessment of a thyroid lesion. It may present diagnostic challenges for the pathologist. Low grade lymphomas can be mistaken for chronic thyroiditis. PTL is usually of large cell type and a diagnosis of large cell lymphoma is easy on FNA and features like lack of cellular cohesion and presence of lymphoglandular bodies in the background are features strongly against a diagnosis of annalistic carcinoma. Immunocytochemistry confirms the lymphoid origin of the cells and their B or T- lineage. By contrast, cytological diagnosis of MALT- lymphomas is difficult, because of heterogeneous appearance of the neoplastic infiltrate. Distinguishing severe chronic thyroiditis from lymphoma puts us as pathologists in great difficulty when the inflammatory exudates is so expressed that it effaces the normal thyroid architecture. Moreover, such thyroiditis leads to cellular aggregates that could be classified as lymphoepitelial lesions. Morphologically, in chronic lymphocytic thyroiditis, the lymphocytes are a mixture of B and T cells but mostly T-cells. Scattered larger lymphoblasts, immunoblasts and plasma cells are also present in cases with chronic lymphocytic thyroiditis. Germinal centers are often prominent [12]. The gold standard for histologic diagnosis is considered the core needle biopsy or surgical biopsy to ensure that aggressive histologies are not missed. It yields more tissue than FNAC and maintains the architecture of the tissue and can facilitate the distinction among HT, PTL, and anapaestic carcinoma; which is not always possible with FNAC.

The gold standard for management of DLBCL is multimodal because of the typically aggressive clinical course. Surgical intervention may be required for palliation in the setting of critical airway obstruction. Intervention in this setting carries high morbidity and should be approached with caution [13]. The Surgery alone has been proposed for the management of localized intra-thyroidal lymphoma. Chemotherapy can control distant dissemination of the disease, while radiation therapy can achieve local control of the lymphoma. Most commonly, radiation therapy is used after 3-6 courses of chemotherapy. Rituximab has recently been effectively used (with cyclophosphamide, mitoxantrone, vincristine, and prednisolone) in elderly patients with diffuse large B-cell lymphoma of thyroid [14].

The identification of mutations and upregulation of cellsignaling pathways has revolutionized cancer treatment in recent years. Although molecular testing for mutations in the BRAF proto-oncogene is now used routinely to aid diagnosis and guide treatment of papillary thyroid carcinoma. Protein kinase inhibition has not yet been applied in the management of thyroid lymphoma. These findings suggest that it may be a potential therapeutic target for treatment [15].

The prognosis of DLBCL can be estimated by using the International Prognostic Index, which uses only clinical parameters. There are two indexes: one for all patients, called the “international index,” and one that is age adjusted, called the “age-adjusted international index.” The international index score is based on age, tumor stage, serum lactate dehydrogenase concentration, performance status, and number of extra nodal disease sites. The age-adjusted international index score is based on tumor stage, lactate dehydrogenase level, and performance status. These indexes stratify patients into four risk groups with specific 5-year survival rates, which, when compared with the Ann Arbor staging system, appear to be more accurate in predicting survival [15].

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Conclusion

We describe a very rare case of primary thyroid lymphoma. Our report emphasizes the need for clinical awareness in such perplexing cases which clearly require a multidisciplinary approach for early diagnosis of such lesions and preventing delay and unnecessary surgery. Diagnosis is often difficult but clinical and radiological suspicion along with pathological features should be taken in account to reach correct diagnosis.

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[echooefrost]

Dropping my Bs from the comment Section Cause I can and apparently and a large majority of Tgs fans don't read the comments

'What is Hyde? '

'An Experiment. A Mistake'

GOD THAT'S GOTTA HURT

I think Its interesting to note How jekyll perceives himself as the sanctimonious 'holier than thou, I'm the 'better' half therefore you are in-superior and insignificant' attitude towards Hyde. (I believe this was particularly personified after the transformation where the both embodied a more extreme version of Henry's subjective 'halves') Now all that's left for Hyde is feed into the persona that Jekyll has cultivated for him. He may as well be the wreck, abomination and 'evil' that he's repeatedly been told he is, he's lost everything, he has no reason or purpose anymore. So why not be the monster Jekyll fears he is? And ultimately Ruin both their lives.... Yeah Shits about to DOWN GOD THE UNDERLYING SUBTEXT OF ALL OF THIS HAS ME SCALING THE WALLS TOP TIER WRITING I SWEAR

anyways Im not okay how are yall holding up??

[echooefrost]

THIS IS SUPER RUSHED BUT WHO CARES ROUGUE SCIENTISTS ALIKE, May I direct you to this lovely post of Sage's:

this may look like your average new page reminder, however Sage specifically mentions 'THE HALL OF MEMORIES', without intending to I think they may have spoiled the next page. THIS MEANS the theory that there might be some kind of memory flashback and mindscape fight is VERY VERY LIKELY!!! perhaps, we get to see what the cliff on the chapter cover means, and or if we see Jekyll/hyde revisiting scotland, or literally anything that people were theorising back when the chapter cover came out!! I'm very very intrigued by the implication of this one sentence...

This could be absolute nonsense, I'm not a reliable source HOWEVER I just thought it was worth mentioning. If i'm right and it is quite literally; 'a trip down memory lane' then I'm gonna go ballistic.