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Non Hodgkin Lymphoma

Summary

Most intraosseous lesions are non-Hodgkin's lymphoma. Non-Hodgkin's lymphoma of bone is found in the femur and pelvis. Primary Hodgkin's lymphoma of bone is exceedingly rare and may occur anywhere in the skeleton.

It is most commonly found in people 20 years and older.
It may present as local pain or swelling. Patients generally feel they are in good health otherwise.
Lymphoma of bone has a variable picture on plain-xray. A lesion may appear as a vague, mottled lucency.
Treatment of lymphoma of bone is usually radiation and chemotherapy.
Complete Information on this Tumor
Introduction and Definition: 

Primary intraosseous lymphoma of bone, known in the past as reticulum cell sarcoma, is an uncommon malignancy that accounts for less than 5% of primary malignant bone tumors. Over 20% of patients with lymphoma have secondary bone involvement Most intraosseous lesions are non-Hodgkin's lymphoma. Non-Hodgkin's lymphoma of bone is found in the femur and pelvis in patients twenty years of age and older. Primary Hodgkin's lymphoma of bone is exceedingly rare and may occur anywhere in the skeleton. Non-Hodgkin's lymphoma of bone is found in the femur and pelvis

Incidence and Demographics: 
It is most commonly found in people 20 years and older.
Symptoms and Presentation: 

It may present as local pain or swelling. Patients generally feel they are in good health otherwise.

X-Ray Appearance and Advanced Imaging Findings: 
Lymphoma of bone has a variable picture on plain-xray. A lesion may appear as a vague, mottled lucency. This intraosseous lesion usually has permeative pattern of lysis but may appear blastic or sclerotic. Periosteal reaction and cortical destruction follow. Plain radiographs often underestimate the extent of the lesion. CT scan is useful for disease staging and delineating spinal lesions. MRI is helpful in demonstrating bone marrow and soft tissue involvement. Lymphoma has an increased uptake on bone scan.
Differential Diagnosis: 
The radiologic differential includes osteosarcoma, Ewing's sarcoma and osteomyelitis. The possibility of metastatic disease needs to be eliminated
Histopathology findings: 
On gross examination. primary non-Hodgkin's lymphoma of bone is a gray-white tumor that diffusely infiltrates bone. Pathological diagnosis requires clinical suspicion of lymphoma for good tissue handling. It is essential to get tissue without crush artifact or decalcification to preserve cell morphology. Needle biopsy is not adequate. Non-Hodgkin's lymphoma appears most commonly with large cells with irregular cleaved nuclei and prominent nucleoli surrounded by reticulin fibers. The most common subtype is diffuse histiocytic lymphoma. Hodgkin's lymphoma has a mixed cell population with plasma cells, lymphocytes, histiocytes and eosinophils. Reed-Sternberg cells are large, sharply delineated cells with abundant cytoplasm and a double nucleus that make the diagnosis of Hodgkin's lymphoma. The pathologic differential includes Ewing's sarcoma, chronic osteomyelitis and eosinophilic granuloma. The following note is in regards to the pathology images (total 7) attached for non-hodgkin lymphoma: NOTE: The sections reveal a monotonous infiltrate of mixed small and large lymphocytes with associated crush artifact and area of extensive necrosis. Immunohistochemical stains reveal: Positive staining for: LCA (CD45) CD20 CD10 Bcl-2 CD15, scattered positivity (hampered by necrosis and associated acute inflammation) Ki-67, approximately 50% Negative staining for: cytokeratin AE1/3, CD3, CD5, cyclin D1, CD30. There are at least 10 large cells/high power field. Flow cytometry was unsuccessful due to low viability. Given the patient's history and the strong co-expression of CD20, CD10 and bcl-2, the results are consistent with a B cell lymphoma of germinal center origin, i.e. a follicular lymphoma, at least grade 2. However, the high proliferative index and increased numbers of large cells over that reported in the patient's original neck lymphoma make the possibility to a higher grade B cell lymphoma likely. Because of the extensive necrosis and crush artifact, exact grading is deferred until examination of the completely excised specimen (as per the surgeon's plan).
Treatment Options for this Tumor: 
Treatment of lymphoma of bone is usually radiation and chemotherapy. Clinical staging studies include chest x-ray, bone scan, CBC, serum chemistries, bone marrow aspirate and biopsy. Surgery is only indicated for pathologic fractures.
Outcomes of Treatment and Prognosis: 
Lymphoma of bone has the best prognosis of all primary malignant bone tumors.
Special and Unusual Features: 
Malloy, PC et al., Lymphoma of Bone, Muscle, and Skin: CT Findings, AJR 159:805-809, October, 1992. 2Bulloughs, Peter, Orthopaedic Pathologv (third edition), Times Mirror International Publishers Limited, London, 1997. Desai, S et al., Primary Lymphoma of Bone: A Clinicopathologic Study of 25 Cases Reported Over 10 Years, Journal of Surgical Oncology,46:265-269, 1991. Huvos, Andrew, Bone Tumors: Diagnosis. Treatment and Prognosis, W.B. Saunders, Co., 1991. Le vis, SJ et al., Malignant Lymphoma of Bone, Canadian Journal of Surgery, 37(1):4349, February, 1994. 12/18/97