Age / Sex : 78 / F

Chief complaint: lower leg pain and palpable soft tissue mass

1) What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

(Quiz는 quiz일 뿐이오니 답안은 한개만 보내주시기 바라오며, 복수의 답안을 보내주시는 분은 정답이 포함되어 있더라도 부득이 semi-correct answer로 처리토록 하겠습니다.)

Courtesy:  정선관(Juhng Seon Kwan),원광의대병원(Wonkwang University Hospital)

Malignant Lymphoma

Discussion

Findings:

 Tibia AP and lateral views show few cortical osteolytic lesions in the anterior cortex of tibia.. MRI shows multiple intramedually and cortical lesions as well as a large soft tissue mass.

Differential Diagnosis: metastasis, myeloma, leukemia, osteosarcoma, Ewing's sarcoma, osteomyelitis

Diagnosis: Malignant Lymphoma, B- cell

Discussion:

Lymphoma affecting the bones is rare, particularly primary bony lymphoma in the absence of systemic disease. Bony involvement is seen in approximately 5% of cases of disseminated lymphoma. Lymphoma of bone has a variable picture on plain radiographs. 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 is an excellent modality for displaying cortical disruption, periosteal reaction, soft-tissue masses, and sequestration. MRI is helpful in demonstrating bone marrow and soft tissue involvement. On T1-weighted images, lymphoma within bone marrow displays low signal intensity (similar to adjacent muscle) but high signal intensity on T2-weighted and STIR image sequence. Because T2-weighted sequences also display surrounding bone marrow edema, T1-weighted images are better for assessing the extent of disease and avoiding overestimation. Lymphoma has an increased uptake on bone scan.

 References:

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4.     Mengiardi B, Honegger H, Hodler J, Exner UG, Csherhati MD, Bruhlmann W. Primary lymphoma of bone: MRI and CT characteristics during and after successful treatment. AJR 2005; 184:185–192

5.     Mulligan ME, McRae GA, Murphey MD. Imaing features of primary lymphoma of bone. AJR 1999; 173:1691–1697