Age / Sex : 79 / M

Chief complaint: Pain and swelling in right medial portion of ankle

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: 김영숙(Young-sook Kim), 조선대학교부속병원(Chosun university hospital)

Primary lymphoma of bone

Discussion

Finding

1) Radiographs (Rt. ankle AP and Lat).

Permeable lesion with sclerosis in distal meta-diphysis of Rt. tibia.

Subtle periosteal reaction and no cortical destruction or erosion

2) MR finding

: MR imaging of both tibia shows localized, irregular and serpiginous lesions with low signal intensity lesion on T1WI and heterogeneous high signal intensity on T2WI in bone marrow area of proximal tibia and mid and distal meta-diaphysis of Rt. tibia. This lesion reveals cortical destruction and erosion with no definite soft tissue mass and shows heterogeneous high enhancement.

Differential diagnosis

1)     Metastasis, bone marrow

2)     Leukemia, Lymphoma

Diagnosis

Primary lymphoma of bone

Discussion

1) Lymphoma of bone

a) Primary lymphoma of bone

Single skeleton site, with or without regional lymph node

involvement or multiple bone involvement, without visceral or

lymph nodes involvement

 b) Secondary lymphoma of bone

   Presentation with bone tumor but work-up shows

involvement of viscera or lymph nodes in multiple regions or

known soft tissue lymphoma with bone biopsy demonstrating

involvement of bone

2) Pathology

->lymphoma of bone may have a spindled morphology.

: histologic differential diagnosis ->Immunohistochemical stain

①Diffuse round cell infiltrates

         : Ewing sarcoma and granulocytic sarcoma

② Spindled metastatic sarcomas and spindled carcinomas

3) Clinical features

a) m/c symptoms

  : Bone pain, Neurologic symptoms, pathologic fracture

 b) other signs/symptoms

  : systemic or B symptoms(Rare)

  c) Wide range of age(Peak incidence in 60-70), M>F(1.5:1)

  d) Epidemiology : Non-Hodgkin lymphoma(m/c)

                 Multifocal at presentation(11-31%) - 50 % of children present with PMOL

* Primary multifocal osseous lymphoma (PMOL) is considered subset of primary lymphoma of bone

    ->Multiple bones affected but no nodal or visceral involvement

PMOL in metaphysis, diaphysis, and epiphysis

4) Imaging finding

a) Radiography

①Extensive involvement of bone with permeative bone destruction without sclerotic

margination (Permeative pattern may be subtle)

②Sclerotic reactive bone (30%) and sequestra(16%) may be present

③Soft tissue mass may be large relative cortical destruction and cortical destruction

may be subtle

④Cortical thickening and periosteal reaction may be presented

b) CT

①Cortical disruption may be demonstrated well

②Useful for workup of body(chest, abdomen and pelvis) for detecting involvement of viscera and lymph node

c) MR

①Presents permeative lesion with tumor serpiginouslyoccupying between areas of normal medullary bone. Tumor regions reveals Low SI on T1WI, high SI on T2WI, intense enhancement

②Cortical destruction may be subtle

: Complete destruction 28%, little overt cortical disruption 52%

③Soft tissue mass 

: large relative to osseous destruction, or small and circumferential

 Low SI on T1WI, heterogenous  high SI on T2WI, heterogenous enhancement(necrosis)

References

1. Heyning, Fenna H., et al. MR imaging characteristics in primary lymphoma of bone with emphasis on non-aggressive appearance.Skeletal radiology2007:36:937-944.
   
2. Krishnan, Anant, et al. Primary Bone Lymphoma: Radiographic–MR Imaging Correlation1.Radiographics 2003:23: 1371-1383.