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Osteolytic Thoracic Spinal Lesions at Presentation in Primary Non-Hodgkin's Lymphoma of the Bone FREE TO VIEW

Gaurang Vaidya, MBBS; Wajihuddin Syed, MBBS; Vishal Shah, MBBS; Amitpal Nat, MD
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SUNY Upstate Medical University, Syracuse, NY

Chest. 2014;146(4_MeetingAbstracts):675A. doi:10.1378/chest.1995088
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SESSION TITLE: Cancer Student/Resident Case Report Posters III

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Back pain is one of the most frequent symptoms affecting the elderly and is viewed as a benign condition until it becomes the harbinger of a fatal disease. The diagnosis is often missed until radicular or myelopathic signs appear. Spinal osteolytic and compressive lesions at presentation of Non-Hodgkin’s lymphoma (NHL) is not widely known in clinical practice, occurring in less than 5% new cases1. This case abstract is one such highlight where the early diagnosis could have improved the outcome.

CASE PRESENTATION: 88 year old man was admitted with mid-thoracic back pain, extending to his right leg, with a gradual onset 6 months ago. He had previously underwent multiple clinic visits with a misdiagnosis of spondylosis. His physical examination including neurological was unremarkable except positive straight leg raising test. CT thorax and lumbar spine showed multiple destructive masses involving T2 to L2 vertebral bodies with pathological fracture of T11 causing spinal canal stenosis. Initial differentials included multiple myeloma or metastasis from an unknown primary but CT thorax and abdomen failed to show any primary lesion. Xray right femur revealed an intramedullary lytic mass within the proximal shaft and the biopsy showed diffuse large B-cell Lymphoma with high Ki-67 proliferation index. Patient underwent spine radiotherapy with considerable benefit in symptoms. Unfortunately, he passed away during follow up due to extensive metastases and cardiopulmonary failure.

DISCUSSION: The involvement of bone in NHL may occur in later stages but is very rare as the presenting finding1 and it commonly involves the thoracic region1. The diagnosis is often missed due to non-specific symptoms and non-confirmatory imaging2, as happened in our case. The severity of symptoms prior to the diagnosis of NHL is often a marker of outcome, with non-ambulatory patients or longer duration of symptoms having poor prognosis1. Early decompression surgery may be indicated for recovery of function. Treatment entails chemotherapy or radiotherapy alone for neurological compression due to soft tissue extension3. Surgical or non-surgical treatment does not influence the survival3

CONCLUSIONS: 1.It is not uncommon for Non-Hodgkin’s lymphoma to primarily present as spinal osteolytic lesions. 2.Early diagnosis and treatment is associated with better outcomes1. 3.The possibility of malignancy in elderly should prompt detailed workup if non-specific symptoms persist.

Reference #1: McDonald AC, Nicoll JA, Rampling RP. Non-hodgkin's lymphoma presenting with spinal cord compression; a clinicopathological review of 25 cases. Eur J Cancer. 2000;36(2):207-213.

Reference #2: Durr HR, Muller PE, Hiller E, et al. Malignant lymphoma of bone. Arch Orthop Trauma Surg. 2002;122(1):10-16.

Reference #3: Peng X, Wan Y, Chen Y, et al. Primary non-hodgkin's lymphoma of the spine with neurologic compression treated by radiotherapy and chemotherapy alone or combined with surgical decompression. Oncol Rep. 2009;21(5):1269-1275.

DISCLOSURE: The following authors have nothing to disclose: Gaurang Vaidya, Wajihuddin Syed, Vishal Shah, Amitpal Nat

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