Primary non-Hodgkin's lymphoma of bone. A clinicopathologic study

The Application of Ultrasonography-Computed Tomography Fusion Navigation Technology in Complex Bone Tumor Biopsy: A Randomized Double-Blind Controlled Trial

OBJECTIVE

This study aims to investigate the clinical application value of ultrasonography-computed tomography (CT) fusion navigation technology in bone tumor biopsy surgery.

METHODS

Thirty patients with bone tumors requiring biopsy surgery were randomly assigned to either the U-C group (ultrasonography-CT group; n = 15) or the control group (n = 15). The U-C group used ultrasonography-CT fusion navigation technology for real-time localization of the biopsy needle, whereas the control group relied on intraoperative C-arm fluoroscopy for localization. The success rate of the surgeries, the number of radiation exposures during the procedure, surgical time, and intraoperative blood loss were compared between the 2 groups.

RESULTS

The number of intraoperative radiation exposures in the U-C group was 2 versus 7 in the control group (P < 0.05), showing significant differences between the 2 groups. The success rate of biopsies in the U-C group and control group was 100% (P > 0.05), the mean operative time was 45 ± 9 minutes versus 42 ± 13 minutes (P > 0.05), and intraoperative bleeding volume was 10 ± 4 mL versus 11 ± 5 mL (P > 0.05), all showing no significant differences between the 2 groups.

CONCLUSIONS

The real-time localization of the biopsy needle in bone tumor biopsy surgery using ultrasonography-CT fusion navigation technology can significantly reduce intraoperative radiation exposure for both patients and surgeons during the procedure. Consequently, this technique holds certain clinical applicability.

Primary Bone Lymphoma: A Review of the Literature with Emphasis on Histopathology and Histogenesis

Primary bone lymphoma (PBL) is a rare neoplasm of malignant lymphoid cells presenting with one or more bone lesions without nodal or other extranodal involvement. It accounts for approximately 1% of all lymphomas and 7% of malignant primary bone tumors. Diffuse large B-cell lymphoma (DLBCL), not otherwise specified (NOS) represents the predominant histological type and constitutes over 80% of all cases. PBL may occur at all ages with a typical diagnosis age of 45–60 years and a slight male predominance. Local bone pain, soft tissue edema, palpable mass and pathological fracture are the most common clinical features. Diagnosis of the disease, which is frequently delayed due to its non-specific clinical presentation, is based on the combination of clinical examination and imaging studies and confirmed by combined histopathological and immunohistochemical examination. PBL can develop in any part of the skeleton, although it occurs most commonly in the femur, humerus, tibia, spine and pelvis. The imaging appearance of PBL is highly variable and unspecific. In terms of the cell-of-origin, most cases of primary bone DLBCL (PB-DLBCL), NOS belong to the germinal center B-cell-like subtype and specifically originate from germinal center centrocytes. PB-DLBCL, NOS has been considered a distinct clinical entity based on its particular prognosis, histogenesis, gene expression and mutational profile and miRNA signature. PBL carries a favorable prognosis, especially when treated with combined chemoradiotherapy.

A Nomogram Predicting Overall and Cancer-Specific Survival of Patients with Primary Bone Lymphoma: A Large Population-Based Study

We aimed to develop a nomogram for evaluating the overall survival (OS) and cancer-specific survival (CSS) in patients with primary bone lymphoma (PBL). Patients diagnosed with PBL between 2007 and 2016 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. All patients were randomly allocated to the training cohort and validation cohort (2 : 1). The nomogram was developed by the training cohort and validated by the validation cohort using the concordance index (C-index), calibration plots, and decision curve analyses (DCAs). The C-index for CSS and OS prediction in the training cohort were 0.76 and 0.77, respectively; in the validation cohort, they were 0.76 and 0.79, respectively. The calibration curve showed good consistency between nomogram prediction and actual survival. The DCA indicated obvious net benefits of the new predictive model. The nomogram showed favorable applicability and accuracy, and it will be a reliable tool for predicting OS and CSS in patients with PBL.

Primary Non-Hodgkin Lymphoma of the temporal bone: A rare case report

INTRODUCTION

Primary lymphoma of the temporal bone is extremely rare, difficult to diagnose and to manage. It is essential that the clinician keeps in mind the possibility of this pathology as a differential diagnosis with the infections resistant to the usual treatment.

CASE REPORT

We report a rare case of a diffuse large B-cell lymphoma in a 70-year-old- woman, with history of diabetes. The pathological study was in favor of a Non-Hodgkin Lymphoma of the Temporal Bone.

DISCUSSION

Lymphomas defined as malignant monoclonal proliferation of lymphoid cells, are not uncommon in the head and neck region. Literature presents with few cases.

CONCLUSION

The aim of this article is to report a rare case of a diffuse large B-cell lymphoma with primary mastoid and external auditory canal infiltration without systemic involvement initially presented as a benign ear infection.

[Adult non-Hodgkin bone lymphomas]

Two forms of bone lymphomas can be distinguished: the primary bone lymphoma (PBL) and the secondary bone lymphoma (SBL). PBL is a rare disease with a good prognosis. Clinical manifestations and imaging findings are usually non-specific. Patient can present with pain, swelling of affected bone or pathologic fracture. Positron emission tomography-CT scan is a sensitive imaging modality and very useful for staging, restaging, surveillance of recurrence, and monitoring of treatment response of lymphoma. The diagnosis of PBL is often difficult and made after biopsy examination. Most patients have diffuse large B-cell lymphoma. Patients have been treated with radiotherapy, chemotherapy or combination of both. Localized disease, low IPI (International Prognostic Index) and complete remission after initial treatment were associated with a better outcome. Management of late sequelae deserves particular attention. SBL is more common than PBL; this is a disseminated lymphoma with concomitant involvement of the skeleton. We review the clinical, imaging and pathologic features of bone lymphomas; and discuss therapeutic modalities as well as prognosis of these lymphomas in the era of immunochemotherapy.

Primary lymphoma of bone: a population-based study of 2558 patients

Background:

Primary lymphoma of bone (PLB) is an extremely rare malignancy arising in the skeletal system. There is no consensus over the best definition of PLB. Most of the published articles are single-institutional retrospective studies with a limited sample size. The rarity of PLB and discrepancies on diagnostic criteria has resulted in a vague understanding of PLB.

Methods

We retrospectively analyzed the clinical characteristics and prognostic factors of 2558 PLB patients who were registered in the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2016. Survival rates were calculated using the Kaplan–Meier method. The effects of various factors on survival outcomes were analyzed by using the log-rank test. Univariate and multivariate analyses were conducted by using the Cox proportional hazards model to determine independent prognostic factors.

Results:

The median follow-up time of all eligible patients was 58 months. There seemed no sex preponderance in PLB incidence. The most involved sites are axial skeletons. The most common histological subtype was diffuse large B-cell lymphoma. The 3-, 5-, 10-, and 20-year overall survival (OS) rates were 70.70%, 65.70%, 54.40% and 39.50%, respectively. PLB patients whose primary tumor sites were appendicular and craniofacial skeletons had a significant survival advantage [hazard ratio (HR) = 0.694, 95% confidence interval (CI) 0.552–0.872; HR = 0.729, 95% CI 0.597–0.889, respectively] over those with axial skeletons as primary tumor sites. Patients with Hodgkin lymphoma, non-Hodgkin lymphoma (NHL)–mature B-cell lymphoma, and NHL-precursor-cell lymphoblastic lymphoma also had a significant OS advantage (HR = 0.392, 95% CI 0.200–0.771; HR = 0.826, 95% CI 0.700–0.973; and HR = 0.453, 95% CI 0.223–0.923, respectively). Patients with Ann Arbor stage III–IV at diagnosis were at higher risk of death than those with stage I–II (HR = 1.348, 95% CI 1.107–1.641). Chemotherapy was an independent favorable prognostic factor (HR = 0.734, 95% CI 0.605–0.890).

Conclusions:

Primary anatomic site, histology type, higher Ann Arbor stage and chemotherapy were independent prognostic factors. Chemotherapy played a pivotal role in PLB treatment.

Primary Bone Lymphoma: A 13 Year Retrospective Institutional Analysis in the Chemo-Immunotherapy Era

Primary Lymphoma of bone (PBL) is an uncommon extranodal tumor accounting for 1% of all malignant lymphomas. The incidence of PBL is so rare that many of its aspects remain unknown. We retrospectively analysed our data in order to know clinical characteristics and treatment outcome in Indian population in chemo-immunotherapy era. We identified 49 patients [2007-2019] (median age 52 years) of which, 35 (71.4%) were males. Nearly one-third patients (n = 18; 36.8%) were elderly (Age > 60). The most common histological subtype was DLBCL. Local pain /swelling (n = 23; 47%) and B symptoms (n = 20; 44.4%) was the most common presentation. Spine was the most frequently involved site (n = 25; 51%) followed by pelvis (n = 17; 34.7%). One third patients had poor ECOG-PS ≥ 2, (n = 16; 32.6). More than 50% of the population presented with IPI score ≥ 2 (n = 25; 55.5%). Majority of the patients presented with Ann-Arbor stage IV disease (n = 31; 63.2%). (n = 32; 71.1%) cases received chemotherapy alone and (n = 13; 28.9%) patients were treated in combination with local radiotherapy. R-CHOP was the most common treatment regimen given to patients (n = 43; 95.5%). Overall, three-fourth patients (n = 36; 80%) achieved a complete response. At a median follow-up of 45 ± 2 (range 3-144) months, 4-year OS (Overall Survival) and PFS (Progression free survival) was 83.1% and 74.5%, respectively, using Kaplan-Meier survival curves. Prognostic factors for OS on multivariate analysis were ECOG-PS 0-1 [p = 0.05], age < 60 [p = 0.03] and achievement of CR [p = 0.001]. PBL in India is usually of DLBCL subtype, with spine as the most common site. It has an excellent prognosis in the R-CHOP era. Chemo-immunotherapy with 6 R-CHOP followed by addition of Radiotherapy if partial response appears to provide good outcomes. However, the exact role of radiation still needs to be confirmed.

Clinical characteristics and outcomes of primary adrenal diffuse large B cell lymphoma in a large contemporary cohort: a SEER-based analysis

Primary adrenal lymphoma (PAL) is an extremely rare lymphoma, and the most common histologic type is diffuse large B cell lymphoma (DLBCL). Primary adrenal DLBCL has a quite poor prognosis, but the prognostic determinants are rarely reported. With the Surveillance, Epidemiology, and End Results (SEER) program, we collected the demographic, clinical, therapeutic information of patients with primary adrenal DLBCL from 1983 to 2015. The Kaplan-Meier method was used to obtain overall survival (OS) and cause-specific survival (CSS) curves. The prognostic values of OS and CSS were assessed using Cox proportional hazards regression model with univariate and multivariate analyses. A total of 136 patients were included in our cohort. Adrenal DLBCL predominantly affected male and the aged, and there was a high rate of unilateral adrenal origin. The patients were more likely to present advanced stage disease. The OS rates of the entire cohort of patients with adrenal DLBCL at 5 and 10 years were respectively 19.17% and 3.33%, and the similar results were shown in 5-year and 10-year CSS rates. Age more than 70 years old and bilateral were identified as independent prognostic factors that were correlated with both adverse OS and CSS, and patients with chemotherapy had a superior OS and CSS to the patients without any treatment.

Maxillary Metastasis of Esophageal Cancer: Report of the First Case and Literature Review

BACKGROUND

Esophageal cancer (EC) is a common digestive system tumor, characterized by high invasion, apparent lethality, and poor prognosis. Direct diffusion is the major metastatic mechanism of early EC, whereas advanced EC is spread mainly by lymphatic metastasis, but also can be transferred to the liver, lungs, bones, and so on, by hematogenous metastasis. The incidence of bone metastasis in esophageal cancer is low, and maxillary metastasis of EC is more rare.

OBJECTIVE

To explore the differential diagnosis in ECMM, the rare metastasis of EC, and the possible mechanisms and predictors of bone metastasis.

METHODS

The clinical materials of a male patient with maxillary metastasis of esophageal cancer (ECMM) were analyzed. Then, the possible mechanism of the ECMM was discussed.

CONCLUSION

ECMM may belong to the hematogenous metastasis. The early detection of rare sites of metastasis of EC should be prioritized in tumor marker detection, imaging, pathology, and other diagnostic techniques.

Primary Lymphoma of the Pelvis: A Case Report

Introduction:

Primary lymphoma of the bone (PLB) is uncommon clinical entity with the vast majority of the cases are non-Hodgkin’s lymphoma. Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of PLB.

Case Report:

We report a case of 60-year-old female presented with pain in the right hip that persisted for 2 months. Plain X-ray, computed tomography, and magnetic resonance imaging of the right hip showed a lytic lesion involving the right acetabulum and adjoining iliac bone with extraosseous mass. The histopathological and immunohistochemical examination confirmed a diagnosis of DLBCL. Treatment with cyclophosphamide, epirubicin, vincristine, and prednisone plus rituximabestablished a complete response (CR) with remodeling of the acetabulum. At the last follow-up, the patient had the ability to walk without any support which obviates the need of primary surgical interference for the tumor.

Conclusion:

The PLB must be considered in the differential diagnosis of lytic lesions involving the pelvic bones in older adults, especially when accompanied by extraosseous soft tissue mass. Our patient of PLB showed goodremodeling of the acetabular area after CR to chemotherapy without primary surgical interference for the tumor with the limitation of weight-bearing during chemotherapy treatment to prevent fracture.

Primary non-Hodgkin lymphoma of the right femur and subsequent metastasis to the left femur: A case report and literature review

Non-Hodgkin lymphoma of the bone is rare and typically causes an extensive bone lesion. The present study describes a case of diffuse large B-cell primary non-Hodgkin lymphoma of the bone, which occurred in the right femur, and was initially treated with surgery and chemotherapy. Following a 7-year period of complete remission, a new, similar lesion was identified in the left femur. With both lesions, there was no accompanying destruction of any other bones or organ involvement. Metastasis of PLB to the contralateral side is extremely rare and, to the best of our knowledge, this is the first report of this particular presentation in China or worldwide. We hypothesized that the present situation arose due to mechanisms involving the tumor microenvironment, circulating tumor cells, lymphocyte homing and self-seeding. The present report describes the case in detail, and discusses the possible underlying mechanisms and their potential contribution to the treatment of non-Hodgkin lymphoma, as well as the prevention of metastasis and recurrence, which may be of considerable clinical significance.

A Case of Extranodal Metastasis of Primary Bone Lymphoma in the Lower Extremity

Primary bone lymphoma is a rare disease, accounting for less than 5% of all extranodal lymphoma. Although the femur is cited as being the most common site, primary bone lymphoma is rare, accounting for less than 1% of all non-Hodgkin's lymphoma. Herein we present a case of diffuse B-cell-type malignant lymphoma manifested as a large soft-tissue mass of the leg, via metastasis of primary non-Hodgkin's lymphoma of the femur, which went untreated. We highlight the advantages of various imaging modalities used throughout the process of diagnosis and treatment because accurate and early diagnosis are essential. This case gives us a unique opportunity to witness the rapid progression of metastasis and an atypical location.

Primary malignant lymphoma of the talus: A case report and review of the literature

Malignant lymphoma commonly occurs in adults, with a peak incidence between the seventh and ninth decades of life. Although malignant lymphoma usually occurs in the lymph nodes, it rarely occurs primarily in the bone. We herein describe an extremely rare case of primary malignant lymphoma of the talus in a 74-year-old man. Although plain radiographs showed no abnormality, gadolinium-enhanced magnetic resonance imaging (MRI) revealed a well-circumscribed intra- and extraosseous tumor of the talus. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/MRI revealed a marked increase of FDG uptake in the right ankle and the right inguinal lymph nodes. As the tumor was diagnosed as diffuse large B-cell lymphoma by core needle biopsy, combination therapy with chemo- and radiotherapy was initiated. The patient achieved complete remission, with no sign of recurrence at 8 months after initial chemoradiotherapy. Since primary malignant lymphoma of the bone is chemo- and radiosensitive and has a good prognosis, accurate staging by radiological investigation as well as correct pathological diagnosis by biopsy are required for optimal treatment.

Bilateral Non-Hodgkin's Lymphoma of the Temporal Bone: A Rare and Unusual Presentation

Primary lymphoma of the temporal bone is an unusual finding in clinical practice and bilateral affection is even more rare. To the best of our knowledge, there are no reports of bilateral primary temporal bone lymphoma without middle ear involvement in the English medical literature so far. We report, for the first time, a case of primary lymphoma involving both temporal bones which presented with left-sided infranuclear facial palsy. A combination of contrast enhanced magnetic resonance imaging (MRI) and high resolution computed tomography (HRCT) was used to characterize and to map the extent of the lesion, as well as to identify the exact site of facial nerve affection. An excision biopsy and immunohistochemistry revealed diffuse large B-cell non-Hodgkin's lymphoma (DLBCL). Whole body fluorodeoxyglucose (FDG) positron emission tomography-computed tomography study (PET-CT) was performed to stage the disease. The patient was treated with chemotherapy and radiation therapy and is now on regular follow-up. The patient is alive and asymptomatic without disease progression for the last twenty months after initial diagnosis.

Clinical characterization and outcome of primary bone lymphoma: a retrospective study of 61 Chinese patients

Primary bone lymphoma(PBL) is a rare disease. To assess the clinical characteristics, outcome, and prognostic factors of this entity in Chinese population, we retrospectively analyzed 61 PBL patients initially treated in our institution between 1997 and 2014. The median age was 45 years. The most common histological subtype was diffuse large B-cell lymphoma (DLBCL) (55.7%), followed by T-cell lymphoma (18.0%). All patients underwent systemic chemotherapy as initial treatment while 24 patients (39.3%) were additionally treated with radiotherapy. The 5-year overall survival (OS) and the 5-year progression-free survival (PFS) rates of 57 cases with completed follow-up were 52.3% and 40.1%, respectively. In further analysis of the primary bone DLBCL (PB-DLBCL) subgroup, the 5-year OS and PFS rates were 53.0% and 47.0%, and a multivariable analysis revealed that baseline Eastern Cooperative Oncology Group (ECOG) score and response to initial treatment (complete remission versus no complete remission) were independent prognostic factors for both OS and PFS. The proportion of T-cell lymphoma is higher in China than in western populations. High baseline ECOG scores (≥2) and unachieved CR in initial therapy were factors for poor PB-DLBCL prognosis. The role of radiotherapy and rituximab in PLB therapy remains to be confirmed in further investigation.

Is Radiation Necessary for Treatment of Non-Hodgkin's Lymphoma of Bone? Clinical Results With Contemporary Therapy

BACKGROUND

Non-Hodgkin's lymphoma (NHL) of bone is a rare musculoskeletal malignancy accounting for fewer than 7% of bone cancers. Traditionally, we have treated patients who have NHL of bone with chemotherapy and radiation therapy, but the role of radiotherapy in disease management and patient functional outcomes after treatment have not been well studied. We investigated the survival advantage of radiotherapy in a large cohort of patients with NHL of bone and assessed associated patient complications of radiotherapy.

QUESTIONS/PURPOSES

The objective of this study was to compare patients treated for NHL of bone with and without radiation in terms of (1) overall survival; (2) pretreatment complications; (3) posttreatment complications; and (4) functional outcomes using the Musculoskeletal Tumor Society (MSTS) score.

METHODS

A retrospective analysis of all patients with biopsy-proven NHL of bone diagnosed at our institution between 1985 and 2013 was undertaken; 70 patients met our criteria for inclusion with minimum followup of 6 months (median, 55 months; range, 10-219 months). Overall survival at 5 and 10 years was estimated and compared between two groups of patients: one group treated with systemic therapy alone (chemotherapy, rituximab; 46 patients [66%]) and the other with combined modality therapy (systemic therapy and radiotherapy; 24 patients [34%]). During the period in question, indications for radiotherapy included bulky disease, an abbreviated course of systemic therapy, and an incomplete response to systemic therapy. Patients not meeting these criteria generally received systemic therapy alone. With the available sample size, it was estimated that a difference in survival of approximately 30% would have to be present for detection with 80% power (α = 0.05, β = 0.2, n = 70, Δ = 30%). Pretreatment and posttreatment complications occurring in both patient groups were retrospectively reviewed with special emphasis on fracture healing after treatment. MSTS scores were obtained for 45 patients with appendicular tumors at a median followup of 42 months (range, 10-215 months).

RESULTS

With the data available, no difference in Kaplan-Meier survivorship was observed between patients treated with and without radiation at 5 years (98%; 95% confidence interval [CI], 93%-100% versus 95%; 95% CI, 85%-100%; p = 0.281). Patients who were treated with radiation were more likely to experience problems with fracture healing (relative risk [RR], 12.8; 95% CI, 1.8-89.8; p = 0.01). Similarly, patients treated with radiation were at a higher risk for fracture in the posttreatment period (five of 24 versus no radiation zero of 46; RR, 20.7; 95% CI, 1.2-359.0; p = 0.0375). MSTS scores were poorer in patients treated with radiation (75% versus 91%; p = 0.034) attributable in part to a higher incidence of bony complications in this group after treatment.

CONCLUSIONS

Based on the numbers of patients in our study, we could not demonstrate a survival advantage with radiation use. Rather, radiotherapy may be associated with orthopaedic complications occurring during and after treatment. Larger, prospective studies are necessary to definitively establish whether radiation is necessary for the treatment of patients with lymphoma of bone.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Primary and secondary bone lymphomas

Recent studies have contributed to the enhancement of clinical and molecular knowledge on bone lymphomas, a group of rare malignancies with particular characteristics. Nevertheless, several questions remain unanswered and the level of evidence supporting some diagnostic and therapeutic decisions remains low. Currently, three different forms of bone lymphomas can be distinguished: the primary bone lymphoma, consisting of a single bone lesion with or without regional lymphadenopathies; the polyostotic lymphoma, consisting of multifocal disease exclusively involving the skeleton; and the disseminated lymphoma with secondary infiltration of the skeleton. The first two forms exhibit a good prognosis, requiring treatments similar to those commonly used for nodal lymphomas of the same category, but several issues regarding the role of surgery and local control of the disease, the sequence of treatment, radiation volumes and doses, management of pathological fractures and prevention of late sequelae deserve particular attention. Due to its rarity, prospective trials exclusively focused on bone lymphomas appear unrealistic, thus, critical revision of our own experience and analyses of large cumulative series as well as molecular studies on archival cases remain valid alternatives to improve our knowledge on this obscure lymphoproliferative malignancy. The present review is based on the analysis of the largest available database of bone lymphomas established under the sponsorship of the International Extranodal Lymphoma Study Group (IELSG) as well as on the critical revision of related literature. We provide recommendations for diagnosis, staging, treatment, and response assessment of these patients in everyday practice as well as for the management of special conditions like pathological fractures, indolent forms and central nervous system prophylaxis.

Primary non Hodgkin's lymphoma of talus in a child-a rare presentation

We report a rare case of primary non-Hodgkin's lymphoma of bone which presented with an osteolytic lesion of the head of the right talus which to the best of our knowledge is the first case to be reported in the paediatric age group. Early and accurate identification is necessary as it has a good prognosis.

Primary diffuse large B-cell lymphoma of the bone: bendamustine and rituximab are able to overcome resistant disease

Primary bone lymphoma (PBL) is a rare disease for which specific therapeutic guidelines have not yet been established. Due to common appearance in the elderly and recurring relapses, new treatments are required. We report the case of multiple relapsed aggressive PBL effectively treated using Bendamustine and Rituximab. A 78-year-old male patient presented with a painful mass in the left arm. Computed tomography (CT) showed a pathological tissue in the humerus diaphysis infiltrating the muscle, confirmed by positron emission tomography (PET) scan. Indeed, PET excluded pathological local lymph node involvement. Biopsy of the humerus revealed the presence of diffuse large B cell lymphoma. Recommended treatments for PBL were used, but relapses after an initial complete response occurred. Following the positive experience of Vacirca et al. the patient underwent Bendamustin 90 mg/mq gg1-2 q28 plus Rituximab 375 mg/mq q28 (BR). Herein we report the first experience of BR combination in PBL and it proved to be an efficacious and safe salvage therapy in relapsed/refractory PBL.

Impact of Rituximab and Radiotherapy on Outcome of Patients With Aggressive B-Cell Lymphoma and Skeletal Involvement

Purpose

To study clinical presentation, outcome, and the role of radiotherapy in patients with aggressive B-cell lymphoma and skeletal involvement treated with and without rituximab.

Patients and Methods

Outcome of patients with skeletal involvement was analyzed in a retrospective study of nine consecutive prospective trials of the German High-Grade Non-Hodgkin lymphoma Study Group.

Results

Of 3,840 patients, 292 (7.6%) had skeletal involvement. In the MabThera International Trial (MInT) for young good-prognosis patients and the Rituximab With CHOP Over 60 Years (RICOVER-60) study for elderly patients, the randomized addition of rituximab improved event-free survival (EFS; hazard ratio for MInT [HRMInT] = 0.4, P > 001; hazard ratio for RICOVER-60 [HRRICOVER-60] = 0.6, P > .001) and overall survival (OS; HRMInT = 0.4, P < .001; HRRICOVER-60 = 0.7, P = .002) in patients without skeletal involvement, but failed to improve the outcome of patients with skeletal involvement (EFS: HRMInT = 1.4, P = .444; HRRICOVER-60 = 0.8, P = .449; OS: HRMInT = 0.6, P = .449; HRRICOVER-60 = 1.0, P = .935). Skeletal involvement was associated with a worse outcome after cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) plus rituximab (HREFS = 1.5, P = .048; HROS = 1.1; P = .828), but not after CHOP without rituximab (HREFS = 0.8, P = .181; HROS = 0.7, P = .083). In contrast to rituximab, additive radiotherapy to sites of skeletal involvement was associated with a decreased risk (HREFS = 0.3, P = .001; HROS = 0.5; P = .111).

Conclusion

Rituximab failed to improve the outcome of patients with diffuse large B-cell lymphoma with skeletal involvement, although our data suggest a beneficial effect of radiotherapy to sites of skeletal involvement. Whether radiotherapy to sites of skeletal involvement can be spared in cases with a negative positron emission tomography after immunochemotherapy should be addressed in appropriately designed prospective trials.

Case report and review of primary bone diffuse large B-cell lymphoma involving the calcaneus

Primary bone lymphoma from diffuse large B-cell lymphoma is a very rare condition, especially in the foot. In the present case report, a 23-year-old female patient presented with long-term pain along the lateral aspect of her right calcaneus. Ancillary magnetic resonance imaging revealed a radiolucent bone tumor in the calcaneus. Computed tomography-guided biopsy of the bone was completed and revealed chronic inflammation with hematopoietic elements. The patient continued to have pain and limitation in her daily activities after the biopsy. The patient underwent surgical excision and curettage by the senior author. Pathologic examination revealed that the lesion was consistent with diffuse, large, B-cell lymphoma, stage IAE. The lesion appeared to have been completely excised at surgery, and the patient underwent 3 cycles of chemotherapy and 15 radiotherapy sessions to the calcaneus. At the last follow-up visit, the patient had been disease free for 5 years. To our knowledge, this is the first case report of primary bone, diffuse, large B-cell lymphoma of the calcaneus to be treated with a combination of surgical excision, chemotherapy, and radiotherapy.

Solitary lymphoblastic lymphoma of the thoracic spine

Non-Hodgkin's lymphoma rarely originates from bone, and even more infrequently from a vertebral body. Lymphoblastic lymphoma is a rare type of non-Hodgkin's lymphoma, and results from an abnormality in adaptive immune cells. A 27-year-old man presented with a two-month history of night sweats, weight loss, and severe back pain. Radiological studies demonstrated an osteolytic lesion compressing the subarachnoid space at the T11 level. Posterolateral fusion with decompression was performed and a pathologic examination confirmed lymphoblastic lymphoma of the B-cell precursor type. To our knowledge, this is the first report of solitary lymphoblastic lymphoma from B-cell precursors in of the thoracic spine. Herein, we discuss the presenting symptoms and the management of this rare case of lymphoblastic lymphoma.

Prognostic factors in primary diffuse large B-cell lymphoma of adrenal gland treated with rituximab-CHOP chemotherapy from the Consortium for Improving Survival of Lymphoma (CISL)

BACKGROUND

The objective of this study was to identify prognostic factors for survival in patients with primary diffuse large B-cell lymphoma (DLBCL) of the adrenal gland.

METHODS

Thirty one patients diagnosed with primary adrenal DLBCL from 14 Korean institutions and treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) were analyzed.

RESULTS

Complete remission (CR) and overall response rate after R-CHOP chemotherapy were 54.8% and 87.0%. The 2-year estimates of overall survival (OS) and progression-free survival (PFS) were 68.3% and 51.1%. In patients achieving CR, significant prolongations of OS (P = 0.029) and PFS (P = 0.005) were observed. Ann Arbor stage had no influence on OS. There was no significant difference in OS between patients with unilateral involvement of adrenal gland and those with bilateral involvement. When staging was modified to include bilateral adrenal involvement as one extranodal site, early stage (I or II) significantly correlated with longer OS (P = 0.021) and PFS (P <0.001).

CONCLUSIONS

Contrary to prior reports, our data suggests that outcomes of primary adrenal DLBCL are encouraging using a regimen of R-CHOP, and that achieving CR after R-CHOP is predictive of survival. Likewise, our modified staging system may have prognostic value.

Primary bone lymphoma

Primary bone lymphoma is a distinct clinical entity that accounts for 5% of extra-nodal lymphoma. Most patients have diffuse large B-cell lymphoma and present with bone pain, a mass or both. The involvement could be in a single focus or disseminated. There are no prospective clinical studies in this disease. Patients have been treated with radiotherapy, chemotherapy or a combination. There is a trend towards improved outcome with combined modality treatment and further improvement with the addition of rituximab. Assessment of response may be difficult with current imaging techniques. The prognosis of primary bone lymphoma is generally good. Here, the current evidence for the optimal treatment of primary bone lymphoma is reviewed and questions for future investigation are addressed.

Recurrent PET FDG Uptake after Sequential Chemotherapy and Radiation Therapy for DLBCL of the Tibia: A Case Report and Review of the Literature

The aim of this paper is to report on the challenges associated with identifying disease recurrence following combined modality therapy (CMT) for primary lymphoma of the tibia in which an intramedullary nail has been placed. A patient with primary bone lymphoma (PBL) was treated with CMT (chemotherapy and radiation therapy). After a complete response, he has been followed for eighteen months by physical exam and radiographic imaging. Despite persistent increased tracer accumulation at the original site, he has no proven recurrence. Literature review showed a small number of retrospective, single institution reviews detailing clinical experience and expected outcome in patients treated with PBL limited to one bony site of disease. PBL presents a treatment challenge, particularly when a weight-bearing long bone is diffusely involved and followup is complicated after placement of stabilizing hardware. Close coordination of the oncology team and diagnostic radiology is required to ensure optimal outcome.

Primary non-Hodgkin's lymphoma presenting as radicular syndrome: report of two cases

We report two cases of primary Non-Hodgkin's Lymphoma in the spine leading to radicular compression secondary to infiltration of lumbar body vertebras. The two patients were free of either nodular or other extra-nodular disease. Treatment consisted of chemotherapy alone, one patient have had a cauda equina syndrome and surgical decompression was performed in emergency. The patients were in remission for 20 months after diagnosis. A review is given for the incidence of primary vertebral localization of lymphoma, its diagnosis, treatment and prognosis.

Primary diffuse large B-cell lymphoma of the skull mimicking osteomyelitis

Primary lymphomas of the skull are extremely rare, as fewer than 20 cases have been reported in the literature. We describe the case of a 51-year-old woman with Huntington chorea who presented with forehead swelling. Imaging studies detected an enhancing mass in the skull with some destruction of the underlying bone. These features were suggestive of osteomyelitis. Surgical excision was performed, and the mass was found to be a primary diffuse large B-cell lymphoma. The patient was administered postoperative chemotherapy, and she was in complete remission at the 1-year follow-up.

Primary bone lymphoma--the University of Miami experience

Primary bone lymphoma (PBL) is a rare disease. There has been paucity of studies addressing its therapy and prognosis. We retrospectively examined PBL cases seen at the University of Miami from June 2000 to August 2007 to describe our single institution experience and review the literature. Fifty-three patients were identified with a median age of 52 (18-87) and a median follow-up of 40 months (0-106). The most common histologic type was diffuse large B-cell lymphoma (83%). Forty-one patients (77%) presented with localized disease and 48 were treated at our institution. Forty-six patients underwent chemotherapy (40 patients) and/or radiation (36 patients). Forty-four patients achieved a complete response and all patients were alive at last follow-up. The progression-free survival (PFS) was 83% at 4 years. No difference in PFS was observed between patients treated with chemotherapy or combined chemotherapy plus radiation. There was a trend toward improvement in PFS (p = 0.062) of patients with DLBCL treated with rituximab plus chemotherapy. Our single institutional experience demonstrates that the outcome of patients with PBL is excellent. Although the current data support the use of combined modality treatment for localized PBL, randomized controlled trials are needed especially now, when rituximab is routinely added to chemotherapy regimens.

Primary bony non-Hodgkin lymphoma of the cervical spine: a case report

Introduction

Non-Hodgkin lymphoma primarily originating from the bone is exceedingly rare. To our knowledge, this is the first report of primary bone lymphoma presenting with progressive cord compression from an origin in the cervical spine. Herein, we discuss the unusual location in this case, the presenting symptoms, and the management of this disease.

Case presentation

We report on a 23-year-old Caucasian-American man who presented with two months of night sweats, fatigue, parasthesias, and progressive weakness that had progressed to near quadriplegia. Magnetic resonance (MR) imaging demonstrated significant cord compression seen primarily at C7. Surgical management, with corpectomy and dorsal segmental fusion, in combination with adjuvant chemotherapy and radiation therapy, halted the progression of the primary disease and preserved neurological function. Histological analysis demonstrated an aggressive anaplastic large cell lymphoma.

Conclusion

Isolated primary bony lymphoma of the spine is exceedingly rare. As in our case, the initial symptoms may be the result of progressive cervical cord compression. Anterior corpectomy with posterolateral decompression and fusion succeeded in preventing progressive neurologic decline and maintaining quality of life. The reader should be aware of the unique presentation of this disease and that surgical management is a successful treatment strategy.

Primary non-Hodgkin's lymphoma of the lumbar vertebrae mimicking tuberculous spondylitis: a case report

Primary non-Hodgkin lymphoma (PHL) of the spine is very rare. A case of a 44-year-old patient with PHL originating from a single lumbar vertebra was initially misdiagnosed as tuberculous spondylitis. After surgical decompression and biopsy, the patient was confirmed as primary B-cell non-Hodgkin lymphoma of the lumbar vertebrae and was further treated with chemotherapy. It warrants attention that PHL from the spine may be misdiagnosed as tuberculous spondylitis.

MR imaging characteristics in primary lymphoma of bone with emphasis on non-aggressive appearance

PURPOSE

To assess the heterogeneity of magnetic resonance (MR) imaging characteristics in primary lymphoma of bone (PLB), in particular the non-aggressive appearance.

SUBJECTS AND METHODS

In a retrospective study, MR imaging features were analyzed in 29 patients with histologically proven PLB. The following parameters were evaluated: tumor size, bone marrow and extension into soft tissues, signal characteristics of bone marrow and soft-tissue components, including enhancement, and involvement of cortical bone (complete disruption, focal destruction, permeative destruction and cortical thickening).

RESULTS

PLB presented with extension into the soft tissue in 22 (76%) of 29 patients, was only subtle in three of these 22 patients, and was absent in seven patients. Signal intensity (SI) of the soft-tissue part was most frequently homogeneously isointense with muscle on T1-weighted images (90%) and high on T2-weighted images (91%). Enhancement was predominantly homogeneous and diffuse (82%). In 93% of patients cortical bone appeared abnormal: among those patients complete cortical disruption was seen in 28%, with extension into soft tissues in all but one patient; a permeative pattern of destruction was present in 52% of patients, 66% of these had an associated soft-tissue mass. Two patients with normal-appearing cortical bone had no extension into soft tissues. In two patients focal cortical destruction was noticed; in one patient cortical bone was homogeneously thickened, and in one patient PLB was selectively localized within the cortical bone. SI of the bone marrow tumor component was more frequently heterogeneous (in 54%), compared with the soft-tissue component, being high on T2-weighted images in 89%, intermediate in 7% and low in 4%. Similarly, enhancement was heterogeneous in 59%.

CONCLUSION

The MR imaging appearance of PLB is variable. In 31% of PLB patients, the tumor was intra-osseous, with linear cortical signal abnormalities or even normal-appearing or thickened cortical bone without soft-tissue mass, and, as such, PLB may not infrequently look non-aggressive on MR imaging.

Primary bone lymphoma: report of a case with multifocal skeletal involvement

Primary bone lymphoma is an uncommon tumour accounting for approximately 4-5% of extra nodal lymphoma and less than 1% of all Non-Hodgkin’s lymphoma. The radiographic appearance of primary bone lymphoma is variable. As lesions frequently resemble other disease processes namely chronic osteomyelitis and metastases, further imaging evaluation and histopathological examination allow early identification for appropriate treatment. The authors present a case of anaplastic large cell lymphoma of bone presenting with multifocal osseus involvement.

Primary Bone Lymphoma: A New and Detailed Characterization of 28 Patients in a Single-Institution Study

BACKGROUND

The incidence of primary bone lymphoma (PBL) is so rare that many of its aspects remain unknown. A number of studies have been reported from Western countries, but only a few reports are available from Asia.

METHODS

We retrospectively analyzed 28 consecutive patients diagnosed with PBL initially treated at our hospital between 1995 and 2004. All patients underwent chemotherapy with half receiving radiotherapy as their initial treatment. A log-rank test was used in a univariate analysis to identify factors affecting overall survival.

RESULTS

Fifteen (54%) patients were male and 13 (46%) female with a median age of 47 (range: 5-81). Although 19 (68%) patients had diffuse large B-cell lymphoma (DLBCL), other histopathological subtypes (three B-lymphoblastic lymphoma, two anaplastic large cell lymphoma, two indolent B-cell lymphoma, one NK/T-cell lymphoma (NTCL) and one Hodgkin lymphoma) were also included. The pelvis was the most frequently involved site (54%). While 68% of patients had stage IV disease, none of them showed bone marrow involvement at their initial diagnosis. Despite 61% high intermediate-risk and high-risk patients based on the International Prognostic Index, the estimated 3-year overall and progression-free survival rates were 84% and 77%, respectively. Only 'histopathological subtype (immunoblastic variant of DLBCL or NTCL versus others)' and 'response to initial treatment (progression versus remission)' were factors significantly affecting overall survival.

CONCLUSIONS

Although the total number of patients was relatively small, the detailed clinical data analyses presented here revealed several new characteristics of PBL and some aspects that may be unique to Japanese patients.

Primary Bone Lymphoma — Treatment and Outcome

AIMS

A retrospective review of patients with histologically confirmed primary bone lymphoma (PBL) diagnosed and treated at a single tertiary referral centre between 1985 and 2003.

MATERIALS AND METHODS

The medical records of all patients treated for histologically primary bone lymphoma were identified using the hospital data base. Data was obtained on patient demographics, stage, treatment and outcome.

RESULTS

Twenty-two patients with PBL were identified. Seventeen had localised disease and five had multifocal bone involvement. The median age was 50 years. Of the patients who could be graded according to the International Prognostic Index (IPI), 12 cases were classified as low risk, seven as intermediate risk and one as high risk. All patients received chemotherapy; 19 with an anthracycline-containing regimen. Eighteen patients were treated with radiotherapy to a median total dose of 40 Gy (range 30-50 Gy). Three patients had surgery instead of radiotherapy as local treatment (one fibulectomy and two endoprosthetic replacements). The median follow-up was 84.5 months (range 3-206 months). The overall 10-year survival was 74%; 92% for low-risk IPI vs 73% for intermediate-risk IPI (P = 0.27). The 10-year relapse-free survival was 85% overall and 83% for both low- and intermediate-risk IPI (P = 0.87). Local relapse was seen in one patient. Orthopaedic complications occurred in two patients--one developed a pathological fracture after biopsy before radiotherapy and the other developed avascular necrosis outside the irradiated area.

CONCLUSIONS

Combined modality treatment for PBL results in good local control and survival rates with acceptable toxicity.

Small Round Cell Tumors of Bone

Context.—Primary small round cell tumors of the bone are a heterogeneous group of malignant neoplasms presenting predominantly in children and adolescents. They include Ewing sarcoma/peripheral neuroectodermal tumor or Ewing family tumors, lymphoma, mesenchymal chondrosarcoma, and small cell osteosarcoma. Even though they share many morphological similarities, their unique biological and genetic characteristics have provided substantial insights into the pathology of these diverse neoplasms.

Objective.—To provide an overview of the clinical, radiologic, pathologic, and genetic characteristics of these tumors along with a pertinent review of the literature.

Data Sources.—A literature search using PubMed and Ovid MEDLINE was performed, and data were obtained from various articles pertaining to clinicopathologic, biological, and genetic findings in these tumors. Additionally, findings from rare cases have been included from author's subspecialty experience.

Conclusion.—The diagnosis of small round cell tumors can be made accurately by applying clinicopathologic criteria, as well as a panel of immunohistochemical and genetic studies in appropriate cases. Molecular genetic studies may provide further insight into the biology, histogenesis, and prognosis of these tumors.

A clinicopathological retrospective study of 131 patients with primary bone lymphoma: a population-based study of successively treated cohorts from the British Columbia Cancer Agency

BACKGROUND

Primary bone lymphoma (PBL) is a distinct clinicopathological entity. Although PBL has been reviewed in several small studies, few reflect recent improvements in primary treatment.

METHODS

We used the British Columbia Cancer Agency Lymphoid Cancer Database to identify all patients with PBL (1983-2005). All were staged in a uniform manner and treated with era-specific protocols.

RESULTS

We identified 131 patients with a median age of 63 years (18-87). One third had disease in long bones and another one third had disease in the spine, of which half presented with spinal cord compression. Patients with diffuse large-cell lymphoma (DLCL) (n=103, 79%) had 5- and 10-year overall survivals (OS) of 62% and 41%, respectively. Multivariate analysis identified three prognostic groups: age<60 with International Prognostic Index (IPI) 1-3 (n=43), age>or=60 with IPI 0-3 (n=23) and age>or=60 with IPI 4-5 (n=33), with markedly different 5-year OS of 90%, 61% and 25%, respectively (P<0.0001). Neither primary site nor pathological fracture at presentation had an impact on OS. The 3-year progression-free survival in patients who received rituximab plus combination chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOPR) chemotherapy was 88% compared with 52% in those who received CHOP-like chemotherapy without rituximab (P=0.005). The 10-year OS for those with advanced-stage disease who received irradiation plus chemotherapy was 25% versus 56% for those who received chemotherapy alone (P=0.025). Patients received irradiation if spinal cord compression was present or residual disease at the end of chemotherapy was thought to require it.

CONCLUSIONS

PBL is usually of DLCL type and has an improved outcome with CHOPR. Younger patients with good IPI score have a favorable prognosis.

The incidence of imaging findings, and the distribution of skeletal lymphoma in a consecutive patient population seen over 5 years

OBJECTIVE

To determine the imaging incidence, distribution, and prognosis of primary and secondary osseous lymphoma from a consecutive, single-institution patient population seen over a 5-year period.

DESIGN AND PATIENTS

Of 1098 newly diagnosed consecutively seen patients with lymphoma between 1996 and 2000, 975 comprised the study group. From the electronic medical records and imaging studies, age, gender, date of diagnosis of lymphoma, bone involvement, location in bone, multifocality in bone, histopathologic type of the lesion and patient survival were recorded. Primary lymphoma of bone was defined as osseous disease with or without regional node involvement and no evidence of systemic disease for 6 months. Secondary osseous lymphoma was considered present when osseous lymphoma was associated with systemic disease or the appearance of systemic disease within 6 months of osseous disease.

RESULTS

Ninety-eight patients had osseous lymphoma (10%, 95% confidence interval [CI] 8.2, 11.9). Ages ranged from 9 to 92 years (mean 54) and gender 6:4 (M:F). Ten patients (1%) had primary lymphoma of bone. Eighty-eight patients (9%) had secondary lymphoma of bone. The vertebral column was the favored site for secondary osseous lymphoma. At 5 years, there were no deaths in the primary osseous lymphoma group and a 51% mortality rate in the secondary osseous lymphoma group.

CONCLUSIONS

Primary lymphoma of bone remains a rare primary malignancy, favors the appendicular skeleton, and has a significantly better 5-year prognosis than secondary lymphoma of bone.

Primary uterine lymphoma: report of 2 cases and review of literature

Primary uterine non-Hodgkin's lymphoma is a rare malignancy. We here describe 2 patients who presented with cervical growth, stage IE, diffuse large B cell histology. Both were treated with chemotherapy followed by involved field radiotherapy in 1 patient. They achieved complete clinical and radiological response. Data of 101 patients collected from the literature are reviewed.

Non-Hodgkin's lymphoma presenting as multiple bone lesions and hypercalcemia

We report a rare case of a patient with non-Hodgkin's lymphoma who developed multiple bone lesions and hypercalcemia. A 50-year-old woman complained of drowsiness and multiple bone pain on admission. Radiographic examination revealed multiple bone fractures and osteolytic lesions. She was diagnosed with diffuse large B cell lymphoma by biopsy of an inguinal lymph node. Elevation of parathyroid hormone-related protein (PTHrP) and hypercalcemia were confirmed pretreatment, and those serum levels decreased during chemotherapy for lymphoma. However, the disease was resistant to chemotherapy combined with rituximab. These findings suggest that hypercalcemia is associated with PTHrP and the prognosis of patients with bone lymphoma in advanced stage is poor, although it is thought to be a relatively favorable prognosis in localized primary lymphoma of bone.

Primary bone lymphoma

Primary bone lymphoma is a rare condition which represents a low percentage of both the malignant primary bone tumours and the non-Hodgkin extranodal lymphoma. This explains the lack of publications, lines of investigations, and specific diagnostic and treatment protocols. In the following article we will carry out a revision of the existing literature on this rare subject, using as argument a clinical case of left femoral location stage IE treated with CHOP chemotherapy and radiotherapy.