Early-stage primary bone lymphoma: a retrospective, multicenter Rare Cancer Network (RCN) Study

Rare case of primary bone lymphoma of the femur

Primary bone lymphoma is a rare type of lymphoma that arises from skeletal tissue. Most cases described are non-Hodgkin's lymphoma with diffuse large B-cell lymphoma being the most common subtype. While it is common for non-Hodgkin's lymphoma to have secondary skeletal system involvement, primary involvement of the skeleton is surprisingly rare. Primary bone lymphoma accounts for less than 5% of all primary bone malignancies, 4%-5% of extranodal lymphomas and less than 1% of all non-Hodgkin's lymphoma. We present an interesting case of a young adult male who was diagnosed with primary bone lymphoma of the femur. Interestingly, his initial X-ray imaging revealed no osseous abnormality and subsequent MRI revealed an infiltrating mass. The patient was treated with chemotherapy of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone resulting in complete remission.

Primary Diffuse Large B-Cell Lymphoma of the Bone

Primary lymphoma of the bone (PLB) is a rare lymphoproliferative neoplasm that can present either as solitary or multiple bone lesions. We report four patients with PLB who were successfully treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) followed by consolidative radiotherapy. All patients achieved a complete remission and had excellent long-term outcomes. PLB has a favorable response to combined modality treatment with chemoimmunotherapy and radiation. Long-term outcomes of PLB tend to be better than those of non-osseous diffuse large B-cell lymphoma.

Nomogram-Based Prediction of Overall and Cancer-Specific Survival in Patients with Primary Bone Diffuse Large B-Cell Lymphoma: A Population-Based Study

Background

Primary bone diffuse large B-cell lymphoma (PD-DLBCL) accounts for more than 80% of primary bone lymphoma. We created two nomograms to predict overall survival (OS) and cancer-specific survival (CSS) in patients with PD-DLBCL for this rare disease.

Methods

In total, 891 patients diagnosed with PB-DLBCL between 2007 and 2016 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox analyses were performed to explore independent prognostic factors and create nomograms for OS and CSS. The area under the curve (AUC), the calibration curve, decision curve analysis (DCA), and Kaplan-Meier (K-M) curve analysis were used to evaluate the nomograms.

Results

Four variables were identified as independent prognostic factors for OS, and three variables were identified as independent prognostic factors for CSS. The receiver operating characteristic (ROC) curves demonstrated the strong discriminatory power of the nomograms. The calibration and DCA curves showed that the nomograms had a satisfactory ability to predict OS and CSS. The K-M curves showed that age, gender, primary site, chemotherapy, and tumor stage affected patient survival.

Conclusions

In patients with PD-DLBCL, age, race, primary site, and chemotherapy affected OS, while age, race, and chemotherapy affected CSS. The two nomograms created based on the aforementioned variables provided more accurate individual survival predictions for PD-DLBCL patients and can help physicians make appropriate clinical decisions.

Primary Diffuse Large B Cell Lymphoma of Bone: A Single-Center Experience

Background

Primary diffuse large B-cell lymphoma of the bone (PB-DLBCL) is a rare type of extra-nodal lymphoma. This study aimed to examine the clinical characteristics, outcomes, treatment modalities and risk of central nervous system relapse (CNSR) among adult Jordanian patients with PB-DLBCL.

Methods

This retrospective study included patients aged >16 years who were diagnosed with PB-DLBCL and treated at our hospital between 2002 and 2021. Clinical characteristics, treatment modalities, outcomes and CNSR events were extracted from the hospital’s data system and analysed. Patients were categorised into unifocal (UF) and multifocal (MF) PB-DLBCL groups according to the number of bone sites involved. The involvement of only one site was defined as UF, whereas the involvement of two or more sites was defined as MF.

Results

In total, 12 patients were diagnosed with PB-DLBCL. Their median age was 47.5 years (range, 17–80 years). The male:female ratio was 1:1. There were eight patients in the UF PB-DLBCL group and four in the MF PB-DLBCL group. All patients received treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone. In the UF PB-DLBCL group, the male:female ratio was 5:3, the median age was 41 years, and the follow-up duration was 9–135 (mean, 83.3) months. In the MF PB-DLBCL group, the male:female ratio was 1:3, the median age was 51.5 years, and the survival time was 3–11 (mean, 7) months. Three patients with vertebral UF PB-DLBCL underwent early vertebroplasty without complications. The most common site involved was the vertebral column. Most patients with UF PB-DLBCL achieved complete remission (CR), whereas no patients with MF PB-DLBCL achieved CR.

Conclusion

PB-DLBCL is rare in adult Jordanian patients. UF PB-DLBCL is more common than MF PB-DLBCL. Patients with UF PB-DLBCL had a good prognosis. Patients with MF PB-DLBCL had a high international prognostic index score, risk of CNSR and short survival time.

Primary Bone Lymphoma: A Rare Cause of Chronic Back Pain

Primary bone lymphoma is a very uncommon malignancy, which is responsible for 3% of all bone tumors. We report a case of an 80-year-old patient with chronic back pain associated with a pathological T9 fracture. During admission, spinal cord compression with paraparesis was detected and managed with radiotherapy. After investigation, it was discovered to be caused by a primary bone lymphoma. Staging showed multiple bone lesions compatible with polyostotic lymphoma. Histopathology revealed a diffuse large B-cell lymphoma, which was treated with chemotherapy (age-adjusted R-CHOP [rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone] regimen). In this case report, imaging modalities used to diagnose and stage the disease are discussed. Traditional and new prognostic tools and treatment are also reviewed.

Limited-stage diffuse large B-cell lymphoma: current management and challenges

Twenty-five to thirty per cent of diffuse large B-cell lymphoma (DLBCL) presents as limited stage (I-II). Prognosis is generally excellent with four to six cycles of R-CHOP alone (rituximab, cyclophosphamide, vincristine, doxorubicin, prednisolone) or combined-modality therapy with three or four cycles and involved-site radiotherapy (RT). There is growing interest in optimising algorithms to retain disease control whilst minimising long-term toxicity, with several recent studies focusing on the safety of abbreviating chemotherapy and omitting RT in low-risk patients and the utility of PET-based response-adapted approaches. As these studies are limited to younger patients without risk factors, application of similar approaches in elderly or higher-risk patients is hampered by a lack of evidence. Whilst there has been a move away from using RT in low-risk patients, it remains a useful adjunct in specific situations. Current evidence cannot exclude a clinically meaningful benefit from RT even in low-risk patients and, given the low expected toxicity from modern RT techniques, a risk-benefit assessment should be individualised and considered in a multidisciplinary fashion. The optimal approach for extranodal limited-stage DLBCL (~40% of cases) varies according to site of origin. Herein we discuss the latest clinical trial evidence and how this can be applied in routine practice.

Primary bone anaplastic lymphoma kinase positive anaplastic large-cell lymphoma: A case report and review of the literature

BACKGROUND

Primary bone lymphoma (PBL) is an uncommon extranodal disease that represents approximately 1%-3% of lymphomas. Anaplastic lymphoma kinase (ALK) positive anaplastic large-cell lymphoma (ALCL) is an extremely rare type of PBL. The aim of this report is describe the symptoms, diagnosis, and treatment of primary bone ALK-positive ALCL.

CASE SUMMARY

A 66-year-old man presented to our hospital with neck and shoulder pain and intermittent fever that lasted for 1 mo. After extensive evaluation, positron emission tomography-computed tomography (CT) examination showed multiple osteolytic bone lesions without other sites lesions. CT-guided biopsy of the T10 vertebral body was performed, and the pathology results showed that neoplastic cells were positive for ALK-1, CD30, and CD3. A diagnosis of primary bone ALK positive ALCL was ultimately made. The patient was in partial response after four cycle soft cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy, and we planned to repeat the biopsy and radiological examination after completion of the fifth cycle of therapy.

CONCLUSION

Primary bone ALK positive ALCL is a rare disease and physicians should keep in mind that ALCL can present with isolated osseous involvement without nodal involvement, and lymphoma should be considered in the differential diagnosis of primary bone lesions.

[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.

Role of Radiation Therapy Differs Between Stages in Primary Bone Large B-Cell Lymphoma in Rituximab Era: A Population-Based Analysis

Background: Primary bone B-cell lymphoma (PB-DLBCL) is a rare entity for which existing data is limited. Whether radiotherapy (RT) should be omitted in the modern treatment of PB-DLBCL is still under debate. We used the SEER database to compare the outcomes among adult patients treated with and without RT in rituximab era. Methods: We included adult patients with PB-DLBCL diagnosed from 2002 to 2016 from SEER 18. The effect of RT on overall survival (OS) using univariate (UVA) and multivariate (MVA) Cox proportional regression and propensity score matching (PSM) was assessed for the entire cohort and subgroups by stages. We calculated the standardized incidence ratio to estimate the short- and long-term risk for second primary malignancies (SPM) from 2002 to 2016 in SEER 18 and 1983-2016 in SEER 9. Results: A total of 1,320 patients were identified, including 856 with early-stage (ES) and 464 with advanced-stage (AS). A decreasing trend was observed in the ES cohort after 2002, while the rate of RT utilization remained stable in the AS cohort over the past three decades. Most patients in ES (63.9%) underwent RT, whereas only 42.2% of AS patients received it. RT significantly improved survival both in UVA and MVA (P < 0.001, P = 0.010, respectively). PSM analysis further validated the survival advantage of RT (P = 0.018). Moreover, a novel web-based prediction model was established to individualize the potential benefit from RT. In subgroup analyses, OS was improved with RT in those who had ES disease (p < 0.001) but not in those who had AS disease (P = 0.776). With short-term follow up in SEER 18, none of the subgroups showed a significantly elevated risk of developing SPMs. However, RT significantly elevated the late toxicities of second malignancies in ES patients diagnosed at the age of 18-39 or those with appendicular sites of bone involvement. Conclusion: This population-based analysis is the largest PB-DLBCL dataset to date and demonstrates a significant survival benefit associated with RT in early stages rather than advanced stages. In the absence of randomized controlled trials, RT should be considered in ES disease with cautions of second cancers in specific subsets of patients.

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.

Primary Bone Lymphoma in Axial Skeleton in a Middle-Aged Female Presented as Recurrent Anemia

Primary bone lymphoma (PBL) is a peculiar extranodal presentation of non-Hodgkin's lymphoma. Primary bone diffuse large B-cell lymphoma (DLBCL) is the most common pathological type, comprising about 80% of PBL. The diagnosis of PBL depends on the combined clinical examination and imaging studies and is confirmed with immunohistochemical examination. Due to the rarity of this disease, more relative studies and case reports are needed to provide insight into this obscure lymphoproliferative malignancy. Here, we report one rare case of primary bone DLBCL involving the axial skeleton in a 37-year-old female.

Primary Bone Lymphoma: A Case Series and Review of Literature

Primary bone lymphoma (PBL) is a subtype of lymphoma that exclusively affects skeletal tissue. Despite the relatively common involvement of skeletal structures as a manifestation of non-Hodgkin's lymphoma (NHL), primary and exclusive involvement of the skeletal system is rare. The prevalence of PBL is estimated to be 3–7% amongst primary bone tumors and less than 2% amongst all lymphomas in adults. However, the definition of primary bone lymphoma has been inconsistent over time. Within our institution, we identified four cases of primary bone lymphoma based on diagnostic criteria formed from the general consensus of multiple organizations, including the World Health Organization (WHO) and International Extranodal Lymphoma Study Group (IELSG). Here, we discuss the distinct characteristics amongst these cases in addition to performing a systematic review of current literature regarding this lymphoproliferative entity.

Prognostic Factors Associated With Bone Lymphoma Primarily Presenting in the Spine

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To determine the prognostic indicators in patients with bone lymphoma of the spine.

SUMMARY OF BACKGROUND DATA

To date, prognosis for patients with spinal bone lymphoma is based on results from small series. Large population-based observational studies are lacking.

METHODS

The Surveillance, Epidemiology, and End Results Registry was used to identify all patients with bone lymphoma of the spine from 1995 through 2014. Overall survival (OS) and disease-specific survival (DSS) estimates were obtained using the Kaplan-Meier method and compared across groups using log-rank test. Association of survival with variables was assessed using Cox proportional-hazards regression analysis. Nomograms were established and validated by R software.

RESULTS

A total of 1338 patients were identified with bone lymphoma of the spine. The trend of incidence was relative steady from 1995 to 2014. The mean and median age of diagnosis was 62.9 and 66.0 years, respectively. Men constituted a slightly greater proportion (55.5%) of the cohort. The most common subtype of lymphoma was diffuse large B-cell lymphoma (59.8%). The 5- and 10-year OS rates for those patients were 60.6% and 44.7%, respectively. Multivariate analysis revealed that age, sex, marital status, and race were sociodemographic predictors of OS and DSS. Extracompartmental invasion of tumor and stage IV of lymphoma were significantly correlated with poor OS and DSS. Patients without surgery or radiotherapy was linked to a poor OS. Both OS and DSS of patients with spinal bone lymphoma improved in 2005 to 2014 when compared to 1995 to 2004. In addition, pretreatment nomograms to predict 5- and 10-year survival were established.

CONCLUSION

The findings of this study provide population-based estimates of the prognosis for patients with spinal bone lymphoma. Both sociodemographic and clinical factors may have an impact on the outcomes.

LEVEL OF EVIDENCE

4.

Epiphyseal Primary Diffuse Large B-Cell Lymphoma of Bone

Primary lymphoma of bone (PLB) confined to the epiphysis has only been described in four other patients. Due to the rarity of this entity, diagnosis has often been delayed, leading to mismanagement with adverse clinical consequences. We report a fifth case of primary epiphyseal lymphoma of bone located in the left distal medial femoral epiphysis of a 13-year-old boy. Radiographic and histologic features of PLB are discussed, along with a review of the literature and pitfalls of misdiagnosis. The patient initially presented with six months of progressive left knee pain with an associated loss of passive range of motion. Imaging revealed a mixed radiolucent lesion within the left distal medial femoral epiphysis with cortical breakthrough. A core biopsy was performed revealing a blue round cell tumor. Thanks to modern immunohistochemistry techniques, a diagnosis of primary lymphoma of bone was quickly made. The patient thus avoided further surgical intervention and received the appropriate treatment of chemotherapy, with subsequent rapid resolution of the lesion. This case highlights the necessity of including primary lymphoma of bone in all epiphyseal lesion differential diagnoses, especially in the pediatric patient population when aggressive radiographic features are present.

Prognostic relevance of protein expression, clinical factors, and MYD88 mutation in primary bone lymphoma

Primary bone lymphomas (PBLs) are composed of malignant lymphoid cells presenting in osseous sites, without supra-regional lymph node or extranodal involvement. We systematically characterized the immunophenotype and the myeloid differentiation factor 88 (MYD88)-L265P gene mutation status in PBL. Clinical data from 19 patients with PBL treated at Nanjing Drum Tower Hospital between 2009 and 2015 were analyzed retrospectively. Protein expression patterns were identified immunohistochemically, and MYD88 mutation was assessed using polymerase chain reaction and direct DNA sequencing. Fifteen patients presented with diffuse large B-cell lymphoma. Clinical factors favoring a good prognosis were an age < 60 years and rituximab treatment. B-cell lymphoma 2 expression was detected in 5/15 diffuse large B-cell lymphoma patients, and was associated with a poor prognosis in a univariate model. Janus kinase/signal transducer and activator of transcription 3 (JAK/STAT3) signaling factors were upregulated in PBLs. All eighteen evaluable PBL samples harbored wild-type MYD88. These data thus suggest that age and rituximab treatment are independent prognostic factors determining overall survival, and that activation of JAK/STAT3 signaling may promote the pathogenesis of PBL. Moreover, the absence of MYD88-L265P mutation in PBL indicate there are distinct pathogenetic backgrounds among extranodal lymphomas.

Case of polyostotic primary bone lymphoma successfully treated with immunochemotherapy and consolidation radiotherapy

A 47-year-old woman presented with symptoms of sharp pain over the left anterior thigh with radiation from the groin to the knee. She subsequently developed numbness in that region and reduced motor strength in extensors of the left knee. Plain radiography of the spine and knee was normal. An MRI of the spine revealed an irregular extramedullary mass with intradural and extradural components, extending from the L3 to L5 vertebrae. She underwent a laminectomy and posterior spinal decompression based on a working diagnosis of nerve sheath tumour. Histopathology revealed a primary bone lymphoma. A positron emission tomography CT (PET-CT) performed as part of the staging workup revealed fluorodeoxyglucose avid lesions in the spine and left femur. She received immunochemotherapy (Rituximab-Cyclophosphamide, Hydroxydaunorubicin, Oncovin and Prednisone) for eight cycles with an interim PET-CT revealing complete response. Subsequently, she received consolidation radiotherapy, 36 Gy in 20 fractions over 4 weeks to both lesions. She is now disease-free on follow-up for the past 1 year.

A rare case report of primary bone lymphoma and a brief review of the literature

Primary bone lymphoma is a rare and peculiar extranodal presentation of non-Hodgkin’s lymphoma, which threatens human health. It can be defined as a lymphoma that occurs in the bone, consisting of a single bone lesion with or without regional lymphadenopathies, and its underlying causes are largely unknown. In this case report, we describe a male who presented with left-sided distal forearm pain, swelling of 2 months duration, and progressive limited wrist motion for about 1 month. The patient had no significant medical history except diabetes. Magnetic Resonance Imaging demonstrated a sheet-like bone destruction area in the left-sided radius, localized discontinuous bone cortex, and adjacent soft tissue masses. Finally, a bone biopsy examined by histopathological and immunochemical methods confirmed a diagnosis of primary bone diffuse large B-cell lymphoma. Due to the rarity of this disease, the level of evidence supporting some diagnostic and therapeutic decisions remains low, and therefore, the details of the rare case may facilitate treatment of similar diseases and provide insight about this obscure lymphoproliferative malignancy. Also, related recent literature reports of primary bone lymphoma are reviewed.

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.

Primary bone diffuse large B-cell lymphoma: a retrospective evaluation on 76 cases from French institutional and LYSA studies

Primary bone diffuse large B-cell lymphoma (PB-DLBCL) is a rare DLBCL location variant. We treated 76 PB-DLBCL patients by immuno-chemotherapy, resulting in an 84% sustained complete remission rate and a 78.9% survival over a 4.7-year median follow-up period. Ann Arbor stage IV and high age-adjusted international prognostic index were predictive of adverse outcome in univariate analysis. In multivariate analysis using a Cox model, only aa-IPI predicted long-term survival. While based on a limited number of cases, we suggested that radiotherapy may be useful as a consolidation modality in PB-DLBCL. We also suggested that positron emission tomography/CT scan should be interpreted with caution due to a persistent [18F]fluorodeoxyglucose [18FDG] uptake of bone lesions even after remission in some in PB-DLBCL patients. Our study based on a homogeneous cohort of PB-DLBCL patients confirmed the favorable outcome of this DLBCL variant and support the implementation of prospective clinical trials in this disease.

Primary lymphoma of bone presenting as spindle cell neoplasm of the vertebral body: a case report and review of the literature

Spindle cell variant of lymphoma is a very rare but known disease entity that can mimic a sarcoma. Diagnosis can be even more challenging if the only site of the disease is in the bone. We report a case of primary lymphoma of bone with spindle cell morphology which was successfully treated with a combination of surgery, chemotherapy, and radiotherapy.

Primary sternum diffuse large B-cell lymphoma: A case report and review of the literature

Primary bone lymphoma (PBL) is a rare disease, accounting for >1% of all cases of malignant lymphoma. Diffuse large B-cell lymphoma (DLBCL) is the most common histological type of PBL. The present study reported the case of a 68-year-old male with primary bone DLBCL, originally occurred in the sternum, which is a rare form of presentation. Computed tomography (CT), magnetic resonance imaging and bone emission CT were performed, followed by immunohistochemical analysis of a biopsy specimen, and the results were used to establish the diagnosis. At the time of diagnosis, no osseous involvement was observed. The clinical, radiological and histological features of PBL can mimic other medical conditions, thereby making the diagnosis difficult, and frequently leading to delays in treatment. The present study investigated the clinical features, management and prognosis of PBL, and reviewed previous relevant cases.

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.

Clinical characteristics and prognostic factors of bone lymphomas: focus on the clinical significance of multifocal bone involvement by primary bone large B-cell lymphomas

Background

Malignant bone lymphoma can be classified as primary (PBL) or secondary (SBL) bone lymphoma. However, the clinico-pathological characteristics and prognostic factors of PBL versus SBL have not yet been well defined. Whether lymphoma with multifocal bone involvement should be considered as stage IV PBL or SBL still remain controversial throughout the literature.

Methods

In this study, we retrospectively reviewed 127 patients with bone lymphoma diagnosed from1998 to 2013 at the Moffitt Cancer Center. Patients were classified as PBL (81 cases) and SBL (46 cases) using the 2013 WHO Classification of Bone/Soft Tissue Tumors and PBL patients were further subdivided into: 1) PBL with unifocal bone disease (uPBL, 46 cases), 2) PBL with multifocal bone involvement (mPBL, 35 cases). Patient characteristics, survival, and prognostic factors were analyzed.

Results

Diffuse large B-cell lymphoma (DLBCL) was the most common histological subtype in all three groups (37/46 of uPBL, 23/35 of mPBL, 23/46 of SBL). B symptoms, lymph node involvement, and bone marrow involvement were found to be more common in mPB-DLBCL and SB-DLBCL groups than in the uPB-DLBCL group. Femur was found to be the most common affected site in uPB-DLBCL patients, while spine was most commonly involved in the other two groups. Survival analysis indicated that uPBL-DLBCL patients had a significantly better progression-free survival (PFS) and overall survival (OS) than those in the other two groups (P < 0.05). We also found by univariate analysis that multifocality, and stage IV were significantly poor prognostic factors for both PFS and OS in PBL patients. Using multivariate analysis, multifocality remained an independent prognostic factor for both PFS and OS (P = 0.0117, RR: 3.789, 95% CI: 1.275-11.256).

Conclusion

Overall, our results suggest that mPBL is more similar to SBL in characteristics and survival rather than uPBL, and thus should be better classified and treated as SBL.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2407-14-900) contains supplementary material, which is available to authorized users.

History of the rare cancer network and past research

Approximately, twenty years ago, the Rare Cancer Network (RCN) was formed in Lausanne, Switzerland, to support the study of rare malignancies. The RCN has grown over the years and now includes 130 investigators from twenty-four nations on six continents. The network held its first international symposium in Nice, France, on March 21-22, 2014. The proceedings of that meeting are presented in two companion papers. This manuscript reviews the history of the growth of the RCN and contains the abstracts of fourteen oral presentations made at the meeting of prior RCN studies. From 1993 to 2014, 74 RCN studies have been initiated, of which 54 were completed, 10 are in progress or under analysis, and 9 were stopped due to poor accrual. Forty-four peer reviewed publications have been written on behalf of the RCN.

Primary bone lymphoma of the left radius: a case report and related literature review

Primary bone lymphoma (PBL) is a rare but distinct clinicopathological disease. Because it is not common, the optimal treatment strategy has not been established. Here, we present a patient with PBL of the left radius and review the related literature. We focus on the standard treatment for PBL. Many aspects such as rehabilitation, local control and overall survival need to be considered. Studies on this disease should be carried out to clarify the optimal treatment in the future.

Clinical features, management, and prognosis of an international series of 161 patients with limited-stage diffuse large B-cell lymphoma of the bone (the IELSG-14 study)

INTRODUCTION

The clinical features, management, and prognosis of stage I-II diffuse large B-cell lymphoma of the bone (PB-DLBCL) included in an international database of 499 lymphoma patients with skeletal involvement were reviewed.

METHODS

HIV-negative patients (n = 161) with diffuse large B-cell lymphoma of the bone (PB-DLBCL) after complete staging workup were considered. The primary objective of this study was to identify the most effective treatment modality; the secondary objectives were to define the contribution of irradiation fields and doses and the pattern of relapse.

RESULTS

Median age was 55 years (range, 18-99 years), with a male/female ratio of 1:2; 141 (87%) patients had stage I, 14 (9%) had B symptoms, 37 (23%) had bulky lesion, 54 (33%) showed elevated lactate dehydrogenase serum levels, and 25 (15%) had fracture. Thirteen (8%) patients received chemotherapy alone, 23 (14%) received radiotherapy alone, and 125 (78%) received both treatments. The response to the first-line treatment was complete in 131 of 152 assessed patients (complete response rate, 86%; 95% confidence interval [CI], 81%-91%) and partial in 7, with an overall response rate of 91% (95% CI, 87%-95%). At a median follow-up of 54 months (range, 3-218), 107 (67%) patients remained relapse-free, with a 5-year progression-free survival of 68% (SE: 4). Four (2.5%) patients had meningeal relapse; 119 patients were alive (113 disease-free), with a 5-year overall survival of 75% (SE: 4). Patients managed with primary chemotherapy, whether followed by radiotherapy or not, had a significantly better outcome than patients treated with primary radiotherapy, whether followed by chemotherapy or not. The addition of consolidative radiotherapy after primary chemotherapy was not associated with improved outcome; doses >36 Gy and the irradiation of the whole affected bone were not associated with better outcome.

CONCLUSION

Patients with PB-DLBCL exhibit a favorable prognosis when treated with primary anthracycline-based chemotherapy whether followed by radiotherapy or not. In patients treated with chemoradiotherapy, the use of larger radiation fields and doses is not associated with better outcome. Central nervous system dissemination is a rare event in PB-DLBCL patients.

Primary bone lymphoma: a retrospective analysis of 22 patients treated in a single tertiary center

BACKGROUND

Primary bone lymphoma is a rare disease, representing less than 5% of all extra-nodal non-Hodgkin lymphomas.

MATERIALS AND METHODS

We retrospectively searched the database of the lymphoma unit, Hematology/Lymphoma Department, Athens General Hospital 'Evangelismos' for primary bone lymphoma patients. Demographic and clinicopathologic data were collected and overall survival was analyzed. A log-rank test was used in a univariate analysis to identify factors affecting overall survival.

RESULTS

We identified 24 and analyzed data from 22 patients. 12 were male (54.5%) and 10 female (45.4%) and their median age was 55 years (range: 19-83). Most patients had localized disease at the time of diagnosis (n = 19, 86.3%), the most common site was the spine (n = 11, 50%) and the most common histology was diffuse large B-cell lymphoma. 21 patients received chemotherapy as initial therapy and 16 received combined chemoradiation. 81.8% of the patients (n = 18) achieved complete remission. 5-year survival rate was 86.3% and overall survival was found to be affected by the patients' initial response to treatment.

CONCLUSIONS

Primary bone lymphoma is usually associated with a good prognosis. Prospective studies are needed in order to clarify the effect of immunochemotherapy in overall survival.

Primary lymphoma of bone: outcome and role of surgery

PURPOSE

Primary bone lymphoma is a rare disease. Little is reported about surgical procedures in these patients. We evaluated a single-centre consecutive series of 21 patients for results, prognostic factors and surgical treatment.

METHODS

Patient ages ranged from 19 to 82 years. The most frequently affected site was the spine (six cases), followed by the ileum, femur and mandible (three cases each). Four patients were treated with chemotherapy and 17 with chemotherapy and radiation therapy. Six patients were affected by a pathological fracture. Surgery was performed in four patients (19%), in two cases before chemotherapy, in one case during chemotherapy and in one case after chemotherapy and radiotherapy. Five patients died within the range of three to 36 months after diagnosis. Average follow-up of the remaining patients was 62.8 (19-145) months.

RESULTS

Overall survival was 74.2% at five years. The only positive prognostic factor was complete remission after chemotherapy. A trend for better survival was present for International Prognostic Index (IPI) score (P = 0.051), under 40 years of age (P = 0.10) and abnormal lactate dehydrogenase (LDH) values (P = 0.10), but it did not reach statistical significance.

CONCLUSIONS

Surgical treatment should be aimed at restoring function and eliminating pain while minimising delays in the chemotherapy schedule. When feasible, postponing surgery until after chemotherapy is advisable.