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Media Gallery

Total skeleton technetium-99m (99mTc) nuclear medicine scan reveals an isolated increased uptake in the left proximal femur at the site of this patient's bone lymphoma.
Total skeleton technetium-99m (99mTc) nuclear medicine scan shows increased uptake in the left acromion, the site of bony involvement by lymphoma in this patient. The initial differential diagnosis suggested metastatic disease to bone in addition to multiple myeloma and lymphoma, in that order.
Coronal, T1-weighted magnetic resonance imaging (MRI) scan of the left shoulder reveals the replacement of the left acromion by a low-signal process extending into the surrounding soft tissue.
Coronal, T2-weighted magnetic resonance imaging (MRI) scan of the left shoulder reveals a high-signal process involving the left acromion and extending to the surrounding soft tissue. The MRI scan's features are suggestive only of a very high cellularity fluid-containing process, but they are nonspecific. Biopsy is required for a specific diagnosis.
Sections of the biopsy show a diffuse infiltrate of atypical large lymphoid cells with vesicular nuclei, small nucleoli, and moderate cytoplasm. Small reactive lymphocytes are in the background.
An immunohistochemical stain using an antibody directed against CD20 (B-cell marker) shows strong positivity in the large lymphoid cells. This is an example of a diffuse large B-cell lymphoma.
A woman who is in the early part of her fifth decade presents with progressive left thigh pain and a limp. An anteroposterior radiograph of her left proximal femur reveals a lytic destructive process involving the subtrochanteric region, with medical cortical erosion, soft-tissue extension, and an associated lesser trochanteric avulsion fracture. The proximal femur is the most common site for primary bone lymphoma.
An elderly woman presents with complaints of left shoulder pain of several months duration. A plain radiograph of the left shoulder (glenoid view) reveals a destructive lytic process eroding the cortical margins of the acromial process.
Diffuse infiltrate of large lymphoid cells is present, with cleared cytoplasm and hyperchromatic nuclei. Admixed small, reactive lymphocytes also are noted.
Immunohistochemical stain using an antibody against CD20 is positive in the large cells; this is a diffuse large B-cell lymphoma.
Clinical photo of a left shoulder shows a prominence in the midportion of the left clavicle. This 45-year-old man was suffering from local pain and tenderness but had no history of prior trauma.
Technetium-99m (99mTc) total skeleton nuclear medicine scan shows increased uptake in the midportion of the left clavicle, an area corresponding to the clinical site of bone enlargement.
Anteroposterior radiograph of the left clavicle reveals a mixed lytic and sclerotic destructive process within the midportion of the bone, with indistinct, permeative borders.
Another example of a diffuse large cell lymphoma. In addition to the large lymphoid cells with moderate cytoplasm, a few cells with lobate nuclei also are seen. Such cells are often observed in large cell lymphoma of the bone.
Plain radiographs in this 12-year-old patient with severely progressive right shoulder pain were interpreted as being normal. At most, they showed the existence of localized osteopenia in the right proximal humerus, but they did not demonstrate the presence of a discrete lesion within the bone. Based on the initial evaluation and plain radiographs, the patient was thought to have referred pain from the cervical region or brachial plexus.
Coronal, T1-weighted magnetic resonance imaging (MRI) scan of the upper thorax and bilateral shoulders reveals a marrow replacement low-signal process involving the entire right proximal humerus. The corresponding T2-weighted MRI scan showed a high-signal process in this area. This MRI scan was produced after plain radiographs were interpreted as normal and an MRI scan of the cervical spine and brachial plexus revealed the unsuspected findings in the humerus.
Histologic sections reveal a highly cellular neoplasm composed of cells with a high nucleus-to-cytoplasm ratio, scant cytoplasm, and fine nuclear chromatin. The cells showed immunohistochemical evidence of B-cell lineage and expressed terminal deoxynucleotidyl transferase (TdT), consistent with a precursor B-lymphoblastic lymphoma.

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Author

Vincent Y Ng, MD Assistant Professor of Orthopedic Oncology, Department of Orthopedics, The Bone Cancer and Soft Tissue Sarcoma Service, UM Greenebaum Cancer Center, University of Maryland Medical Center, University of Maryland School of Medicine

Vincent Y Ng, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Children's Oncology Group, Maryland Orthopaedic Association, Musculoskeletal Tumor Society, Sarcoma Alliance for Research through Collaboration

Disclosure: Nothing to disclose.

Coauthor(s)

Ernest Upshur "Chappie" Conrad, III, MD Associate Professor, Department of Orthopedics, University of Washington School of Medicine; Chair/Co-Director, Department of Orthopedics, Seattle Children’s Hospital; Director, Sarcoma Service, Department of Orthopedics, Professor of Orthopedics and Sports Medicine, University of Washington Medical Center; Chairman, Pediatric Orthopedic Tumor Clinic; Children’s Hospital and Medical Center

Ernest Upshur "Chappie" Conrad, III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American Association of Tissue Banks, American College of Surgeons, American Medical Association, American Orthopaedic Association, Connective Tissue Oncology Society, SWOG, Western Orthopaedic Association, Children's Oncology Group, American Society of Clinical Oncology, Musculoskeletal Tumor Society, Pediatric Orthopaedic Society of North America, International Society of Limb Salvage, Tuberous Sclerosis Alliance, The Paget Foundation, Washington State Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine; Clinical Professor of Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society, Florida Medical Association, Florida Orthopaedic Society

Disclosure: Nothing to disclose.

Acknowledgements

Timothy A Damron, MD David G Murray Endowed Professor, Department of Orthopedic Surgery, Professor, Orthopedic Oncology and Adult Reconstruction, Vice Chair, Department of Orthopedics, State University of New York Upstate Medical University at Syracuse

Timothy A Damron, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, Children's Oncology Group, Connective Tissue Oncology Society, Musculoskeletal Tumor Society, Orthopaedic Research Society, and Society for Experimental Biology and Medicine

Disclosure: Lippincott, Williams, and Wilkins Royalty Editing/writing textbook; Genentech Grant/research funds Clinical research; Orthovita Grant/research funds Clinical research; National Institutes of Health Grant/research funds Clinical research; UpToDate Royalty Update Preparation Author; Wright Medical, Inc. Grant/research funds Clinical research

Sharad Mathur, MD Chief, Pathology and Laboratory Medicine Service, Kansas City Veterans Affairs Medical Center

Sharad Mathur, MD is a member of the following medical societies: American Society for Clinical Pathology, American Society of Cytopathology, American Society of Hematology, College of American Pathologists, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

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