Presentation
Back pain.
Patient Data
MRI demonstrates a pathological crush fracture of L4 with complete replacement of the normal fatty marrow with low T1 signal soft tissue which enhances following administration of contrast. A moderate to severe degree of canal stenosis is present. Additional deposit is seen at T12.
An old crush fracture (non-pathological) of L1 is also present with normal bone marrow signal.
On the sagittal gradient scout image, note the absence of signal loss in the L4 vertebral body due to lack of intralesional lipid.
Case Discussion
This patient has had a previous liver transplant for biliary atresia, splenectomy, and has been on tacrolimus since 1998. Never has rejection issues. PET scan (not shown) demonstrated FDG avid lymph nodes above and below the diaphragm.
Appearances in the spine are consistent with lymphoma, although other metastatic diseases could have similar appearances.
Histology
Cervical lymph node biopsy.
The lymph node is partially effaced by an atypical lymphoid infiltrate, comprising large cellular nodules separated by thin bands of the hyalinized stroma. These nodules contain sheets of large atypical lymphoid cells with rounded to irregular nuclei and one to three large eosinophilic nucleoli. The cells have minimal pale eosinophilic cytoplasm. Admixed lymphocytes, histiocytes and sparse plasma cells are noted. Eosinophils are not seen and discrete granulomas are not identified. No transgression beyond the lymph node capsule is found.
Immunohistochemical studies have been performed. The large atypical lymphoid cells are strongly positive for CD20, Pax-5, CD45, CD30 and EBER-ISH. They are negative for EMA, ALK, CD15, CD79a, and Cyclin D1. The Ki-67 proliferative index in the large cells is approximately 95%.
The admixed small lymphocytes are reactive T cells (CD3 and CD5 positive) and there are a few admixed macrophages showing paranuclear dot-like pattern of staining for CD15. The atypical lymphoid population is CD10 negative, BCL-6 positive, and MUM1 positive.
FINAL DIAGNOSIS: monomorphic post-transplant lymphoproliferative disorder, diffuse large B-cell lymphoma type, with partial nodal involvement.
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