Presentation
Right leg pain for around one year.
Patient Data
Diffuse mixed lytic-sclerotic lesions with areas of a permeative process involving the proximal epiphysis and meta-diaphysis of the right tibia with a wide zone of transition associated with cortical thickening. No periosteal reaction or cortical breakthrough. Minimal soft tissue thickening anterior to the mid tibia bone.
The differential diagnosis of such an appearance is wide and may include Ewing sarcoma, osteosarcoma, leukemia or lymphoma, metastasis, or chronic osteomyelitis.
On MRI, the lesion demonstrates heterogeneous high T2 and low T1 signal intensity replacing the most of the proximal bone marrow cavity of the right tibia. Post contrast administration shows heterogeneous enhancement of the medullary bone cavity. There is associated enhancing soft tissue component with central low enhancing region involving subcutaneous fat and the anterior compartment of the leg. No significant cortical breakthrough. The fibula appears unremarkable. The overall findings are highly suggestive of bone lymphoma.
Case Discussion
Primary bone lymphoma can appear one X-ray with different patterns like solitary lytic lesion with sequestrum or diffuse area of mixed lytic-sclerotic areas with permatic pattern of bone destruction. On MRI, the presence of soft tissue mass and significant bone marrow involvement without extensive cortical destruction would highly suggest the diagnosis of primary bone lymphoma. The patient underwent imaging guided biopsy and the histopathology result was:
"HIGH GRADE B CELL LYMPHOMA CONSISTENT WITH DIFFUSE LARGE B CELL LYMPHOMA".
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