Presentation
3 day history of fluctuant lump on head ?collection ?abscess
Patient Data
Hypoechoic lesion overlying right parietal skull, measuring at least 5 cm in maximum diameter with prominent internal vascularity and underlying bony destruction.
- Large destructive lesion of the right frontoparietal skull as seen on ultrasound, homogeneously enhances post contrast
- Large right retro-orbital soft tissue mass with associated orbital bony destruction and mild proptosis
- Small round destructive lesion to the left of the vertex
- Small round destructive lesion in medial right frontal bone
- Normal intracranial appearances, with no evidence of brain parenchymal involvement
- Multiple, predominantly right sided pulmonary masses and nodules.
- Multiple mediastinal and right hilar nodal masses.
- Pulmonary vessels encased by masses but not obviously invaded.
(CT Abdomen and Pelvis was normal, with no evidence of disease below the diaphragm - images not included here.)
Multiple destructive lesions are again demonstrated on MRI. These enhance post contrast and demonstrate a degree of diffusion restriction.
Pathology Results
Patient underwent EBUS and biopsy of a subcarinal node. Results are as follows:
"Microscopy
This is a cellular sample that consists of multiple small fragments of lesional lymphoid tissue. The lesion consists of discohesive sheets of mostly medium sized lymphoid cells with hyperchromatic nuclei and moderate amount of slightly eosinophilic cytoplasm. Some of the cells show small nucleoli. Apoptotic bodies are readily identified.
Immunohistochemistry shows the lymphoid infiltrate stains positively for CD20, BCL2 and MUM1. It is negative for BCL6, CD10, cyclin D1 and CD30. CD3 and CD5 are similar and stain numerous reactive T cells in the background. MYC antibody is expressed in approximately 50% of cells. EBER-ISH is negative. MIB1 shows a high proliferation index (approximately 90%).
In conclusion, the overall appearances are regarded as those of a high grade B cell lymphoma, best classified as a diffuse large B-cell lymphoma. The tumor shows a non-germinal center cell phenotype.
FISH for MYC rearrangement has been requested.
FNA Station 7 EBUS - Diffuse large B-cell lymphoma"
Case Discussion
The history here makes the diagnosis difficult but it was history she presented with and she denied any headache, visual disturbance, etc.
She did also report some cough and hoarseness over the preceding year, which she had attributed to asthma and had temporarily improved with courses of steroids.
Only on later direct questioning by the consultant hematologist did she report that for months she has also been having night time sweats which can be drenching. She denied fevers or weight loss. She had noticed some intermittent eye swelling and blurring of vision.