Diffuse large B-cell lymphoma

Case contributed by Bruno Di Muzio
Diagnosis certain


Back pain.

Patient Data

Age: 25 years
Gender: Male

CT Thoracic Spine


Lytic lesions causing partial collapse of the vertebras of T3 and T4 and focal severe canal stenosis. Although some degree of extension into the disc spaces is noted, the process is not centered in the discs.

The patient was not septic and did not have epidemiology for tuberculosis. Metastatic or primary bone tumor was then sought, and a bone scan recommended to chase for other lesions.

Bone Scan

Nuclear medicine

A triple-phase bone scan of the thorax, whole body blood pool images, delayed whole body images with oblique views of the ribs and lateral views of the pelvis obtained. SPECT-CT was not possible because of the metal head and neck brace. On the dynamic and blood pool phase, intense perfusion at T3 and T4 is noted. On the delayed images intense uptake at these vertebral bodies is seen corresponding to the lytic lesion with associated loss of vertebral height on the external CT. Uniform uptake elsewhere through the axial and appendicular skeleton is seen.

MRI Cx & Tx spines


The bone marrow of the T3 and T4 vertebra is replaced by a solid tumoral process that extends back into the vertebral arches and also has an extra-osseous and extra-dural component protruding into and narrowing the spinal canal along these levels on the right. The tumor shows marked low T1 signal, low ADC values, elevated T2 signal and vivid contrast enhancement. Both the T3 and T4 vertebral bodies have some degree of pathological fracture with height loss, which is worse in T3 where it is estimated at about 30% with minimal posterior column retropulsion. The intervertebral discs within these levels appear overall preserved and not involved. The tumor also obliterates the right T2/3 and T3/4 intervertebral foramina. The intra canal extradural tumor extension is noted from the level of T1 until T5, and the spinal canal is severely narrowed at the level of T2/3 with the cord compressed to the right along these levels, but with no appreciable cord signal changes. There is another tumoral lesion with similar signal characteristics anterior to the right second costochondral joint, with no convincing sings of continuity with the spinal lesion. The remainder of the vertebral spine have normal appearances, with no other lesions identified. The spinal canal and intervertebral foramina are otherwise capacious. The cord is unremarkable in all the remaining levels. No signs to suggest spinal infection. 

Case Discussion

The imaging findings are those of a spinal bone tumor involving the vertebras of T3 and T4 favored representing a primary bone malignancy, particularly in this age group and in the absence of a known malignancy elsewhere. At this age group, differentials would include lymphoma, sarcoma (Ewing's), or eosinophilic granuloma. Chordoma is felt unlikely differential given its distribution and signal on T2. 

Further surgical approach and biopsy have confirmed diffuse large B-cell lymphoma. B-cell is the most common type of non-Hodgkin lymphomas.

MICROSCOPY: The sections show a proliferation of atypical lymphoid cells, forming diffuse sheets. No follicular arrangement is seen. The atypical lymphocytes are medium to large in size. They have enlarged clefted and hyperchromatic nuclei, prominent nucleoli and scanty cytoplasm. The background contains occasional small lymphocytes and plasma cells. The tumor infiltrates in-between bony trabeculae, with adjacent woven bone formation. The tumor cells are CD20, PAX-5, bcl-6 and MUM1 positive. c-Myc stains about 15% of the tumor cells. Bcl-2 stains weakly less than 10% of the tumor cells. The Ki-67 index is about 90%. They are CD3, CD5, CD10, CD23, CD138, Cyclin D1, TdT, ALK-1 and EBER-CISH negative. The features are those of diffuse large B-cell lymphoma, not otherwise specified, with activated B-cell-like phenotype.

DIAGNOSISDiffuse large B-cell lymphoma

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