Diffuse large B-cell lymphoma: skeletal involvement

Case contributed by Dr Matt Skalski

Presentation

The patient reports progressive severe left hip pain. Presented due to inability to ambulate.

Patient Data

Age: 34
Gender: Male

The iliac wings, ischii, and proximal femurs demonstrate numerous poorly defined regions of mixed lytic and blastic changes bilaterally. There are also multiple areas of lytic cortical disruption, most prominently involving the proximal femoral cortices. The capsular and gluteal fat pads are outwardly displaced on the left, indicating a joint effusion. 

The bilateral iliac bones, proximal femurs, ischii , and right sacral ala are markedly abnormal with diffuse abnormal marrow signal intensity, sparing the pubic bones. The involved osseous structures demonstrate heterogeneously hyperintense fluid-sensitive signal intensity with heterogeneously avid enhancement on postcontrast imaging.

 There is a moderate-sized effusion within the left femoroacetabular joint, and mild effusion on the right. There is enhancement of these effusions with contrast.

The muscles about the left hip demonstrate enhancement and fluid signal intensity involving the anterior compartment musculature, adductors, gluteal muscles and iliacus muscle.

A well circumscribed mass measuring 2.8 x 1.5 cm is observed between the right iliac bone
 and right iliacus muscle on the large field of view coronal images.  This mass is isointense to skeletal muscle on T1, hyperintense on T2, and demonstrates avid contrast enhancement.  There is also a soft tissue mass measuring 3.1 x 2.2 cm located posterior to the left femur, centered with the adductor compartment of the left hip which demonstrates increased STIR signal intensity and mild enhancement. 

Case Discussion

As a differential, the findings seen on the MR could represent an infectious process with extensive osteomyelitis, superimposed septic arthritis and infectious myositis  (?TB); however, given the blastic changes seen on the radiographs this seems unlikely, especially combined with the relatively small extent of soft-tissue involvement on the MR relative to bony, and the clinical demographic of a younger male who is relatively healthy otherwise. 

Neoplastic processes such as leukemia or Ewing sarcoma are reasonable differential considerations, with metastasis much less likely given the age. POEMS syndrome also comes to mind as a differential in a patient of this age with this appearance, but is quite rare and would require other info to be considered more highly. 

This proved to be diffuse large B-cell lymphoma, and responded relatively well to treatment. 

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Case Information

rID: 37078
Case created: 25th May 2015
Last edited: 18th Sep 2015
Inclusion in quiz mode: Included

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