Presentation
Worsening myelopathy.
Patient Data
There is a large enhancing mass centered on the right lamina of the C7 vertebra, with marked extraosseous extension. Extension into the central vertebral canal from C5/6 to mid T1 results in moderate compression of the spinal cord, with effacement of the epidural fat and displacement of the cord to the left. There is no cord signal change, however. The mass also extends into several right neural exit foramina, including at:
- C5/6 (severely narrowed)
- C6/7 and C7/T1 (both effaced)
- T1/2 (mildly narrowed).
Note is made an asymmetrical prominent left level 2b lymph node.
Further masses in the left transverse process of T3 and body of T10 do not extend into the central vertebral canal or neural exit foramina.
The right renal pelvis is enlarged.
Case Discussion
Large mass centered on the right lamina of C7, causing moderate spinal cord compression (but no cord signal change) and compression of severe right-sided nerve roots. The presence of at least two further masses makes lymphoma, myeloma or metastases the likely diagnoses.
The diagnosis was subsequently proven histologically from a biopsy of the femur which had an additional deposit.
Histology
MICROSCOPIC DESCRIPTION: Sections of the bone show a proliferation of atypical lymphoid cells in the medullary spaces. They form loose aggregates and sheets. No follicular structures are seen. The atypical cells are large in size. They have enlarged clefted and hyperchromatic nuclei, prominent nucleoli and scanty cytoplasm. The background contains small mature lymphocytes. The atypical lymphoid cells are CD20, PAX-5, bcl-2, bcl-6 and MUM1 positive. There is also focal staining for CD23. The Ki-67 index is about 35%. CD3, CD5, CD10 and Cyclin D1 are negative.
The features are those of diffuse large B-cell lymphoma, not otherwise specified, with activated B-cell-like phenotype.
FINAL DIAGNOSIS: Diffuse large B-cell lymphoma.
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