Lymphoma case, presented with dysphagia

Clinical manifestations:

• A 36-year-old woman

• Non-smoker

• no known medical illness

• Presented with anterior neck swelling for 4 months

• Associated with dysphagia and loss of weight (about 7 kg in one month)

• No fever, no night sweat.

Clinical examination

shows swelling over the anterior neck which is soft and not ten-der on palpation.

No other remarkable findings.

Lab investigations:

• Hb=12.3, TWBC=4.2, Plt 380, ESR normal, elevated CRP

Radiological investigations:

1- X ray neck lateral view, soft tissue

Findings:

• soft tissue swelling at the prevertebral region extending to in volve cervical region.

• No air pockets within. No radiopaque foci to suggest a for- eign body.

• Bones are otherwise normal in appearance.

2- Chest radiograph (CXR)

findings:

• There is mediastinal widening

• No calcification or air pockets within it

• No obliteration of overlying hilum

• No extension to supraclavicular region

• No significant mass effect or displacement of the tra chea

• No crowding of ribs.

3- CT neck with contrast

findings:

• Elongated thickened retropharyngeal is observed extending from the level of C1 until the C5 vertebra.

• Numerous shotty nodes are seen throughout both triangles on both sides of the neck, more apparent on the anterior triangles.

• It measures at about 1.0 x 2.5 x 8.1cm.

• It is hypodense (CT HU:15-25) with no significant enhance¬ment.

• No calcification seen or air pockets within.

4- CT scan chest with contrast

findings:

• There is anterior mediastinal soft tissue mass with evidence of extensive mediastinal lymphadenopathies.

• Extensive cervical nodes are also observed. Given the pres¬ence of extensive lymphadenopathies

Progress of patient:

• nasal examination shows inferior turbinate hypertrophied with pale nasal mucosa, symmetrical appearance of fossa of Rossenmuller in nasal endoscopy

• Flexible Nasopharyngolaryngoscope (FNPLS) shows pos-terior pharyngeal wall bulging at oropharyngeal and naso-pharyngeal level, no mass, no ulceration. Pyriform fossa is clear. Epiglottis, arytenoids, Vocal cords are symmetrical with normal appearance and movements.

• Biopsy of mediastinal mass done by a chest surgeon using video assisted thoracoscopy VAT

Histopathological Examination (HPE) findings:

• Macroscopy: specimen labeled as biopsy of mediastinal mass

• Microscopy: section shows strips of fibro-collagenous tis-sue diffusely infiltrated by sheets of malignant lymphoid cells. The malignant cells display moderate to marked pleo-morphism, hyperchromatic to vesicular nuclei with promi-nent nucleoli. In areas, multinucleated tumor giant cells are noted. Mitoses are easily seen. Necrosis is present.

• Immunohistochemistry, the malignant cells are positive for CD20, CD10, and negatives for CKAE1/AE3, CD3 with Ki 67 proliferative index of 80%.

• Interpretation: Diffuse large B-cell lymphoma, GCB sub-type.

Diagnosis: Large B-cell lymphoma

The patient underwent chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone), followed by R-EPOCH (rituximab, etoposide, prednisone, vin¬cristine, cyclophosphamide, and doxorubicin hydrochloride). Follow-up at 12 months revealed a complete response.

Discussion

• Lymphoma is a malignancy arising from lymphocytes or lymphoblasts.

• Two main types of lymphomas are Hodgkin lymphoma and non-Hodgkin lymphomas.

• Lymphoma accounts for about 4 % of all cancers.

• Lymphoma can present as nodal or extra nodal disease. It can also present with fever, night sweat and weight loss.

• CT scan is the main imaging modality in lymphoma and widely used in staging.

• Lymphoma cure rates are high.

• Prognosis depends on histological type, grade and stage of the disease.

References

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