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A rare site and appearance for lymphomatous recurrence
Clinical Oncology (1995) 7:332-333 © 1995 The Royal College of Radiologists
Clinical Oncology
Case Report A Rare Site and Appearance for Lymphomatous Recurrence W. M. Lam, J. W. Bergman, A. T. C. Chan and W. T. Leung Prince of W a l e s Hospital, Shatin, H o n g K o n g
Abstract. A patient with a recurrence of large cell lymphoma is reported. There was psoas muscle involvement, which showed ring enhancement post-intravenous contrast on CT scan. Ring enhancement in skeletal muscle infiltration by lymphoma has not been described previously. Keywords: Muscle involvement; NonHodgkin's lymphoma; Recurrence
INTRODUCTION Skeletal muscle infiltration by lymphoma is an unusual occurrence, with an incidence of approximately 1% of autopsy cases [1]. Several authors have reported diffuse muscle enlargement due to lymphomatous infiltration [2-7]. The majority were associated with the synchronous presence of nodal lymphoma [2]. Within this group, psoas muscle involvement is uncommon. We describe a patient with large cell lymphoma recurrence in the right psoas muscle with no nodal involvement, which also demonstrated rim enhancement as yet not described in this situation.
requiring a repeat laparotomy for adhesiolysis at the end of the second cheotherapeutic cycle. At operation no residual disease was detected. CT scanning, performed in June 1993, confirmed complete remission. Six cycles of BACUP were completed by October 1993. Two months after the completion of therapy the patient complained of right leg pain. Abdominal radiography showed enlargement of the right psoas muscle but no underlying evidence of spinal infection (Fig. 1). Contrast enhanced abdominal/ pelvic CT scans confirmed enlargement of the right psoas muscle with multiple areas of decreased attenuation and rim enhancement (Fig. 2), No other abnormal adenopathy was present. The adjacent vertebrae were normal. Ultrasound guided biopsy revealed large cell lymphoma infiltration. A laparotomy 3 weeks later confirmed right psoas muscle
CASE REPORT A 44-year-old Chinese female presented with epigastric discomfort and weight loss in December 1992. Clinical examination revealed a 16 cm abdominal mass with no peripheral lymphadenopathy. Initial imaging showed a large, mainly right-sided, retroperitoneal mass, encasing the duodenum, right ureter, inferior vena cava and common iliac vessels. Both psoas muscles were normal. These findings were confirmed at laparotomy. Biopsy showed a diffuse large cell lymphoma. Combination chemotherapy was commenced with Neomycin, adriamycin, cyclophosphamide, vincristine, and prednisone (BACUP). There was rapid clinical improvement after the initiation of chemotherapy. Two episodes of small bowel obstruction complicated the clinical course, Correspondence and offprint requests to: Dr W. M. Lam, Department of Radiology and Organ Imaging, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.
Fig. 1. Erect abdominal radiograph showing: swollen right psoas muscle with indistinct margin; normal left psoas outline; no bony vertebral abnormality.
involvement and progression of disease to extensive involvement of the omentum, the latter being adherent to the hepatic flexure and the caecum. Debulking surgery and a right hemicolectomy were performed, followed by second line chemotherapy (VP16, methylprednisone, arabinoside-C and cisplatinum).
DISCUSSION Any lymphocyte-containing soft tissue may be affected by lymphoma. The majority of reported patients with muscle involvement have described changes in the lower extremities [3-8]. To the best of our knowledge there have been only two reports of psoas muscle involvement [3,4]. One of these patients had periaortic and iliac
333
A Rare Site and Appearance for Lymphomatous Recurrence
and therefore biopsy for histological proof is mandatory. The discrepancy between the CT scan and the operative findings is presumably on the basis of rapid progression of the disease in the interval period.
References
Fig. 2. CT scan of abdomen, indicating enlargement of the right psoas muscle with areas of hypodensity showing rim enhancement.
lymphadenopathy, and massive enlargement of the quadriceps muscle [3]. The other had lateral abdominal wall and iliacus muscle involvement [4]. Attenuation values are generally those of normal muscle. Grunshaw and Chalmers reported three patients with decreased density and heterogeneous enhancement post-intravenous contrast administration [5]. In our patient, the right psoas was
diffusely enlarged, with multiple areas of decreased attenuation showing rim enhancement, a feature not previously described. Although infection, particularly tuberculosis, had to be considered in the differential diagnosis the patient was clinically well and afebrile, thus making an inflammatory cause less likely. The CT appearance alone cannot discriminate between infective and malignant processes,
1. Komatusda M, Nagao T, Amimori S. An autopsy case of malignant lymphoma associated with remarkable infiltration in skeletal muscle. Rinsho Ketsueki 1981;22:891-5. 2. Malloy PC, Fishman EK, Magid D. Lymphoma of bone, muscle and skin: CT findings. A JR 1992;159:805-9. 3. Greta JL, Neville AJ, Smith SC, et al. Massive skeletal muscle invasion by lymphoma. Arch Intern Med 1985;145:1818-20. 4. Pilepach MV, Carter BL. Muscle enlargement in lymphoma patients. Radiology 1980; 134:521-3. 5. Grunshaw ND, Chalmers AG. Skeletal muscle lymphoma. Clin Radiol 1992;45:399-400. 6. Scally J, Garrett A. Primary extranodal lymphoma in muscle. Br J Radiol 1989; 62:81. 7. Spector JI, Zimbler H. Skeletal muscle involvement by lymphoma. Arch Intern Med 1986;146:1232. 8. Travis WD, Banks PM, Reiman HM. Primary extranodal soft tissue lymphoma of the extremities. Am J Surg Pathol 1987;11:35966.
Received for publication December 1994 Accepted following revision March 1995
Clinical Oncology
Case Report A Rare Site and Appearance for Lymphomatous Recurrence W. M. Lam, J. W. Bergman, A. T. C. Chan and W. T. Leung Prince of W a l e s Hospital, Shatin, H o n g K o n g
Abstract. A patient with a recurrence of large cell lymphoma is reported. There was psoas muscle involvement, which showed ring enhancement post-intravenous contrast on CT scan. Ring enhancement in skeletal muscle infiltration by lymphoma has not been described previously. Keywords: Muscle involvement; NonHodgkin's lymphoma; Recurrence
INTRODUCTION Skeletal muscle infiltration by lymphoma is an unusual occurrence, with an incidence of approximately 1% of autopsy cases [1]. Several authors have reported diffuse muscle enlargement due to lymphomatous infiltration [2-7]. The majority were associated with the synchronous presence of nodal lymphoma [2]. Within this group, psoas muscle involvement is uncommon. We describe a patient with large cell lymphoma recurrence in the right psoas muscle with no nodal involvement, which also demonstrated rim enhancement as yet not described in this situation.
requiring a repeat laparotomy for adhesiolysis at the end of the second cheotherapeutic cycle. At operation no residual disease was detected. CT scanning, performed in June 1993, confirmed complete remission. Six cycles of BACUP were completed by October 1993. Two months after the completion of therapy the patient complained of right leg pain. Abdominal radiography showed enlargement of the right psoas muscle but no underlying evidence of spinal infection (Fig. 1). Contrast enhanced abdominal/ pelvic CT scans confirmed enlargement of the right psoas muscle with multiple areas of decreased attenuation and rim enhancement (Fig. 2), No other abnormal adenopathy was present. The adjacent vertebrae were normal. Ultrasound guided biopsy revealed large cell lymphoma infiltration. A laparotomy 3 weeks later confirmed right psoas muscle
CASE REPORT A 44-year-old Chinese female presented with epigastric discomfort and weight loss in December 1992. Clinical examination revealed a 16 cm abdominal mass with no peripheral lymphadenopathy. Initial imaging showed a large, mainly right-sided, retroperitoneal mass, encasing the duodenum, right ureter, inferior vena cava and common iliac vessels. Both psoas muscles were normal. These findings were confirmed at laparotomy. Biopsy showed a diffuse large cell lymphoma. Combination chemotherapy was commenced with Neomycin, adriamycin, cyclophosphamide, vincristine, and prednisone (BACUP). There was rapid clinical improvement after the initiation of chemotherapy. Two episodes of small bowel obstruction complicated the clinical course, Correspondence and offprint requests to: Dr W. M. Lam, Department of Radiology and Organ Imaging, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.
Fig. 1. Erect abdominal radiograph showing: swollen right psoas muscle with indistinct margin; normal left psoas outline; no bony vertebral abnormality.
involvement and progression of disease to extensive involvement of the omentum, the latter being adherent to the hepatic flexure and the caecum. Debulking surgery and a right hemicolectomy were performed, followed by second line chemotherapy (VP16, methylprednisone, arabinoside-C and cisplatinum).
DISCUSSION Any lymphocyte-containing soft tissue may be affected by lymphoma. The majority of reported patients with muscle involvement have described changes in the lower extremities [3-8]. To the best of our knowledge there have been only two reports of psoas muscle involvement [3,4]. One of these patients had periaortic and iliac
333
A Rare Site and Appearance for Lymphomatous Recurrence
and therefore biopsy for histological proof is mandatory. The discrepancy between the CT scan and the operative findings is presumably on the basis of rapid progression of the disease in the interval period.
References
Fig. 2. CT scan of abdomen, indicating enlargement of the right psoas muscle with areas of hypodensity showing rim enhancement.
lymphadenopathy, and massive enlargement of the quadriceps muscle [3]. The other had lateral abdominal wall and iliacus muscle involvement [4]. Attenuation values are generally those of normal muscle. Grunshaw and Chalmers reported three patients with decreased density and heterogeneous enhancement post-intravenous contrast administration [5]. In our patient, the right psoas was
diffusely enlarged, with multiple areas of decreased attenuation showing rim enhancement, a feature not previously described. Although infection, particularly tuberculosis, had to be considered in the differential diagnosis the patient was clinically well and afebrile, thus making an inflammatory cause less likely. The CT appearance alone cannot discriminate between infective and malignant processes,
1. Komatusda M, Nagao T, Amimori S. An autopsy case of malignant lymphoma associated with remarkable infiltration in skeletal muscle. Rinsho Ketsueki 1981;22:891-5. 2. Malloy PC, Fishman EK, Magid D. Lymphoma of bone, muscle and skin: CT findings. A JR 1992;159:805-9. 3. Greta JL, Neville AJ, Smith SC, et al. Massive skeletal muscle invasion by lymphoma. Arch Intern Med 1985;145:1818-20. 4. Pilepach MV, Carter BL. Muscle enlargement in lymphoma patients. Radiology 1980; 134:521-3. 5. Grunshaw ND, Chalmers AG. Skeletal muscle lymphoma. Clin Radiol 1992;45:399-400. 6. Scally J, Garrett A. Primary extranodal lymphoma in muscle. Br J Radiol 1989; 62:81. 7. Spector JI, Zimbler H. Skeletal muscle involvement by lymphoma. Arch Intern Med 1986;146:1232. 8. Travis WD, Banks PM, Reiman HM. Primary extranodal soft tissue lymphoma of the extremities. Am J Surg Pathol 1987;11:35966.
Received for publication December 1994 Accepted following revision March 1995