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Presented by Edward McCarthy, M.D. and prepared by Maryam Farinola M.D.
Case 2: An 81-year-old man had lower leg pain for two months.
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Question 1 of 1
1. Question
Week 184: Case 2
An 81-year-old man had lower leg pain for two months. Radiographs demonstrated a lytic lesion in the tibia. There was an associated soft tissue mass.images/lymphoma 1.jpg
images/lymphoma 2.jpg
images/lymphoma 3.jpgCorrect
Answer: Malignant lymphoma
Histology: Malignant lymphoma may occur as a primary osseous neoplasm. Generally lymphomas are large B-cell lymphomas as in this case. Histologically, they show sheets of lymphoid cells which stain positively for a CD-20.
Discussion: The lesion is not metastatic carcinoma because of the absent of epithelial cells. However, metastatic carcinoma must always be considered in spinal lesion in a patient above the age 55. Therefore, immunostains are always necessary to differentiate a metastatic carcinoma from a primary bone tumor in this age group.
The diagnosis is not multiple myeloma because of the absence of plasma cells. Occasionally, plasma cells may be so poorly differentiated as to masquerade as lymphocytes. However, the plasma cell morphology is completely absent in this case. However, occasionally a CD-168 stain is necessary to rule in or rule out multiple myeloma. In addition, since almost all patients with multiple myeloma have an elevated serum or urine M-protein, this test should always be performed on evaluating a round cell neoplasm in an older person.
The diagnosis is not Ewing’s sarcoma. Although, Ewing’s sarcoma may rarely occur in older patients, this tumor occurs most commonly in young adults or children. However, an immuno stain for Ewing’s sarcoma should be performed when evaluating any small round blue cell neoplasm in any aged patient. In the present case, the CD-20 positivity identifies the neoplasm as a lymphoma.
Incorrect
Answer: Malignant lymphoma
Histology: Malignant lymphoma may occur as a primary osseous neoplasm. Generally lymphomas are large B-cell lymphomas as in this case. Histologically, they show sheets of lymphoid cells which stain positively for a CD-20.
Discussion: The lesion is not metastatic carcinoma because of the absent of epithelial cells. However, metastatic carcinoma must always be considered in spinal lesion in a patient above the age 55. Therefore, immunostains are always necessary to differentiate a metastatic carcinoma from a primary bone tumor in this age group.
The diagnosis is not multiple myeloma because of the absence of plasma cells. Occasionally, plasma cells may be so poorly differentiated as to masquerade as lymphocytes. However, the plasma cell morphology is completely absent in this case. However, occasionally a CD-168 stain is necessary to rule in or rule out multiple myeloma. In addition, since almost all patients with multiple myeloma have an elevated serum or urine M-protein, this test should always be performed on evaluating a round cell neoplasm in an older person.
The diagnosis is not Ewing’s sarcoma. Although, Ewing’s sarcoma may rarely occur in older patients, this tumor occurs most commonly in young adults or children. However, an immuno stain for Ewing’s sarcoma should be performed when evaluating any small round blue cell neoplasm in any aged patient. In the present case, the CD-20 positivity identifies the neoplasm as a lymphoma.
