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Presented by Edward McCarthy, M.D. and prepared by Sharon Swierczynski, M.D., Ph.D.
Case 4: A 21 year-old man had a painful swelling in his hand for 6 months.
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1. Question
Week 145: Case 4
A 35 year-old man had pain in his leg for 3 months. A radiograph demonstrated a poorly defined destructive radiolytic lesion in his femur. A biopsy was performed./images/072803case4fig1.jpg
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/images/072803case4fig4.jpgCorrect
Answer: Malignant lymphoma
Histology: Malignant lymphoma of bone is usually a large B-cell lymphoma. The histologic features are those of a round cell neoplasm. This diagnosis requires the confirmation by immunohistochemical features. Malignant lymphomas in bone characteristically stain positive for CD45 and CD20. Occasionally, malignant lymphomas in bone are T-cell neoplasms that stain with CD3.
Discussion: The lesion is not Ewing’s sarcoma. Ewing’s sarcoma generally involves younger patients, usually children, and adolescents. Rarely Ewing’s sarcoma can affect older adults. Ewing’s sarcoma would be positive for CD99. The only way to absolutely differentiate Ewing’s sarcoma from a malignant lymphoma is immunohistochemical staining.
The lesion is not metastatic carcinoma. Although metastatic carcinoma would be the most probable diagnosis based on radiographs and clinical history, this diagnosis can be ruled out by the absence of staining with cytokeratins.
Osteomyelitis may sometimes be confused with malignant lymphomas because of the sheets of chronic inflammatory cells that may dominate the histologic fields in bone infections. Chronic osteomyelitis, however, will demonstrate polyclonality of the lymphocytes. Most of the lymphocytes will be T-cells. In addition, the lymphocytes seen in chronic osteomyelitis will not be large and atypical as in the large cell malignant lymphomas.
Incorrect
Answer: Malignant lymphoma
Histology: Malignant lymphoma of bone is usually a large B-cell lymphoma. The histologic features are those of a round cell neoplasm. This diagnosis requires the confirmation by immunohistochemical features. Malignant lymphomas in bone characteristically stain positive for CD45 and CD20. Occasionally, malignant lymphomas in bone are T-cell neoplasms that stain with CD3.
Discussion: The lesion is not Ewing’s sarcoma. Ewing’s sarcoma generally involves younger patients, usually children, and adolescents. Rarely Ewing’s sarcoma can affect older adults. Ewing’s sarcoma would be positive for CD99. The only way to absolutely differentiate Ewing’s sarcoma from a malignant lymphoma is immunohistochemical staining.
The lesion is not metastatic carcinoma. Although metastatic carcinoma would be the most probable diagnosis based on radiographs and clinical history, this diagnosis can be ruled out by the absence of staining with cytokeratins.
Osteomyelitis may sometimes be confused with malignant lymphomas because of the sheets of chronic inflammatory cells that may dominate the histologic fields in bone infections. Chronic osteomyelitis, however, will demonstrate polyclonality of the lymphocytes. Most of the lymphocytes will be T-cells. In addition, the lymphocytes seen in chronic osteomyelitis will not be large and atypical as in the large cell malignant lymphomas.
