Case presentation

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口腔病理科 On-Line KMU Student Bulletin

原文題目(出處)： Primary bone lymphoma of the mandible and thyroid incidentaloma identified by FDG PET/CT: a case report Cases Journal 2009;2:6384

原文作者姓名： Bosch-Barrera J, Arbea L, Garcia-Velloso MJ, Gil-Bazo I, Garcia-Foncillas J, Panizo C

通訊作者學校： Department of Oncology, Clinica Universidad de Navarra, Pamplona, Spain

報告者姓名(組別)： Intern B組詹宜錡

報告日期： 98.11.9

內文：

Introduction

¾ Primary bone lymphoma(PBL) represents approximately 3% of all malignant bone tumor and 5% of all non-Hodgkin lymphomas.

¾ Slightly greater frequency in men, early-stage disease presentation and a median age of appearance in the fifth or sixth decade.

¾ The most common tumor sites- long bones(50% extremities)、axial skeleton(44%) mandibule is a rare location(2-4% of all PBLs).

¾ PBL therapy has evolved from radiotherapy as a standalone strategy (since the 1960s) to combined modality therapy (chemotherapy and radiotherapy).

¾ Surgery is currently limited to diagnostic procedures and repair of pathological fractures of the bone.

¾ Diffuse large B-cell lymphoma (DLBCL) is the most frequent histopathplogical subtype of PBL.

¾ Standard chemotherapy for DLBCL consists of administration of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) in conjunction with the monoclonal antiCD21 rituximad.

¾ Treatment options differ for patients with localized (Ann Arbor stage I-II) or advanced (Ann Arbor stage III-IV) disease.

Case presentation

C.C A 47 y/o Caucasian Spanish man presented with a history of eight months of dental pain.

P.I Despite extraction of two teeth(37, 38), improvement of symptoms was not achieved.

CT scan osteolytic lesion on the left mandible of 3.8×1 cm as well as the presence of a cyst on the right thyroid.

Bone marrow biopsy, hematological and chemical analysis normal

Immunohistochemistry analysis positive for cytoplasmic CD20, Bcl-2 and nuclear Bcl-6

Fine-needle aspiration(FNA) thyroid lesion revealed a papillary thyroid carinoma

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FDG PET/CT showing the thyroid incidentaloma in sagital (a), coronal (b) and axial(d) view. Image (d) shows an osteolytic lesion in the left mandible in an axial view of the CT scan.

FDG PET/CT showing the thyroid incidentaloma in sagital (a), coronal (b) and axial (d) view. Image (b) shows the right thyroid cyst on the CT scan.

Diagnosis DLBCL stage I EA with a low IPI score and a synchronic papillary thyroid carcinoma

Treatment

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z Papillary thyroid carcinoma-total thyroidectomy, anatomopathological examination revealed a follicular variant of papillary carcinoma of the thyroid of 1.5 cm with pT1pN1aM0 stage (stage III). The patient began treatment with levothyroxine z DLBCL－six cycles of chemotherapy(R-CHOP). After chemotherapy the patient

was irradiated with 3D conformational radiotherapy.

Follow-up completely tumor-free of the two tumors for 28 months

Discussion

PBL

z Localized bone pain, sometimes the presence of a palpable mass

z In the mandible－pain, swelling, numbness, tooth mobility and cervical lymphadenopathy

z Correct diagnosis of PBL－8 months Treatment－

1. The treatment and optimal management of patients with PBL are unclear because of the low incidence of this pathology.

2. Combined modality therapy of chemotherapy with radiotherapy leads to better result than a single modality of treatment. It is consistent with the results of studies on patients with early-stage non-Hodgkin lymphoma.

3. Rituximab added to six cycles of CHOP may lead to a reduction in chemotherapy cycles and may therefore be an option for the future treatment of these patients.

FDG-PET

z Influence both the initial choice of chemotherapy and alterations to the management of the disease based on the response to therapy.

z As FDG PET/CT is becoming a more common imaging modality, the incidence of thyroid incidentalomas is also increasing.

z It has a clear role in I¹³¹-negative thyroid cancer and follow-up, but it should not be performed in patients with a stimulated Tg ＜ 10 μgr/L because of its low sensitivity.

題號題目

1 Which area is the most common site of primary bone lymphoma？

(A) long bones (B) axial skeleton (C) mandible (D) ribs

答案( A) 出處：Cases Journal 2009, 2:6384

題號題目

2 Which of following is wrong about lymphoma?

(A) Lymphoma is aneoplastic proliferation within the reticuloendothelial system.

(B) It is as common as a metastatic tumor.

(C) The nodes involved may be solitary or multiple and unilateral or bilateral.

(D) Because of the high cure rate in Hodgkin’s disease, early diagnosis by biopsy is desirable.

答案(B ) 出處：Oral & Maxillofacial pathology P.528~529