Abstract
Objective: Primary lymphoma of bone (PLB) is a rare malignant bone tumor often presenting in the fifth-sixth decades involving appendicular long bones. Published radiological findings indicate that PLB typically presents as a moth-eaten osteolytic lesion with periosteal reaction, while MRI commonly demonstrates marrow infiltration with extraosseous extension. Given rarity and variable appearances, PLB may not be primarily considered prior to biopsy. Our objective was to evaluate preoperative imaging findings in effort to increase awareness and improve a perceived deficiency in preoperative diagnosis. Materials and Methods: Following IRB approval, retrospective review identified 60 patients with newly diagnosed bone lesions proven to represent PLB in accordance with WHO definition. Preoperative radiographs (n = 46), MRI (n = 33) and PET (n = 37) were independently reviewed by two radiologists. At radiography, lesions were classified: purely lytic, mixed, purely sclerotic, or occult; lytic lesions were graded utilizing Lodwick’s classification. At MRI, lesions were defined as focal or infiltrative and the presence or absence of extraosseous disease was recorded. Extraosseous masses were defined as small ( 1 cm) and subjectively correlated with degree of cortical destruction. At PET, lesions were recorded as FDG-avid or not. Primary radiograph reports when available (n = 33) were reviewed and exact wording of differential considerations was recorded. Results: Radiographs demonstrated mixed (n = 22), lytic (n = 15), and sclerotic (n = 8) appearances; one radiographically occult lesion was seen by MRI. Lytic lesions were graded: IB (n = 3), IC (n = 5), II (n = 4), and III (n = 3); none were IA. At MRI, 30 lesions were infiltrative and 3 were focal; 11 were not associated with extraosseous extension, while 22 showed bony disease with small (n = 7) or large (n = 15) soft tissue mass. Of large masses, 13 demonstrated minimal cortical destruction. At PET, 36 demonstrated FDG uptake; one study was technically limited. Review of reports found that only 5 included “lymphoma” as a diagnostic consideration. Conclusion: Contrary to most published data, we suggest that PLB typically demonstrates some degree of osteosclerosis, often a mixed pattern of sclerosis and lucency; purely lytic lesions may be less common. Similar to existing reports, MRI commonly demonstrates marrow infiltration with extraosseous extension of disease, typically a large soft tissue mass with disproportionate (minimal) cortical destruction. Familiarity with these findings should improve preoperative consideration of PLB in the appropriate clinical scenario when a new osteoblastic lesion is identified.
Highlights
Primary lymphoma of bone (PLB) is an uncommon osseous neoplasm comprising less than 5% of primary bone neoplasms, much less common than other primary bone malignancies such as multiple myeloma, osteosarcoma, and chondrosarcoma [1]
The remaining 60 patients represent our study population—patients with newly diagnosed bone lesions referred to our center with subsequently proven primary lymphoma of bone according to the 2013 World Health Organization (WHO) classification of soft tissue and bone tumors
Of 60 patients in our study with newly diagnosed primary lymphoma of bone, patient age ranged from 17 - 89 years including 28 females and 32 males
Summary
Primary lymphoma of bone (PLB) is an uncommon osseous neoplasm comprising less than 5% of primary bone neoplasms, much less common than other primary bone malignancies such as multiple myeloma, osteosarcoma, and chondrosarcoma [1]. When the differential diagnosis does include PLB, the approach to diagnostic biopsy, treatment planning, and prognosis differ significantly from other primary bone tumors; for example, prophylactic intramedullary rod fixation of an impending fracture may be considered in cases of PLB, but contraindicated in chondrosarcoma. For this reason, diagnostic radiologists, orthopedic oncologists, and medical oncologists would benefit from greater familiarity with the common imaging characteristics of PLB. PLB is less often considered preoperatively than other aggressive bone pathologies, though identification of certain imaging features may improve this area of perceived deficiency
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