Description
An 80-year-old man, who enjoyed good health, presented with a 3-month history of a rapidly growing mass over his lower sternum. He had multiple bone pain and weight loss for a few weeks. He did not have a fever or poor appetite. Physical examination found firm, non-tender masses over his lower sternum and right upper chest wall. The remaining examination was unremarkable and there was no lymphadenopathy. Blood test revealed increased serum calcium 3.69 mmol/L (N 2.1–2.65) and alkaline phosphatase 146 µ/L (N 53–141). Positron emission tomography CT (PET-CT) scan showed multiple hypermetabolic soft tissue nodules in the lower sternum (figure 1A), right first intercostal space (figure 1B) and left posterior lower chest wall (figure 1C). There were extensive osseous metastases and diffuse marrow infiltration with no lymphadenopathy. Bone marrow examination and biopsy of the lower sternal mass revealed diffuse large B-cell lymphoma. The patient was referred to an oncologist and given chemotherapy.
Figure 1.
(A) Positron emission tomography CT (PET-CT) scan shows a hypermetabolic lesion located superficial to the lower sternum (arrow), measuring about 3.80×4.77×4.84 cm. SUV max=12.9. (B) PET-CT scan shows a hypermetabolic lesion located in the right first intercostal space with erosion of the first rib (arrow), measuring about 3.25×5.62×4.25 cm. SUV max=10.8. (C) PET-CT scan shows a hypermetabolic lesion located in the left posterior lower chest wall with involvement of the left 11th rib (arrow), measuring about 3.03×2.42×2.71 cm. SUV max=7.6.
Subcutaneous nodules as the presenting symptom of diffuse large B-cell lymphoma is rare. Skin or soft tissue nodules are more commonly seen in subcutaneous panniculitis-like T-cell lymphoma.1 2 PET-CT scan is very helpful in diagnosing lymphoma and allows prompt treatment.
Learning points.
Subcutaneous nodules as the presenting symptom of diffuse large B-cell lymphoma is rare.
Skin or soft tissue nodules are more commonly seen in subcutaneous panniculitis-like T-cell lymphoma.
Positron emission tomography CT scan is very helpful in diagnosing lymphoma and allows prompt treatment.
Footnotes
Competing interests: None.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
- 1.Lee WJ, Jung JM, Won CH et al. Cutaneous extranodal natural killer/T-cell lymphoma: a comparative clinicohistopathologic and survival outcome analysis of 45 cases according to the primary tumor site. J Am Acad Dermatol 2014;70:1002–9. [DOI] [PubMed] [Google Scholar]
- 2.Gao J, Gauerke SJ, Martinez-Escala ME et al. Bone marrow involvement by subcutaneous Panniculitis-like T-cell lymphoma: a report of three cases. Mod Pathol 2014;27:800–7. [DOI] [PubMed] [Google Scholar]