Journal of Clinical Oncology, Vol 20, Issue 7
(April), 2002: 1946-1947
© 2002 American Society for Clinical Oncology
Unusual Presentations of Lymphoma
Case 3. Splenic Hematoma Associated With Non-Hodgkin's Lymphoma
Parthas Narasimhan,
Ibrahim F. Hitti,
Parul Gheewala,
Usha Pulakhandam,
Barry Kanzer
North Shore University Hospital at Forest Hills, Forest Hills, NY
A 64-year-old African-American man was seen because of a 20-pound weight loss, left upper-quadrant pain, and a lump in the left side of the neck. Two weeks earlier, the patient sustained blunt trauma to the left side of the chest in a motor vehicle accident. Clinical examination revealed a 2-cm left supraclavicular lymphadenopathy and a tender, enlarged spleen extending 6 cm below the costal margin. His hemoglobin level was 7.3 g/dL, his WBC count was 6,200/mm3, and his platelet count was 220,000/mm3. His WBC differential was normal, and a review of his peripheral-blood smear revealed no abnormal lymphocytes. A fine-needle aspiration of the neck lymphadenopathy showed atypical lymphoid elements suggestive of lymphomatous involvement. A bone marrow biopsy showed no evidence of lymphoma.
Computed tomography of the abdomen (Fig 1) showed an intrasplenic hematoma and para-aortic and retroperitoneal lymphadenopathy. The patient received pneumococcal vaccine and underwent an exploratory laparotomy with splenectomy.
On pathologic examination, the spleen measured 20 x 17 x 6 cm and consisted mostly of a large hematoma. The wall of the hematoma contained areas of fish-flesh white soft tissue (Fig 2). Microscopic examination disclosed areas of hemorrhage and necrosis (Fig 3, arrowheads, scanning magnification) and diffuse large B-cell lymphoma (Fig 3, curved arrows and inset) that was positive for the CD20 antigen. The patient received six cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy and achieved a complete remission.
The involvement of the spleen with non-Hodgkin’s lymphoma is a common occurrence. The pattern of involvement varies. It may assume a diffuse infiltrative architecture with no discrete masses, a miliary configuration with small deposits of lymphoma, or a massive involvement with one or more large masses. Cystic presentation of splenic lymphoma may be secondary to massive internal tumor necrosis, tumor superinfection with abscess formation, or parenchymal hemorrhage and hematoma formation related to blunt trauma, as in the present case.
Cystic lesions of the spleen run the gamut of splenic pathology.1,2 They may be seen in splenic congenital lesions (true cyst, epidermoid cyst), acquired pseudocysts, inflammatory lesions (abscess, pyogenic or fungal), parasitic lesions (echinococcal), vascular lesions (infarction, posttraumatic hematoma), benign neoplastic lesions (hemangioma), and malignant neoplastic lesions (lymphoma, metastases). Although imaging studies help to narrow the differential diagnosis of these splenic lesions, pathologic examination of the spleen is still required for a definitive diagnosis.
It is not uncommon for trauma to bring attention to neoplasms of various organs, such as the testicles, breasts, and the skeleton. The present case would fall under this category. Rarely, however, do the site of trauma and the resulting hematoma become the focus of a metastatic growth of a primary neoplasm of a distant organ. We have seen two such cases, one of the scalp3 and the other of the leg,4 in which the site of trauma eventually became the focus of malignant lymphoma growth. The association of these events, however, remains speculative.
REFERENCES
1.
Urrutia M, Mergo PJ, Ros LH, et al: Cystic masses of the spleen: Radiologic-pathologic correlation. Radiographics 16: 107-129, 1996[Abstract/Free Full Text]
2.
Wolf BC, Neiman RS: Disorders of the Spleen. Philadelphia, PA, WB Saunders, 1989, pp 189-192
3.
Patel JK, Patel M, Hitti I, et al: Trauma-related presentation of non-Hodgkin’s lymphoma. N Y State J Med 92: 322, 1992 (letter)
4.
Narasimhan P, Arora A, Hitti I, et al: Rapidly progressive fatal cutaneous T cell lymphoma with a trauma-related presentation. Cutis 66: 195-198, 2000[Medline]
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