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Journal of Clinical Oncology, Vol 23, No 16 (June 1), 2005: pp. 3847-3848 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.05.042
Conditions Suggesting LymphomaCASE 3. Primary Synovial Lymphoma With Osteoclast-Like Giant Cells Presenting As a Tenosynovial Giant-Cell TumorDivision of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
Division of Pathology, Niigata University Hospital, Niigata, Japan
Department of Internal Medicine, Kobari General Hospital, Niigata, Japan A 75-year-old man presented to another hospital with a 6-month history of swollen right knee. There was a 17-year history of bilateral osteoarthritis of the knee joints, and the patient had received intra-articular injections of steroids. Physical examination showed a right knee that was swollen and painful, with a range of motion decreased in 90 degrees in flexion. There was no lymphadenopathy. A plain film of the right knee showed narrowing of the medial joint space, erosive change of the femoral and tibial joint surfaces, and small osteophytes (Fig 1A). Preoperative magnetic resonance images demonstrated gross intra-articular tumoral mass without bone involvement (Fig 1B, arrows). He underwent open synovectomy with removal of white to brownish fragile tumor on the synovium. The pathologic diagnosis at the hospital was tenosynovial giant-cell tumor. The postoperative course was uneventful and the surgery provided satisfactory symptomatic relief. Two years after surgery, the tumor mass of the right knee recurred and he was referred to our hospital. There was marked swelling in his right knee and leg. Magnetic resonance images showed intra-articular gross tumor extending to the posterior and involved popliteal vessels (Fig 1C, arrows); however, no bone involvement was seen. The previous surgical specimens were reviewed and found to be composed of round to oval-shaped cells with abundant osteoclast-like, giant-cell proliferations. The tumor cells had coarse vesicular chromatin, prominent nucleoli, and scant cytoplasm (Figs 2A and 2B). Immunohistochemical studies showed positive reactivity with vimentin, leukocyte common antigen, and L26 (Fig 2C). The tumor cells were negative for AE1/AE3, CAM 5.2, S100 protein, HMB-45, CD34, CD99, HHF35, and Leu7. UCHL-1 was focally positive. Osteoclast-like giant cells were strongly positive for CD68 (a marker of monocyte, macrophage, and osteoclast; Fig 2D). The revised diagnosis was diffuse large B-cell lymphoma with osteoclast-like giant cells. The full blood count was normal, lactate dehydrogenase was 264 U/L (normal range, 111 to 216 U/L), and serum interleukin 2 receptor was 778 U/mL (normal range, 190 to 650 U/mL). Staging computed tomography scans and gallium scans revealed no abnormality other than the right knee joint and a right supralcavicular lymph node mass measuring 2 cm. Five courses of chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) and three courses of anti-CD20 (rituximab) resulted in a complete remission.
Musculoskeletal manifestations of lymphoma cover a broad spectrum of disease findings with varying degrees of involvement of bone and soft tissue.1 While bone involvement occurs in up to 25% of malignant lymphoma cases, synovial involvement is rare and is usually the result of direct extension from bone lesions.1-5 We found only six cases of synovial malignant lymphoma without bone involvement in the English literature, including the present case. Of these six cases, two are diffuse large B-cell type, one T-cell type, one diffuse type, one histiocytic type, and one non-Hodgkin's lymphoma without any specific subclassification. The differential diagnosis of a synovial lymphoma includes rheumatoid arthritis, pigmented villonodular synovitis, tenosynovial giant-cell tumor (giant-cell tumor of the tendon sheath), synovial chondromatosis, synovial hemangioma, lipoma arborescens, and synovial cyst.4 Tenosynovial giant-cell tumor is divided into two groups, the first occurring in the digits and the second in large joints. Treatment is surgical and is frequently complicated by recurrence.6 The tumor consists of the mixture of abundant histiocyte-like, foam, and osteoclast-like giant cells.6 The presence of osteoclast-like giant cells in malignant lymphoma has been rarely observed.7 Because the osteoclast-like giant cells are common in synovium of patients with ostoarthritis,8 the medical history of osteoarthritis of the present case may contribute to formation of abundant osteoclast-like giant cells in this tumor. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES 1. Ruzek KA, Wegner DE: The multiple faces of lymphoma of the musculoskeletal system. Skeletal Radiol 33:1-8, 2004[CrossRef][Medline] 2. Tiwari I, Thomas RDR, Pathy MS, et al: Non-Hodgkin's lymphoma presenting in synovial membrane. Br J Clin Practice 36:327-328, 1982[Medline] 3. Dorfman HD, Siegel HL, Perry MC, et al: Non-Hodgkin's lymphoma of the synovium simulating rheumatoid arthritis. Arthritis Rheum 30:155-161, 1987[Medline] 4. Jamieson KA, Beggs I, Robb JE: Synovial presentation of non-Hodgkin's lymphoma. Br J Radiol 71:980-982, 1998[Abstract] 5. Khan SY, Hutchinson DG: Primary synovial non-Hodgkin's lymphoma in association with ankylosing spondylitis. Rheumatology (Oxford) 43:391, 2004 6. Ushijima M, Hashimoto H, Tsuneyoshi M, et al: Giant cell tumor of the tendon sheath (nodular tenosynovitis). Cancer 57:875-884, 1986[CrossRef][Medline] 7. Hara T, Wakatsuki S, Ozaki S, et al: Primary adult T-cell leukemia/lymphoma of bone. Int J Hematol 79:157-160, 2004[Medline]
8. Ashton BA, Ashton IK, Marshall MJ, et al: Localisation of vitronectin receptor immunoreactivity and tartrate resistant acid phosphatase activity in synovium from patients with inflammatory or degenerative arthritis. Ann Rheum Dis 52:133-137, 1993
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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