Journal of Clinical Oncology, Vol 25, No 21 (July 20), 2007: pp. 3175-3176
© 2007 American Society of Clinical Oncology.
DOI: 10.1200/JCO.2007.11.9966
Pathological Bone Fracture in Non-Hodgkin's Lymphoma
Chor-Sang Chim,
Clara Pang Bik Yiu,
Wai Hung Shek
University Departments of Medicine, Radiology and Pathology, Queen Mary Hospital, University of Hong Kong, Hong Kong
In January 2007, a 75-year-old woman was diagnosed with stage IVB primary diffuse large B-cell gastric lymphoma with lymphoma infiltration of the bone marrow. Gastric biopsy showed a dense infiltrate of large lymphoid cells between the gastric glands (Fig 1). These lymphoid cells were positive for CD20. She achieved a partial response with rituximab together with cyclophosphamide, vincristine, procarbazine, and prednisolone. She was admitted to the orthopedic ward with acute onset of right thigh pain after turning around at home that was associated with a cracking sound. X-ray of right femur showed displaced fracture of the shaft of the right femur without osteolytic bone lesion (Fig 2A). Transaxial section view of computed tomography showed displaced transverse fracture at the midshaft of right femur with absence of intramedullary lytic lesion (Fig 2B). Bone scan showed increased technetium tracer uptake over right midfemoral shaft only. Bone biopsy showed an abnormal lymphoid infiltrate between the bone trabeculae. These lymphoid cells were positive for CD20 (Fig 1). Internal fixation was performed. Physical examination showed an epigastric mass of 10 cm in diameter, consistent with lymphoma progression. Serum lactate dehydrogenase measured 5,668 U/L (normal, < 400 U/L). She developed aspiration pneumonia during hospitalization and died 4 weeks after admission. Her family refused a postmortem biopsy.
In multiple myeloma, osteolytic bone lesion, and hence, pathological fracture is common, and constitutes one of the diagnostic criteria. Osteolytic myeloma bone lesions are due to the secretion of receptor associated nuclear factor kappa-B ligand (RANKL) and soluble Wnt antagonists from the myeloma plasma cells, resulting in activation of osteoclasts and inhibition of osteoblastic differentiation respectively.1 In contrast, pathological fracture in bone lymphoma is uncommon. In a large series of 131 patients with primary bone lymphoma over a 22-year period, one third had lymphoma involvement of the long bones with pathological fracture occurring in nine patients.2 In contrast, in a retrospective analysis of 36 patients with primary (n = 17) and secondary (n = 19) bone lymphoma surgically treated at an orthopedic center over a 15-year-period, pathological fracture of the proximal femur or humerus was observed in three patients only.3 Therefore, our patient illustrated pathological fracture secondary to lymphoma involvement of the femur, which is uncommon even in patients with lymphoma involvement of the long bones.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest.
REFERENCES
1. Pearse RN: Wnt antagonism in multiple myeloma: A potential cause of uncoupled bone remodeling. Clin Cancer Res 12:6274s-6278s, 2006[Abstract/Free Full Text] 2. Ramadan KM, Shenkier T, Sehn LH, et al: A clinicopathological retrospective study of 131 patients with primary bone lymphoma: A population-based study of successively treated cohorts from the British Columbia Cancer Agency. Ann Oncol 18:129-135, 2007[Abstract/Free Full Text] 3. Durr HR, Muller PE, Hiller E, et al: Malignant lymphoma of bone. Arch Orthop Trauma Surg 122:10-16, 2002[Medline]
 CiteULike  Complore  Connotea  Del.icio.us  Digg  Facebook  Reddit  Technorati  Twitter What's this?
|
