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Journal of Clinical Oncology, Vol 25, No 6 (February 20), 2007: pp. 726-728 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.09.6388
Recurrent Lymphoma Presenting As Brachial Plexus NeuropathyDivision of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; China Medical University, Taichung, Taiwan; and National Yang-Ming University, Taipei, Taiwan
Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan and China Medical University, Taichung, Taiwan
Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and China Medical University, Taichung, Taiwan
Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan A 70-year-old man suffered from a growing mass in his right upper neck for 2 months. A computed tomography (CT) scan showed a mass of 67 x 53 mm in diameter located in right jugular chain and another oval mass in right posterior cervical space. The pathology of biopsy proved to be diffuse large B-cell lymphoma. The initial positron emission tomography (PET) suggested fluorinated deoxyglucose uptake in right neck, right subclavicular, abdominal, and pelvic areas (Fig 1A). There was no bone marrow involvement. The patient then received immunochemotherapy with rituximab plus cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP). The lymphoma responded very well to chemotherapy. After four courses of chemotherapy, a CT scan did not find residual lesions. However, this patient began to experience left shoulder and left arm numbness after the sixth course of therapy. The paresthesia exacerbated gradually. Later, the muscle power of his left arm decreased. The electromyography/nerve conduction velocity studies found generalized sensorimotor polyneuropathy of axonal degenerative type, and a drop of nerve conduction velocity of left ulnar nerve that suggested a lesion above the axillary level. A magnetic resonance image found only mild central herniated intervertebral discs in C3-4, C4-5, and C5-6 that could not explain the severity of disability. In addition, there was an ill-defined, intensive signal along left side brachial plexus roots. The lesion diffusely infiltrated in the plane between muscle groups (Fig 2). A PET scan found a new hypermetabolic lesion in left supraclavicular region, but no signals in the previous lymphoma sites (Fig 1B). The recurrent lymphoma cells infiltrating the brachial plexus nerves between muscles were found pathologically by exploratory operation. The symptoms of this patient were relieved after local radiotherapy.
Neurolymphomatosis presents as involvement of peripheral nerves or roots with or without pain.1,2 When it occurs as the sole manifestation of lymphoma, a diagnosis is challenging. Differential diagnoses include nerve root compression, neurotoxicity by chemotherapeutic agents, viral infection, autoimmune neuropathy, vasculitis, or paraneoplastic syndrome.3 Approximately half of patients with clinical or histopathologic diagnosis of neurolymphomatosis are not diagnosed until autopsy.4 Before pathologic examination, the magnetic resonance imaging may reveal diffuse thickening and enhancement of roots, trunks, or peripheral nerves.4 PET or PET-CT scans provide more reliable detection than CT or magnetic resonance imaging.2 Most of reported patients with histopathologic diagnosis, as well as our patient, had large B-cell lymphoma. There are many studies addressing the peripheral nerve-seeking behavior of B cells.4,5 Patients with neurolymphomatosis have a similar prognosis like those with primary CNS lymphoma if properly treated.4 Physicians managing patients with lymphoma should be aware of the possibility of neurolymphomatosis even when complete remission of lymphoma is obtained at other sites. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The authors indicated no potential conflicts of interest.
REFERENCES 1. Lhermitte J, Trelles LO: Neurolymphomatose peripherique humaine. Press Med 42:289-292, 1934 2. Kanter P, Zeidman A, Streifler J, et al: PET-CT imaging of combined brachial and lumbosacral neurolymphomatosis. Eur J Haematol 74:66-69, 2005[CrossRef][Medline] 3. Hughes RA, Britton T, Richards M: Effects of lymphoma on the peripheral nervous system. J R Soc Med 87:526-530, 1994[Abstract] 4. Baehring JM, Damek D, Martin EC, et al: Neurolymphomatosis. Neuro-Oncol 5:104-115, 2003[Abstract] 5. Drillenburg P, Pals ST: Cell adhesion receptors in lymphoma dissemination. Blood 95:1900-1910, 2000
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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