ارائه دهنده :دکتر اکرم جوکار

Case report

س�اله 28آق�ای بیم�ار ب�ا خودبخ�ودی ک�ه شکس�تگی ب�ه این مرک�ز مراجع�ه کرده.ش�رح ح�ال وی اس�تخوان ب�ازو از از س�ابقه ای ب�ازو ب�ه م�اه 4درد کن�د قب�ل ذک�ر می

روز قب�ل 3ط�وری ک�ه قادرب�ه ح�رکت دس�ت خ�ود نب�وده از از مراجع�ه بیم�ار ب�ه ط�ور ناگه�انی و در ح�الت اس�تراحت دچ�ار تش�دید درد می ش�ود ک�ه ب�ه ارتوپ�د مراجع�ه می کن�د و طی گ�رافی انج�ام ش�ده ب�ه علت شکس�تگی اس�تخوان ب�ازوبرای وی آت�ل گرفت�ه می ش�ودو ب�ه این مرک�ز ارج�اع داده می ش�ود. بیم�ار س�ابقه ای از تروم�ا در این م�دت

اخیر ذکر نمی کند . آگ�زیالری دس�ت LAP م�اه قب�ل بیم�ار ب�ه علت 6همچ�نین

LAPب�ه پزش�ک مراجع�ه می کن�د ک�ه ب�ه گفت�ه ی بیم�ار چپ وی ب�دون درد ، قرم�زی و گ�رمی ب�وده ک�ه نهایت�اJ بیم�ار

وی پاتولوژی در و گرفته قرار بیوپسی Kikuchiتحت necrotizing lymphadentis.گزارش شده

در طی این م�دت بیم�ار ش�کایتی از تب ، ل�رز ، تعری�ق و درد مختص�ر پ�ای ک�اهش وزن را ذک�ر نمی کن�د. تنه�ا ی�ک

را از یک ماه پیش تاکنون ذکر می کند.چپ

نب�ود paleدر معاین�ات بیم�ار ملتحم�ه گ�ردنی LAP نب�ود .icteric. اس�کلرا

SupraclaVicular لمس واینگوئین�ال .نشد . ارگانومگالی لمس نشد

علت ب��ه چپ س��مت .بازوی گرفت�ه ش�ده گچی آت�ل شکس�تگی

بود. بود . NIمعاینه سایر اندام ها

WBC:7300 ESR: 22 WBC: 69000Hb: 12.4 uric Acid : 9.2 Hb: 12.2Mcv: 68.6 Cr : 0.4 MCV : 64 Mch : 20 Ca : 8.3 MCH : 24PLT : 330000 P : 5.4 PLT : 355000 AST:73ESR : 23 ALT:29 LDH:984 CRP : +++CRP : ++ ALP:325

سی تی اسکن ریه و مدیاستن نرمال گزارش شده

:سی تی اسکن شکم و لگن

کبد و طحال پاراآئورت نرمال گزارش شده تنها 3ندولی به قطر cm

در قدام عضله پسواس چپ در لگن مشاهده .شد که قابل افتراق از سیگموئید نمی باشد

A large tissue mass(7*6 cm)in the proximal left arm with bone marrow edema in the proximal metaphisial of humerous is seen

Abnormal increase uptake is seem in upper portion of left humerus-upper portion of left femur.reminder of skeleton is visualized with normal uptakeImperison:1-Active lesion inmention region2- bone scan finding high suggestive with bone metastase or systemic bone disease

Pathology :Malignant lymphoma,diffuse large cell type left armIHC CD20 + CD3 + Positive In Some Background Lymphocyte CD 45 +CD 99 +

Differential Diagnosis

Osteosarcoma Osteosarcoma is the most common primary

malignant tumor arising in bone (myeloma excluded). Osteosarcoma, which is most common in the second and third decades of life, is usually a high-grade malignancy, . There is usually a mixture of radiodense and radiolucent areas, with periosteal new bone formation, and sometimes formation of Codman's triangl

Ewing sarcomaThe characteristic periosteal reaction produces layers of reactive bone, deposited in an "onion peel" appearance .

Other tumors

– Other malignant tumors that should be considered in the differential diagnosis of a primary lytic lesion include: fibrosarcoma (spindle cell sarcoma), which tends to resemble osteosarcoma but without ossification, primary lymphoma of bone metastasis from a non-bone tumor

.• "Benign" bone tumors that can present as lytic lesions

include:• hemangioma,• various types of cysts, • lipomas,• eosinophilic granuloma• giant cell tumor of bone.• Destructive eosinophilic granulomas usually occur at a

younger age and are not associated with a sizable soft tissue mass

Primary bone lymphoma

Primary bone lymphoma (PBL) is an uncommon tumor accounting for approximately 4-5% of extra nodal lymphoma and less than 1% of all non-Hodgkin's lymphoma. Disease may be complicated at presentation by pathological fracture or spinal cord compression. Diffuse large-B-cell lymphoma (DLBCL) accounts for the majority of cases of PBL.

To be defined as primary bone lymphoma (also known as Coley's criteria), there should be [4]

(i) a primary focus in a single bone

(ii) positive histological diagnosis

(iii) no evidence of distant soft tissue or distant lymph node involvement.it is recognized that primary bone lymphoma may involve multiple bones, as long as the other two criteria are met

PBL occurs commonly between 20 and 50 years of age and shows male preponderance with male to female ratio of 3:2. The femur (29%) is the most common site followed by (in descending order of frequency): pelvis (19%), humerus (13%), skull (11%) and tibia (10%).

Clinical presentation

• Clinical presentation includes local pain and swelling. Radiologically bony lesions may be extensive, destructive or infiltrative.

• Extensive lesions involve 25-50% of affected bone, sometimes entire bone.

• Destructive lesions are radiolucent, mottled, patchy, moth eaten and sometimes the outline of the bone is completely lost

Nearly all variants destroy cortical bone and 25% thicken the cortex.

Often large, obvious soft-tissue extension may be present along with bony lesion. Diagnosis is established by biopsy.

• Other investigations include

skeletal survey, bone scan, bone marrow biopsy, CT scan of

whole abdomen and chest to assess lymph node involvement and

serum LDH estimation are done as part of the staging procedure.

MRI is helpful in demonstrating bone marrow and soft tissue

involvement.

Lymphoma has an increased uptake on bone scan.

treatment

Over the last two decades, chemotherapy (CHOP based) has

become the standard treatment with or without consolidative

irradiation.

The introduction of rituximab since March 2001 has been

accompanied by a remarkable improvement in the PFS for patients

with PBL compared with those treated earlier without rituximab

(3-year PFS 88% versus 52%).

Role of radiation in advanced stage PBL is controversial.

Surgery is only indicated for pathologic fractures

Thus, primary lymphoma of bone should be

considered in the differential diagnosis of bony

tumors in young patients in second to fourth

decade. Chemotherapy followed by radiotherapy

is the treatment of choice and is associated with

good outcome

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