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LETTER TO THE EDITOR
Year : 2013  |  Volume : 9  |  Issue : 2  |  Page : 334-335

Peripheral T-cell lymphoma presenting as Pott's spine


1 Department of Medical Oncology, Cancer Institute, Adyar, Chennai, India
2 Department of Pathology, Cancer Institute, Adyar, Chennai, India
3 Department of Radiodiagnosis, Cancer Institute, Adyar, Chennai, India

Date of Web Publication13-Jun-2013

Correspondence Address:
Nandennavar Manjunath
Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai- 600 020
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.113426

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How to cite this article:
Surath PS, Manjunath N, Prasanth G, Urmila M, Vandana M, Sagar T G. Peripheral T-cell lymphoma presenting as Pott's spine. J Can Res Ther 2013;9:334-5

How to cite this URL:
Surath PS, Manjunath N, Prasanth G, Urmila M, Vandana M, Sagar T G. Peripheral T-cell lymphoma presenting as Pott's spine. J Can Res Ther [serial online] 2013 [cited 2019 Sep 20];9:334-5. Available from: http://www.cancerjournal.net/text.asp?2013/9/2/334/113426

Sir,

Nearly one-fourth of the lymphomas present with an extranodal disease, of which, the extradural lymphoma may be considered as a unique entity. [1],[2],[3] Most of these are diffuse, large-cell, lymphomas. However, the most common cause of extradural cord compression, in a country like India, remains tuberculosis of the spine. We encountered a rare case of Peripheral T-cell lymphoma (PTCL), which clinicoradiologically mimicked tuberculosis of the spine (Pott's spine).

A 65-year-old female presented with a progressively increasing, painful swelling, of one-month duration, in the back. She also had cough and mucoid expectorations for two weeks. There was a 7-cm long, firm, paravertebral swelling in right mid-thoracic (D6-10) region. There were no neurological deficits. The chest radiogram and blood counts were normal, except for an elevated erythrocyte sedimentation rate (90 mm in first hour). Serum electrophoresis and bone marrow studies were normal. Plain radiography showed an anterior wedge compression and collapse of the L1 vertebra [Figure 1]a, and no apparent abnormality in the dorsal spine. Magnetic resonance imaging (MRI) of the dorsolumbar spine demonstrated multi-level, altered, marrow signals, appearing hyperintense in the T2 W sequences at the D8, D9, D11, and L1 levels, along with an associated rib destruction and features of cord compression. Also noted was the extensive overlying soft tissue edema. [Figure 1]b and c. Aspiration from the lesion revealed sterile pus. A diagnosis of Pott's spine was made and she underwent drainage, D8-D9 hemilaminectomy, and cord decompression, and was started on antitubercular therapy. However, the swelling reappeared in two weeks and the patient was referred to us. Review of the D8-D9 decompression biopsy specimen was suspicious of lymphoma [Figure 1]d and e and was confirmed as PTCL (Not otherwise specified) on immunohistochemical studies (IHC) [Figure 1]f and h. The IHC work-up revealed that the leukocyte common antigen (LCA) was positive in some of the lymphoid cells, also many lymphoid cells showed a positive reaction to CD3, while keratin and latent membrane protein (LMP) were negative. A good number of atypical cells were positive for CD5 and CD43. Sixty percent of the lymphoid cells showed strong nuclear positivity for Ki67. The patient has completed Cytoxan, Hydroxydaunorubicin (Adriamycin), Oncovin (Vincristine), Prednisone / Prednisolone (CHOP) chemotherapy and is in remission on follow-up.
Figure 1: (a– c) Plain radiograph (lateral view, lumbar spine) shows wedge compression collapse in L1 spine. (a), the MR images for the same region (b and c) reveal multi-level altered marrow signals, appearing hyperintense in the T2 W sequences at the D8, D9, D11, and L1 levels, along with the associated rib destruction and features of cord compression. Also noted is the extensive overlying soft tissue edema (d– h) The biopsy shows scattered medium-to-large cells, with moderate cytoplasm, large vesicular nuclei, and prominent nucleoli, suspicious of lymphoma ((d) H and E, ×10 and (e) ×40). Immunohistochemistry showed that the malignant cells were strongly positive for Ki-67 (60%, f), membrane positivity for CD3 (g), and negative for CD20 (h)

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Lymphoma of the spine has a variable clinical presentation and patients may present late. Radiologically, a combination of bone production and bone destruction is seen involving a wide area. [4] Frequent occurrence of osteoporosis and bone destruction makes it difficult to differentiate lymphoma from Pott's spine, the hallmark of which is reduced disk space, with osteoporosis. In our patient, the typical radiological features, with osteolysis and a paravertebral sterile fluid collection, prompted the diagnosis of tuberculosis and institution of antitubercular thearpy (ATT). It is frequent for both Pott's spine and spinal lymphomas to involve the cord and present with neurological deficits. Fortunately, in our patient, the bulk of the tumor and inflammatory masses were clinically non-compressive and the patient was spared major morbidity. The lymphoma being a chemosensitive tumor, and with the absence of neurological involvement, we chose to start with chemotherapy, with a plan to consolidate with radiation after completion of the systemic therapy.

This case is reported for its rarity and to convey the importance of the meticulous examination of the tissue, even in cases that may clinically and radiologically look very obvious.

 
 > References Top

1.Zucca E, Roggero E, Bertoni F, Conconi A, Cavalli F. Primary extranodal non-Hodgkin's lymphomas. Part 2: Head and neck, central nervous system and other less common sites. Ann Oncol 1999;10:1023-33.  Back to cited text no. 1
    
2.Zucca E, Roggero E, Bertoni F, Cavalli F. Primary extranodal non-Hodgkin's lymphomas. Part 1: Gastrointestinal, cutaneous and genitourinary lymphomas. Ann Oncol 1997;8:727-37.  Back to cited text no. 2
    
3.Zucca E, Cavalli F. Extranodal lymphomas. Ann Oncol 2000;11Suppl 3:219-22.  Back to cited text no. 3
    
4.Clayton F, Butler JJ, Ayala AG, Ro JY, Zornoza J. Non-Hodgkin's lymphoma in bone. Pathologic and radiologic features with clinical correlates. Cancer 1987;60:2494-501.  Back to cited text no. 4
    


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