|Year : 2015 | Volume
| Issue : 3 | Page : 661
Primary chest wall lymphoma: A rare entity
Binay Kumar Shah
Medical Director, Cancer Center and Blood Institute, St. Joseph Regional Medical Center, Lewiston, Idaho, USA
|Date of Web Publication||9-Oct-2015|
Binay Kumar Shah
Cancer Center and Blood Institute, 1250 Idaho Street, Lewiston, Idaho 83501
Source of Support: None, Conflict of Interest: None
Primary chest wall lymphoma is a rare but curable condition. This paper reports a case of a 52-year-old female patient who presented with a primary chest wall diffuse large B-cell lymphoma.
Keywords: Chemotherapy, chest wall tumor, diffuse large B-cell lymphoma, rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone
|How to cite this article:|
Shah BK. Primary chest wall lymphoma: A rare entity. J Can Res Ther 2015;11:661
| > Introduction|| |
Primary chest wall tumors may be caused by benign or malignant conditions. This report describes a rare case of primary chest wall diffuse large B-cell lymphoma.
| > Case report|| |
A 52-year-old female patient presented with a gradually worsening left lower chest wall pain for 6 weeks. The pain was sharp in character and was non-radiating. The pain worsened with deep breathing and partially improved with over the counter pain medicines. She complained of drenching night sweats for 2 months, but denied any fever, weight loss or change in appetite. She denied any recent trauma to the chest. Past medical history was significant for rheumatoid arthritis, obstructive sleep apnea, depression and insomnia. She denied smoking, alcohol or drug abuse and her Eastern Cooperative Oncology Group performance status was 1.
On physical examination, patients vitals were normal with respiratory rate of 16/min and oxygen saturation of 94% at room air. Chest wall examination was significant for tenderness to palpation in left lower chest wall anteriorly. There was no palpable lymphadenopathy. The rest of the systemic examination was unremarkable.
A computed tomography (CT) scan demonstrated a left-sided chest wall mass measuring 8.1 cm × 7.3 cm × 6.6 cm in the posterior inferior aspect of the left hemithorax enveloping the left-sided ribs [Figure 1]. The mass extended into the chest wall and into the chest cavity. A CT guided biopsy of the chest wall mass revealed sheets of large atypical lymphocytic cells with an irregular nuclei and scant cytoplasm [Figure 2]. Immunohistochemical studies showed CD20+ B-cells with expression of CD10 and negative for expression of BCL6 and MUM 1, consistent with diffuse large B-cell lymphoma, germinal center subtype. The background small lymphocytes were CD3+ T-cells with expression of CD5 and BCL2.
|Figure 2: Sheets of large atypical lymphocytic cells with irregular nuclei and scant cytoplasm|
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Blood tests showed normal blood counts and lactate dehydrogenase of 207 U/L. She was negative for human immunodeficiency virus, hepatitis B surface antigen and core antibody. Bone marrow aspiration and biopsy was negative for involvement by lymphoma. A positron emission tomography-computed tomography (PET-CT) scan showed 8.4 cm x 6.5 cm x 5.0 cm size mass in the left lower chest with some bone destruction. The mass was hypermetabolic with SUV of 20. Multigated acquisition scan showed ejection fraction of 48%.
Patient was diagnosed with stage IE diffuse large B-cell lymphoma of the chest and was treated with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (RCHOP). A PET-CT scan after 2 cycles of chemotherapy showed a complete resolution of the chest wall mass. She completed 6 cycles of chemotherapy and is in complete remission since December 2012.
| > Discussion|| |
A primary chest wall tumor is uncommon. ,, The most common causes of the chest wall lesions are metastasis or an invasion from adjacent malignancies.  A study from Mayo clinic showed that 79% of the chest wall tumors were malignant.  In this study, only one of ninety patients had lymphoma. In a study by Hsu et al., only 7 out of 157 patients presenting with isolated chest wall mass had non-Hodgkin's lymphoma (NHL).  Of the 7 patients with NHL, five had diffuse large B-cell lymphoma. Another study, that evaluated the chest wall involvement by lymphoma showed that only 4 of 250 patients had chest wall involvement as the only site of disease. 
The treatment of diffuse large B-cell lymphoma includes combination chemotherapy with or without radiotherapy. Current national comprehensive cancer network guidelines recommend three cycles of RCHOP and radiotherapy or 6 cycles of RCHOP with or without radiotherapy as the treatment of stage I or II diffuse large B-cell lymphoma.  After a discussion about pro and cons of combination chemotherapy with or without radiotherapy, our patient decided to receive chemotherapy only.
| > Conclusion|| |
Primary chest wall lymphoma is rare. With treatment, it is a curable condition.
| > References|| |
Hsu PK, Hsu HS, Li AF, Wang LS, Huang BS, Huang MH, et al
. Non-Hodgkin′s lymphoma presenting as a large chest wall mass. Ann Thorac Surg 2006;81:1214-8.
Tateishi U, Gladish GW, Kusumoto M, Hasegawa T, Yokoyama R, Tsuchiya R, et al
. Chest wall tumors: Radiologic findings and pathologic correlation: Part 2. Malignant tumors. Radiographics 2003;23:1491-508.
King RM, Pairolero PC, Trastek VF, Piehler JM, Payne WS, Bernatz PE. Primary chest wall tumors: Factors affecting survival. Ann Thorac Surg 1986;41:597-601.
Pairolero PC, Arnold PG. Chest wall tumors. Experience with 100 consecutive patients. J Thorac Cardiovasc Surg 1985;90:367-72.
Press GA, Glazer HS, Wasserman TH, Aronberg DJ, Lee JK, Sagel SS. Thoracic wall involvement by Hodgkin disease and non-Hodgkin lymphoma: CT evaluation. Radiology 1985;157:195-8.
[Figure 1], [Figure 2]