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Year : 2017  |  Volume : 13  |  Issue : 3  |  Page : 589-592

Radiation treatment for chemotherapy-resistant non-Hodgkin's lymphoma in the left thigh

1 Department of Radiation Oncology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
2 Department of Medical Oncology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India

Date of Web Publication31-Aug-2017

Correspondence Address:
Karthikeyan Perumal
Department of Radiation Oncology, Apollo Specialty Hospital, 320 Padma Complex, Teynampet, Chennai - 600 035, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.174531

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 > Abstract 

Extranodal non-Hodgkin lymphomas (NHLs) arising in soft tissue is rare. This study describes a rare case of chemo-resistant large B-cell NHL of skeletal muscle, characterized by voluminous swelling in the thigh which responded well to radiotherapy. In this patient, recurrent NHL showed refractoriness to various chemotherapy regimens and was treated with radiation therapy repeatedly with excellent local response and no evidence of disease for 18 months. Most of the published literature describes surgery or chemotherapy as treatment for NHL soft tissue. This is the first case report describing the durable response with radiation without in-field recurrence in chemo-resistant large B-cell NHL skeletal muscle.

Keywords: Extranodal non-Hodgkin's lymphoma, radiotherapy, skeletal muscle lymphoma

How to cite this article:
Balasundaram S, Ramadas R, Stumpf J, Thirumalairaj R, Perumal K. Radiation treatment for chemotherapy-resistant non-Hodgkin's lymphoma in the left thigh. J Can Res Ther 2017;13:589-92

How to cite this URL:
Balasundaram S, Ramadas R, Stumpf J, Thirumalairaj R, Perumal K. Radiation treatment for chemotherapy-resistant non-Hodgkin's lymphoma in the left thigh. J Can Res Ther [serial online] 2017 [cited 2020 May 27];13:589-92. Available from: http://www.cancerjournal.net/text.asp?2017/13/3/589/174531

 > Introduction Top

Nearly 25% of non-Hodgkin lymphomas (NHLs) arise in extranodal locations[1] and rare in soft tissue.[2] This paper is, describes with literature review as a basis, a rare case of chemo-resistant large B-cell NHL recurrent in skeletal muscle, which responded well to radiotherapy (RT).

 > Case Report Top

A 62-year-old gentleman presented with swelling in the left thigh 2.5 years ago with a significant past history of left axillary region swelling a year before, diagnosed as NHL and treated with RT at that time in a different country. It was not clear if it was a nodal disease, and why chemotherapy was not given.

Computed tomography (CT) of thigh showed well-defined soft-tissue density 6.5 cm × 9.7 cm in the posterior aspect. Biopsy showed NHL large B-cell type. He was treated with sequential six cycles of chemotherapy – R-CHOP regimen followed by RT (40 Gy in 20 fractions) at his hometown.

Follow-up positron emission tomography (PET)-CT at 6 months showed multiple masses in the left thigh [Figure 1] suggestive of disease with left popliteal lymph node involvement.
Figure 1: Left lower thigh non-Hodgkin lymphomas involvement

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Ultrasonogram showed left popliteal lymph node involvement. Biopsy from deep submuscular nodule revealed diffuse large B-cell lymphoma, CD20 positive. Bone marrow study was normal.

Salvage chemotherapy with rituximab and bendamustine regimen was started and changed to R-ESHAP regimen (Ristova, Etoposide, Solumedrol, Cisplatin, and Cytosar) after one cycle due to progression [Figure 2].
Figure 2: Left lower thigh non-Hodgkin lymphomas radiation fields

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Second RT was given after 3rd cycle of salvage chemotherapy to a total dose of 39.6 Gy in 22# to left leg lesion by three-dimensional conformal RT technique [Figure 2] followed by chemotherapy. The dose was kept moderate and the volume low because data from the previous RT were not traceable.

Follow-up PET-CT after 2 months of radiation [Figure 3]a and [Figure 3]b showed good response of the treated lesion and interval new soft-tissue deposit in the medial and posterior compartment of the left thigh just above the knee joint and left rectus abdominis muscle.
Figure 3: (a) Positron emission tomography-computed tomography before radiation; (b) positron emission tomography-computed tomography on postradiation follow-up showing new lesion just above knee joint and resolution of previous lesion (marked by arrow)

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The lesions in left upper thigh (medial compartment) were treated with 50 Gy and that above the left knee joint by 45 Gy in 25 fractions by intensity-modulated RT technique. The patient was relapse free in 18 months of follow-up.

 > Discussion Top

This is the first case description on NHL skeletal muscle involvement not responding to chemotherapy, but with good loco-regional control treated with radiation. Selected case reports and series published on NHL skeletal muscle are listed in [Table 1].
Table 1: Case reports and series on NHL skeletal muscle

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Lymphomas of muscle have been reported in only 1.4% of cases, with 0.3% in Hodgkin disease and 1.1% in NHL[2] and primary muscle lymphoma being 0.11%.[11],[12],[13],[14],[15] The management of varies with literature.

In contrast to Panicek et al.,[8] CT scan of our patient showed hyperdense lesion creating ambiguity with sarcoma. In concurrence with Chong et al., magnetic resonance imaging showed multiple nodular lesions in the soft tissues of left thigh showing T2 hyperintense signal with one mass showing intermediate to hypointense signal. In PET-CT scans, the NHL masses showed intense fluorodeoxyglucose uptake and were seen as heterogeneously enhancing focal lesions.

De Giorgi et al. hypothesized wide-margin surgery constitute a therapeutic aid.[4] Guastafierro et al. reported primary large B-cell NHL masseter muscle (stage IEA) relapse-free interval (RFS) of 72 months on treatment with rituximab-cyclophosphamide, epirubicin, vincristine, and prednisone regimen.[1]

Belaabidia et al. reported NHL right biceps femoris in a 70-year-old woman treated with wide resection and chemotherapy with RFS of 10 months.[2]

 > Conclusion Top

NHL of skeletal muscle is rare. There is dearth of the published data on primary and secondary NHL of skeletal muscle; most of them describe diagnostic methodology, surgery, or chemotherapy. This report describes success of radiation in chemo-resistant large B-cell NHL skeletal muscle.

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Conflicts of interest

There are no conflicts of interest.

 > References Top

Guastafierro S, Falcone U, Petriccione L, Rossiello L, Cappabianca S, Rossiello R, et al. An unusual cause of facial swelling: Primary extranodal non-Hodgkin lymphoma of the masseter muscle. Am J Med Sci 2011;341:160-2.  Back to cited text no. 1
Belaabidia B, Sellami S, Hamdaoui R, Essadki B. Primary malignant non-Hodgkin skeletal muscle lymphoma: A case report. Rev Chir Orthop Reparatrice Appar Mot 2002;88:518-21.  Back to cited text no. 2
Imai T, Michizawa M, Degami H. NK cell lymphoblastic lymphoma in the masticator space: A case of non-Hodgkin lymphoma with challenging maxillofacial manifestation and immunophenotype. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:897-903.  Back to cited text no. 3
De Giorgi S, Piazzolla A, De Giorgi G, Cimmino A, Parisi G, Ricco R. Non-Hodgkin's lymphoma in the gluteal region: A case report. Chir Organi Mov 2004;89:329-38.  Back to cited text no. 4
Connor SE, Chavda SV, West R. Recurrence of non-Hodgkin's lymphoma isolated to the right masticator and left psoas muscles. Eur Radiol 2000;10:841-3.  Back to cited text no. 5
Surov A, Behrmann C, Holzhausen HJ, Kösling S. Lymphomas and metastases of the extra-ocular musculature. Neuroradiology 2011;53:909-16.  Back to cited text no. 6
Chong J, Som PM, Silvers AR, Dalton JF. Extranodal non-Hodgkin lymphoma involving the muscles of mastication. AJNR Am J Neuroradiol 1998;19:1849-51.  Back to cited text no. 7
Panicek DM, Lautin JL, Schwartz LH, Castellino RA. Non-Hodgkin lymphoma in skeletal muscle manifesting as homogeneous masses with CT attenuation similar to muscle. Skeletal Radiol 1997;26:633-5.  Back to cited text no. 8
Gaiser T, Geissinger E, Schattenberg T, Scharf HP, Dürken M, Dinter D, et al. Case report: A unique pediatric case of a primary CD8 expressing ALK-1 positive anaplastic large cell lymphoma of skeletal muscle. Diagn Pathol 2012;7:38.  Back to cited text no. 9
Benson-Mitchell R, Warwick-Brown N, Chappell ME. Non-Hodgkin's lymphoma presenting as an isolated temporal soft tissue swelling. J Laryngol Otol 1996;110:161-2.  Back to cited text no. 10
Komatsuda M, Nagao T, Arimori S. An autopsy case of malignant lymphoma associated with remarkable infiltration in skeletal muscles (author's transl). Rinsho Ketsueki 1981;22:891-5.  Back to cited text no. 11
Travis WD, Banks PM, Reiman HM. Primary extranodal soft tissue lymphoma of the extremities. Am J Surg Pathol 1987;11:359-66.  Back to cited text no. 12
Beggs I. Primary muscle lymphoma. Clin Radiol 1997;52:203-12.  Back to cited text no. 13
Eustace S, Winalski CS, McGowen A, Lan H, Dorfman D. Skeletal muscle lymphoma: Observations at MR imaging. Skeletal Radiol 1996;25:425-30.  Back to cited text no. 14
Lee VS, Martinez S, Coleman RE. Primary muscle lymphoma: Clinical and imaging findings. Radiology 1997;203:237-44.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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