W J C O N R A D I ED E P A R T M E N T O F I M A G I N G S C I E N C E S

U N I V E R S I T Y O F T H E F R E E S T A T ES E P T E M B E R 2 0 1 2

CASE STUDY: LYMPHOMA/ GRANULOMATOUS DISEASE

HISTORY

• 12 April 2012• 36 year old female (black)• Referred to Surgery department from private GP

• RVD + on ART since 13/01/2012 (EFV, TDF, Lamivudine)• PTB on treatment since 19/03/2012

• Presents with:• Right neck mass• Started as small lump 2 months ago• Progressing in size• Painful

CLINICAL EXAM

• Large solid mass • Extending from right earlobe to angle of jaw• Not mobile• No bruit• No fluctuance• Smaller lympnodes right cervical area

• PROBLEM LIST:• Enlarging mass in upper cervical region (?lymphoma)

• Plan: Ultrasound then TRUCUT

INCISIONAL BIOPSY

• 19 April 2012• Wedge incision made into mass in posterior triangle of

neck• Skin closed with sub-cuticular monocryl sutures• No complications• Discharged following day

• Plan:• F/U in 2 weeks for results

• 29 May 2012• CT scan

SPACES INVOLVED

Parotid space• Parotid gland; Lympnodes• CN VII; retro-mandibular vein, ECA

Masticator space• Masseter, Pterygoid and temporalis muscle• CN V3; venous plexus and mandible

Parapharyngeal space• Fat, deep cervical lympnodes and paraganglia• Maxillary art• Lingual/inferior alveolar/auriculo-temporal nerve.

DIFFERENTIAL DIAGNOSISSOLID TUMOR

Paro

tid sp

ace • BMT

• Warthin tumor• Schwannoma

• Lymphoma• Parotid Ca

• Mucoepidermoid• Adenoid cystic M

astic

ator

spac

e• Schwannoma• Neurofibroma

• Sarcoma• Lymphoma• SCC from PMS

Para

phar

ynge

al sp

ace

• Neuroma• Paraganglioma

• Lymphoma• SCC of nodes• Metasteses

• systemic

HISTOLOGY RESULTS

• 23 May 2012• Microscopy• Fibro-fatty tissue; muscle and tumor • Atypical cells

• large hyperchromatic nuclei• Scanty eosinophilic cytoplasm• Prominent nuclear polymorphism

• Tumor infiltrate skeletal muscle

• Immuno-histochemical stains• CK/AE13 and MNF116 - Negative (Carcinomas)• CD3 - Negative (T cell origin)• CD20/10 - Positive (B cell origin)• Ki67 - Positive (80%) (Mitotic activity)

DIAGNOSIS:

LARGE B-CELL LYMPHOMA

OUTCOME

• 31 May 2012• (Parotid tumor?)• No infiltration of bone• Cervical and axillary

lympnodes

• PLAN:• Theatre on 07/08/2012• superficial

parotidectomy • cervical dissection

• Missed theatre date!

• September 2012• Mass still enlarging• Tender• Not mobile

• PLAN:• Repeat CT• Surgery on 16/10/2012

REFERENCES

• Harnsberger. Diagnostic Imaging: Head and neck. First edition; 2006. AMIRSYS. Elsevier Saunders.

• Weissleder. Primer of Diagnostic Imaging. Fifth edition; 2011. Elsevier Mosby.

• Robbins and Cotran. Pathological Basis o Disease. Eight Edition. Saunders Elsevier