Multifocal skeletal involvement in primary non-Hodgkin’s Lymphoma (NHL) is very rare as compared to the focal one. Thesefindings of multifocal nature are more common in children than in adults. We present 52 years old male patient who presentedwith slow growing multiple tender swellings on the left side of mandible and on the medial end of right first rib. We presentthe clinico-radiological aspects of the disease which lead to suspicion of the NHL and later proved to be primary non-Hodgkin’s Lymphoma on fine needle aspiration cytology

A, Bhardwaj

BB, Sharma

S, Jilowa

S, Sharma

SS, Atwal

English

Atharva Scientific Publications (E-Jounals)

Jilowa et al                                           Primary Multifocal Osseous NHL 
Vol 1 / Issue 1 / Jan-Mar 2015                                                                                         Indian J Case Reports / 28   
Case Report 
Clinico-radiological correlation of Primary Multifocal Osseous NHL  
Jilowa S
1
, Sharma S
2
, Sharma S
3
 Atwal SS
1
,
 
Bhardwaj A
1
, Sharma BB
1
 
From 1Department of Radio diagnosis and 2 Department of ENT and Head & Neck Surgery, Post Graduate Institute of 
Medical Education and Research & Dr. Ram Manohar Lohia hospital, New Delhi, India and 3Department  Anaesthesia, SGT 
Medical, Gurgaon, Haryana, India. 
Correspondence to:  Dr Sarita Jilowa, Associate Professor, Department of Radio-diagnosis, PGIMER & Dr RML Hospital, 
New Delhi, Email: saritajilowa@gmail.com. 
Received: 08 December 2015     Initial Review: 02 January 2015      Accepted: 13 March 2015     Published  online: 23 March 2015 
ABSTRACT 
Multifocal skeletal involvement in primary non-Hodgkin’s Lymphoma (NHL) is very rare as compared to the focal one. These 
findings of multifocal nature are more common in children than in adults. We present 52 years old male patient who presented 
with slow growing multiple tender swellings on the left side of mandible and on the medial end of right first rib. We present 
the clinico-radiological aspects of the disease which lead to suspicion of the NHL and later proved to be primary non-
Hodgkin’s Lymphoma on fine needle aspiration cytology. 
Key words: FNAC, Multifocal, Non-Hodgkin’s Lymphoma, Osseous 
rimary bone lymphoma is often challenging for the 
radiologists to diagnose and for the physicians to 
manage it. Though, the secondary bone marrow 
involvement in non-Hodgkin’s lymphoma (NHL) is 
quite common but the primary osseous manifestation is 
very rare. This can manifest as monostotic or polyostotic 
in its presentation. The commonest sites of involvement 
are long bones followed by vertebral column and pelvis. 
The femur is the most common long bone to be involved.  
In normal healthy bone marrow, stem cells give origin 
to all three cell lines i.e. red blood cells, white blood cells 
and platelets. However in bone lymphomas, accumulation 
of lymphoma cells in bone marrow leads to suppression of 
other two cell lines which manifests as anemia and 
thrombocytopenia. In addition to these changes, they can 
also present with nodal, visceral or bony manifestations. 
These can exclusively be the bony swellings at various 
places which may be the presenting feature as it was in our 
case. 
 
CASE REPORT 
A 52 years old male presented with painful swellings at 
left side of the face and right upper chest region. These 
have increased in size slowly over the past two years. 
There is dull type of pain at the sites of the swellings. The 
patient reported to the dental department for the loose 
tooth and from there he was referred to ENT department. 
Swelling was not associated with fever, cough, or any 
bleeding manifestations. There was no history of blood 
transfusion, trauma or contact with tuberculosis.  
On examination, patient was afebrile, conscious and 
well oriented with normal vital parameters. He was pale 
without any rash, bone tenderness or significant 
lymphadenopathy. There was a firm and slightly tender 
swelling over angle of the mandible on left side (18×12 
mm) and on the medial end of right first rib (15×10 mm). 
Abdominal examination revealed no organomegaly. Rest 
of the systemic examination was also normal.  
P 
Jilowa et al                                           Primary Multifocal Osseous NHL 
Vol 1 / Issue 1 / Jan-Mar 2015                                                                                         Indian J Case Reports / 29   
On laboratory workup, patient was anemic with 
hemoglobin level of 10 g/dL with raised ESR, leukocytosis 
and normal platelets. His sputum for AFB was negative. 
LDH level was 285 U/l and ALP level was 145 U/l. Plain 
radiograph has shown some lytic lesion with soft tissue 
swelling at the ramus of left side of the mandible with loss 
of fat planes. The patient was advised Computerized 
Tomography (CT) scan. 
Contrast enhanced CT scan showed lytic destructive 
lesion with surrounding soft tissue component at the angle 
of mandible on left side. There was mild enhancement of 
the soft tissue (Figure 1a and 1b). The bone window has 
also shown the destructive lesion with corresponding loose 
teeth (Figure 1c). CECT at the level of right first rib has 
shown similar lesion with the adjoining soft tissue 
component (Figure 2a and 2b).  
The Fine Needle Aspiration Cytology (FNAC) 
confirmed the diagnosis as non-Hodgkin’s Lymphoma. 
The patient has been advised the combination of 
radiotherapy and chemotherapy with subsequent follow 
up. 
 
     
                         
Figure 1: Contrast enhanced CT scan axial section of mandibular region. Figure 1a and 1b - soft tissue swelling in soft 
tissue window shows the underlying pathology of heterogeneous density with mild enhancement on left side (white 
arrows). Figure 1c - Bone window shows lytic destructive lesion (white arrows) and loosening of corresponding teeth 
(black arrow). 
    
 
Figure 2:  Contrast enhanced CT scan axial section at the level of right first rib adjoining sterno-clavicular joint. Figure 
2a - Mediastinal window shows destruction of the anterior end of the first rib of the right side (white arrow) with the 
soft tissue involvement. Figure 2b - Bone window of the same region showing lytic lesion with destruction (white 
arrows). 
Figure 2a 
Figure 1a Figure 1b Figure 1c 
Figure 2b 
Jilowa et al                                           Primary Multifocal Osseous NHL 
Vol 1 / Issue 1 / Jan-Mar 2015                                                                                         Indian J Case Reports / 30   
DISCUSSION 
Most of the primary bone lymphomas are non-Hodgkin 
Lymphomas (NHL) which further comes in subtype of 
Diffuse Large B-cell lymphomas (DLBCL). Primary 
lymphomas of bone (PLB) constitute 3% of all malignant 
bone tumors and predominantly seen in male in 4
th
 and 5
th 
decade [1]. Though, the exact etiology is not known but 
the underlying viral infection is considered to be the most 
common factor. These can have different types of 
progression and grading and response to treatment can 
vary accordingly.  
Malignant lymphomas constitute 10% of the 
malignancies in pediatric age group where skeletal 
involvement is uncommon. Ivins and Dahlin introduced 
the term primary bone lymphoma first in 1963. The 
osseous involvement varies from 6.8% to 13.6% in 
different series. Multifocal osseous involvement is seen 
more commonly in children (47 – 64 %) than in adults [2]. 
The adjacent soft tissue swellings is seen with most 
(37.5%) of these lesions [3,4]. WHO has categorized 
lymphomas in the following four groups on the basis of 
osseous involvement– 1) Single primary bone site without 
regional nodes 2) Multiple bone sites without any visceral 
involvement 3) Bone sites with multiple visceral or nodes 
involvement and 4) Soft tissue lymphoma with proved 
bone involvement [5]. Our case falls in group two as there 
was no visceral involvement.  
Plain radiography and cross sectional imaging alone 
cannot diagnose the entity and the aspiration cytology is 
required. CT scan reveals features of lytic lesion (74%) 
with soft tissue mass (80-100 %) in majority of the cases 
[6]. These can resemble with other types of similar entities 
like osteomyelitis and malignant Hodgkin’s lymphoma 
because there is no internal production of the matrix. The 
confirmation by histopathological examination is essential 
for its differentiation. The management of non-Hodgkin’s 
bone lymphoma varies from case to case but the 
combination of radiotherapy and chemotherapy is required 
in most of the cases. The treatment poses the problem as 
the etiology of these tumors is not definite. 
 
 
 
CONCLUSION 
Multifocal skeletal involvement by NHL in adults is rare 
and can be misdiagnosed as other inflammatory or 
malignant conditions. Radiological examination by CT 
scan and histopathological examination play an important 
role in evaluation of these cases. 
REFERENCES 
1. Power DG, McVey GP, Korpanty G, Treacy A, Dervan P, 
O’keane C, et al. Primary bone lymphoma single 
institution case series. Ir J Med Sci. 2008;177(3):247-51.  
2. Iotzbecker MP, Kersun LS, Choi JK, Wills BP, Schaffer 
AA, Dormans JP. Primary non-Hodgkin’s lymphoma of 
bone in children. J Bone Joint Surg Am. 2006;88:583-94. 
3. Zinzani PL, Carrillo G, Ascani S, Barbieri E, Tani M, 
Paulli M, et al. Primary bone lymphoma: experience with 
52 patients. Haematologica. 2003;88:280-5. 
4. Beal K, Allen L, Yahalom J. Primary bone lymphoma: 
treatment results and prognostic factors with long-term 
follow-up of 82 patients. Cancer. 2006;106:2652-6. 
5. Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, 
Stein H, et al, eds. WHO Classification of Tumours of 
Haematopoietic and Lymphoid Tissues. 4
th
 ed. Geneva, 
Switzerland: IARC Press; 2008. 
6. Stein ME, Kuten A, Gez E, Rosenblatt KE, Drumea K, 
Ben-Shachar M, et al. Primary lymphoma of bone - a 
retrospective study; Experience at the Northern Israel 
Oncology Centre (1979-2000). Oncology. 
2003;64(4):322-7. 
 
 
___________________________________________ 
How to cite this article: Jilowa S, Sharma S, Sharma S, 
Atwal SS,
 
Bhardwaj A, Sharma BB. Clinico-radiological 
correlation of Primary Multifocal Osseous NHL. Indian J 
Case Reports. 2015;1(1):28-30. 
Conflict of interest: None stated, Funding: Nil 


Clinico-radiological correlation of Primary Multifocal Osseous NHL

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Clinico-radiological correlation of Primary Multifocal Osseous NHL

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