Bone Tumors
Lymphoma of Bone

James C. Wittig, MD
Sarcoma Surgeon
Orthopedic Oncologist

Primary lymphoma of bone is defined as lymphoma arising within the medullary cavity of a bone in the absence of lymph node or organ involvement for at least 6 months after diagnosis
Primary lymphoma of bone is rare (3% of primary bone tumors) and most lymphomas that involve bone are metastatic from lymph node. If a lymphoma of bone is diagnosed one must look for another site.
Most primary lymphomas of bone are Non Hodgkin's, large cell lymphomas
In U.S. majority are B-cell proliferations
Must rule out presence of extraskeletal disease
May be misdiagnosed as chronic osteomyelitis

Permeative or moth eaten  lytic lesion Often barely perceptible on X-ray Reactive sclerosis (28%) Metaphysis or metadiaphysis of long bones No Mineralization Soft tissue mass common Femur/tibia/humerus

25% involve flat bones (pelvis, sacrum, ribs) Mixed lysis/sclerosis in 28% Aggressive or nonaggressive PR common     Permeative Lesion

Increased activity on bone scan Increased activity on scintigraphy and normal XR highly suggestive of lymphoma Marrow replacement, cortical destruction and ST mass on CT Sequestra formation in 11-16% Marrow Replacement

Variable SI MR       Intermediate on T1       High on T2 ST mass common (permeation of tumor cells through small vascular channels in the cortical bone without frank cortical breakthrough (also seen with Ewing/PNET) Intrasseous Lesion Soft Tissue Mass

Radiographic Presentation:  Primary Lymphoma of Bone

Cortex Appears Inteact (top)
Soft Tissue Mass (bottom)
T2 Weighted MRI

TI Weighted MRI

T2 Weighted MRI

MRI: Primary Lymphoma of Bone

 

Permeative/Moth eaten lesion Reactive sclerosis (mixed lysis and sclerosis) Slight periosteal reaction

X-ray: Primary Lymphoma of Femur

Permeative Lesion

X-ray: Primary Lymphoma of Distal Humerus

X-ray: Primary Lymphoma of Tibia
Permeative Moth eaten Lesion

Permeative/Motheaten Lesion with Pathologic Fracture

X-ray: Primary Lymphoma of Humerus

Permeative Lesion of Proximal Tibia with Pathological Fracture

X-Ray: Primary Lymphoma of Proximal Tibia

GROSS PATHOLOGY

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Diffuse infiltrative growth pattern with soft tissue extension
Intraosseous component
       Mixture of bone spicules and marrow fat as lesion permeates through the medullary canal and has an indistinct margin
Extraosseous tissue
      Tan or white, resembles lymphomatous lymph nodes
Areas of necrosis, hemorrhage, and cystic degeneration are present

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MICROSCOPIC PATHOLOGY

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Diffuse growth pattern
Mixture of small lymphocytic cells and larger histiocytic components (Large Malignant B Cells in most cases)
Cells and no matrix
Nuclei
      Vary in shape and size
      Grooved vesicular nuclei
      Prominant nucleoli
Cytoplasmic glycogen is absent
Complex reticulin framework
Prominent fibroblastic component
CD5 and Leukocyte Common Antigen Positive
CD3+ and CD45+ for B Cell Lymphoma; CD3+ for Rare T-Cell

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Small Round Blue Cell Tumor Cells without Matrix Crush artifact Cells are different sizes and shapes

Microscopic Pathology: Lymphoma

Microscopic Pathology: Lymphoma

Small round blue cells No matrix Extensive reticulin fibers

Microscopic Pathology: Lymphoma

Mixture of small round blue cells of different sizes and shapes No Matrix production Large B-Cells mixed with reactive inflammatory infiltrate leads to different cell types

Microscopic Pathology: Lymphoma

Reactive Inflammatory Infiltrate of Plasma Cells and Lymphocytes   Large Malignant B-cells

Microscopic Pathology: Lymphoma

Microscopic Pathology: Lymphoma

 
Microscopic Pathology: Lymphoma

 

Microscopic Pathology: Lymphoma

Ewing Sarcoma
Chronic Osteomyelitis
Leukemia