Romanian Neurosurgery (Jun 2016)
Diagnostic challenge in a patient with primary bilateral Dumbbell-shaped lumbar non-Hodgkin’s lymphoma
Abstract
Objective: Primary bilateral dumbbell-shaped lumbar non-Hodgkin lymphomas with epidural and extraspinal involvement, are rare occurrences. Patients presenting at advanced stages and rapid evolution towards neurological impairment lead to diagnostic dilemmas for which only immunohistochemistry can provide a correct, although delayed solution. Case report: We report the first case of a bilateral, dumbbell-shaped, lumbar lymphoma in a 65-year-old man with a medical history of chronic viral hepatitis type B and D under interferon treatment. The patient presented with back pain radiating down the right leg, with rapid progression to paraplegia and sphincter dysfunction. CT and MRI revealed a large dumbbell mass (approx. 5/5/10 cm) in the right paraspinal musculature, at the L4-L5 level, with intraspinal epidural extension. A similar mass of smaller size was described on the left side, almost mirroring the first lesion, the imagistic aspect suggesting a neural sheath tumor. Intraoperatively, in the right lumbar paraspinal musculature, a soft, yellowish region was discovered, the macroscopic appearance being rather suggestive for a diffuse infection. Clinical, imagistic and surgical findings were not conclusive, nor was the histological examination in light microscopy of the surgical specimen or of the bone marrow biopsy. Immunohistochemistry identified the presence of large B cells, leading to the diagnosis of B cell lymphoma. Although the patient was treated with systemic chemotherapy, his condition rapidly deteriorated and he died within 3 months. Conclusions: In the case of a lumbosacral, dumbbell shaped mass, developed both epidural and extraspinal, the differential diagnosis must include lymphoma. The histological examination, especially immunohistochemistry provided the final diagnosis. Delays in establishing a diagnosis, associated with a malignant evolution of lymphoma, diminish the chances of determining and applying a treatment strategy that could prolong survival.
