Case study: lymphoma/ granulomatous disease

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Presentation transcript:

Case study: lymphoma/ granulomatous disease WJ CONRADIE Department of imaging sciences University of the free State September 2012

History 12 April 2012 Presents with: 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 Plan: 29 May 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 Masticator space Parapharyngeal 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 diagnosis solid tumor Parotid space BMT Warthin tumor Schwannoma Lymphoma Parotid Ca Mucoepidermoid Adenoid cystic Masticator space Neurofibroma Sarcoma SCC from PMS Parapharyngeal space Neuroma Paraganglioma SCC of nodes Metasteses systemic

Histology Results 23 May 2012 Microscopy Immuno-histochemical stains 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 PLAN: Missed theatre date! September 2012 PLAN: (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