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

2. History 12 April 2012 Presents with: 36 year old female (black)
Referred to Surgery department from private GP
RVD + on ART since 13/01/ (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

3. 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

4. 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

5. 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.

6. 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

7. 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/ Positive (B cell origin)
Ki Positive (80%) (Mitotic activity)
DIAGNOSIS:
LARGE B-CELL LYMPHOMA

8. 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

9. references
Harnsberger. Diagnostic Imaging: Head and neck. First edition; AMIRSYS. Elsevier Saunders.
Weissleder. Primer of Diagnostic Imaging. Fifth edition; Elsevier Mosby.
Robbins and Cotran. Pathological Basis o Disease. Eight Edition. Saunders Elsevier