This 70-year-old patient presented with generalized muscle weakness, weight loss, decreased appetite, mild hypercalcemia, and a 2-month history of progressive right elbow swelling. The patient’s past medical history was significant for gout. Laboratory studies showed elevated ESR (80s-90s). The patient was treated with steroids prior to muscle biopsy and reported significant improvement. Muscle biopsy was performed to evaluate for myopathy.
What is your diagnosis based on Figures #1 through #4?
B. Pyogenic myositis
D. B-cell lymphoma
Answer: B-cell lymphoma
The morphologic and immunophenotypic features are consistent with the presence of a “B-cell lymphoma”; specifically Diffuse Large B-cell Lymphoma (DLBCL). Further studies are needed to provide additional prognostic and predictive information, and guide treatment; including immunostains (i.e. Hans algorithm: CD10, BCL6, and MUM1 to determine cell of origin (GCB/germinal center B-cell-like versus ABC/activated B-cell-like subtypes), and Fluorescence In-Situ Hybridiation (FISH) to evaluate for cytogenetic rearrangements involving MYC [IGH-MYC t(8;14)], BCL2 [IGH-BCL2 t(14;18)(q32;q21)], and BCL6 [3q27 gene rearrangement].
More recently DLBCL subtypes are being further investigated using gene expression profiling, next-generation sequencing, and copy number variation type assays.
The lymphoid cells are atypical – rather than mature appearing as would be expected in polymyositis, and are present as a dense infiltrate of B-cells which nearly replaces the skeletal muscle tissue. No neutrophils are seen to suggest that this represents pyogenic/bacterial myositis. Granulomata characteristic of sarcoidosis are not present.
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Jeffery GM, Golding PF, Mead GM. Non-Hodgkin’s lymphoma arising in skeletal muscle. Ann Oncol. 1991 Jul;2(7):501-4. doi: 10.1093/oxfordjournals.annonc.a058002. PMID: 1911457.
Binici DNR, Karaman A, Timur O, Tasar PNT, Sanibas AV. Primary skeletal muscle lymphoma: A case report. Mol Clin Oncol. 2018 Jan;8(1):80-82. doi: 10.3892/mco.2017.1483. Epub 2017 Nov 3. PMID: 29387400; PMCID: PMC5768100.
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