DOI: 10.1148/rg.236025056
Primary Bone Lymphoma: Radiographic–MR Imaging Correlation1
Anant Krishnan, MD,
Ali Shirkhoda, MD,
Jamshid Tehranzadeh, MD,
Ali R. Armin, MD,
Ronald Irwin, MD and
Kimberly Les, MD
1 From the Departments of Diagnostic Radiology (A.K., A.S.), Pathology (A.R.A.), and Orthopedic Oncology (R.I., K.L.), William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073; and Department of Radiological Sciences and Orthopedics, University of California, Irvine (J.T.). Presented as an education exhibit at the 2001 RSNA scientific assembly. Received March 14, 2002; revision requested April 16; revision received February 24, 2003; accepted March 24. Address correspondence to A.K. (e-mail: tadaastu@yahoo.com).
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Figure 1a. Lytic permeative pattern. (a) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) of an intramedullary lesion of primary bone lymphoma reveals diffuse replacement of marrow elements by large atypical lymphocytes with large nuclei and a small amount of eosinophilic cytoplasm. (b, c) Photomicrographs (original magnification, x100; immunoperoxidase stain) show that the atypical cells stain strongly for common leukocyte antigen (b) but negatively for cytokeratin stain (c). Further testing showed that the cells stained positively for B-cell antigen. (For radiologic images, see Fig 2.)
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Figure 1b. Lytic permeative pattern. (a) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) of an intramedullary lesion of primary bone lymphoma reveals diffuse replacement of marrow elements by large atypical lymphocytes with large nuclei and a small amount of eosinophilic cytoplasm. (b, c) Photomicrographs (original magnification, x100; immunoperoxidase stain) show that the atypical cells stain strongly for common leukocyte antigen (b) but negatively for cytokeratin stain (c). Further testing showed that the cells stained positively for B-cell antigen. (For radiologic images, see Fig 2.)
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Figure 1c. Lytic permeative pattern. (a) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) of an intramedullary lesion of primary bone lymphoma reveals diffuse replacement of marrow elements by large atypical lymphocytes with large nuclei and a small amount of eosinophilic cytoplasm. (b, c) Photomicrographs (original magnification, x100; immunoperoxidase stain) show that the atypical cells stain strongly for common leukocyte antigen (b) but negatively for cytokeratin stain (c). Further testing showed that the cells stained positively for B-cell antigen. (For radiologic images, see Fig 2.)
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Figure 2a. Lytic permeative pattern. (a) Lateral radiograph of a 56-year-old woman shows permeative changes within the distal femur. (b) Coronal T2-weighted image (repetition time msec/echo time msec = 3,000/90) shows high signal intensity within the marrow and associated soft-tissue masses (arrows). (c) Sagittal contrast material-enhanced T1-weighted image (600/30) shows areas of enhancement within the intramedullary lesion and a soft-tissue mass off the posterior aspect of the femur (arrow). (d) Lateral view obtained 6 years after irradiation and combination chemotherapy shows sclerotic changes related to therapy.
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Figure 2b. Lytic permeative pattern. (a) Lateral radiograph of a 56-year-old woman shows permeative changes within the distal femur. (b) Coronal T2-weighted image (repetition time msec/echo time msec = 3,000/90) shows high signal intensity within the marrow and associated soft-tissue masses (arrows). (c) Sagittal contrast material-enhanced T1-weighted image (600/30) shows areas of enhancement within the intramedullary lesion and a soft-tissue mass off the posterior aspect of the femur (arrow). (d) Lateral view obtained 6 years after irradiation and combination chemotherapy shows sclerotic changes related to therapy.
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Figure 2c. Lytic permeative pattern. (a) Lateral radiograph of a 56-year-old woman shows permeative changes within the distal femur. (b) Coronal T2-weighted image (repetition time msec/echo time msec = 3,000/90) shows high signal intensity within the marrow and associated soft-tissue masses (arrows). (c) Sagittal contrast material-enhanced T1-weighted image (600/30) shows areas of enhancement within the intramedullary lesion and a soft-tissue mass off the posterior aspect of the femur (arrow). (d) Lateral view obtained 6 years after irradiation and combination chemotherapy shows sclerotic changes related to therapy.
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Figure 2d. Lytic permeative pattern. (a) Lateral radiograph of a 56-year-old woman shows permeative changes within the distal femur. (b) Coronal T2-weighted image (repetition time msec/echo time msec = 3,000/90) shows high signal intensity within the marrow and associated soft-tissue masses (arrows). (c) Sagittal contrast material-enhanced T1-weighted image (600/30) shows areas of enhancement within the intramedullary lesion and a soft-tissue mass off the posterior aspect of the femur (arrow). (d) Lateral view obtained 6 years after irradiation and combination chemotherapy shows sclerotic changes related to therapy.
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Figure 3a. Lytic pattern with well-defined margins. (a) Lateral radiograph of a 77-year-old woman shows a large but fairly well-defined lytic lesion (arrows) of the proximal tibia that appears to extend superiorly into the tibial plateau. (b) Sagittal T2-weighted image (3,030/70) shows that the lesion is confined within the marrow but extends superiorly into the anterior aspect of the proximal tibia (arrowheads). No soft-tissue mass is seen.
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Figure 3b. Lytic pattern with well-defined margins. (a) Lateral radiograph of a 77-year-old woman shows a large but fairly well-defined lytic lesion (arrows) of the proximal tibia that appears to extend superiorly into the tibial plateau. (b) Sagittal T2-weighted image (3,030/70) shows that the lesion is confined within the marrow but extends superiorly into the anterior aspect of the proximal tibia (arrowheads). No soft-tissue mass is seen.
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Figure 4a. Cortical destruction. (a) Plain radiograph of a 24-year-old man with right elbow pain shows a pathologic fracture through the markedly eroded ulna and extensive cortical breakthrough. A soft-tissue mass is also seen. (b, c) Coronal STIR image (4,800/30; flip angle, 180°) (b) and axial contrast-enhanced T1-weighted image (700/12; flip angle, 90°) (c) reveal a large soft-tissue mass and marrow involvement. On c, areas of necrosis are seen within the soft-tissue part of the lesion.
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Figure 4b. Cortical destruction. (a) Plain radiograph of a 24-year-old man with right elbow pain shows a pathologic fracture through the markedly eroded ulna and extensive cortical breakthrough. A soft-tissue mass is also seen. (b, c) Coronal STIR image (4,800/30; flip angle, 180°) (b) and axial contrast-enhanced T1-weighted image (700/12; flip angle, 90°) (c) reveal a large soft-tissue mass and marrow involvement. On c, areas of necrosis are seen within the soft-tissue part of the lesion.
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Figure 4c. Cortical destruction. (a) Plain radiograph of a 24-year-old man with right elbow pain shows a pathologic fracture through the markedly eroded ulna and extensive cortical breakthrough. A soft-tissue mass is also seen. (b, c) Coronal STIR image (4,800/30; flip angle, 180°) (b) and axial contrast-enhanced T1-weighted image (700/12; flip angle, 90°) (c) reveal a large soft-tissue mass and marrow involvement. On c, areas of necrosis are seen within the soft-tissue part of the lesion.
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Figure 5a. Lytic pattern with a sequestrum. (a) Frontal radiograph of an 83-year-old man reveals a mottled appearance of the right medial femoral condyle. (b) Axial CT scan shows destruction of the medial femoral condyle, sequestrum formation (arrow), and cortical erosion with a small soft-tissue mass (arrowheads).
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Figure 5b. Lytic pattern with a sequestrum. (a) Frontal radiograph of an 83-year-old man reveals a mottled appearance of the right medial femoral condyle. (b) Axial CT scan shows destruction of the medial femoral condyle, sequestrum formation (arrow), and cortical erosion with a small soft-tissue mass (arrowheads).
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Figure 6a. Periosteal reaction. (a) Frontal radiograph of a 9-year-old boy shows permeative changes of the distal femoral shaft with a dense periosteal reaction. (b) Lateral view clearly shows the laminated and interrupted periosteal reaction (arrow), a feature of round cell tumors including lymphoma and Ewing sarcoma. (c) Axial T2-weighted image (4,500/80) reveals the circumferential nature of the soft-tissue mass and abnormal marrow. Note disuse atrophy of muscles in the affected side.
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Figure 6b. Periosteal reaction. (a) Frontal radiograph of a 9-year-old boy shows permeative changes of the distal femoral shaft with a dense periosteal reaction. (b) Lateral view clearly shows the laminated and interrupted periosteal reaction (arrow), a feature of round cell tumors including lymphoma and Ewing sarcoma. (c) Axial T2-weighted image (4,500/80) reveals the circumferential nature of the soft-tissue mass and abnormal marrow. Note disuse atrophy of muscles in the affected side.
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Figure 6c. Periosteal reaction. (a) Frontal radiograph of a 9-year-old boy shows permeative changes of the distal femoral shaft with a dense periosteal reaction. (b) Lateral view clearly shows the laminated and interrupted periosteal reaction (arrow), a feature of round cell tumors including lymphoma and Ewing sarcoma. (c) Axial T2-weighted image (4,500/80) reveals the circumferential nature of the soft-tissue mass and abnormal marrow. Note disuse atrophy of muscles in the affected side.
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Figure 7a. Mixed lytic-sclerotic pattern. (a) Frontal radiograph of a 24-year-old woman shows a predominantly sclerotic appearance of the distal femur with a few lytic areas. (b) Coronal STIR image (4,800/30; flip angle, 180°) reveals increased signal intensity primarily involving the medial condyle. Although cortical erosion is seen (arrow), there is no indication of a definite soft-tissue mass. (c, d) Axial T1-weighted images (800/12; flip angle 180°) obtained before (c) and after (d) the administration of contrast material reveal enhancement of the lesion in the medial femoral condyle.
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Figure 7b. Mixed lytic-sclerotic pattern. (a) Frontal radiograph of a 24-year-old woman shows a predominantly sclerotic appearance of the distal femur with a few lytic areas. (b) Coronal STIR image (4,800/30; flip angle, 180°) reveals increased signal intensity primarily involving the medial condyle. Although cortical erosion is seen (arrow), there is no indication of a definite soft-tissue mass. (c, d) Axial T1-weighted images (800/12; flip angle 180°) obtained before (c) and after (d) the administration of contrast material reveal enhancement of the lesion in the medial femoral condyle.
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Figure 7c. Mixed lytic-sclerotic pattern. (a) Frontal radiograph of a 24-year-old woman shows a predominantly sclerotic appearance of the distal femur with a few lytic areas. (b) Coronal STIR image (4,800/30; flip angle, 180°) reveals increased signal intensity primarily involving the medial condyle. Although cortical erosion is seen (arrow), there is no indication of a definite soft-tissue mass. (c, d) Axial T1-weighted images (800/12; flip angle 180°) obtained before (c) and after (d) the administration of contrast material reveal enhancement of the lesion in the medial femoral condyle.
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Figure 7d. Mixed lytic-sclerotic pattern. (a) Frontal radiograph of a 24-year-old woman shows a predominantly sclerotic appearance of the distal femur with a few lytic areas. (b) Coronal STIR image (4,800/30; flip angle, 180°) reveals increased signal intensity primarily involving the medial condyle. Although cortical erosion is seen (arrow), there is no indication of a definite soft-tissue mass. (c, d) Axial T1-weighted images (800/12; flip angle 180°) obtained before (c) and after (d) the administration of contrast material reveal enhancement of the lesion in the medial femoral condyle.
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Figure 8. Mixed lytic-sclerotic pattern. Frontal radiograph of the left shoulder in a 44-year-old man reveals a sclerotic lesion involving the coracoid process and extending into the glenoid. No MR imaging was performed, as biopsy was done with fluoroscopic guidance.
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Figure 9. Mixed lytic-sclerotic pattern. Frontal radiograph of the left shoulder in an 83 year-old-woman reveals an expansile, predominantly lytic lesion of the scapula. The lesion is slightly more extensive than the one seen in Figure 8. No MR imaging was performed.
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Figure 10a. Subtle radiographic findings. (a) Frontal radiograph of the right femur in a 31-year-old woman with a 10-month history of right thigh pain was unremarkable. Because of the patient’s continued pain, whole-body bone scintigraphy was performed to rule out possible metastasis. (b) Anterior and posterior views of the whole-body bone scan reveal increased uptake in the midshaft of the right femur. (c) Coronal T1-weighted image (400/14) reveals two lesions in the marrow of the femoral shaft. No cortical erosion or soft-tissue mass was seen.
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Figure 10b. Subtle radiographic findings. (a) Frontal radiograph of the right femur in a 31-year-old woman with a 10-month history of right thigh pain was unremarkable. Because of the patient’s continued pain, whole-body bone scintigraphy was performed to rule out possible metastasis. (b) Anterior and posterior views of the whole-body bone scan reveal increased uptake in the midshaft of the right femur. (c) Coronal T1-weighted image (400/14) reveals two lesions in the marrow of the femoral shaft. No cortical erosion or soft-tissue mass was seen.
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Figure 10c. Subtle radiographic findings. (a) Frontal radiograph of the right femur in a 31-year-old woman with a 10-month history of right thigh pain was unremarkable. Because of the patient’s continued pain, whole-body bone scintigraphy was performed to rule out possible metastasis. (b) Anterior and posterior views of the whole-body bone scan reveal increased uptake in the midshaft of the right femur. (c) Coronal T1-weighted image (400/14) reveals two lesions in the marrow of the femoral shaft. No cortical erosion or soft-tissue mass was seen.
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Figure 11a. Subtle radiographic findings. (a) Frontal radiograph of the right humerus in a 42-year-old man reveals a subtle permeative appearance of the proximal third of the bone. (b) Anterior view of a whole-body bone scan shows diffuse uptake involving almost the entire proximal half of the right humerus. (c, d) Coronal T1-weighted (488/14) (c) and STIR T2-weighted (3,400/70) (d) images show that the lesion is associated with a small soft-tissue mass, which is best seen on the STIR image (arrows).
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Figure 11b. Subtle radiographic findings. (a) Frontal radiograph of the right humerus in a 42-year-old man reveals a subtle permeative appearance of the proximal third of the bone. (b) Anterior view of a whole-body bone scan shows diffuse uptake involving almost the entire proximal half of the right humerus. (c, d) Coronal T1-weighted (488/14) (c) and STIR T2-weighted (3,400/70) (d) images show that the lesion is associated with a small soft-tissue mass, which is best seen on the STIR image (arrows).
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Figure 11c. Subtle radiographic findings. (a) Frontal radiograph of the right humerus in a 42-year-old man reveals a subtle permeative appearance of the proximal third of the bone. (b) Anterior view of a whole-body bone scan shows diffuse uptake involving almost the entire proximal half of the right humerus. (c, d) Coronal T1-weighted (488/14) (c) and STIR T2-weighted (3,400/70) (d) images show that the lesion is associated with a small soft-tissue mass, which is best seen on the STIR image (arrows).
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Figure 11d. Subtle radiographic findings. (a) Frontal radiograph of the right humerus in a 42-year-old man reveals a subtle permeative appearance of the proximal third of the bone. (b) Anterior view of a whole-body bone scan shows diffuse uptake involving almost the entire proximal half of the right humerus. (c, d) Coronal T1-weighted (488/14) (c) and STIR T2-weighted (3,400/70) (d) images show that the lesion is associated with a small soft-tissue mass, which is best seen on the STIR image (arrows).
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Figure 12a. MR imaging appearance. (a) Coronal T2-weighted fat-suppressed image (4,100/102) of a 21-year-old woman reveals a large lesion in the distal right femur with an associated soft-tissue mass. Plain radiograph (not shown) was reported to have shown a lytic lesion. (b) Sagittal T2-weighted image (4,100/102) reveals the posterior extent of the soft-tissue mass, which provided an ample site for biopsy.
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Figure 12b. MR imaging appearance. (a) Coronal T2-weighted fat-suppressed image (4,100/102) of a 21-year-old woman reveals a large lesion in the distal right femur with an associated soft-tissue mass. Plain radiograph (not shown) was reported to have shown a lytic lesion. (b) Sagittal T2-weighted image (4,100/102) reveals the posterior extent of the soft-tissue mass, which provided an ample site for biopsy.
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Figure 13a. MR imaging appearance. (a) Frontal radiograph of the right knee in a 31-year-old man with a history of knee injuries reveals a mixed lytic and sclerotic lesion in the distal femur. (b) Coronal T1-weighted image (600/15) shows the predominantly intramedullary lesion with minimal cortical erosion. (c) Axial T2-weighted image (2,500/80) also shows the intramedullary component, as well as a small joint effusion. Analysis of the biopsy specimen revealed primary Hodgkin lymphoma of the bone.
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Figure 13b. MR imaging appearance. (a) Frontal radiograph of the right knee in a 31-year-old man with a history of knee injuries reveals a mixed lytic and sclerotic lesion in the distal femur. (b) Coronal T1-weighted image (600/15) shows the predominantly intramedullary lesion with minimal cortical erosion. (c) Axial T2-weighted image (2,500/80) also shows the intramedullary component, as well as a small joint effusion. Analysis of the biopsy specimen revealed primary Hodgkin lymphoma of the bone.
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Figure 13c. MR imaging appearance. (a) Frontal radiograph of the right knee in a 31-year-old man with a history of knee injuries reveals a mixed lytic and sclerotic lesion in the distal femur. (b) Coronal T1-weighted image (600/15) shows the predominantly intramedullary lesion with minimal cortical erosion. (c) Axial T2-weighted image (2,500/80) also shows the intramedullary component, as well as a small joint effusion. Analysis of the biopsy specimen revealed primary Hodgkin lymphoma of the bone.
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Copyright © 2003 by the Radiological Society of North America.
