A 56-year-old woman presented to the ED with a several months history of pain in her right shoulder. Physical examination revealed a swelling and palpable mass. There was no significant past medical history.
An X-ray, MRI and thoracoabdominal CT were performed. X-ray showed enlargement of the soft tissue overlying the right scapular girdle. While MRI demonstrated osseous and soft tissue involvement. Bone findings consisted of marrow infiltration in the body and spine of scapula and in the acromion with extension to the clavicle through acromioclavicular joint. The marrow disease did not associate cortical destruction, excepting the acromion where discrete cortical permeation was presented. The soft tissue component consisted of multiple masses and diffuse infiltration in rotator cuff and deltoid. These lesions were isointense with muscle on T1, had intermediate signal between muscle and fat on T2, and with homogeneous enhancement after the administration of IV contrast. Through the possibility of malignant tumour, the thoracoabdominal CT was performed, and it showed retro and intraperitoneal masses without other bone and soft tissue lesions. US-guided biopsy in shoulder confirmed the diagnosis of diffuse large B-cell lymphoma (DLBCL)
Lymphoma of the bone accounts for 7% of all bone malignant tumours and 5% of extranodal lymphomas [1] and is more frequent in patients over 30 years. It can be primary bone lymphoma (PBL) or disseminate lymphoma with secondary osseus involvement. The PBL is within a single bone with no evidence of lymphomatous disease elsewhere for at least 6 months after diagnosis [2]. The osseus involvement is usually due to non-Hodgkin and with diffuse large cell (DLBCL), the most common cell type [3].
The clinical presentation includes bone pain, palpable mass, and B-symptoms. While PBL is more common in appendicular skeletal, the secondary bone lymphoma prefers the axial and flat bones such as scapula and ribs. The bone lymphoma may cross to adjacent bone by invading the joint, a specific sign that lymphoma shares with other tumours like metastasis, chordomas and chondrosarcomas, and with the infections [4].
Plain radiographic appearance is variable and non-specific. The permeative lytic pattern is the most common presentation. Sometimes the bone lymphoma shows normal appearance on radiographic and CT, and in these cases, the MRI plays a fundamental role. MRI imaging is more accurate, showing infiltration of the marrow with low signal on T1-weighted imaging and a moderate high signal on T2, except when the lymphoma has a high content of fibrous tissue that shows low signal on T2.
The pattern of large soft tissue masses without extensive cortical destruction is common. This is a specific feature of small round cells tumours such as multiple myeloma, lymphoma, and Ewing sarcoma [5]. This is explained by the spread of tumour cells from the marrow through small vascular channels that cross the cortex into the surrounding soft tissue.
The final diagnosis was DLBCL stage IV. The patient was treated with chemotherapy: R-DA-EPOCH scheme (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin) and get to disappearance of the shoulder masses on physical examination.
In conclusion, the bone lymphoma has non-specific radiological features but recognition of certain characteristics such as (1) the involvement of adjacent bone crossing the joint, (2) the presence of extensive soft tissue mass with minimal cortical destruction and (3) patients with insidious bone pain that persist for months and sometimes with systemic symptoms, help to do the diagnosis.
Although MRI findings may suggest the diagnosis of bone lymphoma, the biopsy is mandatory. MRI, and particularly Gd-enhanced sequences, can determine the response to therapy, with a direct impact on individual care.
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Non Hodgkin lymphoma
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Based on the provided right shoulder X-ray and MRI images, the proximal humerus (shoulder joint region) shows lytic changes in the bone, with mild cortical disruption or thinning. A soft tissue mass is also visible. On the T1-weighted MRI sequence, the lesion appears relatively hypointense, while on the T2-weighted sequence, the signal is relatively high, indicating infiltration in the bone marrow. Surrounding this area, a large extent of soft tissue swelling or mass is observed. These imaging features suggest that the lesion may cross the joint surface and connect to adjacent bones, resulting in continuous involvement across multiple adjacent structures.
In addition, based on the abdominal CT images, there are enlarged lymph nodes or masses in the abdominal and retroperitoneal regions, suggesting the possibility of systemic disease involvement. Overall, the imaging indicates tumor-like changes in the bone with soft tissue extension, accompanied by multiple lymph node abnormalities.
Considering the 56-year-old female patient with several months of persistent right shoulder pain and a palpable mass, imaging reveals lytic bone destruction, a lesion that crosses the joint, and significant bone marrow infiltration on MRI along with a large soft tissue mass. Meanwhile, abdominal CT indicates multiple enlarged lymph nodes or tissue infiltration. After biopsy and pathological examination, the diagnosis of Diffuse Large B-Cell Lymphoma (DLBCL) in stage IV was confirmed. Thus, the most likely final diagnosis is Bone Lymphoma (DLBCL, involving multiple sites).
For bone lymphoma, the standard first-line therapy is systemic chemotherapy combined with immunotherapy, such as the R-DA-EPOCH regimen (comprising rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin). For patients with severely compromised bone stability or high risk of pathological fracture, local radiotherapy or procedures like bone cement augmentation may be considered. Where there is a large soft tissue mass and potential local complications, surgical intervention may be suggested after a multidisciplinary team (MDT) evaluation.
During and after chemotherapy, patients often experience reduced physical fitness due to both the disease and its treatment, necessitating an individualized rehabilitation plan. The focus is on maintaining appropriate activity levels, improving musculoskeletal endurance, and ensuring safety. Below is an example following the FITT-VP principle (Frequency, Intensity, Time, Type, Progression, Individualization & Monitoring):
This report is a reference-based medical analysis drawn from the provided materials and does not substitute for an in-person consultation or professional medical opinion. Specific diagnoses and treatment decisions should be made by the attending physician, taking into account the patient’s comprehensive clinical status.
Non Hodgkin lymphoma
