Cancer Treatment Communications (2013) 1, 11–13

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Non-Hodgkin's lymphoma presenting as anisolated chest wall tumour$

Nikhil Guptaa,n, Niladhar S. Hadkeb, Nita Khuranac

aDepartment of Surgery, University College of Medical Sciences, Delhi, IndiabDepartment of Surgery, Maulana Azad Medical College, Delhi, IndiacDepartment of Pathology, Maulana Azad Medical College, Delhi, India

Received 30 August 2012; received in revised form 3 April 2013; accepted 14 April 2013

KEYWORDSChest wall tumor;Lymphoma;Resection;Chemotherapy

nt matter & 20130.1016/j.ctrc.2013

ccess article distrittribution-NonCommits non-commemedium, provid

thor. Tel.: +91 11: nikhil_ms26@yah(N.S. Hadke), nit

AbstractPrimary chest wall tumors are uncommon. Common soft tissue neoplasms and non-neoplasticchest wall masses include peripheral nerve tumors, lipomas, liposarcomas, lymphoma,haemangiomas, elastofibromas, metastases from distant tumors, desmoids tumors, infectiousmass lesions, and malignant fibrous histiocytoma. Lymphoma comprises 2% of primary chest walltumors. Treatment of these tumors is unclear. We are presenting a case of 65 years old malewho presented to us with primary chest wall lymphoma on right lateral chest wall. Resectionfollowed by adjuvant chemotherapy provided optimal disease control in our case.Key message: Isolated chest wall lymphoma is a rare entity, treatment is also uncertain.Resection followed by adjuvant chemotherapy may be the appropriate management.& 2013 The Authors. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Lymphoma presenting as an isolated chest wall mass is notfrequently seen. Only a few case reports have been found inthe English literature. The treatment for primary chest walllymphoma remains unclear.

The Authors. Published by Elsevi.04.001

buted under the terms of themercial-No Derivative Worksrcial use, distribution, anded the original author and

45526090, +91 9810592084.oo.co.in (N. Gupta),akhurana2@rediffmail.com

2. Case

A 64 years old male presented to surgical out patientsdepartment with a gradually increasing mass lesion on rightlateral chest wall for 3 months. There was about 14�12 cm2 mass lesion on right chest wall about 7 cm lateral tonipple areola with a bleeding ulcer at its apex (Figure 1).Clinically it was fixed to underlying pectoralis major andlatissimus dorsi muscles. Incision biopsy suggested a possibilityof small cell tumor or NHL. CT chest showed a lesion of15� 12 cm2 over right lateral chest wall with loss of fat planeswith the underlying muscles (Figure 2). Mediastinum wasnormal in appearance. CT abdomen, bone scan and bonemarrow examination were normal. Wide excision of tumorwas performed with a 2 cm margin along with involved portionsof muscles (Figure 3). Histopathological examination confirmedthe diagnosis of diffuse large B cell lymphoma (Figure 4). The

er Ltd. All rights reserved.

Figure 1 Ulcerated lesion on right lateral chest wall.

Figure 2 CT thorax showing extent of the lesion.

Figure 3 Tumor bed after resection.

Figure 4 Histology of the tumor showing CD20 expression bytumor cells.

N. Gupta et al.12

lymphoma cell was positive for LCA (leukocyte common anti-gen) and L26 (CD20) and negative for CD3 and CD45 marker inthe immunohistochemical analysis. All the margins were free oftumor. Patient received adjuvant chemotherapy (CHOP regime)in the post-operative period. Patient is disease free after 18months of follow-up.

3. Discussion

Soft tissue tumors of chest wall include peripheral nervetumors, lipomas, liposarcomas, haemangiomas, elastofibro-mas, desmoid tumors, metastases from distant tumors,lymphomas and malignant fibrous histiocytomas [1]. Lym-phoma comprises about 2% of all chest wall tumors [2–5].In most of these cases, it is the extension of mediastinaldisease. There was one study of 324 patients with stages 1–2Hodgkin's lymphoma which identified 22 patients (6.7%) withchest wall invasion [6]. Isolated chest wall lymphoma is arare entity [4,5]. In one study of 157 patients with initialpresentation of chest wall mass, NHL was diagnosed in 7 ofthem. Out of 7, only 4 were having isolated chest wallinvolvement [7]. In the report of Press and colleagues, 4 ofthe 250 patients with lymphoma had the chest wall as theonly site of disease (1.6%) [5].

Role of fine needle aspiration cytology in diagnosis ofprimary chest wall tumor is controversial. Cytologic

specimen is sometimes unsatisfactory and may give rise towrong diagnosis. Some authors suggest that all patients withprimary chest wall tumors should undergo excision biopsyfor small tumors and incision biopsy for large tumors.

Computed tomography (CT) enables more accurateassessment of tumor morphology, composition, location,and extent. When used with contrast material, CT also canprovide an indication of the vascularity of a tumor [7].

Patients with lymphoma are usually treated with che-motherapy and/or irradiation. Hodgson reported outcomeof 324 patients with stages 1–2 Hodgkin's lymphoma treatedwith chemotherapy and local irradiation [6]. However, Ryanet al. reported that 1 patient with primary soft tissuelymphoma of the anterior chest wall remained free ofdisease 49 months after surgical resection [8]. In anothercase report from Lones et al., a 71-year-old man with largecell lymphoma arising from the rib was successfully mana-ged with surgical resection and local irradiation with notumor recurrence [9]. Hsu et al. also performed surgicalexcision in 3 out of 4 patients having isolated chest walllymphoma [7]. Results of these studies and the presence ofbleeding ulcer prompted us to manage our patient withsurgical resection and adjuvant chemotherapy.

In conclusion, primary chest wall lymphoma as an isolatedinvolvement is not common. Biopsy has a definite advantage

13Non-Hodgkin's lymphoma presenting as an isolated chest wall tumour

over FNAC in reaching at a diagnosis. Chemoradiation is themainstay of treatment of such tumors as done by Witteet al. in their series of 4 patients [10]. Surgical resectionfollowed by adjuvant chemotherapy, though suboptimal,may be offered in unusual situations.

Conflict of interest

None of the authors has any conflicts of interest or anyfinancial ties to disclose. Written informed consent wastaken from the patient for publication of this case reportand figures.

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