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Follicular lymphoma presenting as scalp mass deformity: Case Report and Review of the literature

Divine Nwafor

Department of Neurosurgery, School of Medicine, West Virginia University, Morgantown, WV, USA

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Walid Radwan

Department of Neurosurgery, School of Medicine, West Virginia University, Morgantown, WV, USA

Brandon Lucke-Wold

Department of Neurosurgery, School of Medicine, West Virginia University, Morgantown, WV, USA

William Underwood

Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA

Kymberly Gyure

Department of Pathology, School of Medicine, West Virginia University, Morgantown, WV, USA

Robert Marsh

Department of Neurosurgery, School of Medicine, West Virginia University, Morgantown, WV, USA

DOI: 10.15761/BRCP.1000155

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Abstract

Lymphoma presenting as a scalp mass is a rare but serious medical condition mandating aggressive treatment and neurosurgical intervention. We report a case of 53-year-old male who presented with a large right sided frontal scalp mass and a smaller mass located on the left frontal scalp. After discussion with the patient, it was decided to resect the larger mass for definitive diagnosis. After subtotal resection of the mass, biopsy revealed WHO grade 1 follicular lymphoma (FL), diffuse pattern stage IV. The patient was subsequently treated with 4 grays (Gy) of palliative radiotherapy over 2 fractions to the right frontal scalp and systemic chemo-immunotherapy (6 cycles) followed by rituximab maintenance. Lumbar puncture to obtain cerebrospinal fluid was done a month after therapy began and the results were negative for spread of malignant cells. Approximately 3 months after initiation of therapy, PET/CT showed no evidence of active malignancy and MRI revealed a complete internal resolution of the enlarged right frontal scalp mass. We use this case to provide a detailed discussion regarding disease pathophysiology, early diagnosis, and management

Key words

scalp mass, follicular lymphoma, radiotherapy, chemo-immunotherapy

Introduction

Non-Hodgkin’s lymphoma (NHL) is a broad class of malignant neoplasms originating from B-cell progenitors, T-cell progenitors, mature B-cells, mature T-cells, and in rare cases natural killer cells (NK-cells) [1]. The second most common type of NHL is follicular lymphoma (FL). FL has been described as a heterogeneous malignancy that includes tumors often derived from germinal center B-cells, centrocytes, and occasionally centroblasts [2]. There are 3.18 cases of FL per 100,000 people seen in the United States with a greater predilection (2X) in Caucasian than African-American or Asian populations [3]. Patients diagnosed with this malignancy are often asymptomatic and do not present with the B symptoms of fever, weight loss, and night sweats. Because of its indolent nature, the disease (FL) may have already disseminated to other regions at the time of diagnosis [4]. We discuss a patient with a rare disseminated scalp follicular lymphoma and look at the histopathology associated with this patient’s disease. Furthermore, we use the case to illustrate the importance of early detection and appropriate clinical management.

Editorial Information

Editor-in-Chief

Kazuhisa Nishizawa
Teikyo University

Article Type

Case Report

Publication history

Received date: February 12, 2018
Accepted date: February 21, 2018
Published date: February 24, 2018

Copyright

© 2018 Nwafor D, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Nwafor D, Radwan W, Lucke-Wold B, Underwood W, Gyure K, et al. (2018) Follicular Lymphoma Presenting as Scalp Mass Deformity: Case Report and Review of the Literature. Biomed Res Clin Prac 3: DOI: 10.15761/BRCP.1000155

Corresponding author

Brandon Lucke-Wold

Department of Neurosurgery, School of Medicine, West Virginia University, Morgantown, WV 26505, USA

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Figure 1. CT head showing enlarged right frontal scalp mass. A: axial view non-contrast, B: axial view with contrast, C: Coronal view with contrast.

Figure 2. MRI showing scalp mass, vasogenic edema, and midline shift. A: Axial view T1 no contrast, B: Axial view T1 with contrast.

Figure 3. Nuclear medicine bone scan with 99mTc-hydroxymethylene diphosphonate (HMDP) and SPECT showed multiple areas of uptake concerning for malignancy. Uptake shown in right posterior iliac bone.

Figure 4. Histopathologic staining showing monotonous infiltrate composed of small cells with irregular nuclei, condensed chromatin, and inconspicuous nucleoli.

Figure 5. Immunohistochemistry showing cells that are CD20 positive and co-express CD10 and Bcl2.