A great mimicker in thoracic spine: Spinal lymphoma
Diffuse large B-cell lymphoma (DLBCL) is one of the most common causes of non-Hodgkin’s lymphoma (NHL). Some of these DLBCLs can have genetic mutations as well as protein overexpression. The genes involved are MYC, BCL-2 and BCL-6. Protein overexpression can be seen on immunohistochemistry (IHC) and genetic mutations in the florescent in situ hybridization (FISH) analysis.

DLBCL with just two protein overexpressions are classified as double expressor lymphomas (DELs), while the ones with two chromosomal mutations are called double hit lymphomas. If all three genes are involved, it will be triple expressor/triple hit lymphoma respectively.

Published in the Journal of Hematology, the authors present a case of a 39-year-old male with a history HIV and multiple psychiatric issues who initially presented to the ER after falling while cycling, landing on his back and complaining of pain in the lower back. A bony injury was ruled out with spinal X-ray and patient was ambulating with no neurological symptoms; therefore, he was discharged to home.

The patient presented to the ER again after 2 weeks, reporting that the back pain had persisted, and he had developed tingling, numbness and weakness in his lower extremities, requiring him to use a cane for ambulation. Also reported difficulty urinating that started the night before. Patient’s physical exam was inconsistent, with being able to move his lower extremities without a problem at times, and at others, barely moving his legs, mostly complaining of pain.

A stat MRI of the spine was done. Lumbar MRI was unremarkable, but thoracic MRI revealed a large right posterior epidural mass extending from T3 to T7, 10.9 cm craniocaudally by 1.6 cm transverse by 1.6 cm anteroposteriorly, causing severe compression of the spinal cord, displacing it to the left anteriorly.

The mass was extending to the right T4-T8 neural foramina. It was isointense on T1- and T2-weighted imaging. Considering the patient’s history of recent trauma, the mass was read as an epidural hematoma by the radiologist. Neurosurgery was consulted, and they decided to take the patient to the operating room for evacuation of the presumed hematoma.

When the epidural space was opened, no hematoma was visualized. Instead, a soft tissue epidural mass was seen, which was removed in a piecemeal fashion, and specimen was sent for histopathology. Postoperatively, the patient reported some improvement in his weakness and numbness in lower extremities, with the resolution of the tingling.

IHC of the specimen revealed Epstein-Barr virus (EBV)-positive high-grade B-cell lymphoma overexpression BCL-2 and C-MYC on IHC. FISH studies were sent were indicative of MYC gene rearrangement and trisomy 14, IgH gene duplication/rearrangement with a chromosome other than chromosome 18.

The patient was diagnosed with DEL (double expressor lymphoma). The patient was started on dose-adjusted EPOCH-R regiment, and an Omaya reservoir was placed. The patient was discharged to a skilled nursing facility once he was stable to follow up outpatient with the oncologist.

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