Paraspinal mass as a presentation in relapsed Hodgkin lymphoma.

Dear Editor,

Hodgkin Lymphoma commonly presents with cervical lymphadenopathy. We report the case of a 13-year-old boy, presenting with a paraspinal mass as the only manifestation of Hodgkin disease.

Hodgkin lymphoma commonly presents with painless lymphadenopathy in approximately 70 percent of the cases. The involved lymph nodes are usually nontender with a rubbery consistency. The most commonly involved site is the neck, as 60 to 80 percent of the patients have enlarged cervical and/or supraclavicular nodes. Enlarged nodes are found in the axilla in 10 to 20 percent of the patients and inguinal nodes are involved in six to twelve percent.[1] Very few cases of Hodgkin lymphoma presenting as a paraspinal mass have been reported in literature.[23]

A 13-year-old boy presented with a one-month history of swelling over the back - a firm globular mass in the left paraspinal region at the T4 - T7 level. A large right axillary lymph node (approximately 15 × 15 mm) was palpable and the rest of the systemic examination was normal. Laboratory investigations revealed an Hb of 9.5 gm/dl and a high LDH level. The rest of the parameters were normal. The patient was treated as a case of Hodgkin Lymphoma Lymphocyte Predominance Type 5, years back, with six courses of Adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD)-based chemotherapy.

A computed tomography (CT) scan of the chest showed a lytic expansile bony lesion involving the fifth and sixth ribs and the left transverse process of the T6 vertebrae, surrounded by a significant soft tissue mass (approximately 40 × 32 mm), which was infiltrating the adjacent left posterior paraspinous muscle. A 16 × 17 mm large lymph node was seen in the right axilla and few lymph nodes were seen in the right paratracheal, pretracheal, and paracarinal region [Figure 1]. Biopsy of the mass was consistent with the diagnosis of relapsed Hodgkin disease. The CTs of the neck and abdomen were normal. A radioactive isotope bone scan suggested an increased uptake in the fifth and sixth ribs and in the left transverse process of the T6 vertebrae. Bone marrow aspiration and biopsy did not confirm any marrow infiltration. Echocardiography showed an ejection fraction of 64% and the pulmonary function tests were normal. The patient was given eight cycles of chemotherapy, with bleomycin, etoposide, Adriamycin, cyclophosphamide, vincristine, procarbazine, and prednisolone-based chemotherapy and local radiotherapy. The patient has been doing well four months post therapy to date.

Figure 1

Lytic expansile bony lesion involving the fifth and sixth ribs and the left transverse process of the T6 vertebrae surrounded by a significant soft tissue mass

The differential diagnosis of paraspinal masses includes a variety of lesions like Schwannoma, neurofibroma, meningioma, ependymoma, sarcoma, ganglioneuroma, tumor arising from a lymphoid, connective and bone tissue, abscess, herniated disc, hematoma, spinal arteriovenous malformation, and spinal aneurysm; metastatic disease must also be taken under consideration.

We conclude that lymphoma must be considered in the differential diagnosis of a paraspinal mass; and in a patient with a past history of Hodgkin lymphoma, this must be considered as being due to lymphoma, however, for a definitive diagnosis, a biopsy must be done before starting therapy.[4]