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| LETTERS TO EDITOR |
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| Year : 2018 | Volume
: 66
| Issue : 1 | Page : 258-260 |
Primary lymphoma of the radial nerve presenting as nerve sheath tumor
Jayapalan Jayendrapalan1, Vengalathur G Ramesh1, Kavindapadi V Karthikeyan1, Subburayan Devi2
1 Department of Neurosurgery, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai, Tamil Nadu, India
2 Department of Pathology, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai, Tamil Nadu, India
| Date of Web Publication | 11-Jan-2018 |
Correspondence Address:
Dr. Vengalathur G Ramesh
Department of Neurosurgery, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai, Tamil Nadu,
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.222865
How to cite this article:
Jayendrapalan J, Ramesh VG, Karthikeyan KV, Devi S. Primary lymphoma of the radial nerve presenting as nerve sheath tumor. Neurol India 2018;66:258-60 |
Sir,
Extranodal lymphomas are uncommon. Primary extranodal lymphomas are found mainly in the central nervous system, gastrointestinal tract, and skin. Lymphomas arising from the peripheral nerves are exceedingly rare. Sciatic nerve has been the most common nerve involved in the reports so far. Primary lymphoma arising from the radial nerve is rare.
A 65-year old woman presented with a swelling in the left arm with localized pain radiating up to the palm since the last 2 months. Local examination showed a nontender mass on the medial aspect of the lower half of the left arm; the mass was firm in consistency and located in the intermuscular plane. There was no Tinel's sign. There were no signs of distal neurological involvement. There was no evidence of lymphadenopathy or hepatosplenomegaly. Magnetic resonance imaging (MRI) of the left arm showed a T1 isointense, T2 hyperintense mass with intense homogeneous contrast enhancement within the lesion [Figure 1]. Hematological investigations and sonography of the abdomen were normal. The tumor was exposed by a longitudinal incision over the arm overlying the swelling. The tumor was found deeper to the muscle plane and was attached to the radial nerve in the radial groove. The cut section revealed a gray-white, fleshy tumor measuring 8 cm × 5 cm in size with a firm consistency. The tumor could be easily separated from the nerve and excised completely as is the experience with a typical nerve sheath tumor [Figure 2]. Histopathology showed discrete tumor cells arranged in a diffuse pattern with moderate pleomorphism admixed with small lymphocytes. The tumor cells showed moderate amount of clear cytoplasm with marked sclerosis and hyalinization. Immunohistochemically, the tumor cells were positive for leukocyte common antigen (LCA) and cluster of differentiation (CD) 20, and negative for CD3, pancytokeratin, and S100 [Figure 3], [Figure 4], [Figure 5]. These features were suggestive of a diffuse large B-cell lymphoma. The patient is undergoing chemotherapy and is being followed up. | Figure 1: T1 contrast MRI image showing evidence of tumor in the middle and lower 3rd of the right arm with an intense homogeneous contrast enhancement
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 | Figure 2: The cut section of the tumor revealed a gray white, fleshy tumor measuring 8 cm × 5 cm in size with a firm consistency
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 | Figure 3: Microphotograph showing discrete tumor cells in a diffuse pattern with clear cytoplasm, irregular nuclear contour and hyalinisation (hematoxylin and eosin ×40)
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 | Figure 4: Immunohistochemistry for leukocyte common antigen (LCA) showing diffuse membranous positivity in tumor cells
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 | Figure 5: Immunohistochemistry for CD20 showing diffuse membranous positivity
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The most common tumors of peripheral nerves are schwannomas and neurofibromas. Primary lymphomas of peripheral nerves are very rare. Only 14 cases of peripheral lymphoma of the peripheral nerve have been reported so far [Table 1].
The sciatic nerve is the most commonly involved nerve. Only two cases of lymphoma arising from the radial nerve have been reported so far, one of which had associated lymph node involvement and hence cannot be considered as a primary lymphoma [1], and the other was a primary lymphoma of the radial nerve.[2] The association of autoimmune disorders have been found in the reports of Misdraji et al.,[1] and Descamps et al.[3] Most of the extranodal lymphomas are thought to arise from the lymphoid tissue in the extranodal sites, as in the stomach, thyroid gland, lung, and salivary gland in response to some antigenic stimuli (“mucosa-associated lymphoid tissue”).[1] However, extranodal lymphomas are also found to arise from organs without “mucosa-associated lymphoid tissue”[1] such as the central nervous system, bone, gonads, kidney, soft tissue, and peripheral nerves.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] The majority of reported cases of peripheral nerve lymphomas, including the present case, have been diffuse large B-cell lymphomas. Only two reported cases have been T-cell tumors. The optimal adjuvant treatment has not been established so far. Majority of the reported cases underwent chemotherapy. A few authors administered prophylactic radiotherapy to the central nervous system because of the presumed association of central nervous system lymphoma. Our patient is only the second reported case of primary lymphoma arising from the radial nerve.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1]
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