PMC6383425_01
Left forearm masses. (a) Initial mass at time of antibiotic treatment on 03/03/17. (b) Appearance of the second lesion on 03/08/17. (c) Lesion appearance on 03/30/17. Skin biopsy representing cutaneous (d) DLBCL and (e) CD20 staining.
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She presented to her primary care provider with a progressively growing erythematous nodule and was treated with antibiotics (Figure 1(a)). While the initial lesion continued to grow, a second lesion appeared next to the first (Figure 1(b)). The patient was diagnosed with DLBCL non-GC subtype (Figures 1(c)-1(e)).
Left forearm tumor. (a) Before receiving first R-CHOP regimen on 04/19/17. (b) After the first R-CHOP cycle on 04/22/17. (c) After the second R-CHOP cycle on 05/11/17. (d) Left forearm at the end of the third cycle on 07/14/17 R-CHOP cycle on 06/01/17.
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Following three cycles of R-CHOP, the tumor continued to grow (Figure 2).
Left forearm during radiotherapy. (a) Left forearm at the beginning of radiotherapy on 06/05/17. (b) Left forearm at the end of radiotherapy on 06/25/17. (c) Left forearm at the end of the fifth R-CHOP cycle on 07/14/17.
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After the fifth R-CHOP cycle and radiotherapy completion, the tumor began to shrink (Figure 3).
(a) Left upper arm mass on 08/11/17. (b) Left upper arm mass on 11/05/17.
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Unfortunately, one month later, the patient noted a nodule on her left upper arm (Figure 4(a)). Skin masses and nodules in her left upper arm continued to grow fast within 3 months (Figure 4(b)).
(a) H&E staining of diffuse large B-cell lymphoma; (b) CD20 immunostaining; (c) BCL2 immunostaining; (d) BCL6 immunostaining; (e) MYC immunostaining.
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Combined with the BCL2 result, the neoplasm was a double expressor immunophenotype (Figure 5).
(a) Left upper arm mass 12/04/17. (b) Third nodule appearance on left forearm 12/18/17.
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At the beginning of December, the left upper arm mass had continued to grow (Figure 6(a)). Days later, a third nodule was present in the patient's left forearm (Figure 6(b)).
(A and B) MRI cervical and thoracic showed C5 metastasis that extended into the right C4-C5 and C5-C6 foramina (C) with leptomeningeal metastasis.
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CSF flow cytometry was positive for lymphoma with aberrant cell phenotype positive for CD19, CD20, CD22, CD38, CD43, CD79b, and CD200. Cervical, thoracic, and lumbar MRI showed an enhancing mass involving the right C5 vertebral body with extension into the right C4-C5 foramina (Figures 7(a) and 7(b)) and epidural extension of tumor along the right aspect of the spinal canal touching the right aspect of the cord and leptomeningeal metastasis (Figure 7(c)).
Left upper arm during radiotherapy. (a) Left upper arm at the beginning of radiotherapy on 01/07/18. (b) Left upper arm after completing radiotherapy on 01/11/18. (c) Left upper arm after excision of mass on 02/27/18.
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In February 2018, the patient had a left upper arm mass infection, treated with IV antibiotics, and the left arm tumor mass was excised (Figure 8). Her left forearm and left upper arm skin had healed (Figure 8).
(a) Region of left thigh where skin graft was obtained. (b) Left upper arm with skin graft. (c) Left forearm.
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She received a skin graft from her left thigh (Figure 9).