Winning Abstracts from the 2008 Medical Student Abstract Competition: Medical Hide and Seek...With A Twist!
Chun Chin Huang, Medical College of Georgia
Small Leukocytic Lymphoma/Chronic Leukocytic Leukemia (SLL/CLL) is a low grade lymphoma usually characterized by slow clinical progression. However, in patients with concurrent malignancy or who later develop another primary malignancy, the clinical progression of SLL/CLL can be somewhat unexpected.
A 59 y/o WF with a prior history of SLL/CLL was diagnosed with Non-Small Cell lung Cancer (NSCC) in 1996. She underwent surgical resection, radiation and chemotherapy with cisplatin and etopiside. Her original laboratory studies at the time of diagnosis with NSCC showed minor peripheral lymphocytosis but subsequent labs failed to show clinical evidence of SLL/CLL. Therefore this diagnosis was not further pursued and the patient was followed by the cancer clinic primarily for her NSCC. In November 2006 she presented to the clinic with worsening back and shoulder pain Bone scan showed focal uptakes in T5 and the coracoid process of the L scapula. Subsequent thoracic spine MRI showed findings consistent with metastatic lesions in T4, T5, and T7. She described a chronic cough, shortness of breath and an 8lb weight loss, but denied night sweats, fatigue, anorexia, or hemoptysis. Needle biopsy of the lesion from T5 vertebrate was done for evaluation of possible recurrence of NSSC vs metastatic tumor of unknown primary. Surprisingly, the final pathology report showed that the lesion was composed of lymphoid cells. Morphology and immunophenotype were most consistent with SLL/CLL. CT scan of chest, abdomen, and pelvis showed no lymphadenopathy or hepatosplenomegaly. Based on the pathology report and past medical history, the patient was diagnosed with recurrent SLL/CLL.
Although spontaneous remissions SLL/CLL have been reported prior to the development of a second malignancy, this case is particularly unusual because the patient went into prolonged clinical remission at the time of the treatment of her NSSC. It is unclear whether this is one of the rare spontaneous remissions documented or an unintended benefit of the chemotherapy and XRT. In addition, the patient’s disease presented itself in an unusual location for SLL/CLL– the thoracic vertebral body, with no other lymphadenopathy or hepatosplenomegaly. The patient was very fortunate in that her past medical history made the presenting symptoms of thoracic back pain much more alarming, which prompted a bone scan that revealed the lesions.
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