Sudden appearance and spontaneous regression of diffuse large B cell lymphoma in a man with a broken arm

Abstract

An elderly, demented man with stable κ bi-clonal gammopathy of unknown significance suffered a severe displaced right humeral fracture in a fall. One week later a rapidly enlarging head, neck and axillary adenopathy first appeared, including a 2 cm tonsillar node that partially obstructed the oropharynx. A left cervical node biopsy demonstrated diffuse large B cell lymphoma with CD20+, bcl-2+, κ+, CD3–, Epstein–Barr virus negative malignant cells. During the next month lymphadenopathy regressed more than 90% in the absence of treatment with chemotherapeutic agents, radiation or glucocorticoids. Following 2 months of clinical improvement, he died of pneumonia 95 days after the injury. An autopsy demonstrated residual right hilar and mediastinal malignant lymphadenopathy. These unusual events may be related to immunosuppressive and other systemic effects of acute injury on tumour behaviour.

Case Details

Disease Location

Neck

Personal Characteristics

Elderly man dementia with severe osteoporosis suffered severe displace humeral fracture in a fall died 95 days after the fall from pneumonia

Clinical Characteristics

After the fall, was fitted with a stabilizing cast and transferred to a nursing home. No lymphadenopathy was seen during the admission exam 6 days follow the fall. During the next 6 days, a visibly enlarging mass developed in the left anterior neck and dysphagia became prominent day 13 after the injury, clusters of firm, non-tender 0.5-1.5cm nodes appeared in the left anterior and posterior cervical chains as did bilateral axillary adenopathy and a 2.0cm mass of the left tonsil that partially obstructed the posterior pharynx. Right cervical and supraclavicular adenopathy developed the following week. A left neck mass biopsy on day 22 showed obliteration of normal nodal architecture by a diffuse infiltrate of atypical, large immunoreactive b cells (CD20+, bcl-2+, kappa+) and background t cells (CD3+). Flow cytometry of biopsy material quantified t cells (CD3+) at 77.9% and b cells (CD19+) at 14.4% with a b cell kappa-lambda light chain rato of 4.7. Malignant cells were negative for ebv. "dlbcl" patient had a stable biclonal IGA kappa, IGM kappa gammopathy of unknown significance 3 years prior during a bone marrow biopsy which discovered scattered plasmacytoid cells of less than 10%. Serum IGA 485mg/dl, IGM 1376mg/dl and urinary free kappa light chain remained stable. Serial exams showed no lymphadenopathy or splenomegaly transferred to hospice on day 29 post-mortem exam found malignant enlargement of the mediastinal and right hilar lymph nodes, microscopic features of these nodes and of bone marrow was identical to original finding

Remission Characteristics

During the next 4 weeks at hospice, neck and axillary adenopathy regressed more than 90% and the tonsillar mass completely disappeared he became more interactive and could feed himself until a week before death

Treatment & Mechanisms

Proposed Remission Mechanisms

Withdrawal from immunosuppressive agents a link between trauma and tumor

Clinical Treatment

Biopsies

Non-Clinical Treatment

No chemotherapy