J Islamabad Med Dental Coll 2022 259
O p e n A c c e s s
Primary Diffuse Large B Cell Lymphoma Presenting as Chest
Wall Mass: A Case Report
Shajee Ahmed Siddiqui1, Muhammad Zeeshan2, Muhammad Azhar Jamil3, Ghazal Iftikhar4, Adil Farooq5
1Professor and Head of Department of Medicine, Pakistan Institute of Medical Sciences, Islamabad.
2,3,5Resident, Pakistan Institute of Medical Sciences, Islamabad.
4Medical Officer, Shifa International Hospital. Islamabad.
A B S T R A C T
Primary chest wall masses or tumors can be of two types, either benign or malignant. Diffuse large B cell lymphoma
(DLBCL) is an aggressive type of non-Hodgkin lymphoma (NHL). Though an aggressive malignancy, with timely and
appropriate treatment, approximately two-third of all patients can be cured. We present a rare case of DLBCL presenting
as chest wall mass. This case suggests the possibility of the presence of primary malignant B cell lymphoma, with the
presentation as a chest wall lesion.
Keywords: Chest mass, Diffuse large B cell lymphoma, Mass, Non- Hodgkin’s lymphoma.
Correspondence:
Muhammad Zeeshan
Email: zeeshanchaudhry23.zc@gmail.com
Article info:
Received: August 9, 2022
Accepted: December15, 2022
Cite this article. Siddique S A, Zeeshan M, Jamil M A, Iftikhar G,
Farooq A.Primary Diffuse Large B Cell Lymphoma Presenting as
Chest Wall Mass: A Case Report J Islamabad Med Dental Coll. 2022;
11(4): 259-262
https://doi.org/10.35787/jimdc.v11i4.903
Funding Source: Nil
Conflict of Interest: Nil
I n t r o d u c t i o n
Diffuse large B cell lymphoma (DLBCL) is one of the
most common types of non-Hodgkin lymphoma
(NHL).1 Though they mostly involve lymph nodes,
extra nodal involvement is seen in 30% of the cases.2
Among these extra-nodal sites, soft tissue
involvement is rarely seen and very rarely as chest
wall mass. Soft tissue masses are sometimes
misdiagnosed as soft tissue sarcoma. Since these
two disease entities differ in treatment and
prognosis, their timely diagnosis is essential for
management.3,4 This case report highlights the
importance of including DLBCL in differential
diagnosis of chest wall mass.
C a s e P r e s e n t a t i o n
A 65-year-old male resident of Rawalpindi, city of
Pakistan, with no previous known comorbidities, but
smoker (35 pack year), presented in emergency
department with the history of chest wall mass for
the past 2 months, undocumented weight loss and
shortness of breath with complain of stridor for 3
days. The mass was on left side of the chest wall and
was progressively increasing in size. Shortness of
breath progressed from MMRC grade 2 to grade 4,
associated with stridor. There was no history of
chest pain, cough, hemoptysis, fever, orthopnea,
Paroxysmal nocturnal dyspnea (PND), night sweats
or trauma. On arrival, patient was in distress and was
having stridor with 94% oxygen saturation at room
air, tachycardia (126 beats/min) and tachypnea (30
breaths /min). Systemic examination revealed
C A S E R E P O R T
J Islamabad Med Dental Coll 2022 260
swelling of 7 into 8 cm size, extending from 2nd to 8th
left intercostal space upon inspection, non-tender,
firm to hard in consistency, immobile, with overlying
skin non adherent with irregular margins upon
palpation, resonant though-out the lung field and
dull over the swelling upon percussion and bilateral
monomorphic wheeze more on left side along with
stridor upon auscultation.
Indirect laryngoscopy was done which showed right
vocal cord fixed and left vocal cord mobile. In
addition to this, there was one more swelling
observed on anterior aspect of right thigh, 3 into 4
cm in size, firm in consistency, irregular margins,
fixed to underlying tissue with overlying skin pinch
able. During admission, multiple laboratory blood
tests were done including total leukocyte count
which was slightly raised (15000 cells/mm3 with 96%
neutrophils and 2% lymphocytes), raised serum uric
acid levels 13.6 mg /dl (reference:3.5-7.2 mg/dl) ,
and slight decrease in serum albumin levels 3.1g/dl
(reference:3.4-5.4 g/dl), normochromic normocytic
blood picture with neutrophilic leukocytosis on
blood peripheral film. Rest of the lab values
including hemoglobin, platelet count, ESR, CPK,
serum calcium, serum electrolytes, liver function
tests and renal function test, were within normal
ranges.
As an initial imaging, chest X-ray was done which
showed enlarged cardiac silhouette and left sided
extra pleural opacification. Ultrasound chest was
done which revealed minimal right sided pleural
effusion along with the streak of free fluid in left
pleural cavity. Computed tomography of chest with
contrast showed heterogeneous soft tissue density
area measuring 23x18 (APxT) in dimensions
involving right sided vocal cord causing narrowing of
laryngeal lumen (residual lumen of 10mm at this site)
and extend caudally involving right lobe of thyroid
gland which appears enlarge. No surround erosion
or distortion noted. A heterogeneous soft tissue
density area measuring 15x5x12mm (CCxAPxT) was
noted involving left hemithorax, it was insinuating
between anterior muscles of chest wall and reaching
upto anterior aspect of pleura of left lung, also
involving all muscles of left hemithorax. Another
heterogeneous mass soft tissue density lesion
approximately measuring 10x6x7cm (CCxAPxT) was
noted involving right hemipelvis, involving right
iliopsoas muscle and causing elevation and abutting
right common iliac vessels and its branches. Under
lying bone appeared normal and no erosion was
noted.
Ultrasound of right leg showed soft tissue swelling
anterior to tibia with internal blood flow and no
adjacent bony reaction. Given the patients
symptoms of painless progressive mass, combined
with findings on chest imaging, the provisional
diagnosis was deduced to be a lymphoma.
Figure 1: Chest X-Ray PA View
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Figure 2: CT Scan Chest with contrast
Trucut biopsy of chest mass revealed patchy
infiltrates of cells with hyper chromic friable nuclei
and minimal cytoplasm. Immunohistochemical
staining was positive for (CD-45, LCA) and negative
for epithelium maker cytokeratin, representing
atypical lymphoid infiltrate. Additional immune-
stains were taken on this small biopsy (CD-3 and CD-
20), which indicated cellular infiltrate composed of
CD-20 positive in B-cells, with possibility of
malignant B-cell lymphocytes.
Figure 3: Histopathological and Immunohistochemistry Sections
D i s c u s s i o n
Chest wall tumors are of various entities and may be
both benign and malignant. Primary chest wall
lymphoma is a very rare, yet a treatable condition.5
In a retrospective study found in a literature, out of
total 157 patients with non-Hodgkin lymphoma, only
7 presented with large chest wall mass.6 Few reports
state that DLBCL is most common type of primary
chest wall lymphoma.5 There is mostly some
predisposing disease like chronic tuberculous
pyothorax or tuberculous pleuritis, our case
however had no predisposing disease or any
comorbidities.7 Majority of cases of NHL are of B cell
origin, especially in adults.8 Single chest wall masses
are uncommon, but those appearing mostly
represents non Hodgkin lymphoma, commonly large
cell type.9 Majority of chest wall masses presents as
metastasis.5 Patients always present with non-
specific symptoms which is the most common
reason for delay in a diagnosis until radiology and
histopathology confirm the diagnosis.10 Surgical
treatment including local excision, chest wall
resection followed by reconstruction surgeries,
J Islamabad Med Dental Coll 2022 262
along with chemotherapy can result in good
prognosis in some of the cases.11,.12
C o n c l u s i o n
Diffuse large B cell lymphoma presenting as a chest
wall mass, is a rare entity but should always be
considered in differential diagnosis of chest wall, so
that it can be treated early with a better prognosis.
R E F E R E N C E S
1. Le Huy T, Manh PD et al.Primary Diffuse Large B-
Cell Lymphoma, Presenting as a chest wall mass: A
Case Report. JMR 2022; 154 E10 (6):131-136
2. Li S, Young KH, Medeiros LJ. Diffuse large B-cell
lymphoma. Pathology (Phila). 2018; 50(1): 74-87.
doi:10.1016/j.pathol.2017.09.006.
3. Shah B. Primary chest wall lymphoma: A rare entity.
Journal of Cancer Research and Therapeutics.
2015;11(3):661-.
4. Ahuja A, Mirchandani LV, Kamath S, Jayalakshmi T.
Diffuse large B-cell lymphoma presenting as a chest
wall mass: case report with review of literature.
International Journal of Current Research.
2015;7(11):22667-9.
5. Hsu PK, Hsu HS, Li AF, Wang LS, Huang BS, Huang
MH, et al. Non-Hodgkin's lymphoma presenting as a
large chest wall mass. The Annals of thoracic
surgery. 2006;81(4):1214-8.
6. Qiu X, Liu Y, Qiao Y, Chen G, Shi T, Chen J, et al.
Primary diffuse large B-cell lymphoma of the chest
wall: a case report. World journal of surgical
oncology. 2014;12:104.
7. Kitada S, Komuta K, Takatsugi K, Maeda K, Kimura
R, Igarashi T. [Primary Non-Hodgkin's lymphoma in
the chest wall without preceding disease]. Nihon
Kyobu Shikkan Gakkai zasshi. 1996;34(5):592-6.
8. Gaynor ER, Fisher RI. Recent advances in the
management of non-Hodgkin's lymphomas.
Disease-a-month : DM. 1989;35(9):597-650.
9. Lau MC, Mhandu P, Parissis H, McGuigan J. Primary
diffuse B-cell lymphoma presenting as a solitary
chest-wall lesion. Journal of surgical case reports.
2015;2015(6).
10. Navejar CA, Morris MJ. Diffuse Large B-Cell
Lymphoma Presenting as an Anterior Chest Wall
Mass: A Case Report and Literature Review. Current
Respiratory Medicine Reviews. 2009;5(4):239-41.
11. Foroulis CN, Kleontas AD, Tagarakis G, Nana C,
Alexiou I, Grosomanidis V, et al. Massive chest wall
resection and reconstruction for malignant disease.
OncoTargets and therapy. 2016;9:2349.
12. Zhang Q, Ju Y, Qu T, Wang T, Liu X. Primary diffuse
large B-cell lymphoma as a chest-wall mass: a case
report. Medicine. 2018;97(47).