AdamD_DiagnosticChallenge


 

 

 

 

 
168 | Adam et al - Dumbbell-shaped lumbar non-Hodgkin’s lymphoma 

 

 

 

 

 

 

 

Diagnostic challenge in a patient with primary bilateral 

Dumbbell-shaped lumbar non-Hodgkin’s lymphoma 

D. Adam1,2, Gina Burduşa2, D. Iftimie2, Ioana Hornea2, 

Camelia Dobrea1,3, Sorina Nicoleta Badelita4 

1„Carol Davila” University of Medicine and Pharmacy, Bucharest 
2Department of Neurosurgery, „Saint Pantelimon” Clinical Emergency Hospital, Bucharest 
3Department of Pathology, Monza Hospital, Bucharest 
4Department of Hematology, „Fundeni” Clinical Institute, Bucharest 

 
Abstract: Objective: Primary bilateral dumbbell-shaped lumbar non-Hodgkin 

lymphomas with epidural and extraspinal involvement, are rare occurrences. Patients 

presenting at advanced stages and rapid evolution towards neurological impairment lead 

to diagnostic dilemmas for which only immunohistochemistry can provide a correct, 

although delayed solution. Case report: We report the first case of a bilateral, dumbbell-

shaped, lumbar lymphoma in a 65-year-old man with a medical history of chronic viral 

hepatitis type B and D under interferon treatment. The patient presented with back pain 

radiating down the right leg, with rapid progression to paraplegia and sphincter 

dysfunction. CT and MRI revealed a large dumbbell mass (approx. 5/5/10 cm) in the 

right paraspinal musculature, at the L4-L5 level, with intraspinal epidural extension.  A 

similar mass of smaller size was described on the left side, almost mirroring the first 

lesion, the imagistic aspect suggesting a neural sheath tumor. Intraoperatively, in the 

right lumbar paraspinal musculature, a soft, yellowish region was discovered, the 

macroscopic appearance being rather suggestive for a diffuse infection. Clinical, 

imagistic and surgical findings were not conclusive, nor was the histological examination 

in light microscopy of the surgical specimen or of the bone marrow biopsy. 

Immunohistochemistry identified the presence of large B cells, leading to the diagnosis 

of B cell lymphoma. Although the patient was treated with systemic chemotherapy, his 

condition rapidly deteriorated and he died within 3 months. Conclusions: In the case of 

a lumbosacral, dumbbell shaped mass, developed both epidural and extraspinal, the 

differential diagnosis must include lymphoma. The histological examination, especially 

immunohistochemistry provided the final diagnosis. Delays in establishing a diagnosis, 

associated with a malignant evolution of lymphoma, diminish the chances of 

determining and applying a treatment strategy that could prolong survival. 

 

Key words: dumbbell shaped tumor, non-Hodgkin lymphoma, lumbar spine, sciatica, 

paraspinal musculature 
 



 

 

 

 

 
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Case report 

A 65-year-old patient was referred to our 

department for low back pain radiating to the 

posterior aspect of right thigh down to the heel 

associated with numbness and tingling on the 

plantar aspect of the right foot. Symptoms 

were resistant to NSAID treatment and were 

more pronounced during the night. His gait 

was difficult due to pain. 

Significant medical history included 

chronic viral hepatitis type B and D treated 

with interferon up until 3 months prior to 

admission and diabetes mellitus type II. 

Physical examination was normal, except 

for a firm region located superficially on the 

right paravertebral lumbar spine. He 

presented no fever, nor lymphadenopathy or 

weight loss. 

Neurologic examination was normal at 

presentation with negative sciatic nerve stretch 

test. 

Notable laboratory results included an ESR 

of 42 mm/h, total white cell count of 8720/µL, 

neutrophils 5940/µL (68.20%), lymphocytes 

2030/µL (23.30%), eosinophils 100/µL 

(1.12%), basophils 20/µL (0.20%). No atypical 

lymphocytes were encountered. 

Lumbar computer tomography revealed 

swelling of the iliopsoas muscle and the right 

paraspinal muscles adjacent to L4 and L5 

vertebras, with post-contrast enhancement 

and enlargement of the corresponding neural 

foramina (Figure 1). 

 
Figure 1 - Axial CT image at the level of the L4 

vertebra that shows swelling of the iliopsoas muscle 

and the right paraspinal muscles with post-contrast 

enhancement 

 

MRI showed a polylobed dumbbell-shaped 

mass, posterior to the insertion of the right 

psoas, extended in the right paraspinal 

muscles in close contact with the L4 and L5 

posterior arches, entering the spinal canal 

through the L4-L5 and L5-S1 foramina, 

compressing and left-displacing the dural 

sack. Within the spinal canal, the tumor 

presented epidural extension over the entire 

length of the sacral canal. The mass, measuring 

5/5/10 cm, appeared homogenous, with T1, T2 

and STIR hyperintensity and homogenous 

enhancement. On the left side, an identical 

mass of smaller size was identified, located 

lateral to the L4-L5 intervertebral foramen, 

extending in the paraspinal musculature 

(Figure 2). 



 

 

 

 

 
170 | Adam et al - Dumbbell-shaped lumbar non-Hodgkin’s lymphoma 

 

 

 

 

 

 

 

 

 

 
Figure 2 - Lumbar spine MRI, T1 weighted images 

after contrast administration in coronal plane that 

show a bilateral dumbbell shaped hyper intense mass 

that extends in the paravertebral muscles (A); the 

tumor enters the spinal canal at the L4-L5 level, with 

left displacement of the dural sack (B); axial image at 

S1 level reveals the epidural extension in the sacral 

canal (C) 

 

Chest, abdomen and pelvic contrast CT 

scans as well as abdominal ultrasound were 

negative for enlarged lymph nodes or 

additional masses. 

The patient underwent decompression of 

the L5 and S1 right spinal roots performed via 

L4 and L5 right hemilaminectomy. At this 

level the epidural tissue mass was debrided and 

its extension in the paraspinal musculature 

was partially resected. Intraoperatively, in the 

central area of the paraspinal tumor, a mass of 

yellowish color and soft consistency was 

found, the macroscopic aspect being rather 

that of a diffuse infection in a very infiltrative 

mass. 

Immediately following the surgical 

decompression, the patient’s pain was 

alleviated. He was able to walk with the aid of 

a cane. 

Bacteriological examination of the 

debrided muscular tissue isolated 

Staphylococcus aureus, sensitive to 

Gentamicin, Linezolid and 

Trimethoprim/sulfamethoxazole. 

Two weeks later the patient presented a 

difficult gait due to foot drop on the right side. 

He also showed sensory impairment of the L5 

and S1 radicular territories. No sphincter 

disturbances were encountered. 

The general physical examination revealed 

a painless, 1 cm diameter inguinal adenopathy 

of firm consistency, adherent to the adjacent 

planes. Organomegaly was absent. 



 

 

 

 

 
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Histological examination of the specimen 

with light microscopy was inconclusive, 

indicating an undifferentiated tumor, with 

medium/large cells, proliferating in a 

discohesive manner (Figure 3). Bone marrow 

obtained through biopsy showed at 

histopathological examination hematogenous 

marrow with age appropriate cellularity with 

the presence of all cellular series, light 

megakaryocytic reactive hyperplasia and 

extremely rare, small cell, mature lymphoid 

interstitial infiltrate (reactive aspect). 

Immunostaining was used in order to 

establish the diagnosis. The microscopic 

characteristics made necessary an 

investigation of cell type as Vimentin and 

cytokeratin MNF116 were the first applied 

markers. The cytokeratin MNF116 was 

negativ and Vimentin was positive in a fashion 

suggesting a lymphoid proliferation. The 

common leukocyte antigen CLA (CD45) and 

CD20 were diffusely positive while CD3 

showed only rare positive cells. For typing the 

Lymphoid B cell proliferation CD10 (for 

germinal center subtype) and MUM1 (for 

activated B cell type) were applied. MUM1 was 

diffusely positive, indicating the activated B 

cell and that the final diagnosis was diffuse 

large B cell non-Hodgkin’s lymphoma 

activated subtype, infiltrating skeletal muscle. 

A high proliferative cell index reveals the 

aggresive nature of the tumor. (Figure 4). The 

origin of the lymphoid proliferation is more 

difficult to establish; it may be in a lymph node 

near the muscle, near the bone or even in the 

bone marrow of the vertebra. 
 

 
Figure 3 - Light microscopy examination of the 

tumor specimen revealing skeletal muscle with 

diffuse tumor invasion. Tumor cells are large, with 

scant cytoplasm and rounded nuclei with dispersed 

chromatin and with a discohesive feature (HE 

staining, 20x magnification) 

 

 

 



 

 

 

 

 
172 | Adam et al - Dumbbell-shaped lumbar non-Hodgkin’s lymphoma 

 

 

 

 

 

 

 

 
Figure 4 - Immunostaining of the tumor tissue. A: 

CD20 appears diffusely positive, revealing the 

lymphoid nature of the tumor proliferation. (CD20 

staining, 20x magnification); B: MUM1 staining is 

positive for activated B cells (MUM1 staining, 20x 

magnification); C: The proliferative cell index is very 

high (~90%), illustrating the aggressive character of 

the tumor (Ki67 staining, 20x magnification) 

 

 
Figure 5 - Postoperative (1 month) contrast lumbar 

CT at the level of the L5 vertebra showing the 

increase in size of both paravertebral masses 

 

Neurological deficits rapidly progressed to 

paraparesis and urinary retention. 

A lumbar CT was repeated at 1 month after 

surgery that showed the increase in size of both 

paravertebral masses with central necrosis and 

also bony erosion of the right iliac bone and 

sacrum (Figure 5). 

Repeated laboratory tests revealed an 

increased CRP of 47,2 mg/dl and LDH of 719 

mmol/L. 

The patients’ postoperative course 

included pain relief medication, 

antibiotherapy, Dexamethasone, Zoledronic 

acid, Filgrastim and 3 cycles of chemotherapy 

with Cyclophosphamide and Doxorubicin. 

The patient’s general condition 

progressively worsened, in parallel with 

gradual neurological impairment, followed by 

death at 3 months postoperatively. 

Discussion 

Basic notions regarding the immune 

system and non-Hodgkin lymphomas 

The human body has defensive immune 

mechanisms through which it triggers 

immune responses: 

•The innate immune response consists of 

macrophages, monocytes, granulocytes and 

natural killer cells that detect pathogens and 

rapidly respond to the nonspecific signals that 

appear in case of infection and tissue damage 

•The adaptive immune response is 

provided by lymphocytes. They are 

immunocompetent cells that present 

specificity and memory for foreign agents. 

Lymphocytes present specific receptors: B cell 

receptor or T cell receptor. The adaptive 

immunity can be humoral or cellular, 

depending on the receptor type expressed by 

lymphocytes. (1)  

The humoral immune system consists 

primarily of B cells and plasma cells that 



 

 

 

 

 
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secrete antibodies. The B cell receptor is 

located at the surface of the cell and has 

specificity for antigens. Antibodies represent 

the weapons of the humoral immune system, 

secreted by B cells. 

The cellular immune system is provided by 

T cells that can express CD4 or CD8 co-

receptors. CD8+ T-cells are also called 

cytotoxic lymphocytes. CD4+ T-cells are 

known as T-helper cells that regulate the 

function of other immune cells via the 

cytokines that they secrete. 

Non-Hodgkin lymphomas (NHLs) are 

caused by lymphocytic proliferation in the 

lymph nodes, spleen or bone marrow. NHLs 

can develop in any site of the body where 

lymphatic tissue is present. (2, 3) 

The non-Hodgkin lymphoma is a systemic 

condition that has the tendency to disseminate 

even at the level of the central nervous system, 

both intra and extracranial, spine (4), spinal 

epidural space, at the level of the nerve roots, 

nerve plexuses, even cranial or peripheral 

nerves (5–9) and can be primary or secondary 

lesions of the nervous system.  Because it is 

capable of mimicking any other condition at 

affected sites, the diagnosis is sometimes 

delayed, and the outcome is grim, despite 

therapeutic advances in recent years. 

NHLs are heterogeneous, blood cell tumors 

composed of B and T cells. There are several 

types of lymphoma that are classified by the 

WHO in: 

• large, diffuse B-cell lymphomas 

• T-cell lymphomas 

• plasmablastic lymphomas 

• natural killer T-cell lymphomas (NK/T-cell) 

 There are approximatively 30 subtypes of 

non-Hodgkin lymphomas, with variable 

severity, from mild to aggressive.  

Non-Hodgkin lymphomas with spinal 

cord compression are often aggressive (10–

13). NHL is the seventh most common cancer 

in the United States (14). 

Monnard et al (15) have reported that 4% 

of spinal epidural lymphomas were developed 

at the lumbosacral level and 27% in the lumbar 

area. Spinal cord compression occurred in 

0,1% to 3,3% of patients with non-Hodgkin 

lymphomas (15, 16) and up to 10,2% in 

aggressive forms (11, 12). 

While their cause is unknown, several risk 

factors have been identified. Although NHLs 

can develop at any age, they most frequently 

occur in the seventh and eight decades. Men 

are more frequently affected than women. 

Various risk factors are mentioned in the 

literature: viral or baterial infections (Epstein-

Barr virus, HIV), immune system defficiencies 

in immunosupressed patients, under 

immunosupresive theraphy, after organ 

transplant, autoimmune diseases and 

radiation exposure (8, 17, 18). 

Immune system compromise in the 

presence of a risk factor predisposes patients to 

develop lymphomas. 

Surgical intervention followed by 

chemotherapy and radioterapy, can improve 

neurological function and can prolong the 

patient’s lifespan (19). 

Differential Diagnosis 

In the presented case, the patient was under 

interferon treatment for chronic viral hepatitis 

type B and D. The presence of this element in 

recent case history was not a sufficiently 

powerful aspect to guide towards the diagnosis 



 

 

 

 

 
174 | Adam et al - Dumbbell-shaped lumbar non-Hodgkin’s lymphoma 

 

 

 

 

 

 

 

of lymphoma at the time of admission. 

CT and MRI revealed a bilateral, dumbbell-

shaped mass, at the level of the lumbar spine, 

extending in the paraspinal muscles and 

intrapinally that raised the suspicion of 

malignant nerve sheath tumor at the L4 and L5 

level. According to Tsai (5), lymphomas can 

grow in patterns that are indistiguishable from 

nerve sheath tumors. The radiological 

characteristics of the lession are not fully 

consistent with the diagnosis of malignant 

nerve sheath tumor because it is highly 

unlikely for this tumor type to develop 

bilaterally, at two levels simultaneously and 

also extend epidurally along the entire length 

of the sacral canal, while also presenting an 

extraspinal globular shape and not stretched 

along the length of the sciatic nerve roots. 

Also, nerve sheath tumors appear iso or 

hypointense in T1 weighted images and 

hyperintense in T2 with heterogenous 

enhancement. In the presented case, the tumor 

showed hyperintensity in T1 and T2 sequences 

and homogenous enhancement. 

Increased lab test values corellated with the 

inflamatory aspect of the central area of the 

lesions developed in the paraspinal muscles 

along with the bacteriological examination 

positive for Stafilococcus aureus suggest a 

defficiency of the patient’s immune system. All 

these elements sustained the diagnosis of an 

infectious process and to begin treatment 

according to the germ’s sensitivity, but at the 

same time further strengthened the diagnostic 

dilemma. Bobba et al (20) reported a Hodgkin 

lymphoma with a bilateral fluid collection in 

the epidural space and paraspinal region at the 

L4-L5 level which was initially treated with 

Vancomycin. 

The diagnosis of NHL was not solved with 

the help of histopathological examination in 

light microscopy. 

We include in the differential diagnosis soft 

tissue tumors like rhabdomyosarcoma or 

metastases but these were ruled out by 

histopathological examination in light 

microscopy. 

The diagnosis of lymphoma could only be 

made with the help of immunohistochemistry. 

The tumor cells were positive for Vimentin 

that suggested a lymphoid proliferation, also 

diffusely positive for CLA and CD 20, while 

only rare CD3 positive cells were encountered. 

MUM1 was diffusely positive, establishing the 

final diagnosis of diffuse large B cell non-

Hodgkin lymphoma, activating subtype, 

infiltrating skeletal muscle. Not even 

immunostaining could pinpoint the origin of 

the lymphoid proliferation. 

The fact that at the time of admission no 

adenopathies were found at general physical 

examination, nor organomegaly and the 

thoracic, abdominal and pelvic CT scan did 

not reveal enlarged lymph nodes, 

demonstrates that this particular tumor is a 

primary lymphoma with an uncommon 

radiological appearance, presenting a lumbar, 

bilateral, dumbbell-shaped development. 

Swelling of the inguinal lymph node appeared 

as the condition progressed and so was not the 

origin of the lymphoma. 

The purpose of the surgical procedure was 

to obtain a tissue sample for histopathologic 

examination ant to decompress the neural 

roots in accordance with recommendations of 

Hong et al (21). 



 

 

 

 

 
Romanian Neurosurgery (2016) XXX 2: 168-176 | 175 

 

 

 

 

 

 

 

Postoperative survival was short because, 

although primary lymphomas are sensitive to 

chemotherapy, only 3 cycles could be 

administered, without iradiation. 

Radiotherapy, some authors claim, is no 

longer justified (22, 23). 

Conclusions 

Primary non-Hodgkin lymphomas have to 

be taken into consideration in the differential 

diagnosis of patients presenting with low back 

pain and radiculopathy. 

We report a very rare case of primary 

lumbosacral and paraspinal lymphoma with 

late discovery which was correctly diagnosed 

only after immunhistochemical examination. 

Late presentation associated with an 

aggressive form of disease prevent an optimal 

and complete treatment protocol with a 

chance to prolong survival. 

In the diagnosis and treatment of patients 

with primary non-Hodgkin lymphoma, a 

multidisciplinary team is necessary. 

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