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A 73-year-old man, diagnosed as concomitant presence of Spermatic Cord and Testicular Non-Hodgkin's Lymphoma

An initial diagnosis of a mass of neoplastic origin   and right-sided low-level orchidectomy was performed.  

Intraoperatively, surgeons found a hard mass entirely replacing the right testis and epididymis measuring approximately 8 x 5 cm, with a thickened and nodular cord up to the level of the superficial inguinal ring 

The histopathological report showed diffuse sheets and discrete medium to large atypical cells with pale eosinophilic to clear cytoplasm, vesicular nuclei, prominent nucleoli, and increased mitosis. The tumor cells were seen to be encroaching on the local blood vessels. Similar types of cells were also seen in the ipsilateral spermatic cord.  

Immunohistochemistry studies are positive for CD45 and CD20; these immunohistochemistry markers are specific for diffuse B-cell lymphoma 

MRI of the head and neck and a CT thorax revealed no spread within these typical regions where the disease can potentially spread.  

The patient was given six cycles of chemotherapy in the form of an R-CHOP regimen, which includes rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. Once the patient completed this part of the treatment, he was further advised to undergo radiotherapy, which he declined. 

According to your knowledge, what advance treatment options are available to treat concomitant presence of Spermatic Cord and Testicular Non-Hodgkin's Lymphoma?

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A 26-year-old patient presented to a local hospital in August 2017 with a thumb-sized lump in the left neck for 7 months

The patient was diagnosed with IV stage BL. The morphology and immunohistochemistry from a lymph node biopsy were compatible with that of BL. The patient was treated with intensified induction chemotherapy of one cycle of R-HyperCVAD (rituximab, cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with high-dose methotrexate and cytarabine), then received one cycle of R-HyperCVAD-B, and transferred to another hospital for treatment in 2018.

However, the disease progressed to refractory BL stage II. After R-EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab) treatment and a period of anti-CD19 bispecific T-cell engaging antibody (Blincyto) treatment, the tumor basically disappeared. This was followed by a chemotherapy regimen with R-IVAC (rituximab, ifosfamide, etoposide, and high dose cytarabine). However, two weeks later, the patient found that the tumor grew again.

According to the background history and clinical investigations, what is your differential diagnosis?

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A 57-year-old woman with a previous history of diabetes mellitus and obesity was diagnosed with germinal-center DLBCL, Ann-Arbor stage IVs-A

In August 2019, a 57-year-old woman with a previous history of diabetes mellitus and obesity was diagnosed with germinal-center DLBCL, Ann-Arbor stage IVs-A.

At diagnosis, the patient presented cervical lymphadenopathies and spleen involvement.A bone marrow (BM) biopsy revealed the presence of 25% infiltrate of lymphocytes in the context of normal hematopoiesis. She was classified with age-adjusted International Prognostic Index (IPI) (score 3) and central nervous system (CNS-IPI) (score 4) high risk score. The patient was treated with four cycles of rituximab, cyclophosphamide, adriamycin, vincristine, and prednisolone (R-CHOP), achieving a computed tomography complete response (CR).Subsequently, she received one course of consolidation chemotherapy with rituximab, mitoxantrone, cytarabine, and dexamethasone (R-MAD), and one course of high dose cytarabine with stem cell collection showing a metabolic CR according to the Lugano criteria.In April 2020, autologous stem cell transplantation (ASCT) was performed using FEAM (fotemustine, etoposide, cytarabine, and melphalan) as a conditioning regimen.In December 2020 the patient developed enlarged retroperitoneal lymph-nodes, a hypodense liver, and uterine lesions

According to background history and laboratory investigations, what is your differential diagnosis?

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  • C

    Are you referring to R-CVP (rituximab, cyclophosphamide, vincristine, prednisolone)? Did leukopenia result from the disease itself or from previous treatment? I'm not an oncologist, but perhaps the ESMO guidelines may help you - 

    https://www.esmo.org/guidelines/guidelines-by-topic/haematological-malignancies/chronic-lymphocytic-leukaemia 

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    • R

      I had to really laugh when I saw this because I started my career as a Pharmacist - back in the mid 50s.  This was just as BigPharma was getting rid of the 'friendly pharmacist' who spent untold hours compounding medications - and being paid a pittance for so doing - and the launch of 'ethicals' or brand name creations made by the drug houses, sold to pharmacies and peddled to doctors.  We really did not have a lot to choose from.  There were a few -illins, an few -mycins - a few -diazines - so 'reading the scrawl' wasn't so bad because Aureomycin didn't have any 'spike' like Achromycin - so if we could decipher the Au or Ac and the -mycin we would look to see if there was an up 'h' or a down 'y' and we were pretty safe.

      Who on earth is now able to decipher the -mabs, -mibs, -nibs, -nabs and all the other biologics??  Can you imagine trying to unravel the difference between pertuzumab and rituximab.  There are currently over 100 different -mabs around - growing daily.

      So now for a humorous story - if you'd like to read on.

      I was apprenticed to a Pharmacy in a low socioeconomic part of Pretoria - in South Africa.  Families were LARGE - very poorly educated - and glommed onto product names - refusing to budge.  So in those days the common 'cotton wool' was made by Johnson and Johnson and was referred to as J&J Cottonwool 1lb (it was 16 ounces).  Every family had several rolls of this in their homes.

      Being young at the time - only 15 years old - I was very careful to do everything right - and when I read each prescription I got used to seeing a Rx for J&J Cotton wool at the end of each Rx and duly handed one out every time.

      One day the Boss was watching me and was fascinated to see me giving EVERY PERSON a roll of cotton wool.  He asked me why and I told him at was at the end of each Rx.

      He nearly choked laughing.  The doctor in that area was Dr John James Commerford and his scrawl made his signature look like JJ Cottonwool lb.

      This followed me to University were I was fondly referred to as the J&J guy. :-)

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      • For your case, you need EMG/NCS, serum CK, muscle specific antibody panel including immune mediated necrotizing Ab level, muscle biopsy to see if there is actual myositis ?

        Otherwise, the DDx will be similar to any non-vaccinated patients who presents with myalgia .

        In Toronto, Canada; I had seen several cases of COVID-19 related GBS and inflammatory myositis following either Pfizer/Biontech or Moderna COVID-19 vaccine. For myositis, high dose steroids, IVIG and Rituximab were used to manage.

        Hope this helps ?

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