Primary and secondary bone lymphomas

doi:10.1016/j.ctrv.2015.02.001

Cancer Treatment Reviews

Volume 41, Issue 3, March 2015, Pages 235-246

https://doi.org/10.1016/j.ctrv.2015.02.001 Get rights and content

Highlights

•
Three clinical forms of bone lymphoma exist: the primary, the polyostotic and the secondary bone lymphoma.
•
Level of evidence supporting therapeutic decisions in these rare tumors is low, and prospective trials appear unrealistic.
•
This review is based on the analysis of the largest available database of bone lymphomas and of relevant literature.
•
We provide recommendations for diagnosis, staging and treatment of patients with bone lymphoma in everyday practice.
•
Special conditions like pathological fractures, indolent lymphomas and central nervous system prophylaxis are also discussed.

Abstract

Recent studies have contributed to the enhancement of clinical and molecular knowledge on bone lymphomas, a group of rare malignancies with particular characteristics. Nevertheless, several questions remain unanswered and the level of evidence supporting some diagnostic and therapeutic decisions remains low. Currently, three different forms of bone lymphomas can be distinguished: the primary bone lymphoma, consisting of a single bone lesion with or without regional lymphadenopathies; the polyostotic lymphoma, consisting of multifocal disease exclusively involving the skeleton; and the disseminated lymphoma with secondary infiltration of the skeleton. The first two forms exhibit a good prognosis, requiring treatments similar to those commonly used for nodal lymphomas of the same category, but several issues regarding the role of surgery and local control of the disease, the sequence of treatment, radiation volumes and doses, management of pathological fractures and prevention of late sequelae deserve particular attention. Due to its rarity, prospective trials exclusively focused on bone lymphomas appear unrealistic, thus, critical revision of our own experience and analyses of large cumulative series as well as molecular studies on archival cases remain valid alternatives to improve our knowledge on this obscure lymphoproliferative malignancy.

The present review is based on the analysis of the largest available database of bone lymphomas established under the sponsorship of the International Extranodal Lymphoma Study Group (IELSG) as well as on the critical revision of related literature. We provide recommendations for diagnosis, staging, treatment, and response assessment of these patients in everyday practice as well as for the management of special conditions like pathological fractures, indolent forms and central nervous system prophylaxis.

Introduction

Every lymphoma category can involve the skeleton, as an exclusive lesion or as a part of a disseminated disease. Although skeletal involvement is relatively common in non-Hodgkin lymphomas, the available literature on diagnostic and therapeutic management of primary bone lymphomas, that is lymphomas exclusively involving the skeleton, is sparse and fragmentary, mostly reported before worldwide use of rituximab and positron emission tomography (PET). The level of evidence supporting therapeutic decisions in primary bone lymphomas is very low as no prospective trials have been published. The relevant literature is almost exclusively constituted by small, retrospective series often furnishing conclusions on unreliable subgroup analyses, and with important interpretation biases due to stage migration and use of obsolete histopathological classifications. An additional bias regards the use of radiotherapy as exclusive treatment in unfit patients, whereas recent advances in supportive care have extended the number of patients treated with curative intent. As a consequence of these methodological caveats and the impossibility of conducting large prospective trials, several therapeutic questions remain open: the role of surgery and radiotherapy, the best radiation volumes and doses, the most effective chemoimmunotherapy combination, and prognostic factors, among others. In this complicated context, large, retrospective studies of cumulative, unselected series remain a valid tool to improve our knowledge on primary bone lymphomas.

This review is based on the analysis of the largest available database of bone lymphomas, established under the sponsorship of the International Extranodal Lymphoma Study Group (IELSG), as well as on the critical analysis of related literature. It provides recommendations for the diagnosis, staging, treatment, and response assessment of these patients, and addresses the management of special conditions like pathological fractures, indolent bone lymphomas and CNS dissemination risk in everyday practice.

Section snippets

Definition, incidence and epidemiology

Criteria used to define and classify primary bone lymphomas changed several times in the last decades. While there is general agreement that cases with a solitary lesion arising in a bone should be considered as a primary bone lymphomas, there is no consensus over the best categorization of cases with multifocal osseous disease or cases with concomitant soft tissue, visceral and/or lymph nodal infiltration [1], [2], [3], [4], [5]. In the previous version of the World Health Organization (WHO)

Clinical presentation

Table 1 summarizes the main patient characteristics at presentation reported in the largest available series of bone lymphomas [9], [26]. Although the tumour itself can affect fitness, particularly if it occurs in weight-bearing bones, most patients have ECOG performance status of 0–1. Pain is the most common presenting symptom (80–95%), tumour mass is present in 30–40% of cases and pathological fracture in 15–20%, with a mean duration of the period between symptoms and diagnosis of 8 months [11]

Diagnosis

A clinic-radiological suspicion of bone lymphoma must be confirmed by histopathological examination (morphological exam, immunohistochemistry and molecular analyses) of a diagnostic sample obtained by surgical procedure. This is mandatory to confirm lymphomatous nature and to define histotype since current knowledge and available radiologic tools do not allow a distinction among the different lymphoma categories involving the skeleton. Excision biopsy should be avoided; biopsies should be

Staging

Diagnostic tests and procedures in the initial work-up of patients with primary bone lymphomas are listed in Table 2. Stage of disease is defined according to the Ann Arbor staging system [71]. However, this staging system has some important limitations when attempting to analyze different stage subgroups and to compare reported studies. Based on their different prognosis and outcome (Fig. 1), the IELSG staging system has been proposed (Table 3), where bone lymphomas are classified into four

Prognosis

The survival of patients with primary bone DLBCL is significantly related to disease stage, with the 5-year overall survival (OS) varying from 82% for patients with stage-IE disease to 38% for patients with disseminated DLBCL and skeleton involvement (Fig. 1). In early-stage disease, relapses occur equally within and outside the primary sites of disease, with local and systemic relapse rate of 10% and 17%, respectively [72]. In polyostotic lymphomas, most relapses exclusively involve the

Stage IE-IIE DLBCL of the bone (or primary bone DLBCL)

Different strategies like chemotherapy, immunotherapy, surgery and radiotherapy have been used to treat primary bone DLBCL, a separate entity usually displaying favourable clinical features and good prognosis. The role of surgery in primary bone lymphomas is limited to sampling for histopathological diagnosis, stabilization and internal fixation of affected bone and resolution of pathological fracture (see below). The use of surgery instead of radiotherapy has been suggested in patients with

Response to treatment

Conventional radiologic and functional procedures exhibit limitations in the assessment of response to treatment in primary bone lymphomas patients; architectural osseous distortion can remain unchanged for many years in X-rays and CT scans, and residual uptake can persist in bone scintigraphy and ¹⁸FDG-PET (Fig. 2). Bone remodelling and artefacts due to stabilizing hardware complicate the assessment of local disease control; in particular, artefacts caused by intramedullary titanium rods

Late iatrogenic sequelae

Chronic pain, limb dysfunction and late pathological fracture are the most common iatrogenic sequelae in patients with bone lymphoma. The involvement of the femur, pelvis and the spine is more commonly associated with chronic symptoms, and a second pathological fracture after anti-lymphoma treatment has been recorded in 10% of patients with secondary bone DLBCL [75]. Such fractures can occur in the absence of local recurrence and can lead to persisting non-union with subsequent disability,

Conflict of Interest

The authors declared no conflict of interest.

References (134)

R.K. Fairbanks et al.
Treatment of stage IE primary lymphoma of bone
Int J Radiat Oncol Biol Phys
(1994)
N.G. Mikhaeel
Primary bone lymphoma
Clin Oncol (R Coll Radiol)
(2012)
W.G. Maxymiw et al.
Primary multifocal non-Hodgkin’s lymphoma of the jaws presenting as periodontal disease in a renal transplant patient
Int J Oral Maxillofac Surg
(1991)
K.M. Ramadan et al.
A clinicopathological retrospective study of 131 patients with primary bone lymphoma: a population-based study of successively treated cohorts from the British Columbia Cancer Agency
Ann Oncol
(2007)
P. Seam et al.
The role of F-FDG-PET scans in patients with lymphoma
Blood
(2007)
D.J. Theodorou et al.
Delayed diagnosis of primary non-Hodgkin’s lymphoma of the sacrum
Clin Imaging
(2000)
T. Akahane et al.
Serum soluble interleukin-2 receptor levels in patients with malignant lymphoma of bone
J Orthop Sci
(2009)
D. Huebner-Chan et al.
An immunophenotypic and molecular study of primary large B-cell lymphoma of bone
Mod Pathol
(2001)
B. Falini et al.
A monoclonal antibody (MUM1p) detects expression of the MUM1/IRF4 protein in a subset of germinal center B cells, plasma cells, and activated T cells
Blood
(2000)
J.Z. Huang et al.
The t(14;18) defines a unique subset of diffuse large B-cell lymphoma with a germinal center B-cell gene expression profile
Blood
(2002)

L. Cai et al.

Early-stage primary bone lymphoma: a retrospective, multicenter rare cancer network (RCN) study

Int J Radiat Oncol Biol Phys

(2012)

S. Govi et al.

The clinical features, management and prognostic effects of pathological fractures in a multicenter series of 373 patients with diffuse large B-cell lymphoma of the bone

Ann Oncol

(2014)

E. Barbieri et al.

Primary non-Hodgkin’s lymphoma of the bone: treatment and analysis of prognostic factors for stage I and II

Int J Radiat Oncol Biol Phys

(2004)

H. Adams et al.

Primary diffuse large B-cell lymphomas of the bone: prognostic relevance of protein expression and clinical factors

Hum Pathol

(2008)

R. Suzuki et al.

Prognostic significance of CD56 expression for ALK-positive and ALK-negative anaplastic large-cell lymphoma of T/null cell phenotype

Blood

(2000)

C. Pellegrini et al.

Primary bone lymphoma: evaluation of chemoimmunotherapy as front-line treatment in 21 patients

Clin Lymphoma Myeloma Leuk

(2011)

M. Rieger et al.

Primary mediastinal B-cell lymphoma treated with CHOP-like chemotherapy with or without rituximab: results of the Mabthera International Trial Group study

Ann Oncol

(2011)

L. Lowry et al.

Reduced dose radiotherapy for local control in non-Hodgkin lymphoma: a randomised phase III trial

Radiother Oncol

(2011)

K. Beal et al.

Primary bone lymphoma: treatment results and prognostic factors with long-term follow-up of 82 patients

Cancer

(2006)

S. Desai et al.

Primary lymphoma of bone: a clinico-pathologic study of 25 cases reported over 10 years

J Surg Oncol

(1991)

M. Ostrowski et al.

Malignant lymphoma of bone

Cancer

(1986)

A.J. Rathmell et al.

Localised lymphoma of bone: prognostic factors and treatment recommendations. The Princess Margaret Hospital Lymphoma Group

Br J Cancer

(1992)

C.D.M. Fletcher et al.

Pathology and genetics of tumours of soft tissue and bone

(2002)

C.D.M. Fletcher

The evolving classification of soft tissue tumours: an update based on the new WHO classification

Histopathology

(2006)

C.D.M. Fletcher et al.

World health organization classification of tumours of soft tissue and bone

(2013)

C. Messina et al.

Clinical features, management and prognosis of multifocal primary bone lymphoma: a retrospective study of the international Extranodal Lymphoma Study Group (the IELSG 14 study)

Br J Haematol

(2014)

D. Limb et al.

Primary lymphoma of bone

Int Orthop

(1994)

N.A. Bakshi et al.

ALK-positive anaplastic large cell lymphoma with primary bone involvement in children

Am J Clin Pathol

(2006)

A. Qureshi et al.

Primary non-Hodgkin’s lymphoma of bone: experience of a decade

Indian J Pathol Microbiol

(2010)

X.F. Zhao et al.

Pediatric primary bone lymphomas – diffuse large B-cell lymphoma: morphologic and immunohistochemical characteristics of 10 cases

Am J Clin Pathol

(2007)

N.V. Sipsas et al.

Extranodal non-Hodgkin lymphoma presenting as a soft tissue mass in the proximal femur in a HIV⁺ patient

Leuk Lymphoma

(2002)

M.M. Thurnher et al.

Malignant lymphoma of the cranial vault in an HIV-positive patient: imaging findings

Eur Radiol

(2001)

H. Kobayashi et al.

Malignant lymphoma of the bone associated with systemic sarcoidosis

Intern Med

(2001)

P. Bohm et al.

Adult Gaucher disease in association with primary malignant bone tumors

Cancer

(2001)

M. Manz et al.

High grade lymphoma mimicking bone crisis in Gaucher’s disease

Br J Haematol

(2001)

K. Neben et al.

A man with hereditary exostoses and high grade non-Hodgkin’s lymphoma of the bone

Ann Hematol

(2001)

G.C. Stephens et al.

Primary lymphoma and Paget’s disease of the femur

AJCP

(1994)

H. Ito et al.

Malignant lymphoma at the site of a total hip replacement

Orthopaedics

(1999)

A.A. Syed et al.

Osseous malignant non-Hodgkin’s B-cell Lymphoma associated with total hip replacement

Leuk Lymphoma

(2002)

T. Robak et al.

Richter’s syndrome following cladribine therapy for chronic lymphocytic leukemia first manifested as pathological fracture of the femur

Leuk Lymphoma

(2001)

M. Bruno Ventre et al.

Clinical features, management and prognosis of an international series of 161 patients with limited-stage diffuse large B-cell lymphoma of the bone (the IELSG-14 study)

Oncologist

(2014)

J.M. Horsman et al.

Primary bone lymphoma: a retrospective analysis

Int J Oncol

(2006)

H. Shoji et al.

Primary reticulum cell sarcoma of bone – significance of clinical features upon the prognosis

Cancer

(1971)

D. Marayuma et al.

Primary bone lymphoma: a new and detailed characterization of 28 patients in a single-institution study

Jpn J Clin Oncol

(2007)

W.C. Phillips et al.

Primary lymphoma of bone: relationship of radiographic appearance and prognosis

Radiology

(1982)

M.E. Mulligan et al.

Sequestra in primary lymphoma of bone: prevalence and radiologic features

AJR

(1993)

D. Hicks et al.

Primary lymphoma of bone. Correlation of magnetic resonance imaging features with cytokine production by tumour cells

Cancer

(1995)

R. Stiglbauer et al.

MRI in the diagnosis of primary lymphoma of bone: correlation with histopathology

J Comput Assist Tomogr

(1992)

A. Krishnan et al.

Primary bone lymphoma: radiographic-MR imaging correlation

Radiographics

(2003)

P.D. Humphries et al.

Tumors in pediatric patients at diffusion-weighted MR imaging: apparent diffusion coefficient and tumor cellularity

Radiology

(2007)

Cited by (83)

Follicular Lymphoma Presenting With Symptomatic Bone Involvement: A Clinicopathologic and Molecular Analysis of 16 Cases
2024, Modern Pathology
Primary bone lymphoma (PBL) is rare and mostly represented by diffuse large B-cell lymphomas (DLBCL). Follicular lymphoma (FL), albeit commonly disseminating to the bone marrow, rarely presents primarily as bone lesions. Here, we studied 16 patients (12 men:4 women, median age 60 years) who presented with bone pain and/or skeletal radiologic abnormalities revealing bone FL. Lesions were multifocal in 11 patients (spine ± appendicular skeleton), and unifocal in 5 patients (femoral, tibial, or vertebral). An infiltrate of centrocytes and centroblasts (CD20+ CD5− CD10+ BCL2+ BCL6+) with abundant reactive T cells and an increased reticulin fibrosis massively replaced the marrow spaces between preserved bone trabeculae. The pattern was diffuse ± nodular, often with paratrabecular reinforcement and/or peripheral paratrabecular extension. Ki-67 was usually <15%. Two cases had necrosis. BCL2 rearrangement was demonstrated in 14 of 14 evaluable cases (with concomitant BCL6 rearrangement in one). High-throughput sequencing revealed BCL2, KMT2D, and TNFRSF14 to be the most frequently mutated genes. After staging, 5 qualified for PBL (3 limited stage) and 11 had stage IV systemic FL. All patients received rituximab ± polychemotherapy as firstline treatment, and 7 received local therapy (6 radiotherapy and 2 surgery). Three patients experienced transformation to DLBCL. At the last follow-up (15/16, median 48 months), 11 patients achieved complete remission, including all cases with PBL and most patients with limited extraosseous disease (3-year progression-free survival 71%). One patient died of unrelated cause (3-year overall survival 91%). FL may manifest as a localized or polyostotic bone disease. A minority represent PBL, whereas most reveal systemic disease.
Primary B cell lymphoma of the patella presenting as anterior knee pain: A case report
2024, Journal of Orthopaedics
A 76-year-old female with a history of multiple falls on the patella presented with worsening knee pain, swelling, and reduced range of motion. Radiographs revealed tricompartmental osteoarthritis and subtle erosion of the posterior cortex of the patella that was missed by the referring orthopedist and radiologist. Her persistent pain prompted an MRI, revealing a mass later confirmed to be primary diffuse large B-cell lymphoma of the patella after biopsy and appropriate metastatic workup.
Primary B-cell patellar lymphoma is a rarely described cause of knee pain requiring broad differential diagnosis and multidisciplinary workup in order to avoid erroneous treatment and ensure prompt oncologic treatment.
Comparison of the Effect of Chemoradiotherapy and Chemotherapy on the Survival of Patients with Primary Diffuse Large B-Cell Lymphoma of the Spine: A SEER-Based Study
2023, World Neurosurgery
The role of radiotherapy in primary spinal diffuse large B-cell lymphoma (PB-DLBCL) remains controversial. This study explored the effects of chemoradiotherapy and chemotherapy alone on the survival of patients with PB-DLBCL and established an instructive nomogram.
Survival analysis using the Kaplan-Meier method and log-rank test was performed for patients diagnosed with PB-DLBCL from 1983 to 2016, identified in the Surveillance Epidemiology and End Results database. The Cox regression model was used to analyze the effects of each variable on the overall survival (OS) and construct a nomogram for predicting OS in patients.
Overall, 873 patients with PB-DLBCL were included. The patients were divided into the 1983–2001 (227 [26%]) and 2002–2016 (646 [74%]) groups. The 5-and 10-year OS rates of patients with PB-DLBCL in the 2002–2016 group were 62.8% and 49.9%, respectively. The results of the multivariate Cox regression analysis in the 2002–2016 group showed that age, stage, marriage, and treatment strategy were independent prognostic factors. Kaplan-Meier analysis showed that the OS of patients who underwent chemoradiotherapy from 2002 to 2016 was significantly better than that of patients treated with chemotherapy alone. Further subgroup analysis of patients with different stages of DLBCL and at different ages showed that chemoradiotherapy had a better prognosis than chemotherapy alone in stages I–II and age >60 years, whereas the advantages of chemoradiotherapy were not reflected in stages III–IV and age <60 years.
Chemoradiotherapy improves the OS of patients with PB-DLBCL who are aged >60 years or have stage I–II disease. The nomograms established in this study can help clinicians determine prognosis and select treatment strategies.
Frequent mutated B2M, EZH2, IRF8, and TNFRSF14 in primary bone diffuse large B-cell lymphoma reflect a GCB phenotype
2021, Blood Advances
Citation Excerpt :
In addition, focusing on 19 disseminated-DLBCL cases with bulky osseous disease (Figure 3), comparable mutational profiles as PB-DLBCL were identified with high frequencies of mutations in B2M (16%), EZH2 (26%), IRF8 (21%), and TNFRSF14 (42%), suggesting that this lymphoma originated in bone. Consistent with the prognostic importance of International Extranodal Lymphoma Study Group staging,2 PB-DLBCL and polyostotic-DLBCL showed superior PFS/OS (P = .011/P = .042) (Figure 5A-B), compared with disseminated-DLBCL, with 3-year OS rates of 91% (95% CI, 0.83-1.00), 100% (95% CI, 1.00-1.00), and 77% (95% CI, 0.64-0.90), respectively. No significant difference in PFS/OS was observed for extranodal, nodal, and mixed NO-DLBCL-GCB subentities (Figure 5C-D).
Primary bone diffuse large B-cell lymphoma (PB-DLBCL) is a rare extranodal lymphoma subtype. This retrospective study elucidates the currently unknown genetic background of a large clinically well-annotated cohort of DLBCL with osseous localizations (O-DLBCL), including PB-DLBCL. A total of 103 patients with O-DLBCL were included and compared with 63 (extra)nodal non-osseous (NO)-DLBCLs with germinal center B-cell phenotype (NO-DLBCL-GCB). Cell-of-origin was determined by immunohistochemistry and gene-expression profiling (GEP) using (extended)-NanoString/Lymph2Cx analysis. Mutational profiles were identified with targeted next-generation deep sequencing, including 52 B-cell lymphoma-relevant genes. O-DLBCLs, including 34 PB-DLBCLs, were predominantly classified as GCB phenotype based on immunohistochemistry (74%) and NanoString analysis (88%). Unsupervised hierarchical clustering of an extended-NanoString/Lymph2Cx revealed significantly different GEP clusters for PB-DLBCL as opposed to NO-DLBCL-GCB (P < .001). Expression levels of 23 genes of 2 different targeted GEP panels indicated a centrocyte-like phenotype for PB-DLBCL, whereas NO-DLBCL-GCB exhibited a centroblast-like constitution. PB-DLBCL had significantly more frequent mutations in four GCB-associated genes (ie, B2M, EZH2, IRF8, TNFRSF14) compared with NO-DLBCL-GCB (P = .031, P = .010, P = .047, and P = .003, respectively). PB-DLBCL, with its corresponding specific mutational profile, was significantly associated with a superior survival compared with equivalent Ann Arbor limited-stage I/II NO-DLBCL-GCB (P = .016). This study is the first to show that PB-DLBCL is characterized by a GCB phenotype, with a centrocyte-like GEP pattern and a GCB-associated mutational profile (both involved in immune surveillance) and a favorable prognosis. These novel biology-associated features provide evidence that PB-DLBCL represents a distinct extranodal DLBCL entity, and its specific mutational landscape offers potential for targeted therapies (eg, EZH2 inhibitors).
Primary Bone Lymphoma of the Scapula
2024, Hematology Reports
Diffuse large B-cell lymphoma involving osseous sites: utility of response assessment by PET/CT and good long-term outcomes
2024, Haematologica

View all citing articles on Scopus

¹: International Extranodal Lymphoma Study Group.

View full text

Tumour ReviewPrimary and secondary bone lymphomas

Highlights

Abstract

Introduction

Section snippets

Definition, incidence and epidemiology

Clinical presentation

Diagnosis

Staging

Prognosis

Stage IE-IIE DLBCL of the bone (or primary bone DLBCL)

Response to treatment

Late iatrogenic sequelae

Conflict of Interest

Int J Radiat Oncol Biol Phys

Clin Oncol (R Coll Radiol)

Int J Oral Maxillofac Surg

Ann Oncol

Blood

Clin Imaging

J Orthop Sci

Mod Pathol

Blood

Blood

Int J Radiat Oncol Biol Phys

Ann Oncol

Int J Radiat Oncol Biol Phys

Hum Pathol

Blood

Clin Lymphoma Myeloma Leuk

Ann Oncol

Radiother Oncol

Primary bone lymphoma: treatment results and prognostic factors with long-term follow-up of 82 patients

Cancer

Primary lymphoma of bone: a clinico-pathologic study of 25 cases reported over 10 years

J Surg Oncol

Malignant lymphoma of bone

Cancer

Localised lymphoma of bone: prognostic factors and treatment recommendations. The Princess Margaret Hospital Lymphoma Group

Br J Cancer

Pathology and genetics of tumours of soft tissue and bone

The evolving classification of soft tissue tumours: an update based on the new WHO classification

Histopathology

World health organization classification of tumours of soft tissue and bone

Clinical features, management and prognosis of multifocal primary bone lymphoma: a retrospective study of the international Extranodal Lymphoma Study Group (the IELSG 14 study)

Br J Haematol

Primary lymphoma of bone

Int Orthop

ALK-positive anaplastic large cell lymphoma with primary bone involvement in children

Am J Clin Pathol

Primary non-Hodgkin’s lymphoma of bone: experience of a decade

Indian J Pathol Microbiol

Pediatric primary bone lymphomas – diffuse large B-cell lymphoma: morphologic and immunohistochemical characteristics of 10 cases

Am J Clin Pathol

Extranodal non-Hodgkin lymphoma presenting as a soft tissue mass in the proximal femur in a HIV+ patient

Leuk Lymphoma

Malignant lymphoma of the cranial vault in an HIV-positive patient: imaging findings

Eur Radiol

Malignant lymphoma of the bone associated with systemic sarcoidosis

Intern Med

Adult Gaucher disease in association with primary malignant bone tumors

Cancer

High grade lymphoma mimicking bone crisis in Gaucher’s disease

Br J Haematol

A man with hereditary exostoses and high grade non-Hodgkin’s lymphoma of the bone

Ann Hematol

Primary lymphoma and Paget’s disease of the femur

AJCP

Malignant lymphoma at the site of a total hip replacement

Orthopaedics

Osseous malignant non-Hodgkin’s B-cell Lymphoma associated with total hip replacement

Leuk Lymphoma

Richter’s syndrome following cladribine therapy for chronic lymphocytic leukemia first manifested as pathological fracture of the femur

Leuk Lymphoma

Clinical features, management and prognosis of an international series of 161 patients with limited-stage diffuse large B-cell lymphoma of the bone (the IELSG-14 study)

Oncologist

Primary bone lymphoma: a retrospective analysis

Int J Oncol

Primary reticulum cell sarcoma of bone – significance of clinical features upon the prognosis

Cancer

Tumour Review
Primary and secondary bone lymphomas

Extranodal non-Hodgkin lymphoma presenting as a soft tissue mass in the proximal femur in a HIV⁺ patient