Calcification in splenic lymphoma before chemotherapy.

To the Editor: An 18-year-old student was evaluated for generalized lymphadenopathy with unexplained weight loss. Diffuse large B cell lymphoma was confirmed by pathologic examination of the neck lymph nodes. Further systemic evaluation by computed tomography disclosed extensive submental, subaxillary, mediastinal, and paraaortic lymph node enlargement and a tumor in the liver as well as a huge spleen with marked diffuse, amorphous calcification (Fig. 1). Laboratory analysis revealed a slightly elevated lactate dehydrogenase level of 769 U/L and normal serum alanine transaminase, alkaline phosphatase, bilimbin, and calcium. The patient reported no prior splenic trauma or chronic granulomatous infection. Viral studies did not yield significant results, except that the patient was a hepatitis B virus carrier. After undergoing six courses of chemotherapy with eyclophosphamide, doxorubicin, vincristine, and prednisone therapy, he experienced complete remission. The follow-up abdominal computed tomographic scan showed a normal-sized spleen with apparent condensing foci of calcification (Fig. 2). The patient remained free of lymphoma at the 7-year follow-up visit.

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Calcification within the spleen parenchyma has many different causes, such as phlebolith, hemangioma, and hematoma. (1) More diffuse calcification may be associated with tuberculosis, histoplasmosis, Pneumocystis infection, or splenic infarction, as is seen in patients with sickle cell anemia. (2) Lymphomatous tissue calcifies in approximately 2% of the cases, typically at least 8 months after the patient undergoes chemo- or radiotherapy. Several causes of calcification in lymphoma have been postulated, such as disordered calcium metabolism, parenchymal hemorrhage, and infarction. Diffuse calcification is exceedingly rare in patients with splenic lymphoma before they undergo chemotherapy. (3) Pretreatment calcification in both Hodgkin's and non-Hodgkin's lymphoma has been reported and is often associated with hypercalcemia. (4) Our patient presented with diffuse splenic calcification with normocalcemia before undergoing chemotherapy. Diagnoses other than lymphoma traditionally have been made when calcification within the spleen or a mediastihal or retroperitoneal mass have been seen. On the basis of the literature published to date, the possibility of lymphoma should not be excluded merely because of calcification.

References

(1.) Freeman JL, Jafri SZ, Roberts JL, et al. CT of congenital and acquired abnormalities of the spleen. Radiographics 1993;13:597-610.

(2.) Moody AR, King DM. Splenic calcification following treatment of Hodgkin's disease. Br J Radiol 1991;64:55-56.

(3.) Panicek DM, Harry MP, Scicutella CJ, et al. Calcification in untreated mediastinal lymphoma. Radiology 1988;166:735-736.

(4.) Lautin EM, Rosenblatt M, Friedman AC, et al. Calcification in non-Hodgkin lymphoma occurring before therapy: Identification on plain films and CT. AJR Am J Roentgenol 1990;155:739-740.

Ming-Shen Dai, MD

Tsu-Yi Chao, MD, PhD

Hematology/Oncology Division

Department of Medicine

Chih-Yung Yu, MD

Department of Radiology

Tri-Service General Hospital

National Defense Medical Center

Taipei, Taiwan