Abstract
Diffuse large B-cell lymphoma of the scalp with extra and intracranial extension without systemic invasion in a non-immune compromised patient is extremely rare. It should be considered in the differential diagnosis of scalp masses and meningeal lesions. Early diagnosis and surgical treatment is associated with a good outcome. 74 years old male patient with no known history of malignancy came to our clinic for left frontal swelling. He had no systemic cancer involvement. Contrast-enhanced cranial MRI showed a mass lesion invading left frontal skin, subcutaneous tissue, temporal muscle, bone and the underlying dural layer (Figure 1). Surgical excision was decided and after planning with the plastic surgery consultation, the patient was taken into surgery. Skin was lifted with a left frontal flap and the invasion was observed. Skin flap was placed down and the tumoral tissue was totally excised with a margin of normal bone tissue. The pathology assessment of the frozen specimen was found concordant with lymphoma. No injury or invasion of the dura was seen macroscopically. After dural closure, metacrilate cranioplasty was performed in order to replace the removed bone flap. Afterwards patient was handed over to the plastic surgeon. To ensure tumor resection with a safe margin, a transposition scalp flap was designed in the parieto-occipital region. The flap was raised in the supraperiosteal plane with preservation of the pericranium and it was transferred to the defect site. In addition, the flap donor area was reconstructed with a split-thickness skin graft taken from the right thigh region. Then, a wound dressing was applied to the surgical area and opened on postoperative 4th day. No complications such as necrosis, hematoma, infection or wound dehiscence occurred postoperatively. Both the graft and the flap completely healed (Figure 2). The patient showed no new neurological deficits or wound problems postoperatively and did not experience any problems both in plastic surgical and neurosurgical follow-up period (Figure 3). The final pathology result reported as diffuse large B cell lymphoma with invasion of the skin, subcutaneous tissue, temporal muscle and bone. Afterwards, medical treatment was planned with consultation to the hematology and radiotherapy clinics. Primary Non-Hodgkin’s lymphoma (NHL) extending extra cranially and intra cranially without any systemic or skeletal findings is extremely rare. These lesions usually get misdiagnosed as they mimic other conditions such as meningiomas. Both radiological and histopathological diagnoses are very important. Radical surgical resection and reconstruction must be contemplated in treatment and also chemotherapy and radiotherapy alternatives should be considered. Malignant NHL should be taken into account for differential diagnosis in the mass lesions of the scalp.
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