Discussion:
DLBCL is a non-Hodgkin lymphoma (NHL) and constitute about a third of
all NHL lymphomas.2,3 DLBCL is
further divided into two categories - germinal cell or non-germinal
center type which has prognostic implications but not
therapeutic.4 Presentation at stage 3 or 4 at the time
of diagnosis is commonly seen.4 In morbidly obese
patients with thick neck, lymph node examination is significantly
challenging whether axillary, inguinal, or cervical nodes. Subcutaneous
fatty tissue nodules are common in obese patients which frequently
puzzles clinicians. Careful examination in our patient revealed lymph
nodes in the neck which eventually proved to be the diagnostic clue and
unveiled the whole disease process. As her PET-CT was negative for
supraclavicular lymphadenopathy 5 months ago, it is likely that our
patient developed this recently. The superficial lymphadenopathy was the
cornerstone in reaching to the final diagnosis in our case. Another
important fact to remember is the relative ease of obtaining superficial
lymph node biopsy and preferably performing excisional lymph node biopsy
when lymphoma is suspected.4 A simple but effective
examination technique by medical student proved immensely beneficial
from patient care standpoint in our case. Due to high peri-procedural
risk in morbidly obese patients, a surgical biopsy of lung masses under
general anesthesia can be challenging. Recommended first line therapy is
R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin, Vincristine,
and prednisone).4 Benign residual masses after
treatment completion are common. Prognosis is poor without treatment,
but cure rate is as high as 90% in treated patients.5Our patient went into cardiac arrest during mediastinal biopsy, where
procedure had to be aborted and confirmative diagnosis was delayed. In
future, authors recommend, focus should also be paid in developing
improved protocols to attain mediastinal biopsy in morbidly obese
patients who are at high risk for peri-procedural complications.