Case Report

Presenting a case of primary splenic diffuse large B-cell lymphoma

Ehsani M1,2*‚ Moeeni M3

1- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, I. R. Iran.
Downloaded from feyz.kaums.ac.ir at 0:01 +0430 on Wednesday May 5th 2021

2- Department of Internal Medicine‚ Faculty of Medicine‚ Kashan University of Medical Sciences, Kashan,
I. R. Iran.
3- Student Research Committee‚ Kashan University of Medical Sciences, Kashan, I. R. Iran.

Received, June 20, 2015; Accepted, October 19, 2015

Abstract:

Background: Primary splenic lymphoma approximately comprises 2% of all Non-

Hodgkin’s lymphomas. Diffuse large B cell lymphoma, a rare disease, is responsible for
33% of primary splenic lymphomas. In this study a case of primary splenic diffuse large B-
cell lymphoma is reported.
Case Report: The case is a 57 years old woman admitted because of weakness‚ malaise‚
abdominal fullness‚ early satiety and weight loss and no lymphadenopathy. Except for huge
splenomegaly, no significant finding was found on her physical examination.
No positive finding was found for infections and inflammatory diseases in virology and
serology tests. Bone marrow aspiration and biopsy were hypercellular. Except for huge
spelenomegaly, central lymphadenopathy was not seen in chest and abdominopelvic CT.
The patient had anemia‚ elevated ESR‚ CRP‚ and LDH.
Based on findings, a diagnostic-therapeutic splenectomy was planed. Pathology tests
reported a non-hodgkin’s diffuse large B cell lymphoma with a positive CD20 in
mmunohistochemistry. Following spelenectomy the patient received chemotherapy (R-
CHOP) regimen.
Conclusion: In classical approach to splenomegaly, after ruling out any common causes‚
primary splenic lymphoma must be kept in mind. Splenectomy in these patients is
considered not only as a diagnostic‚ but also a therapeutic attempt.

Keywords: Splenic lymphoma, Non-hodgkin’s lymphoma, Diffuse large B cell lymphoma

* Corresponding Author.
Email: ehsanimajid21@gmail.com
Tel: 0098 912 330 6384
Fax: 0098 315 554 8900 Conflict of Interests: No
Feyz, Journal of Kashan University of Medical Sciences, April, 2016; Vol. 20, No 1, Pages 96-99

Please cite this article as: Ehsani M‚ Moeeni M. Presenting a case of primary splenic diffuse large B-cell lymphoma. Feyz 2016; 20(1):
96-9.

96
 ‫ﻣﻌﺮﻓﻲ ﻳﻚ ﻣﻮرد ﻟﻨﻔﻮم ﻃﺤﺎﻟﻲ اوﻟﻴﻪ از ﻧﻮع ﺳﻠﻮل ﺑﺰرگ ﻣﻨﺘﺸﺮ ‪B‬‬

‫‪3‬‬ ‫‪1‬و‪*2‬‬
‫‪ ،‬ﻣﺴﻌﻮد ﻣﻌﻴﻨﻲ‬ ‫ﻣﺠﻴﺪ اﺣﺴﺎﻧﻲ‬
‫ﺧﻼﺻﻪ‪:‬‬
‫ﺳﺎﺑﻘﻪ و ﻫﺪف‪ :‬ﻟﻨﻔﻮم اوﻟﻴﻪ ﻃﺤﺎﻟﻲ ﺣﺪود ‪ 2‬درﺻﺪ ﺗﻤﺎﻣﻲ ﻓﺮمﻫﺎي ﻏﻴﺮﻫﻮﭼﻜﻴﻦ ﻟﻨﻔﻮم را ﺷﺎﻣﻞ ﻣﻲﺷﻮد‪ 33 .‬درﺻﺪ ﻟﻨﻔﻮمﻫﺎي اوﻟﻴﻪ ﻃﺤﺎﻟﻲ‬
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‫)‪ 0/66‬درﺻﺪ ﻛﻞ ﻟﻨﻔﻮمﻫﺎي ﻏﻴﺮﻫﻮﭼﻜﻴﻦ( از ﻧﻮع ﻟﻨﻔﻮم ﻣﻨﺘﺸﺮ ﺳﻠﻮلﻫﺎي ﺑﺰرگ ‪ (Diffuse large B cell lymphomas) B‬ﻣﻲﺑﺎﺷﺪ ﻛﻪ‬
‫ﻳﻚ ﺑﻴﻤﺎري ﻧﺎدر اﺳﺖ‪ .‬در اﻳﻨﺠﺎ ﻳﻚ ﻣﻮرد ﻟﻨﻔﻮم ﻃﺤﺎﻟﻲ اوﻟﻴﻪ از ﻧﻮع ﺳﻠﻮل ﺑﺰرگ ﻣﻨﺘﺸﺮ ‪ B‬ﮔﺰارش ﻣﻲﺷﻮد‪.‬‬
‫ﻣﻌﺮﻓﻲ ﺑﻴﻤﺎر‪ :‬ﺑﻴﻤﺎر ﺧﺎﻧﻢ ‪ 57‬ﺳﺎﻟﻪاﻳﻲ اﺳﺖ ﻛﻪ ﺑﺎ ﺿﻌﻒ و ﺑﻲﺣﺎﻟﻲ‪ ،‬اﺣﺴﺎس ﭘﺮي ﺷﻜﻢ‪ ،‬ﺳﻴﺮي زودرس‪ ،‬و ﻛﺎﻫﺶ وزن ﻣﺮاﺟﻌﻪ ﻛﺮده و‬
‫در ﻣﻌﺎﻳﻨﻪ ﻟﻨﻔﺎدﻧﻮﭘﺎﺗﻲ ﻧﺪاﺷﺖ و ﺑﻪﺟﺰ اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ ﻧﻜﺘﻪ دﻳﮕﺮي ﻣﺸﺎﻫﺪه ﻧﺸﺪ‪ .‬در ﺑﺮرﺳﻲﻫﺎي اﻧﺠﺎم ﺷﺪه ﺑﺎ آزﻣﺎﻳﺸﺎت وﻳﺮوﻟﻮژي و‬
‫ﺳﺮوﻟﻮژي ﻧﻜﺘﻪ ﻣﺜﺒﺘﻲ ﺑﻪ ﻧﻔﻊ ﺑﻴﻤﺎريﻫﺎي ﻋﻔﻮﻧﻲ و اﻟﺘﻬﺎﺑﻲ ﻳﺎﻓﺖ ﻧﺸﺪ‪ .‬آﺳﭙﻴﺮاﺳﻴﻮن ﻣﻐﺰ اﺳﺘﺨﻮان ﭘﺮﺳﻠﻮﻟﻲ را ﻧﺸﺎن داد و در ﺳﻲﺗﻲ اﺳﻜﻦ‬
‫ﻗﻔﺴﻪ ﺳﻴﻨﻪ‪ ،‬ﺷﻜﻢ و ﻟﮕﻦ ﻟﻨﻔﺎدﻧﻮﭘﺎﺗﻲ ﻣﺮﻛﺰي ﻳﺎﻓﺖ ﻧﺸﺪ و ﻓﻘﻂ اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ ﺷﺪﻳﺪ دﻳﺪه ﺷﺪ‪ .‬ﺑﻴﻤﺎر آﻧﻤﻲ ﻟﻜﻮﭘﻨﻲ‪ CRP ،ESR ،‬و ‪LDH‬‬
‫اﻓﺰاﻳﺶ ﻳﺎﻓﺘﻪ داﺷﺖ‪ .‬ﺑﺎﺗﻮﺟﻪ ﺑﻪ ﻧﺘﺎﻳﺞ ﺑﺮرﺳﻲﻫﺎ‪ ،‬ﺑﻴﻤﺎر ﺗﺤﺖ اﺳﭙﻠﻨﻜﺘﻮﻣﻲ ﺗﺸﺨﻴﺼﻲ‪-‬درﻣﺎﻧﻲ ﻗﺮار ﮔﺮﻓﺖ و ﭘﺎﺗﻮﻟﻮژي ﻟﻨﻔﻮم ﻃﺤﺎﻟﻲ ﻏﻴﺮ‪-‬‬
‫ﻫﻮﭼﻜﻴﻦ از ﻧﻮع ﺳﻠﻮلﻫﺎي ﺑﺰرگ ﻣﻨﺘﺸﺮ ‪ B‬را ﮔﺰارش ﻛﺮد ﻛﻪ در ﺑﺮرﺳﻲ ‪ IHC‬ﻧﻴﺰ ‪ CD20‬ﻣﺜﺒﺖ داﺷﺖ‪ .‬ﺑﻴﻤﺎر ﭘﺲ از ﺟﺮاﺣﻲ ﺑﺎ‬
‫ﻛﻤﻮﺗﺮاﭘﻲ )رژﻳﻢ ‪ (R-CHOP‬ﺗﺤﺖ درﻣﺎن ﻗﺮار ﮔﺮﻓﺖ‪.‬‬
‫ﻧﺘﻴﺠﻪﮔﻴﺮي‪ :‬در ﺑﺮرﺳﻲﻫﺎي ﻋﻠﻞ اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ ﭘﺲ از رد ﺳﺎﻳﺮ ﻋﻠﻞ ﺷﺎﻳﻊ در روﻳﻜﺮد ﻛﻼﺳﻴﻚ ﺑﺎﻳﺪ ﻟﻨﻔﻮم اوﻟﻴﻪ ﻃﺤﺎﻟﻲ ﻣﺪﻧﻈﺮ ﺑﺎﺷﺪ‪.‬‬
‫ﻃﺤﺎﻟﻲ ﺑﺮداري در اﻳﻦ ﺑﻴﻤﺎران ﻧﻪﺗﻨﻬﺎ ﻳﻚ اﻗﺪام ﺗﺸﺨﻴﺼﻲ ﺑﻠﻜﻪ ﻳﻚ اﻗﺪام درﻣﺎﻧﻲ ﻧﻴﺰ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫واژﮔﺎنﻛﻠﻴﺪي‪ :‬ﻟﻨﻔﻮم ﻃﺤﺎﻟﻲ‪ ،‬ﻟﻨﻔﻮم ﻏﻴﺮﻫﻮﭼﻜﻴﻦ‪ ،‬ﺳﻠﻮل ﺑﺰرگ ﻣﻨﺘﺸﺮ ‪B‬‬
‫دو ﻣﺎهﻧﺎﻣﻪ ﻋﻠﻤﻲ– ﭘﮋوﻫﺸﻲ ﻓﻴﺾ‪ ،‬دوره ﺑﻴﺴﺘﻢ‪ ،‬ﺷﻤﺎره ‪ ،1‬ﻓﺮوردﻳﻦ و اردﻳﺒﻬﺸﺖ ‪ ،1395‬ﺻﻔﺤﺎت ‪  96-99‬‬

‫ﺑﻴﻤﺎر ﻫﻢﭼﻨﻴﻦ از ﭘﺮي ﺷﻜﻢ و ﺳﻴﺮي زودرس ﻧﻴﺰ ﺷﺎﻛﻲ ﺑﻮد‪ .‬ﺑﻴﻤﺎر‬
‫در دو ﻣﺎه ﻗﺒﻞ از ﻣﺮاﺟﻌﻪ ﺣﺪود ‪ 5‬ﻛﻴﻠﻮﮔﺮم ﻛﺎﻫﺶ وزن را ذﻛﺮ‬
‫ﻣﻲﻛﺮد‪ ،‬وﻟﻲ ﻋﻼﻳﻤﻲ از اﺳﻬﺎل و ﻳﺒﻮﺳﺖ‪ ،‬درد ﺷﻜﻢ‪ ،‬و ﺧﻮﻧﺮﻳﺰي‬
‫ﮔﻮارﺷﻲ را ذﻛﺮ ﻧﻤﻲﻧﻤﻮد‪ .‬ﺑﻴﻤﺎر ﻫﻢﭼﻨﻴﻦ از ﺗﻌﺮﻳﻖ ﺳﺮد و ﺗﺐ و‬
‫ﻟﺮز ﺷﺎﻛﻲ ﺑﻮد‪ .‬ﺑﻴﻤﺎر ﺗﺎرﻳﺨﭽﻪ ﭘﺰﺷﻜﻲ ﺧﺎﺻﻲ را ﻗﺒﻞ از اﻳﻦ‪40‬‬
‫روز ذﻛﺮ ﻧﻤﻲﻛﺮد و ﺳﺎﺑﻘﻪ ﺑﺴﺘﺮي در ﺑﻴﻤﺎرﺳﺘﺎن را ﻧﺪاﺷﺖ‪ .‬در اﻳﻦ‬
‫ﻣﺪت ﺑﻪ ﭘﺰﺷﻚ ﻣﺮاﺟﻌﻪ ﻧﻜﺮده و داروﻳﻲ ﻧﻴﺰ ﻣﺼﺮف ﻧﻜﺮده ﺑﻮد‪.‬‬
‫ﺑﻴﻤﺎر ﻫﻢﭼﻨﻴﻦ ﺳﺎﺑﻘﻪاي از ﺑﻴﻤﺎري ﺧﻮن و ﻣﺸﻜﻼت ﻃﺤﺎﻟﻲ را در‬
‫ﻓﺎﻣﻴﻞ ﺧﻮد ذﻛﺮ ﻧﻤﻲﻛﺮد‪ .‬در ﻣﻌﺎﻳﻨﻪ ﺑﻴﻤﺎر رﻧﮓ ﭘﺮﻳﺪه ﺑﻮد‪ ،‬وﻟﻲ‬
‫اﻳﻜﺘﺮﻳﻚ ﻧﺒﻮد‪ .‬ﻫﻢﭼﻨﻴﻦ‪ ،‬ﻟﻨﻔﺎدﻧﻮﭘﺎﺗﻲ ﻣﺤﻴﻄﻲ ﻧﺪاﺷﺖ‪ .‬در ﻣﻌﺎﻳﻨﻪ‬
‫ﻗﻔﺴﻪ ﺳﻴﻨﻪ و ﻗﻠﺐ ﻳﺎﻓﺘﻪ ﻏﻴﺮﻃﺒﻴﻌﻲ وﺟﻮد ﻧﺪاﺷﺖ‪ .‬در ﻣﻌﺎﻳﻨﻪ ﺷﻜﻢ‪،‬‬
‫ﻧﺮم ﺑﻮد‪ .‬ﺗﻨﺪرﻧﺲ‪ ،‬رﻳﺒﺎﻧﺪ ﺗﻨﺪرﻧﺲ‪ ،‬ﮔﺎردﻳﻨﮓ و رﻳﺠﻴﺪﻳﺘﻲ وﺟﻮد‬
‫ﻣﻘﺪﻣﻪ‬
‫ﻟﻨﻔﻮم اوﻟﻴﻪ ﻃﺤﺎل ﺟﺰء ﻟﻨﻔﻮمﻫﺎي ﺑﺪﺧﻴﻢ ﻃﺤﺎل ﻣﻲﺑﺎﺷﺪ ﻛﻪ‬
‫در ﺣﺪود ‪ 2‬درﺻﺪ از ﺗﻤﺎﻣﻲ ﻓﺮمﻫﺎي ﻏﻴﺮﻫﻮﭼﻜﻴﻦ را ﺷﺎﻣﻞ ﻣﻲ‪-‬‬
‫ﺷﻮد‪ 33 .‬درﺻﺪ ﻟﻨﻔﻮمﻫﺎي اوﻟﻴﻪ ﻃﺤﺎﻟﻲ )‪ 0/66‬درﺻﺪ ﻛﻞ ﻟﻨﻔﻮمﻫﺎي‬
‫ﻏﻴﺮﻫﻮﭼﻜﻴﻦ( از ﻧﻮع ﻟﻨﻔﻮم ﻣﻨﺘﺸﺮ ﺳﻠﻮلﻫﺎي ﺑﺰرگ ‪B‬‬
‫)‪ (Diffuse large B cell lymphomas‬ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻳﻚ‬
‫ﺑﻴﻤﺎري ﻧﺎدر اﺳﺖ ]‪ .[1-3‬در اﻳﻨﺠﺎ ﻣﺎ ﻳﻚ ﻣﻮرد ﻟﻨﻔﻮم اوﻟﻴﻪ ﻃﺤﺎﻟﻲ‬
‫از ﻧﻮع ﻟﻨﻔﻮم ﻣﻨﺘﺸﺮ ﺳﻠﻮلﻫﺎي ﺑﺰرگ ‪ B‬ﺑﺎ اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ ﺷﺪﻳﺪ را‬
‫ﻣﻌﺮﻓﻲ را ﻣﻲﻧﻤﺎﻳﻴﻢ‪.‬‬
‫ﻣﻌﺮﻓﻲ ﺑﻴﻤﺎر‬
‫ﺑﻴﻤﺎر ﺧﺎﻧﻢ ‪ 57‬ﺳﺎﻟﻪاي ﺑﻮد ﻛﻪ ﺑﺎ ﺷﻜﺎﻳﺖ ﺿﻌﻒ و ﺑﻲ‪-‬‬

‫ﻧﺪاﺷﺖ‪ .‬ﻫﭙﺎﺗﻮﻣﮕﺎﻟﻲ وﺟﻮد ﻧﺪاﺷﺖ‪ .‬ﻃﺤﺎل در ﻟﻤﺲ‪ ،‬ﺗﺎ ‪ 4‬ﺳﺎﻧﺘﻲﻣﺘﺮ‬ ‫ﺣﺎﻟﻲ ﻋﻤﻮﻣﻲ ﺑﺪن ﻣﺮاﺟﻌﻪ ﻛﺮد ﻛﻪ از ‪ 40‬روز ﻗﺒﻞ از ﻣﺮاﺟﻌﻪ در‬

‫زﻳﺮ ﻧﺎف ﺑﻪدﺳﺖ ﻣﻲﺧﻮرد‪ .‬در ﻣﻌﺎﻳﻨﻪ اﻧﺪامﻫﺎ ﻧﻴﺰ ﻳﺎﻓﺘﻪ ﺧﺎﺻﻲ وﺟﻮد‬ ‫وي اﻳﺠﺎد ﺷﺪه ﺑﻮد‪.‬‬

‫ﻧﺪاﺷﺖ‪ .‬درآزﻣﺎﻳﺶﻫﺎي اﻧﺠﺎم ﺷﺪه در ﻫﻨﮕﺎم ورود ﻧﺘﺎﻳﺞ زﻳﺮ‬ ‫اﺳﺘﺎدﻳﺎر‪ ،‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﺑﻴﻤﺎريﻫﺎي ﻋﻔﻮﻧﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻛﺎﺷﺎن‬ ‫‪1‬‬

‫‪2‬‬
‫ﻣﺸﺎﻫﺪه ﺷﺪ‪:‬‬ ‫اﺳﺘﺎدﻳﺎر‪ ،‬ﮔﺮوه داﺧﻠﻲ‪ ،‬داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻛﺎﺷﺎن‬
‫‪3‬‬
‫‪WBC: 2.900 µl, HGB: 8.7 gr/dl, PLT: 167000,‬‬ ‫دﺳﺘﻴﺎر ﺑﻴﻤﺎريﻫﺎي داﺧﻠﻲ‪ ،‬ﻛﻤﻴﺘﻪ ﺗﺤﻘﻴﻘﺎت داﻧﺸﺠﻮﻳﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ‬
‫)‪ESR: 22, CRP:+2, LDH: 643 (NL<550‬‬ ‫ﻛﺎﺷﺎن‬
‫آزﻣﺎﻳﺸﺎت ﻣﺮﺑﻮط ﺑﻪ ﻣﺎرﻛﺮﻫﺎي واﻳﺮال از ﺟﻤﻠﻪ ‪ EBV‬و ‪CMV‬‬ ‫*ﻧﺸﺎﻧﻲ ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪:‬‬

‫ﻧﺮﻣﺎل ﺑﻮد‪ .‬ﺗﺴﺖﻫﺎي ﻣﺮﺑﻮط ﺑﻪ ﺑﻴﻤﺎريﻫﺎي ﻛﻼژن واﺳﻜﻮﻻر از‬ ‫ﻛﺎﺷﺎن‪ ،‬ﻛﻴﻠﻮﻣﺘﺮ ‪ 5‬ﺑﻠﻮار ﻗﻄﺐ راوﻧﺪي‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻬﻴﺪ ﺑﻬﺸﺘﻲ‬
‫دورﻧﻮﻳﺲ‪031 55548900 :‬‬ ‫ﺗﻠﻔﻦ‪0912 3306384 :‬‬
‫ﻗﺒﻴﻞ ‪ FANA‬و ‪ Anti dsDNA‬و ﺗﺴﺖﻫﺎي ﻛﻤﭙﻠﻤﺎن ﻧﻴﺰ ﻧﺮﻣﺎل‬
‫ﭘﺴﺖ اﻟﻜﺘﺮوﻧﻴﻚ‪   ehsanimajid21@gmail.com :‬‬
‫ﺑﻮد‪ .‬در ﺳﻮﻧﻮﮔﺮاﻓﻲ ﺷﻜﻢ و ﻟﮕﻦ‪ ،‬ﻛﺒﺪ و ﻣﺠﺎري ﺻﻔﺮاوي و ﻛﻠﻴﻪﻫﺎ‬ ‫ﺗﺎرﻳﺦ ﭘﺬﻳﺮش ﻧﻬﺎﻳﻲ‪94/7/27 :‬‬ ‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ‪94/3/30 :‬‬

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‫ﻛﻪ ﻣﻄﺮح ﻣﻲﺑﺎﺷﺪ ﻟﻨﻔﻮم اوﻟﻴﻪ ﻃﺤﺎﻟﻲ ﻫﺴﺖ ]‪ Kraemer .[6‬و‬
‫ﻫﻤﻜﺎران ﺗﺸﺨﻴﺺ ﻟﻨﻔﻮم اوﻟﻴﻪ ﻃﺤﺎﻟﻲ را در ﺻﻮرت وﺟﻮد اﺳﭙﻠﻨﻮ‪-‬‬
‫ﻣﮕﺎﻟﻲ‪ ،‬ﺳﻴﺘﻮﭘﻨﻲ ﺣﺪاﻗﻞ در دو رده ﺳﻠﻮل ﺧﻮﻧﻲ و ﻋﺪم وﺟﻮد‬
‫آدﻧﻮﭘﺎﺗﻲ ﻣﺤﻴﻄﻲ ﻣﻄﺮح ﻣﻲﻛﻨﻨﺪ ]‪ .[7‬در اﻳﻦ ﮔﺰارش ﻣﺎ ﻳﻚ ﻣﻮرد‬
‫ﻟﻨﻔﻮم اوﻟﻴﻪ ﻃﺤﺎﻟﻲ از ﻧﻮع ﻟﻨﻔﻮم ﻣﻨﺘﺸﺮ از ﻧﻮع ﺳﻠﻮلﻫﺎي ﺑﺰرگ ‪B‬‬
‫ﻣﻌﺮﻓﻲ ﻧﻤﻮدﻳﻢ ﻛﻪ ﺑﺎ ﺗﻈﺎﻫﺮ اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ وﺳﻴﻊ ﺑﺮوز ﻳﺎﻓﺘﻪ ﺑﻮد‪ .‬ﻟﻨﻔﻮم‬
‫‪Downloaded from feyz.kaums.ac.ir at 0:01 +0430 on Wednesday May 5th 2021‬‬
‫ﻣﻨﺘﺸﺮ از ﻧﻮع ﺳﻠﻮلﻫﺎي ﺑﺰرگ ‪ B‬ﺣﺪود ﻳﻚ ﺳﻮم ﺗﻤﺎم ﻟﻨﻔﻮمﻫﺎي‬
‫اوﻟﻴﻪ ﻃﺤﺎل را ﺷﺎﻣﻞ ﻣﻲﺷﻮد ]‪ .[8‬در ﻟﻨﻔﻮم ﻣﻨﺘﺸﺮ از ﻧﻮع ﺳﻠﻮلﻫﺎي‬
‫ﺑﺰرگ ‪ B‬ﻃﻴﻒ ﺳﻨﻲ اﺑﺘﻼ وﺳﻴﻊ ﻣﻲﺑﺎﺷﺪ‪ ،‬وﻟﻲ ﺑﻴﺸﺘﺮ در دﻫﻪﻫﺎي‬
‫ﺷﺶ و ﻫﻔﺖ زﻧﺪﮔﻲ دﻳﺪه ﻣﻲﺷﻮد‪ .‬اﻳﻦ ﺑﻴﻤﺎري ﻣﺨﺘﺼﺮ در ﻣﺮدان‬
‫ﺑﻴﺸﺘﺮ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﻴﻤﺎر ﻣﻮرد ﮔﺰارش ﻣﺎ ﻳﻚ ﺧﺎﻧﻢ ‪ 57‬ﺳﺎﻟﻪ ﺑﻮد ]‪.[9‬‬
‫ﻫﻢﭼﻨﻴﻦ‪ ،‬اﻳﻦ ﺗﻮﻣﻮر ﺑﻴﺸﺘﺮ ﺑﻪﺻﻮرت ﺗﻮده ﻣﻨﻔﺮد ﻃﺤﺎﻟﻲ ﻛﻪ ﺑﻴﺶ از‬
‫‪ 50‬درﺻﺪ ﻃﺤﺎل را درﮔﻴﺮ ﻣﻲﻛﻨﺪ‪ ،‬ﺑﺮوز ﻣﻲﻳﺎﺑﺪ‪ .‬ﺗﻈﺎﻫﺮات اﻳﻦ‬
‫ﺑﻴﻤﺎران ﺑﻴﺸﺘﺮ ﺑﻪﺻﻮرت ﺗﺐ ﻣﺨﺘﺼﺮ‪ ،‬ﺗﻌﺮﻳﻖ ﺷﺒﺎﻧﻪ و ﻋﻼﺋﻤﻲ ﻣﺜﻞ‬
‫درد در ﻧﺎﺣﻴﻪ ﺑﺎﻻي ﺷﻜﻢ در ﺳﻤﺖ ﭼﭗ اﺳﺖ ﻛﻪ ﺑﺎ اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ‬
‫ﺑﻴﻤﺎر ﻣﺮﺗﺒﻂ ﻣﻲﺑﺎﺷﺪ ]‪ .[3‬ﺗﻈﺎﻫﺮات ﺑﺎﻟﻴﻨﻲ در ﺑﻴﻤﺎر ﻣﺎ ﻧﻴﺰ ﭘﺮي‬
‫ﺷﻜﻢ‪ ،‬ﻛﺎﻫﺶ اﺷﺘﻬﺎ‪ ،‬ﻛﺎﻫﺶ وزن‪ ،‬ﺗﻌﺮﻳﻖ ﺷﺒﺎﻧﻪ و ﺗﺐ و ﻟﺮز ﺑﻮد‪.‬‬
‫ﺷﺎﻳﻊﺗﺮﻳﻦ ﻳﺎﻓﺘﻪ آزﻣﺎﻳﺸﮕﺎﻫﻲ در اﻳﻦ ﺑﻴﻤﺎران آﻧﻤﻲ‪ ،‬اﻓﺰاﻳﺶ ‪ ESR‬و‬
‫اﻓﺰاﻳﺶ ﺳﻄﺢ ‪ LDH‬ﻣﻲﺑﺎﺷﺪ ﻛﻪ در ﺑﻴﻤﺎر ﮔﺰارش ﺷﺪه ﺗﻮﺳﻂ ﻣﺎ‬
‫ﻧﻴﺰ وﺟﻮد داﺷﺖ‪ .‬ﻟﻨﻔﻮم ﻣﻨﺘﺸﺮ از ﻧﻮع ﺳﻠﻮلﻫﺎي ﺑﺰرگ ‪ B‬در‬
‫ﺗﺼﺎوﻳﺮ ﺳﻮﻧﻮﮔﺮاﻓﻲ ﺧﻮد را ﺑﻪﺻﻮرت اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ ﻫﻤﺮاه ﺑﺎ ﻳﻚ‬
‫ﺗﻮده ﺑﺎ ﺣﺎﺷﻴﻪ ﻣﺸﺨﺺ و ﻫﺎﻳﭙﻮاﻛﻮ ﻧﺸﺎن ﻣﻲدﻫﺪ‪ ،‬وﻟﻲ ﮔﺎﻫﻲ ﻣﻤﻜﻦ‬
‫اﺳﺖ ﺿﺎﻳﻌﺎت اﻛﻮژن ﺑﺎ اﻛﻮژﻧﻴﺴﻴﺘﻪ روﺷﻦ ﻧﺎﺷﻲ از ﻛﻠﺴﻴﻔﻴﻜﺎﺳﻴﻮن‬
‫و ﻳﺎ ﮔﺎز دﻳﺪه ﺷﻮد ]‪ .[10‬ﺑﻪﻃﻮر ﻛﻠﻲ ﺳﻲﺗﻲ اﺳﻜﻦ از دﻗﺖ ﻛﺎﻓﻲ‬
‫ﺑﺮاي ﺗﺸﺨﻴﺺ ﺑﻴﻤﺎري ﺑﺮﺧﻮردار ﻧﻴﺴﺖ؛ ﺑﻪﻃﻮريﻛﻪ دﻗﺖ آن در‬
‫ﺑﻌﻀﻲ ﻣﻄﺎﻟﻌﺎت ﺣﺪود ‪ 50‬درﺻﺪ ﮔﺰارش ﺷﺪه اﺳﺖ ]‪ .[11‬ﻧﻤﻮﻧﻪ‬
‫ﺑﺮداري از ﻣﻐﺰ اﺳﺘﺨﻮان ﻣﻌﻤﻮﻻ در ﻫﻨﮕﺎم ﺑﺮوز ﺑﻴﻤﺎري ﻧﺮﻣﺎل ﻣﻲ‪-‬‬
‫ﺑﺎﺷﺪ ﻛﻪ در ﺑﻴﻤﺎر ﻣﺎ ﻧﻴﺰ اﻳﻦﮔﻮﻧﻪ ﺑﻮد ]‪ .[8‬ﻫﻢﭼﻨﻴﻦ‪ ،‬ﻣﺜﺒﺖ ﺷﺪن‬
‫ﻣﺎرﻛﺮ ‪ CD20‬در ﺳﻠﻮلﻫﺎي ﻧﺌﻮﭘﻼﺳﺘﻴﻚ ﻳﺎﻓﺘﻪاي دﻳﮕﺮ ﺑﻮد ﻛﻪ در‬
‫ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻣﺸﺎﻫﺪه ﺷﺪ‪ .‬اﻗﺪام درﻣﺎﻧﻲ ارﺟﺢ در ﻣﺒﺘﻼﻳﺎن ﺑﻪ ﻟﻨﻔﻮم‬
‫اوﻟﻴﻪ ﻃﺤﺎل اﺳﭙﻠﻨﻜﺘﻮﻣﻲ ﻣﻲﺑﺎﺷﺪ‪ .‬از ﻓﻮاﻳﺪ اﺳﭙﻠﻨﻜﺘﻮﻣﻲ ﻗﻄﻌﻲ ﻛﺮدن‬
‫ﺗﺸﺨﻴﺺ ﭘﺎﺗﻮﻟﻮژي‪ ،‬ﺟﻠﻮﮔﻴﺮي از ﻫﺎﻳﭙﺮاﺳﭙﻠﻨﻴﺴﻢ‪ ،‬اﺻﻼح اﺧﺘﻼﻻت‬
‫ﺧﻮﻧﻲ‪ ،‬ﺑﻬﺒﻮد ﻋﻼﻳﻢ ﺑﻴﻤﺎر و ﺟﻠﻮﮔﻴﺮي از ﭘﺎرﮔﻲ ﻃﺤﺎل ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺑﻴﺸﺘﺮ ﺑﻴﻤﺎران ﺑﻌﺪ ﻋﻤﻞ ﺗﺤﺖ ﻛﻤﻮﺗﺮاﭘﻲ ﻗﺮار ﻣﻲﮔﻴﺮﻧﺪ‪ .‬ﻛﻤﻮﺗﺮاﭘﻲ‪،‬‬
‫ﺷﺎﻧﺲ زﻧﺪه ﻣﺎﻧﺪن ﺑﻴﻤﺎر را اﻓﺰاﻳﺶ ﻣﻲدﻫﺪ ]‪ .[12‬در ﻛﻤﻮﺗﺮاﭘﻲ ﺑﺮاي‬
‫ﺑﻴﻤﺎران ﺑﺎ ﻟﻨﻔﻮم ﻣﻨﺘﺸﺮ از ﻧﻮع ﺳﻠﻮلﻫﺎي ﺑﺰرگ ‪ ،B‬ﻋﻤﻮﻣﺎ از رژﻳﻢ‬
‫‪ R-CHOP‬اﺳﺘﻔﺎده ﻣﻲﺷﻮد ]‪ .[13‬ﺑﻴﻤﺎر ﻣﺎ ﻧﻴﺰ ﺗﺤﺖ رژﻳﻢ ‪R-‬‬
‫‪ CHOP‬ﻗﺮار ﮔﺮﻓﺖ ﻛﻪ در ﺣﺎل ﺣﺎﺿﺮ ﺣﺎل ﻋﻤﻮﻣﻲ ﻣﺴﺎﻋﺪي‬
‫دارد‪ .‬از ﻓﺎﻛﺘﻮرﻫﺎي ﭘﻴﺶﺑﻴﻨﻲﻛﻨﻨﺪه ﺑﺪ ﺑﺮاي اﻳﻦ ﺑﻴﻤﺎران ﻋﺪم اﺻﻼح‬
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‫اﺣﺴﺎﻧﻲ و ﻣﻌﻴﻨﻲ‬
‫‪ ‬‬
‫و ﻣﺠﺎري ادراري ﻃﺒﻴﻌﻲ ﺑﻮدﻧﺪ‪ ،‬وﻟﻲ ﻃﺤﺎل داراي اﻧﺪازه ‪180‬‬
‫ﻣﻴﻠﻲﻣﺘﺮ )ﺑﺰرگﺗﺮ از ﺣﺪﻃﺒﻴﻌﻲ( و داراي ﭘﺎراﻧﺸﻴﻢ ﻃﺒﻴﻌﻲ ﺑﻮد‪ .‬ﺑﺎ‪-‬‬
‫ﺗﻮﺟﻪ ﺑﻪ اﻳﻨﻜﻪ در ﻣﻌﺎﻳﻨﻪ ﻳﺎﻓﺘﻪاي ﺑﻪﺟﺰ اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ وﺟﻮد ﻧﺪاﺷﺖ و‬
‫در آزﻣﺎﻳﺸﺎت ﺻﻮرت ﮔﺮﻓﺘﻪ ﺑﺮاي ﺑﻴﻤﺎر ﻳﺎﻓﺘﻪاي ﻣﺒﻨﻲ ﺑﺮ ﻣﻨﺸﺎ و‬
‫ﻋﻠﺖ اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ ﻳﺎﻓﺖ ﻧﺸﺪ‪ ،‬ﺑﻴﻤﺎر ﺗﺤﺖ آﺳﭙﻴﺮاﺳﻴﻮن و ﺑﻴﻮﭘﺴﻲ‬
‫ﻣﻐﺰ اﺳﺘﺨﻮان ﻗﺮار ﮔﺮﻓﺖ‪ .‬در آﺳﭙﺮاﺳﻴﻮن ﻣﻐﺰ اﺳﺘﺨﻮان ﻫﺮ ﺳﻪ رده‬
‫ﺑﻠﻮغ ﻧﺴﺒﻲ داﺷﺘﻪ و ﻧﺴﺒﺖ ﻣﻴﻠﻮﻳﻴﺪ ﺑﻪ ارﻳﺘﺮوﻳﻴﺪ ﻳﻚ ﺑﻪ ﻳﻚ ﺑﻮد‪.‬‬
‫ﺳﻠﻮﻻرﻳﺘﻪ ﻣﻐﺰ اﺳﺘﺨﻮان ‪ 90‬درﺻﺪ ﺑﻮد و رﻧﮓ آﻣﻴﺰي رﺗﻴﻜﻮﻟﻴﻦ ﻣﻐﺰ‬
‫اﺳﺘﺨﻮان ‪ +‬ﺗﺎ ‪) ++‬ﻛﻢ ﺗﺎ ﻣﺘﻮﺳﻂ( ﺑﻮد و در ﻛﻞ ﻣﻐﺰ اﺳﺘﺨﻮان ﭘﺮ‪-‬‬
‫ﺳﻠﻮل داﺷﺖ‪ .‬در ﺳﻲﺗﻲ اﺳﻜﻦ ﻗﻔﺴﻪ ﺳﻴﻨﻪ ﺑﺎ ﻛﻨﺘﺮاﺳﺖ رﻳﻪﻫﺎ‪ ،‬ﻗﻠﺐ‬
‫و ﻋﺮوق ﺑﺰرگ ﻧﺮﻣﺎل ﺑﻮده و ﻟﻨﻔﺎدﻧﻮﭘﺎﺗﻲ ﻣﺪﻳﺎﺳﺘﻦ و اﻓﻴﻮژن ﭘﻠﻮرال‬
‫دﻳﺪه ﻧﺸﺪ‪ .‬در ﺳﻲﺗﻲ اﺳﻜﻦ ﺷﻜﻢ ﺑﺎ ﻛﻨﺘﺮاﺳﺖ اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ ﻣﺎﺳﻴﻮ‬
‫داﺷﺖ‪ ،‬ﻟﻨﻔﺎدﻧﻮﭘﺎﺗﻲ ﭘﺎراآﺋﻮرت دﻳﺪه ﻧﺸﺪه و از ﺳﺎﻳﺮ ﺟﻬﺎت ﻧﻴﺰ‬
‫ﻧﺮﻣﺎل ﺑﻮد‪ .‬در ﺑﺮرﺳﻲ ﮔﻮارﺷﻲ ﻳﺎﻓﺘﻪاﻳﻲ ﺑﻪﻧﻔﻊ ﻣﺸﻜﻼت ﻛﺒﺪي‬
‫)ﺳﻴﺮوز( و اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ اﺣﺘﻘﺎﻧﻲ ﭘﻴﺪا ﻧﺸﺪ‪ .‬ﻟﺬا‪ ،‬ﺑﺎﺗﻮﺟﻪ ﺑﻪ ﻧﺘﺎﻳﺞ‬
‫ﺑﺮرﺳﻲﻫﺎي اﻧﺠﺎم ﺷﺪه ﺑﻴﻤﺎر ﺟﻬﺖ اﺳﭙﻠﻨﻜﺘﻮﻣﻲ ﺑﻪ ﺑﺨﺶ ﺟﺮاﺣﻲ‬
‫ارﺟﺎع ﺷﺪ و ﻛﺎﻧﺪﻳﺪ ﻻﭘﺎراﺗﻮﻣﻲ و اﺳﭙﻠﻨﻜﺘﻮﻣﻲ ﺗﺸﺨﻴﺼﻲ‪-‬درﻣﺎﻧﻲ‬
‫ﮔﺮدﻳﺪ‪ .‬در ﺑﺮرﺳﻲ ﭘﺎﺗﻮﻟﻮژي‪ ،‬ﺑﺎﻓﺖ ﻃﺤﺎل ﻣﺸﻬﻮد ﺑﻮد ﻛﻪ در آن‬
‫اﻧﻔﻴﻠﺘﺮاﺳﻴﻮن ﻟﻨﻔﻮﻳﻴﺪي ﻧﻮدوﻻر وﺟﻮد داﺷﺖ ﻛﻪ ﺑﻌﻀﺎ داراي‬
‫ژرﻣﻴﻨﺎل ﻣﻨﺘﺸﺮ ﻧﺎﻣﺸﺨﺺ ﺑﻮدﻧﺪ ﻛﻪ ﺑﺮاي ﺑﻴﻤﺎر ‪MZBCL‬‬
‫)‪ (Marginal zone B-cell lymphoma‬ﻣﻄﺮح ﺷﺪ‪ .‬در ﺑﺮرﺳﻲ‬
‫اﻳﻤﻮﻧﻮﻫﻴﺴﺘﻮﺷﻴﻤﻲ ﻣﺎرﻛﺮ ‪ CD20‬ﻣﺜﺒﺖ ﮔﺰاش ﮔﺮدﻳﺪ وﻟﻲ ‪،CD30‬‬
‫‪ CD3 ،CD5‬و ‪ CD15‬در ﺳﻠﻮلﻫﺎي ﻧﺌﻮﭘﻼﺳﺘﻴﻚ ﻣﻨﻔﻲ ﺑﻮد‪ .‬ﺑﺎ‪-‬‬
‫ﺗﻮﺟﻪ ﺑﻪ ﭘﺎﺗﻮﻟﻮژي و ﺑﺮرﺳﻲ اﻳﻤﻮﻧﻮﻫﻴﺴﺘﻮﺷﻴﻤﻲ ﺑﺮاي ﺑﻴﻤﺎر‬
‫‪ Diffuse large B-cell lymphoma‬ﻣﻄﺮح ﺷﺪ‪ .‬ﭘﺲ از‬
‫اﺳﭙﻠﻨﻜﺘﻮﻣﻲ ﺑﻴﻤﺎر ﺗﺤﺖ رژﻳﻢ ‪ R-CHOP‬ﻗﺮار ﮔﺮﻓﺖ‪ .‬ﺗﺎﻛﻨﻮن ﺷﺶ‬
‫دوره ﻛﻤﻮﺗﺮاﭘﻲ ﺑﺮاي ﺑﻴﻤﺎر ﺻﻮرت ﮔﺮﻓﺘﻪ اﺳﺖ‪ .‬در ﺣﺎل ﺣﺎﺿﺮ‬
‫ﺣﺎل ﻋﻤﻮﻣﻲ ﺑﻴﻤﺎر ﻣﺴﺎﻋﺪ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺑﺤﺚ‬
‫)‪ Primary splenic lymphoma (PLS‬ﻳﻚ ﺑﻴﻤﺎري‬
‫ﻧﺎدر اﺳﺖ ﻛﻪ ﺷﻴﻮﻋﻲ ﻛﻤﺘﺮ از ‪ 1‬درﺻﺪ دارد ]‪ Das Gupta .[4‬و‬
‫ﻫﻤﻜﺎران ﻟﻨﻔﻮمﻫﺎي اوﻟﻴﻪ ﻃﺤﺎل را ﻧﻮﻋﻲ از ﻟﻨﻔﻮمﻫﺎ ﺗﻌﺮﻳﻒ ﻣﻲﻛﻨﻨﺪ‬
‫ﻛﻪ ﻓﻘﻂ ﻃﺤﺎل و ﻏﺪد ﻟﻨﻔﺎوي ﻧﺎف ﻃﺤﺎل را درﮔﻴﺮ ﻣﻲﻛﻨﻨﺪ‪.‬‬
‫ﺗﺸﺨﻴﺺ ﻟﻨﻔﻮم اوﻟﻴﻪ ﻃﺤﺎل ﻣﻮﻗﻌﻲ ﮔﺬاﺷﺘﻪ ﻣﻲﺷﻮد ﻛﻪ ﻣﻨﺤﺼﺮا‬
‫اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ رخ دﻫﺪ و ﺗﻮﻣﻮري در ﻧﺎﺣﻴﻪ دﻳﮕﺮ ﺑﻪﺧﺼﻮص در ﻛﺒﺪ‬
‫و ﻳﺎ ﻏﺪد ﻟﻨﻔﺎوي ﭘﺎراآﺋﻮرﺗﻴﻚ و ﻣﺰاﻧﺘﺮﻳﻚ دﻳﺪه ﻧﺸﻮد ]‪Skarin .[5‬‬
‫و ﻫﻤﻜﺎران ﺑﻴﺎن ﻛﺮدهاﻧﺪ درﺻﻮرﺗﻲﻛﻪ اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ ﺗﻈﺎﻫﺮ ﻏﺎﻟﺐ‬
‫ﻳﻚ ﻟﻨﻔﻮﻣﻲ ﺑﺎﺷﺪ ﻛﻪ ﻃﺤﺎل را درﮔﻴﺮ ﻣﻲﻛﻨﺪ‪ ،‬ﻳﻜﻲ از ﺗﺸﺨﻴﺺﻫﺎﻳﻲ‬
‫دوﻣﺎهﻧﺎﻣﻪ ﻓﻴﺾ| ﻓﺮوردﻳﻦ و اردﻳﺒﻬﺸﺖ|‪ |1395‬دوره ‪ |20‬ﺷﻤﺎره ‪1‬‬
   ... ،‫ﻣﻌﺮﻓﻲ ﻳﻚ ﻣﻮرد ﻟﻨﻔﻮم ﻃﺤﺎﻟﻲ اوﻟﻴﻪ‬
-‫اوﻟﻴﻪ ﻃﺤﺎﻟﻲ ﻧﻪﺗﻨﻬﺎ ﻳﻚ اﻗﺪام ﺗﺸﺨﻴﺼﻲ ﺑﻠﻜﻪ ﻳﻚ اﻗﺪام درﻣﺎﻧﻲ ﻣﻲ‬
.‫ﺑﺎﺷﺪ ﻛﻪ ﻣﻲﺗﻮاﻧﺪ ﻋﻼﻳﻢ و اﺧﺘﻼﻻت ﺧﻮﻧﻲ ﺑﻴﻤﺎر را ﺑﺮﻃﺮف ﻧﻤﺎﻳﺪ‬
‫ﺗﺸﻜﺮ و ﻗﺪرداﻧﻲ‬
‫ﻧﻮﻳﺴﻨﺪﮔﺎن از ﺣﻤﺎﻳﺖ ﻣﺎدي و ﻣﻌﻨﻮي واﺣﺪ ﺣﻤﺎﻳﺖ از‬
.‫ﺗﺤﻘﻴﻘﺎت ﺑﺎﻟﻴﻨﻲ ﺗﻘﺪﻳﺮ و ﺗﺸﻜﺮ ﺑﻪ ﻋﻤﻞ ﻣﻲآورﻧﺪ‬
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  1 ‫| ﺷﻤﺎره‬20 ‫| دوره‬1395|‫دوﻣﺎهﻧﺎﻣﻪ ﻓﻴﺾ| ﻓﺮوردﻳﻦ و اردﻳﺒﻬﺸﺖ‬
.[14] ‫ﺳﻴﺘﻮﭘﻨﻲ ﻣﻲﺑﺎﺷﺪ ﻛﻪ در ﺑﻴﻤﺎر ﻣﺎ وﺟﻮد ﻧﺪاﺷﺖ‬
‫ﻧﺘﻴﺠﻪ ﮔﻴﺮي‬
‫اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ ﺑﻪﻋﻨﻮان ﻳﻚ ﻧﺸﺎﻧﻪ ﺑﺮاي ﻟﻨﻔﻮم اوﻟﻴﻪ ﻃﺤﺎﻟﻲ‬
‫ در ﺗﺸﺨﻴﺺﻫﺎي اﻓﺘﺮاﻗﻲ اﺳﭙﻠﻨﻮﻣﮕﺎﻟﻲ ﺑﺎﻳﺪ اﻳﻦ ﺗﺸﺨﻴﺺ‬.‫ﻣﻲﺑﺎﺷﺪ‬
‫ اﺳﭙﻠﻨﻜﺘﻮﻣﻲ در ﺑﻴﻤﺎران داراي ﻟﻨﻔﻮمﻫﺎي‬،‫ ﻫﻢﭼﻨﻴﻦ‬.‫ﻣﺪﻧﻈﺮ ﻗﺮار ﮔﻴﺮد‬
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