Working Diagnosis:
Stage II Cutaneous Diffuse Large B-Cell Lymphoma (DLBCL)

Treatment:
At the time of initial evaluation, dermatology was consulted, and the patient was prescribed oral antibiotics for one week and topical steroids for one month due to concern for infectious versus inflammatory dermatosis. Follow up with dermatology was delayed by a positive COVID-19 infection and quarantining precautions. Ten weeks after initial presentation, punch biopsy confirmed the final diagnosis of lymphoma, and the patient was enrolled into a therapeutic clinical trial (ANHL1131) by pediatric oncology. The patient received four cycles of chemotherapy with traditional chemotherapeutic agents and the addition of rituximab. Her course of treatment was complicated by two urinary tract infections and one hospitalization for neutropenic fever.

Outcome:
One year after her initial presentation of painful anterior chest nodules, the patient returned to competition with her high school dance team and the local performing arts center. The first PET scan after completion of chemotherapy revealed her cancer was in remission. She received nine PET scans for surveillance in the first two years after treatment, and her cancer remained in remission throughout.

Author's Comments:
This 14-year-old female was diagnosed with a rare presentation of Non-Hodgkin Lymphoma (NHL). In the pediatric population, there are approximately 800 new cases of NHL each year which includes DLBCL. About 20% of DLBCL cases will present with cutaneous manifestations alone. It is possible to have a normal lab work up as demonstrated by this patient. Diagnosis is made by punch biopsy, and chemotherapy is the gold-standard for treating DLBCL. In addition, patients receive prophylactic antibiotics for opportunistic infections and re-immunizations as the bone marrow recovers. The greatest risk for recurrence is in the first 18-24 months, so patients undergo serial PET scan imaging in the first two years for surveillance. The 5-year survival rate of cutaneous DLBCL is 41-66% with some higher rates reported with the incorporation of rituximab. Evidence supports the benefits of exercise in athletes undergoing cancer treatment. These benefits include improved muscle strength, walking performance, fatigue, self-esteem, and self-reported physical function.

Editor's Comments:
While cutaneous manifestations of neoplastic disease may be rare, sports medicine physicians must maintain a keen eye and high index of suspicion when encountering atypical skin lesions. What may appear as “just a bug bite” or “simply a rash” ceases to be so when the lesions persist, worsen, or are associated with other symptoms such as pain or constitutional complaints.
Dermatologic manifestations of disease are not uncommon. Whether it is dermatitis herpetiformis suggesting celiac disease, erythema migrans in Lyme disease, acanthosis nigricans in insulin resistance or as a paraneoplastic disorder, sports medicine physicians have a duty to recognize and interpret the messages almost literally “written” on the patient’s skin.
This case also highlights the potential shortfalls of standard imaging, including plain radiographs, ultrasound, and computed tomography when evaluating lymphoma.
The diligence of the clinicians involved in this patient’s care in their steadfast investigation of the root cause of the presenting symptoms, including judicious specialist consultation and employing appropriate advanced imaging certainly contributed to this patient’s favorable outcome. To carry the title’s theme, in the words of Ms. Swift, this editor’s message to the patient in this case is “it’s wonderful to see that you’re OK.”

References:
Raetz, Elizabeth, et al. "B large-cell lymphoma in children and adolescents." Cancer treatment reviews 29.2 (2003): 91-98.

Schwartz, Anna L., and Christopher M. Terry. "Returning to sport: female athletes living with and beyond cancer." International journal of environmental research and public health 18.15 (2021): 8151.

Campbell, Kristin L., et al. Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Medicine & Science in Sports & Exercise 51(11):p 2375-2390, November 2019. | DOI: 10.1249/MSS.0000000000002116

Senff, Nancy J., et al. "Results of radiotherapy in 153 primary cutaneous B-Cell lymphomas classified according to the WHO-EORTC classification." Archives of dermatology 143.12 (2007): 1520-1526.

Minard-Colin, Véronique, et al. "Rituximab for high-risk, mature B-cell non-Hodgkin’s lymphoma in children." New England Journal of Medicine 382.23 (2020): 2207-2219.

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