Cases report of unicentric Castleman's disease: revisit of radiotherapy role
A twenty-year-old female referred with the impression of inflammatory pseudotumor on left supraclavicular area. She visited provincial hospital with 3 months history of hoarseness and left neck mass. Laboratory test such as complete blood cell count (CBC) and chemistry did not show any abnormality. At that time, left true vocal cord palsy was found on laryngoscopic examination. On the computed tomography (CT) scan, there was a heterogenous enhanced and carotid artery encasing huge mass with multiple enlarged lymph nodes from left level IV lymph node station to supraclavicular area (). Incisional biopsy was done and pathologic examination showed infiltrations of heterogenous inflammatory cells with fibroblastic proliferations. Diagnosis was not definite and referred for the further work-up and appropriate treatment. For the definite diagnosis, incisional biopsy was performed once more. On the pathologic review, small lymphocytes, plasma cells, and eosinophilic infiltrations were seen. Inflammatory pseudotumor, Kimura disease, Hodgkin's disease, and CD were discussed as possible diagnosis, but were not conclusive. For more precise pathologic examination, excisional biopsy was done under general anesthesia. Mass was not fully excised because of carotid artery encasement (). However, vocal cord palsy was recovered after excisional biopsy (). In immunohistochemical studies, CD3 and CD20 were negative and CD21 was positive in follicular dendritic cells. Kappa and lambda in situ hybridization (ISH) revealed polyclonality and the Epstein-Barr virus (EBV) ISH was negative. Ki-67 labeling index was not increased. Patient was diagnosed as hyaline-vascular type CD on excisional specimen and consulted for postoperative radiotherapy to residual mass. Patient was treated with 3-dimensional conformal radiotherapy on 2 months after surgery. The target volume included tumor bed with generous margin. Radiation dose of 36 Gy/20 fractions was delivered for 30 days and radiotherapy was completed without treatment related complication except mild radiation esophagitis (). Three months later after radiotherapy, CT imaging showed a partial response of residual mass (). On follow-up CT scan at 14 months after radiotherapy, there was additional decrease in mass size.