My name is Jordan Orr and I'm a PGY-4 at the University of Michigan, and my case is on a patient that I saw with Dr. Sean Smith while on my cancer rehabilitation month, working on the inpatient service and doing consults. The title of our presentation is Bilateral Sciatic Neuropathies of Different Causes in a Patient with Lymphoma. Our patient is a 46-year-old woman with a history of stage 4 diffuse large B-cell lymphoma, status post-RTROP, rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone makeup RTROP, and she completed this treatment eight weeks ago, presented to the hospital for an unrelated reason to the reason that we were consulted, and we were consulted for a three-week history of severe right leg pain and new onset of left foot drop. So just based off of this little blurb, I was thinking about peripheral neuropathy caused by vincristine, but I also wanted to know the location of her lymphoma, and of course I wanted to see the patient and examine her myself. So on exam, she had an atrophic left lower extremity. Her reflexes were diminished bilaterally in her lower extremities. Sensation was decreased over the saphenous, sural, and perineal nerve distributions, left worse than right. Her strength was intact and 5 out of 5 throughout, except at her left ankle, which was 0 out of 5 for dorsiflexion. After seeing the patient, we recommended an MRI of her pelvis and lumbosacral plexus, which showed an enlarged left sciatic nerve as well as compression of the right sciatic nerve. If we move over to our imaging, you can see the lymphoma marked by the yellow arrows, circle, and carrots. So in the first picture, that is the right lymphoma compressing where the sciatic nerve would come out of the sciatic notch. In the second picture, the circle is around the enlarged sciatic nerve, which has an intrasciatic lymphoma. And then the third picture is just a sagittal view of the left intrasciatic lymphoma. So diffuse large B-cell lymphoma is an aggressive cancer that can manifest within nerves or next to them, causing mass effect and affecting them like we did see on the right side of our patient. However, this cancer is radiosensitive and responds well to chemotherapy. She was already undergoing chemotherapy, and we recommended that the primary team consult radiation oncology and discuss targeted radiation to this area in hopes to shrink the lesions and improve her symptoms. After radiation, she had a decrease in pain, which made it easier for her to get out of bed. She was able to ambulate with an AFO on her left ankle. She did not actually regain strength there, but her pain was dramatically improved, and she was able to decrease her opioid dosing. This case was really cool for me to see because as a consultant, sometimes it's hard to see your difference unless you actually bring them to inpatient rehab for me. But she actually didn't come to inpatient rehab, and we had a big impact on her treatment trajectory and her improvement of symptoms. So it was nice to see her respond well to the radiation, decrease her pain, and be able to go home without actually having to come to inpatient rehab. And before our consultation, the oncology providers didn't attribute her pain to her lymphoma, so they would not have considered radiation as a treatment for her.

lymphoma

sciatic neuropathies

MRI

radiation therapy

mass effect