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.