Primary central nervous system lymphoma

Epstein-Barr virus in AIDS-related primary central nervous system lymphoma

Primary central nervous system lymphoma occurs more often in patients with AIDS. Epstein-Barr virus (EBV) has been detected in these tumours, but the degree of association has not been defined because of both the highly restricted expression of EBV in malignant tissue and the lack of a technique that is reliable in formalin-fixed paraffin-embedded specimens. EBV-transformed lymphocytes contain short non-protein coding EBV transcripts (EBERs), which are expressed in much higher quantity than other EBV-latency transcripts. We describe a new strategy for detection of latent EBV with these transcripts as targets for in-situ hybridisation. 18 cases of AIDS-related primary CNS lymphoma from a consecutive necropsy series together with specimens from 3 further cases were studied. In each case, a strong positive signal over tumour cells indicated abundant expression of the EBV-EBER1 transcript. This 100% association suggests that the pathogenesis of these AIDS-associated lymphomas may differ from the systemic disease in which only 30-50% of tumours are associated with EBV. A pathogenetic role for EBV was further supported by showing expression of a viral protein (the latent membrane protein) that is implicated as an effector for EBV-associated lymphomagenesis. EBV might have a role as a tumour marker in the diagnosis and management of AIDS-related primary CNS lymphoma.

Primary non-Hodgkin's lymphoma of the central nervous system: phase II study of chemotherapy (BVAM) prior to radiotherapy

Ten patients were diagnosed as having primary non-Hodgkin's lymphoma of the central nervous system at University Hospital, Nottingham, between September 1986 and April 1989. None had clinical evidence of HIV-1 infection. All the patients started treatment with chemotherapy (BVAM), designed to cross the blood-brain barrier, followed by radiotherapy. Seven patients completed both chemotherapy and radiotherapy. Dose reduction during chemotherapy was necessary in three patients because of neutropenia. In two of the six patients with solitary tumours, complete resection was achieved surgically prior to treatment. Five of the remaining eight patients (63%) had radiological evidence of a complete response with chemotherapy. The other three patients had no response to chemotherapy but one had a complete response after radiotherapy. The two-year cause-specific survival of the 10 patients was 37%. Two of the three patients who had a postoperative performance status of 0 or 1 (ECOG/WHO) are alive and disease-free at 26 and 46 months from diagnosis. The median survival of the seven patients with a performance status of 2-4 was 10 months with two patients alive and disease-free at 19 and 26 months. The two-year cause-specific survival of these seven patients was 22%.

Primary meningeal B lymphoma presenting as a subacute ascending polyradiculoneuropathy

A subacute ascending polyradiculoneuropathy was the main feature of a primary meningeal B lymphoma in two patients. Tumour cells appeared in the CSF eight and six months respectively after the onset of the disease. Treatment by intrathecal methotrexate resulted in transient improvement.

Total Circulating b Lymphocyte Abnormalities in a Primary Cerebral Localization of Non-Hodgkin Lymphoma: A Case Report

The authors describe a case of primary central nervous system lymphoma In a 43-year-old male. Interest in this rare form of B-lymphocyte non-Hodgkin's lymphoma is due to its increasing incidence in the last decade, especially in immunodeficient patients. Extraneural involvement was excluded by staging examinations: bilateral bone marrow biopsy from the posterior iliac crest, bipedal lymphography, abdominal CT scan, skeletal, thoracic and gastrointestinal X-rays, spinal puncture, ORL and clinical examination. The peripheral immunologic state was particularly interesting: there was a substantial decrease in total circulating B-lymphocytes at diagnosis (4.4 % = 80/mmc; nv 13 ± 4 % = 287 ± 130/mmc) and a further decrease after 2 and 4 months of therapy (0.16% = 2/mmc). Three months after completion of therapy, the B-lymphocyte level returned to the base level at diagnosis (7 % = 88/mmc). At 10 months after diagnosis and 3 months after completion of chemotherapy, the patient is alive and in good health except for the after-effects of a left hemiparesis. The etiologic and possible pathogenic factors are considered.

Primary central nervous system lymphoma in acquired immune deficiency syndrome. A clinical and pathologic study with results of treatment with radiation

Primary central nervous system (CNS) lymphoma occurs frequently in patients with the acquired immune deficiency syndrome (AIDS). Seventeen patients with AIDS and biopsy-proven CNS lymphoma were treated with whole-brain radiation. At presentation, most patients were severely debilitated from previous AIDS-related illnesses. Patients generally had focal neurologic symptoms such as seizures and paralysis. Headaches and mental status changes, often noticed after hospital admission, seldom brought our patients to seek medical attention. Computed tomography (CT) scan showed low-density, contrast-enhancing, mass lesions with variable amounts of peritumor edema. Size, location, and pattern of contrast enhancement of the lesions varied. No specific pattern was seen that could be used to distinguish between CNS lymphoma, toxoplasmosis, or other CNS diseases that occur in patients with AIDS. Biopsy results showed angiocentric, high-grade, large cell tumors with frequent necrosis. Immunohistochemical analysis showed B-cell phenotype with small amounts of T-cells, presumably reactive. All patients received irradiation to the whole brain with parallel opposed fields. A variety of doses and treatment regimens were used. Mean survival was only 72 days. Survival was longer in patients with higher pretreatment Karnofsky scores. The correlation between dose and survival was not significant. At completion of therapy, most patients showed improvement in Karnofsky score and had partial improvement in neurologic symptoms. CNS lymphomas in patients with AIDS are responsive to radiation. Posttreatment CT scans showed regression of tumors. Autopsy examinations showed regression of tumors, but also showed concurrent CNS infections, AIDS encephalopathy, and radiation-induced changes within the normal CNS tissue. Opportunistic infections rather than cerebral herniation or uncontrolled lymphoma was the most common cause of death.

Immunocytochemical evidence of lymphocytic derivation of neoplastic cells in malignant angioendotheliomatosis

Neoplastic angioendotheliomatosis is a rare disorder usually characterized by primarily cutaneous or neurological symptoms. Approximately 40 cases of malignant angioendotheliomatosis with primary central nervous system (CNS) symptoms have been reported. Some investigators have postulated a hematopoietic origin for this neoplasm. Most of the literature, however, has perpetuated the idea that the often bizarre symptoms seen with this entity result from neoplastic endothelial cell proliferation within the small vessels of affected organs, including the brain and spinal cord. This report describes the immunohistochemical examination and confirmation of the cell of origin of this neoplasm based on five previously unpublished cases of malignant angioendotheliomatosis with primarily CNS symptoms. It includes the first documentation of a T-cell lymphoma presenting as malignant angioendotheliomatosis. All cases include autopsy findings, and in four cases the diagnosis was made postmortem. One case was proven by stereotactic biopsy, but the patient succumbed as a result of severe intracranial bleeding that occurred at the time of biopsy. Tissues were studied with avidin-biotin peroxidase immunohistochemical techniques using a panel of monoclonal antibodies directed against the leukocyte common antigen, LN-1, LN-2, and anti-Factor VIII, and also using Ulex europaeus agglutinin 1. Based on the results obtained, the authors conclude that the proliferative cells seen within the vessel lumina are of lymphocytic origin and agree that the condition should more properly be designated intravascular lymphomatosis. The therapeutic implications of this conclusion point to the possible administration of chemotherapy and radiotherapy in an effort to achieve remissions in an otherwise relentlessly progressive neurological disorder.

AIDS-related non-Hodgkin's lymphoma: the outcome and efficacy of radiation therapy

The records of all 16 patients with AIDS-related lymphoma treated with radiation therapy at our institutions were reviewed. All patients were male with a median age of 32 years, and all but one had biopsy proven high-grade NHL. Eleven had lymphoma involving the central nervous system and five had lymphoma involving other sites. Seven of the 11 patients with CNS involvement had primary CNS lymphoma. All patients were treated with megavoltage X rays to doses ranging from 1050 cGy in 1 1/2 weeks to 5037 cGy in 6 weeks. Of those patients with CNS lymphoma, only one responded completely and four responded partially to irradiation. All patients died within a range of 0.2 to 5.3 months (median survival = 2.2 months) from starting radiation therapy. In contrast, 3 of 5 patients (60%) with NHL outside the CNS responded completely and 1 responded partially to involved-field irradiation. These patients survived a median of 12.6 months with one achieving long-term lymphoma-free survival at 40 months. This long-term survivor presented with Stage IE lymphoma as his only manifestation of AIDS. We conclude that AIDS-related lymphomas respond less favorably to radiation therapy than lymphomas in non-immunosuppressed patients. Furthermore, CNS lymphomatous involvement is an ominous occurrence in the AIDS patient. In our experience, cranial irradiation failed to provide significant palliation or survival prolongation in this group of patients. Instead, long-term survival is possible in AIDS patients with limited NHL outside the CNS, and it is in these patients that combination chemotherapy plus involved-field radiation therapy may play a curative role.

Primary central nervous system T-cell lymphoma. Case report

Primary central nervous system (CNS) T-cell lymphoma is extremely rare. The present case report provides immunocytochemical evidence for a cerebellar CNS T-cell lymphoma. The patient underwent surgery followed by radiation therapy and is alive and well 36 months postoperatively. The clinical and pathological features of primary CNS T-cell lymphoma as well as diagnostic measures and treatment options are discussed, together with a compilation of all previous case reports of primary CNS T-cell lymphomas.

Immunocytological diagnosis of primary cerebral non-Hodgkin's lymphoma

Four men with primary cerebral non-Hodgkin's lymphoma diagnosed by immunocytological analysis of cerebrospinal fluid (CSF) presented with cranial nerve palsies. All had CSF lymphocytoses and low CSF glucose. The cell phenotypes were two T cell tumours, one B cell, and one null. A review of 13 previously recorded cases of immunocytologically diagnosed CNS non-Hodgkin's lymphoma showed that there were 10 B cell, two T cell, and one null tumour. Overall (17 cases) the cell phenotype distribution was 65% B cell, 24% T cell, and 11% null. High CSF lymphocyte counts were found in 94%, proteinosis in 85%, and low CSF glucose in 87%. In contrast to the B cell tumours, all of the T cell tumours were diagnosed by CSF cytology before being visualised radiologically. It is suggested that all CSF lymphocytes (greater than 5 x 10(6)/ml) should be immunohistochemically typed to permit earlier diagnosis of CNS non-Hodgkin's lymphoma.

Primary central nervous system lymphoma as a secondary malignancy

Primary central nervous system lymphoma (PCNSL) is a rare neoplasm, but it is occurring with increased frequency even among apparently immunocompetent patients. Although secondary malignancies frequently involve the lymphoreticular system, PCNSL has been reported as a second neoplasm only once previously. Seven patients are discussed who developed PCNSL after successful treatment for a prior neoplasm. The original cancer was colon (one), breast (one), thyroid (one), Hodgkin's disease (two), and non-Hodgkin's lymphoma (two). Patients with systemic non-Hodgkin's lymphoma were thought to have a separate cerebral lymphoma on the basis of a prolonged disease-free interval from their systemic lymphoma, and the absence of systemic disease, when PCNSL was diagnosed and through subsequent follow-up. The PCNSL developed a median of 10 years after the diagnosis of the first tumor and 6 years after the last evidence of systemic disease. The diagnosis of PCNSL was often delayed because of confusion with brain metastases, and initial shrinkage or disappearance of the lesion after corticosteroids. Formation of PCNSL may be a consequence of treatment for the first malignancy, reflect an unidentified inherent predisposition to neoplastic transformation, or result from the changing epidemiology of PCNSL in the general population. These mechanisms are not mutually exclusive, and a single hypothesis cannot account for all these cases.

The treatment of primary malignant brain tumours

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Ki-1 positive meningeal lymphoma in a patient with a history of Hodgkin lymphoma

We describe the case of a woman in whom a Ki-1 lymphoma confined to the meninges developed nearly 4 years after complete remission of a Hodgkin lymphoma. The neurological symptoms appeared in two stages. The first, marked by multi-radicular impairment, cleared almost completely within a few months. The second, a year after the beginning of the first, manifested with a syndrome of meningeal irritation, which quickly led to death. We discuss the clinical course and the possible relationship between Hodgkin lymphoma and Ki-1 lymphoma.

Non-Hodgkin's lymphoma of the brain after Hodgkin's disease. An immunohistochemical study

Non-Hodgkin's lymphoma (NHL) of the central nervous system (CNS) is a rarely reported complication of Hodgkin's disease (HD). Two patients with NHL of the brain after HD were studied by histologic and immunohistochemical methods. Both patients were in the second decade, had been treated with radiation and chemotherapy, had experienced a relapse of HD before development of NHL, had no evidence of HD at the time of diagnosis of NHL, and died within 1 year of diagnosis. Both brain neoplasms were large cell immunoblastic lymphomas of B-cell lineage. Patients with HD appear to be at increased risk for NHL of the CNS, which may have a poor prognosis.

Stereotactic-endoscopic procedures on processes of the cranial midline

The term "midline tumour" is defined partly from the topographic and from the pathogenetic point of view. Problems of modern imagegenerating procedures in establishing the diagnosis of cerebral midline lesions are described. The role of stereotactic diagnostic and therapeutic interventions is emphasized. Stereotactic brain tumour biopsy, installation of shunts and reservoirs under visual control are performed. Interstitial radiotherapy is carried out for low-grade gliomas. As an important innovation, stereotactic procedures are combined with endoscopic techniques. Particular diagnostic and therapeutic difficulties of typical midline tumours such as craniopharyngeoma, germinoma, glioma and primary cerebral lymphoma as a local extension are discussed. A reasonable concept in diagnosis and therapy of cerebral midline lesions is proposed.

Primary ocular malignant lymphoma associated with the acquired immune deficiency syndrome

A 42-year-old man who was human immunodeficiency virus (HIV)-positive complained of floaters in his right eye, which had existed for 1 week, followed by loss of central vision. Results of ophthalmoscopic examination disclosed confluent yellowish-white retinochoroidal infiltrates with perivascular sheathing, which were more prominent superiorly in the right eye. Approximately 10 small, white, intraretinal and choroidal lesions were observed in the nasal periphery of the left eye. Results of cytologic examination of the vitreous of the right eye showed neoplastic cells characteristic of large cell type malignant lymphoma. Shortly thereafter, cytologic examination of the cerebrospinal fluid also showed large cell malignant lymphoma. Magnetic resonance imaging (MRI) showed a mass involving the left cerebellar hemisphere. After bilateral whole-eye radiation therapy, there was complete resolution of the lymphomatous retinochoroidal infiltrates in both eyes. The ophthalmologic and neurologic manifestations of acquired immune deficiency syndrome (AIDS) are discussed. The authors believe this is the first report of ocular malignant lymphoma occurring in a patient with AIDS.

Primary central nervous system lymphoma in a pediatric patient with acquired immune deficiency syndrome. Treatment with radiation therapy

Primary central nervous system (CNS) lymphoma, an otherwise rare pediatric tumor, has been reported with increasing frequency in children with acquired immune deficiency syndrome (AIDS). With current therapy, the outcome of this disease is invariably fatal. The authors present a case of primary CNS lymphoma in a 3.5-year-old girl with AIDS who received treatment with total brain irradiation. After treatment, the patient's mental status improved, the seizures resolved, and she had no further progression of her neurologic symptoms until she died of pneumonia 6 months later. The autopsy revealed a necrotic mass at the site of the original tumor. The brain stem and spinal cord, unirradiated, contained lymphomatous lesions. The patient had extensive fibrinoid necrosis and leukoencephalopathy that were consistent with radiation-induced CNS damage. Coexisting AIDS encephalopathy also contributed to the patient's CNS injury. Effective palliation of CNS lymphoma in children with AIDS may be obtained with cranial irradiation. Pediatric AIDS patients may show more severe tissue effects from irradiation than unaffected children.

What's new in primary central nervous system lymphomas?

Primary central nervous system lymphomas (CNSL) are uncommon neoplasms accounting for about 1% of primary brain tumors. Patients with congenital or acquired immunodeficiencies including AIDS patients and transplant recipients represent the main high-risk population for CNSL occurrence. An important point emerging from the literature is that CNSL incidence has dramatically increased during the last years not only in HIV infected patients by virtue of the AIDS epidemic spread, but also for unclear reasons in immunologically normal persons. Although c-myc oncogene activation and Epstein-Barr virus infection are considered to play a role in CNSL development, the peculiar tendency of these lymphomas to occur and remain inside the CNS is not well understood and may involve putative CNS binding molecules carried by lymphocytes. The clinical presentation is characterized by a great variety of neurological disorders. Radiological features consist of hyperdense homogeneous deposits within the subcortical white matter with a pattern of marked enhancement after injection of contrast material. The tumor masses are usually ill-defined and multicentric. Although all cytological types can be observed, the most common types belong to the high-grade category of non-Hodgkin's lymphoma. Monoclonal antibodies reactive with formalin-fixed, paraffin-embedded sections can be used in conjunction with stereotactic needle biopsy to provide accurate immunological characterization of CNSL. The large majority of CNSL is of B-cell origin but T-cell lymphomas seem at the present time less exceptional than previously thought. Although radiotherapy and chemotherapy can increase length of survival, the prognosis of CNS remains dramatically poor, the shortest survival being observed in AIDS patients.

Toxoplasmosis of the conus medullaris in a patient with hemophilia A-associated AIDS. Case report

Toxoplasma gondii has been reported to be the most common cause of focal brain lesions in patients with acquired immunodeficiency syndrome (AIDS). A case of intramedullary toxoplasmosis of the conus medullaris is reported in a patient with hemophilia A-associated AIDS. The diagnosis is discussed, with particular emphasis on the magnetic resonance imaging appearance.

Primary leptomeningeal B-cell lymphoma in a 8-year-old child

A case of primary leptomeningeal B-cell lymphoma in an 8-year-old, previously healthy child is described. The child was found to have hypogammaglobulinemia, and the Epstein-Barr virus genome was identified in cultured tumor cells despite blood serology being negative for the virus. The patient was treated with cyclophosphamide, doxorubicin, vincristine, and dexamethasone, plus intrathecal methotrexate, and initially improved. Before the initiation of craniospinal radiation, the patient developed progressive disease, deteriorated, and died 9 months after the onset of symptoms.

Primary central nervous system lymphoma imitates multiple sclerosis

Primary central nervous system lymphoma (PCNSL) can be confused with multiple sclerosis (MS) in patients who present with neurological dysfunction, a non-enhancing periventricular lesion, and CSF pleocytosis. Administration of corticosteroid causes clinical improvement and regression of PCNSL in some patients which may be interpreted as a steroid-induced remission from an exacerbation of MS. Sustained clinical dependence upon corticosteroid is unusual in MS, and should lead to consideration of PCNSL. Repeat CSF examination and gadolinium-enhanced MRI scan obtained off corticosteroid should differentiate between the two diagnostic possibilities.

Intracerebral malignant lymphoma with fluctuating regression and spatial evolution

Seven patients with histologically proven primary intracerebral malignant lymphoma, characterized by a fluctuating nature with both transient regression and spatial evolution of the tumors without contiguity to the initial lesion, are presented. Although the overall outcome was unfavorable, two cases had a long-term survival of 3 years or more and one of them showed a good quality of life. Correlation among characteristic clinical presentations, computed tomography scans, and prognostic factors after management with surgery, radiation, and chemotherapy, including steroids, is discussed.

A case of large cell CNS lymphoma associated with a systemic small cell lymphocytic lymphoma

A case is reported of a 59 y/o woman with a large cell CNS lymphoma and a small cell lymphocytic lymphoma in the bone marrow. The brain tumor underwent spontaneous regression and subsequent regrowth while there was slow progression of the systemic small cell lymphoma. The CNS lymphoma regressed rapidly following treatment with prednisone and cyclophosphamide. We hypothesize that the small cell lymphoma in this patient may represent an underlying immunodeficiency disorder.

Glucocorticoid therapy obscures the diagnosis of cerebral lymphoma

Neuropathological and radiographical findings of two patients with primary CNS B cell lymphoma are presented. Prior to computerized tomographic (CT)-guided stereotactic biopsy both patients had received glucocorticoid therapy which led to marked tumor regression on CT scans and transient improvement of neurological deficits. Despite careful targeting and serial sampling, multiple biopsy specimens examined cytologically, histologically and immunomorphologically showed nonspecific reactive astrogliosis and conspicuous perivascular infiltrates of T lymphocytes. A second biopsy performed after an interval of 2 and 8 weeks, respectively, and short-term discontinuation of dexamethasone therapy in one case, unequivocally established the diagnosis of Non-Hodgkin lymphoma. It is concluded that steroid therapy may obscure the bioptic diagnosis of cerebral lymphoma. In addition to the well-known antiedematous effect of glucocorticoids neuropathologists and neurosurgeons should be aware of a rapid and pronounced lymphodepletive action of steroids on malignant CNS lymphomas.

Craniocerebral involvement in lymphoma

Nine-hundred-eighty-nine patients with lymphoma were studied. Fifty-three cases (5.3%) had lymphomatous craniocerebral infiltration. The principal factors of risk for this complication were: advanced stage of the lymphoma (III or IV), diffuse histiocytic, diffuse poorly differentiated lymphocytic, or mixed cellularity lymphoma histological type, bone marrow involvement, and previous systemic chemotherapy. Thirty-two per cent of the cases of meningeal lymphomatous infiltration were asymptomatic and represented autopsy findings. CT-scan was an useful test to detect brain focal parenchymatous infiltration, as opposed to meningeal infiltration. Mean survival time in patients with lymphomatous meningeal infiltration was 4.3 months, following the combined use of systemic chemotherapy, radiation therapy and intrathecal methotrexate. Two cases had primary cerebral lymphoma, although without associated immunodeficiency. Twenty patients (2%) had intracranial hemorrhage, in clear relationship with platelet alterations. Fifteen patients (1.5%) had CNS infection, caused by common bacteria or opportunistic agents. In 7 cases, the diagnosis was made at autopsy. Thirty-six autopsies were performed. In 8 cases (22%), pathologic findings such as, demyelination, microcalcifications, coagulative necrosis, or gliosis, suggested complications from treatment.

Stereotactic biopsy diagnosis of primary non-Hodgkin's lymphoma of the central nervous system. A histological and immunohistochemical study

We report 29 cases of primary non-Hodgkin lymphomas (NHL) of the Central Nervous System (CNS), 26 of which were diagnosed by stereotactic biopsy and 3 by autopsy. In seven cases the patients were affected by AIDS. Histological examination of this series revealed 15 cases of immunoblastic lymphoma, 12 cases of centroblastic lymphoma, 1 case of lymphoplasmacytic immunocytoma and 1 case of unclassified high grade lymphoma. By immunohistochemistry the B-cell origin of lymphoma cells was demonstrated in 28/29 cases. Eight cases were assigned to the B-cell lineage by demonstration of monotypic surface or cytoplasmic immunoglobulin or of the B-cell phenotype CD22+, CD2-, CD3-, CD5-. In twenty cases the B-cell nature of lymphoma was identified by positivity with two or more anti-B monoclonal antibodies (LN1LN2MB2) and negativity by the anti-T monoclonal antibody UCHL1. The histologically unclassified case was a peripheral T-NHL (CD1-, CD2+, CD3-, CD5+, CD22-). We conclude that histological and immunohistological evaluation of stereotactic biopsy specimens provides sufficient information for diagnosis and phenotypic characterization of primary NHL of the CNS. These lymphomas exhibit important predominance of high-grade malignancy histological types and are nearly always B-cell derived. In addition, we provide further evidence that the panel of monoclonal antibodies LN1, LN2, MB2, and UCHL1 is useful for immunophenotypic characterization of brain lymphomas when only paraffin embedded stereotactic biopsy tissue is available.

Primary CNS lymphoma: lymphomatous meningitis presenting as a cauda equina lesion in an AIDS patient

Neurologic complications of the acquired immune deficiency syndrome (AIDS) most often present as brain dysfunction and/or a polyneuropathy. We describe a unique neurological problem of a woman with AIDS who presented with a cauda equina mass due to primary CNS lymphoma. She subsequently developed a fulminant lymphomatous meningitis and died. Although previously rare, primary spinal cord lymphoma is expected to be encountered more often with the current AIDS epidemic and may be difficult to distinguish from infectious mass lesions.

Cerebral lymphomas: review of 70 cases

Seventy cerebral lymphomas from 37 men and 33 women were reviewed and reclassified using the modified Kiel classification. Fifty two of the patients were over the age of 50 years (age range 23-85 years). Only two patients were known to be immune deficient--one case of AIDS and one renal transplant recipient. Necropsies only were performed on 31 cases, biopsies only in 23 cases, and both biopsies and necropsies in 16 cases. Systemic tumour was found in 16 of 47 necropsy cases. All the tumours available for review were classic diffuse non-Hodgkin's lymphomas. Where immunocytological studies were positive, the tumour cells were of B cell origin. None was of T cell origin, although reactive T cells in the tumours were frequently identified. It is concluded from this and other studies that the incidence of intrinsic cerebral lymphomas is increasing.

Peripheral neuropathies and lymphoma without monoclonal gammopathy: a new classification

Recent progress in immunopathological studies of peripheral nerve and lymph node fragments together with 16 personal cases and numerous clinicopathological reports have suggested a new classification of peripheral neuropathies (PN) and lymphomas. These are: (1) PN due to local infiltrations by a T-cell lymphoma: (2) acute polyradiculoneuritis due to active demyelination and associated with infiltrates of a T-cell lymphoma in the epineurium, resembling Marek's disease (which is a T-cell lymphoma); (3) B-cell lymphoma proliferation which may be restricted to or predominate in the peripheral nervous system, with a large clinicopathological heterogeneity ranging from localized forms to ascending polyradiculoneuropathies; (4) angiotropic lymphoma, which is a B-cell lymphoma and may present as an acute mononeuropathy; (5) patients with acquired immunodeficiency syndrome due to lymphomatous infiltrates in the endoneurium, of which 2 cases of PN have been reported; (6) PN associated with organomegaly, endocrinopathy, M-component and skin lesions, certain cases being associated with a plasmocytoma and sometimes Castleman's disease but without any monoclonal gammopathy: (7) classic Guillain-Barré syndrome, prone to develop in patients with extraneural lymphoma but without any lymphomatous infiltrates in the peripheral nervous system; (8) certain cases (4 out of 16 in our series) where there is no clear relationship between PN and lymphoma, and there are mainly features of axonal degeneration. Inflammatory perivascular infiltrates were sometimes present in the epineurium.

Improved survival rate in primary intracranial lymphoma treated by high-dose radiation and systemic vincristine-doxorubicin-cyclophosphamide-prednisolone chemotherapy

Thirty patients with histologically proven primary intracranial non-Hodgkin's lymphoma were treated at Kyoto University. Ten of them were treated prospectively with a radiation-chemotherapy protocol. All but four specimens were recently reexamined and classified according to the Working Formulation system. The predominant histologic types were diffuse large cell type, large cell immunoblastic type, and diffuse mixed small and large cell type, seen in 38%, 21%, and 21% of cases, respectively. Before 1980, 16 patients were treated with postoperative radiation without definite chemotherapy, and only one has survived more than 5 years. Local recurrence was the most common cause of failure. In 1981, the authors started a protocol in which four to six courses of systemic chemotherapy with vincristine, doxorubicin, cyclophosphamide, and prednisolone (VEPA) was given after whole brain radiation (30-40 Gy) with a local boost up to 50 to 60 Gy. Eight patients completed this protocol, and all of them are alive at 16 to 100 months after diagnosis, with three patients surviving more than 5 years. Only one patient developed recurrence. On the other hand, six patients who did not complete or receive chemotherapy after 1981 are dead or alive with recurrence. Correlation between the Working Formulation subtype and prognosis was not clear because of the variety of treatment. Two patients receiving chemotherapy developed brain necrosis, which was fatal in one case, and the other two patients treated with the protocol are in a poor state without signs of recurrence. Chemotherapy may enhance the radiation effect on normal brain tissue as well as tumor. Combination of radiotherapy and chemotherapy can improve the survival rate, but the optimal dosage needs to be investigated further.

Demonstration of Epstein-Barr virus in primary central nervous system lymphomas by the polymerase chain reaction and in situ hybridization

Primary lymphomas of the central nervous system (CNS) account for 0.3% to 1.5% of all intracranial neoplasms. Several reports have noted a coincidence between this neoplasm and serologic evidence of Epstein-Barr virus (EBV) infection, but in only a few instances has the EBV genome been demonstrated in these tumors. To further evaluate the frequency of this occurrence, we analyzed primary CNS lymphomas using nucleic acid hybridization methods and the polymerase chain reaction (PCR). In situ hybridization was used in selected cases. Sequences of EBV were found in two of nine cases by PCR and in situ hybridization. Southern blot hybridization of genomic DNA from these samples was negative for EBV. Both tumors arose in patients with conditions shown to produce secondary immunodeficiency, namely, chronic alcohol abuse and diabetes mellitus. We conclude that the association of EBV and CNS lymphoma is not restricted to patients with severe primary immune deficiency, and that PCR can be applied successfully to paraffin-embedded tissue for the detection of low-abundance viral sequences.

Adult supratentorial tumors

MR imaging has represented a significant advance in the diagnosis and management of adult supratentorial neoplasms, and indeed MR has become the modality of choice for the initial diagnosis and follow-up in these cases. It is clear that the overall sensitivity has increased significantly, due to both the use of MR itself and to the implementation of IV contrast agents. It appears that some inroads have been made with regard to specificity, but significant overlap still exists in the imaging appearance of many of these entities. A thorough knowledge of neuroanatomy, pathophysiology, and neuropathology aid markedly in the imaging diagnosis of these processes.

Demonstration of Epstein-Barr virus in primary brain lymphoma by in situ DNA hybridisation in paraffin wax embedded tissue

Tumour tissue from 29 patients with primary brain lymphoma was reviewed to determine if there was an aetiological association between Epstein-Barr virus and polyclonal and monoclonal lymphoproliferations. The morphology and immunophenotype in 24 patients for whom paraffin wax embedded tissue was available were studied. A high grade pleomorphic tumour morphology with plasmacytoid features was seen in 13 tumours. Because of the large number of pleomorphic lymphomas, all tumours were examined for the presence of the Epstein-Barr virus genome using in situ DNA hybridisation. A panel of three biotinylated probes to different sequences in the Epstein-Barr virus genome was used. Positive hybridisation with one or more probes was shown in tumours from 11 patients. The remaining tumours gave no hybridisation signal. There was no correlation between positive hybridisation and morphological subtype or clinical outcome.

Primary lymphoma of the central nervous system. An unresolved therapeutic problem

From January 1979 to December 1987, 35 cases of primary central nervous system lymphoma (CNS-L) were treated. We recently reviewed these cases focusing on treatment results, treatment modalities, and radiotherapy (RT) or chemotherapy-radiotherapy (CT-RT). Variables such as age, risk factors, presenting symptoms, and histologic condition (all were high-grade or intermediate-grade non-Hodgkin's lymphomas [NHL]) and radiologic data were similar to those of series reported previously. The median survival time was 36 months (+/- 0.2 months) and the disease-free survival (DFS) time was 16 months (+/- 0.12 months). Twelve of 32 patients evaluable for treatment results experienced a recurrence (all but one occurred in the CNS). The DFS rate was 70% for the CT-RT group and 50% for the RT group (median follow-up time, 24 months). Therapeutic results in CNS-L are discussed with special emphasis on a putative role of CT in the management of this rare type of tumor.

Diagnosis of primary cerebral lymphoma with particular reference to CT-guided stereotactic biopsy

In establishing the histological diagnosis of primary cerebral lymphoma, stereotactic brain tumour biopsy is the method of choice as the mainstay of therapy is radiation and chemotherapy. This study describes the histopathology and diagnostic immunohistochemistry of 54 primary brain lymphomas in a mainly non-AIDS population. The stereotactic biopsies were performed using the Leksell CT stereotactic frame and a spiral needle which procured about 10-mm-long tissue cylinders. Usually, three successive biopsy cylinders were taken along the target trajectory. Histological examination revealed the prevalence of high-grade non-Hodgkin's lymphoma of the polymorphous centroblastic type. The series did not include any low-grade lymphomas or T-cell lymphomas. L-26 immunohistochemistry resulted in a positive staining of the blasts, thus confirming the B-cell origin of primary brain lymphomas. Small reactive T-lymphocytes and monohistiocytic cells were also found within and at the periphery of the lymphomas and in areas of degeneration. In the biopsies of nine patients, who had shown significant reduction of the lesions on the CT scans, after corticosteroid medication, regressive tissue changes were predominant and consisted of T-lymphocytes, macrophages, and occasionally bizarre reactive astrocytes.

Primary intracranial lymphomas

We present 20 cases of primary intracranial lymphoma and review the most important published series on this subject. The clinical patterns and the differential diagnosis from other intracranial space-occupying lesions on the CT and angiographic evidence are discussed. Surgical treatment was given in 19 of our cases, followed in 17 cases by radiotherapy and in 4 by chemotherapy. One patient was treated by a ventriculo-peritoneal shunt. The effectiveness of the various modalities of treatment is discussed in the light of survival.

Morphologic and immunophenotypic characterization of primary brain lymphomas using paraffin-embedded tissue

Primary lymphomas of the brain constitute about 1% of all primary intracranial neoplasms, but recent studies suggest an increasing incidence. Most cases are associated with an immunosuppressed state. We reviewed 29 cases of primary brain lymphoma from the Yorkshire Health Authority Region between 1970 and 1988 and found a striking increase in incidence over this period. No overt evidence of immunosuppression was found in any case. All were non-Hodgkin's in type and were classified morphologically using Kiel criteria and immunophenotypically using a panel of antibodies. Cryo-preserved tissue was available in five cases for parallel immunophenotyping. The majority of tumours were high-grade lymphomas together with three of lymphoplasmacytoid type. Thirteen tumours showed a striking pleomorphic morphology with plasmacytoid features. A reactive, predominantly perivascular monomorphic T-cell population was seen in all tumours. Most tumours were of B-cell lineage. No cases of Hodgkin's disease, T-cell or histiocytic lymphoma were present. Light chain restriction was present in only 46% of cases. The results of tumour immunophenotyping on cryostat sections were comparable with those from paraffin blocks. Our study emphasizes the value of a panel of antibodies reactive in paraffin-embedded tissue, allowing simultaneous evaluation of morphology and immunophenotype, and suitable for small biopsies received from stereotactic procedures.

Membranous changes in primary malignant CNS lymphomas

Ultrastructural studies of 17 primary malignant CNS lymphomas revealed 6 tumors with abnormal intracytoplasmic and/or intranuclear membranous structures, most frequently associated with the endoplasmic reticulum or perinuclear envelope. In most cases, tubuloreticular inclusions and paired cisternae were present. Less frequent were accumulation of microtubules, concentric lamellar bodies, and rod-like or paracrystalline intranuclear inclusions. The specificity and significance of these membranous structures remain questionable because of their frequent occurrence in a variety of normal and pathological conditions. Some of these changes may be considered as cellular reactions to viral infections, others may indicate cellular activity or degeneration.

Computed tomography in the diagnosis of malignant brain tumours: do all patients require biopsy?

A proportion of patients with computed tomographic (CT) scan appearances of malignant brain tumour undergo conservative management, despite the absence of histological confirmation of the diagnosis. Concern that this policy risked misdiagnosing a benign tumour prompted us to examine the accuracy of CT scanning in diagnosing malignant lesions. The study was designed to determine whether within a group of 300 patients with intracerebral mass lesions of known pathology, two sub-groups existed: one with appearances so specific for malignant glioma that biopsy was unnecessary, and the other in which the appearances were characteristic of malignancy, though not specific for glioma. Three neuroradiologists independently reviewed the CT scans, together with brief clinical details. When diagnosing malignant tumours, all made errors: nine benign lesions were considered to be malignant. When diagnosing malignant glioma, one neuroradiologist made errors, but the other two adopted a more cautious approach and were accurate. The restricted a "certain" diagnosis to about one in five scans considered to show malignant tumour. Those diagnosed specifically as malignant glioma were intrinsic, irregular, mixed density lesions, exhibiting variable enhancement and infiltrating the peri-ventricular tissues, especially the corpus callosum. Using these criteria, they could correctly identify a small proportion of patients with malignant gliomas. In all other patients, biopsy remains the only means of obtaining a definitive diagnosis.

High-dose methotrexate for non-AIDS primary central nervous system lymphoma. Report of 13 cases

Thirteen patients with primary lymphoma of the central nervous system (CNS) were treated with high-dose intravenous methotrexate (MTX), 3.5 gm/sq m, followed by calcium leucovorin rescue, at 3-week intervals, for three cycles. Eleven patients subsequently received radiation therapy to the whole brain, 30 to 44 Gy. Before radiation therapy, eight patients responded completely and four partially; there was one non-responder. The median Karnofsky score before high-dose MTX therapy was 60 and increased to 90 after treatment. Five of the eight complete responders reached a Karnofsky rating of 100. The three longest responders (one of whom received MTX only) were without recurrence of their disease at 29+, 32, and 32+ months posttherapy. The median response period is 9+ months. The median survival time from the date of the first MTX treatment is 9+ months, and the three longest survival times are 29+, 32+, and 54+ months. All patients received corticosteroids in either unchanging or diminishing dosages during therapy. It is concluded that primary CNS lymphoma is sensitive to high-dose MTX, which provides a safe and easily administered adjuvant to radiation therapy for this neoplasm.

Non-Hodgkin's lymphoma involving the brain. Diagnostic usefulness of stereotactic needle biopsy in combination with paraffin-section immunohistochemistry

A stereotactic needle biopsy was examined for applicability in diagnosing brain non-Hodgkin's lymphoma (NHL), because the procedure is far less aggressive than biopsy by open surgery. Formalin-fixed materials including four stereotactic specimens were available from nine patients with brain NHL. In addition to routine histopathology and histochemistry, paraffin-section immunohistochemistry was performed using a panel of monoclonal antibodies suited to such sections. Although several histopathological features characteristic of brain NHL could not be evaluated in three of the four stereotactic specimens owing to the small size of the specimens and partial invasion by lymphoma cells, the lesions in all cases could be characterised by immunohistochemistry. Examination for cytoplasmic immunoglobulin (cIg) was also performed, but specific identification of cIg was difficult in five cases because of diffuse background staining and passive diffusion of plasma protein into the cells during tissue processing. A review of the literature indicates the technical difficulty in cIg staining, since the incidence of cIg-positive cases in an individual study varied considerably, and lymphoma cells in 15 of 128 cIg-positive brain NHL cases have been reported to possess both light chains. From these findings, together with the relative difficulty in obtaining fresh tissues for study, it is concluded that, when the specimens are to be examined by paraffin-section immunohistochemistry using the above monoclonal antibodies, stereotactic needle biopsy is a useful, less aggressive method for diagnosing brain NHL.