Glucocorticoid therapy obscures the diagnosis of cerebral lymphoma

Analysis of False-negative Findings of the Incomparable Accuracy and Swiftness of Flow Cytometric Diagnosis of Primary Central Nervous System Lymphoma

Primary central nervous system lymphoma (PCNSL), a relatively rare brain tumor, bears a dire prognosis. On occasion, the rapid progression of the tumor makes immediate diagnosis and initiation of therapy imperative. To achieve swift diagnosis, we adopt flow cytometry (FCM) in addition to conventional histopathology. This study aimed to reveal the utility of FCM diagnosis for PCNSL and the cause of false-negative results of FCM diagnosis. We investigated 33 patients with suspected PCNSL on neuroradiological findings and received both FCM and histological diagnosis. The patients' electronic medical records were investigated, and histological findings, results of FCM, and other clinical data were evaluated. Overall, 27 patients (14 males and 13 females) were diagnosed with PCNSL by histological confirmation. The median age at diagnosis was 68 years. FCM analysis showed lymphoma pattern in 24 cases; however, FCM results did not show lymphoma pattern (sensitivity: 88.9%, specificity: 100%) in the other three lymphoma cases (FCM discordant: FCM-D) and six nonlymphomatous tumor cases. Analysis of FCM-D cases showed the infiltration of T lymphocytes or astrocytes into the tumor tissue, indicating tumor microenvironmental reaction; it is assumed that these reactions deceived FCM diagnosis. The survival of FCM-D patients was superior to FCM concordant counterpart, although the difference was not significant (p = 0.459). The diagnosis of PCNSL by FCM is rapid and highly reliable. Some FCM-D cases are PCNSLs with strong tumor microenvironmental reactions.

Empiric treatment for persistent fever from suspected autoinflammatory disease: Experience from an undiagnosed diseases program

BACKGROUND

Patients with persistent fevers of undetermined etiology often undergo extensive evaluation without a diagnosis. Autoinflammatory syndromes may not always be considered in the differential, as these are rare entities, there are no consensus clinical criteria and genetic testing can only capture a few of these diseases. We aimed to describe the experience and value of an undiagnosed diseases program in the evaluation and management of patients who present with persistent fevers.

METHODS

A retrospective analysis was performed on eleven patients who presented with persistent fevers to the Undiagnosed Diseases Program (UDP) at University of Alabama at Birmingham. All patients received extensive testing prior to referral and were seen by multiple subspecialists. The primary outcome of complete remission was resolution of episodes of fever and malaise in response to empiric biological anti-inflammatory treatment.

RESULTS

All patients received genetic testing and further diagnostic evaluation by the UDP. Even without confirmed genetic testing, they were empirically started on anti-inflammatory therapies (including colchicine, IL-1 inhibitors, IL-6 inhibitors). Ten patients have achieved complete remission on empiric treatment. Three patients were given formal diagnoses. No patients have had any major adverse events from therapy.

CONCLUSIONS

This is a pilot study suggesting the role for empiric treatment trials of biologics for patients with suspected autoinflammatory diseases. As the differential diagnosis of patients with persistent fevers is broad, and the diagnosis of autoinflammatory diseases often comes with some degree of uncertainty, evaluation by a center with expertise in diagnosing these conditions can help determine which patients should have empiric trials of biologics.

Evidence-based expert consensus on the management of primary central nervous system lymphoma in China

Primary central nervous system lymphoma (PCNSL) is a type of central nervous system restricted non-Hodgkin lymphoma, whose histopathological diagnosis is majorly large B cell lymphoma. To provide specific, evidence-based recommendations for medical professionals and to promote more standardized, effective and safe treatment for patients with PCNSL, a panel of experts from the Chinese Neurosurgical Society of the Chinese Medical Association and the Society of Hematological Malignancies of the Chinese Anti-Cancer Association jointly developed an evidence-based consensus. After comprehensively searching literature and conducting systematic reviews, two rounds of Delphi were conducted to reach consensus on the recommendations as follows: The histopathological specimens of PCNSL patients should be obtained as safely and comprehensively as possible by multimodal tomography-guided biopsy or minimally invasive surgery. Corticosteroids should be withdrawn from, or not be administered to, patients with suspected PCNSL before biopsy if the patient's status permits. MRI (enhanced and DWI) should be performed for diagnosing and evaluating PCNSL patients where whole-body PET-CT be used at necessary time points. Mini-mental status examination can be used to assess cognitive function in the clinical management. Newly diagnosed PCNSL patients should be treated with combined high-dose methotrexate-based regimen and can be treated with a rituximab-inclusive regimen at induction therapy. Autologous stem cell transplantation can be used as a consolidation therapy. Refractory or relapsed PCNSL patients can be treated with ibrutinib with or without high-dose chemotherapy as re-induction therapy. Stereotactic radiosurgery can be used for PCNSL patients with a limited recurrent lesion who were refractory to chemotherapy and have previously received whole-brain radiotherapy. Patients with suspected primary vitreoretinal lymphoma (PVRL) should be diagnosed by vitreous biopsy. PVRL or PCNSL patients with concurrent VRL can be treated with combined systemic and local therapy.

Primary Central Nervous System Lymphomas: A Diagnostic Overview of Key Histomorphologic, Immunophenotypic, and Genetic Features

Primary central nervous system lymphoma (PCNSL) is a rare form of extranodal non-Hodgkin lymphoma that primarily arises in the brain, spinal cord, leptomeninges, and vitreoretinal compartment of the eye. The term is sometimes used interchangeably with primary central nervous system diffuse large B-cell lymphoma (PCNS DLBCL) because DLBCL comprises a great majority (90–95%) of PCNSL. Although rare, other types of lymphomas can be seen in the central nervous system (CNS), and familiarity with these entities will help their recognition and further workup in order to establish the diagnosis. The latter is especially important in the case of PCNSL where procurement of diagnostic specimen is often challenging and yields scant tissue. In this review, we will discuss the most common types of primary lymphomas that can be seen in the CNS with emphasis on the diagnostic histomorphologic, immunophenotypic, and molecular genetic features. The differential diagnostic approach to these cases and potential pitfalls will also be discussed.

Newly diagnosed enhancing lesions: Steroid initiation may impede diagnosis of lymphoma involving the central nervous system

Establishing the pathologic diagnosis of central nervous system (CNS) lymphoma can be challenging, yet management of this potentially curable disease depends heavily on it. One avoidable impediment to obtaining an accurate and timely diagnosis is the pre-operative administration of steroids, which causes tumor involution and prevents appropriate sampling of viable tissue. We discuss a case of primary CNS lymphoma that highlights the evolution of the disease and the attempts to establish a diagnosis in the setting of prior administration of corticosteroids. Familiarity with these clinical scenarios will help others avoid delays in patient care that results from delayed diagnosis.

The Impact of Early Corticosteroid Pretreatment Before Initiation of Chemotherapy in Patients With Primary Central Nervous System Lymphoma

BACKGROUND

The optimal timing of corticosteroid (CS) treatment in patients with primary central nervous system (CNS) lymphoma (PCNSL) remains controversial. While poor clinical presentation may justify early treatment with CS, this may ultimately result in reduced concentrations of chemotherapeutic agents via perturbations in the permeability of the blood-brain barrier.

OBJECTIVE

To investigate whether early CS exposure is associated with beneficial outcomes and/or reduced occurrence of adverse events as opposed to delayed/concomitant administration.

METHODS

Herein we performed a retrospective observational analysis using patients that were prospectively entered into a database. All patients whom were admitted to the University Hospital between 2009 and 2015 with newly diagnosed PCNSL were included within our study.

RESULTS

Our cohort included 50 consecutive patients diagnosed with PCNSL; of these, in 30 patients CS administration was initiated prior to chemotherapy (early), whilst in the remaining 20 patients CS administration was initiated concomitantly with their chemotherapeutic regimen (concomitant). Within the early vs concomitant CS administration groups, no significant differences were observed with regard to progression-free survival (PFS) (P = .81), overall survival (OS) (P = .75), or remission (P = .68; odds ratio 0.76 and confidence interval [95%] 0.22-2.71). Critically, the timing of CS initiation was not associated with either PFS (P = .81) or PFS (P = .75).

CONCLUSION

Early CS administration was not associated with a deterioration in response to chemotherapy, PFS, or OS. As such, administration of CS prior to initiation of chemotherapy is both reasonable and safe for patients with newly diagnosed PCNSL.

Diagnostic impact of preoperative corticosteroids in primary central nervous system lymphoma

PURPOSE

High dose corticosteroids are an effective tool for rapidly alleviating neurologic symptoms caused by intracranial mass lesions. However, there is concern that preoperative corticosteroids limit the ability to obtain a definitive pathologic diagnosis, particularly if imaging features suggest primary central nervous system lymphoma (PCNSL).

METHODS

To explore the impact of preoperative corticosteroids in newly diagnosed PCNSL patients, from 2009 to 2018 treated at our institution.

RESULTS

We identified 54 patients; 18 had received corticosteroids prior to biopsy or resection. Only in one case did the patient have a prior non-diagnostic biopsy, requiring a second procedure. The cumulative doses of preoperative dexamethasone ranged from 4 mg to 120 mg (mean 32 mg, median 24 mg), given over 1-14 days (mean 2 days, median 1 day), and the majority had received corticosteroids for only 1-2 days. There was a trend for a larger diameter of lesional T1 contrast enhancement for patients who received steroids (39 mm vs. 34 mm, p = 0.11). In this series of cases with pathologically and clinically proven PCNSL, preoperative corticosteroids had been given in a third of cases, suggesting that they may be given for symptomatic relief without compromising pathologic diagnosis.

CONCLUSIONS

Despite the commonly held tenet that preoperative corticosteroids can obscure the pathologic diagnosis in PCNSL, this is likely not the case in the majority of patients who receive a short course preoperatively. Obtaining a second stereotactic scan to confirm continued presence of the lesion prior to tissue sampling may also mitigate these concerns.

Efficacy of a Second Brain Biopsy for Intracranial Lesions after Initial Negativity

Background and Purpose

The rationale for performing a second brain biopsy after initial negativity is not well evaluated in the literature. This study was designed to 1) assess the efficacy of a second brain biopsy when the first biopsy was nondiagnostic, 2) identify possible factors associated with an increased diagnostic rate in the second biopsy, and 3) analyze additional morbidity induced by the second biopsy.

Methods

We performed a retrospective cohort study from 2009 to 2019, during which 1,919 patients underwent a brain biopsy, including 30 who were biopsied twice (1.6%). The specific histological diagnosis rate, diagnosis-associated factors, and complication rate were assessed for the 30 twice-biopsied patients.

Results

The second biopsy allowed a specific histological diagnosis in 86.7% of the patients who had initially undergone a nondiagnostic brain biopsy [odds ratio (OR)=7.5, 95% confidence interval (CI)=3.0–18.7, p<0.001]. The multivariate analysis showed that only prebiopsy corticosteroid administration (OR=2.6, 95% CI=1.1–6.0, p=0.01) was an important factor in predicting a nondiagnostic biopsy. None of the patients developed a symptomatic complication after the first biopsy, while two (6.0%) patients experienced a transient complication after the second biopsy (p=0.49).

Conclusions

Performing a second brain biopsy in patients who have an initial nondiagnostic biopsy is effective in most cases. We advocate that a second biopsy be systematically considered in the diagnosis algorithm of these patients after it has been verified that molecular testing cannot help to obtain a diagnosis. Corticosteroid administration can lead to nondiagnostic biopsies and should be avoided when possible during the prebiopsy period.

Diagnostic red flags: steroid-treated malignant CNS lymphoma mimicking autoimmune inflammatory demyelination

The presence of inflammation and demyelination in a central nervous system (CNS) biopsy points towards a limited, yet heterogeneous group of pathologies, of which multiple sclerosis (MS) represents one of the principal considerations. Inflammatory demyelination has also been reported in patients with clinically suspected primary central nervous system lymphoma (PCNSL), especially when steroids had been administered prior to biopsy acquisition. The histopathological changes induced by corticosteroid treatment can range from mild reduction to complete disappearance of lymphoma cells. It has been proposed that in the absence of neoplastic B cells, these biopsies are indistinguishable from MS, yet despite the clinical relevance, no histological studies have specifically compared the two entities. In this work, we analyzed CNS biopsies from eight patients with inflammatory demyelination in whom PCNSL was later histologically confirmed, and compared them with nine well defined early active multiple sclerosis lesions. In the patients with steroid-treated PCNSL (ST-PCNSL) the interval between first and second biopsy ranged from 3 to 32 weeks; all of the patients had received corticosteroids before the first, but not the second biopsy. ST-PCNSL patients were older than MS patients (mean age: ST-PCNSL: 62 ± 4 years, MS: 30 ± 2 years), and histological analysis revealed numerous apoptoses, patchy and incomplete rather than confluent and complete demyelination and a fuzzy lesion edge. The loss of Luxol fast blue histochemistry was more profound than that of myelin proteins in immunohistochemistry, and T cell infiltration in ST-PCNSL exceeded that in MS by around fivefold (P = 0.005). Our data indicate that in the presence of extensive inflammation and incomplete, inhomogeneous demyelination, the neuropathologist should refrain from primarily considering autoimmune inflammatory demyelination and, even in the absence of lymphoma cells, instigate close clinical follow-up of the patient to detect recurrent lymphoma.

Guidelines for diagnosis, prevention and management of central nervous system involvement in diffuse large B-cell lymphoma patients by the Spanish Lymphoma Group (GELTAMO)

Diffuse large B-cell lymphoma patients have a 5% overall risk of central nervous system events (relapse or progression), which account for high morbidity and frequently fatal outcomes,¹ and shortened overall survival of <6 months.² Early diagnosis of central nervous system events is critical for successful treatment and improved prognosis. Identification of patients at risk of central nervous system disease is critical to accurately identify candidates for central nervous system prophylaxis vs.

THERAPY

^3-5 This report by the Spanish Lymphoma Group (GELTAMO) aims to provide useful guidelines and recommendations for the prevention, diagnosis, and treatment of central nervous system diffuse large B-cell lymphoma patients with, or at risk of, leptomeningeal and/or brain parenchyma lymphoma relapse. A panel of lymphoma experts working on behalf of GELTAMO reviewed all data published on these topics available in PubMed up to May 2016. Recommendations were classified according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach.⁶ A practical algorithm based on the proposed recommendations was then developed (Figure 1). Initial discussions among experts were held in May 2014, and final consensus was reached in June 2016. The final manuscript was reviewed by all authors and the Scientific Committee of GELTAMO.

Neurosurgery and human immunodeficiency virus in the era of combination antiretroviral therapy: a review

Human immunodeficiency virus (HIV) is a global health problem. It renders the central nervous system susceptible to infectious and noninfectious diseases. HIV-positive individuals may present to neurosurgical services with brain lesions of unknown etiology. The differential diagnosis in these cases is broad, including opportunistic infections and malignancies, and investigation should be tailored accordingly. Opportunistic infections of the central nervous system can be complicated by hydrocephalus, and the management is pathogen dependent. Patients may also present to a neurosurgical service with conditions unrelated to their HIV status. This review outlines important conditions that cause brain lesions and hydrocephalus. It addresses the issues of diagnosis and intervention in HIV-positive patients in the era of combination antiretroviral therapy, while not ignoring the potential for opportunistic central nervous system infection in undiagnosed patients. The care of HIV-positive patients presenting to neurosurgical services requires a multidisciplinary approach, which is reflected in the authorship of this review, as well as in the guidance given.

Performance of Apparent Diffusion Coefficient Values and Conventional MRI Features in Differentiating Tumefactive Demyelinating Lesions From Primary Brain Neoplasms

OBJECTIVE

Tumefactive demyelinating lesions (TDLs) remain one of the most common brain lesions to mimic a brain tumor, particularly primary CNS lymphoma (PCNSL) and high-grade gliomas. The purpose of our study was to evaluate the ability of apparent diffusion coefficient (ADC) values and conventional MRI features to differentiate TDLs from PCNSLs and high-grade gliomas.

MATERIALS AND METHODS

Seventy-five patients (24 patients with TDLs, 28 with PCNSLs, and 23 with high-grade gliomas) with 168 brain lesions (70 TDLs, 68 PCNSLs, and 30 high-grade gliomas) who underwent DWI before surgery or therapy were included in the study. Minimum ADC (ADC(min)) and average ADC (ADC(avg)) values were calculated for each lesion. ANOVA and ROC analyses were performed. ROC analyses were also performed for the presence of incomplete rim enhancement and for the number of lesions. Multiple-variable logistic regression with ROC analysis was then performed to evaluate performance in multiple-variable models.

RESULTS

ADC(min) was statistically significantly higher (p < 0.01) in TDLs (mean, 0.886; 95% CI, 0.802-0.931) than in PCNSLs (0.547; 95% CI, 0.496-0.598) and high-grade gliomas (0.470; 95% CI, 0.385-0.555). (All ADC values in this article are reported in units of × 10(-3) mm(2)/s.) ADC(avg) was statistically significantly higher (p < 0.01) in TDLs (mean, 1.362; 95% CI, 1.268-1.456) than in PCNSLs (0.990; 95% CI, 0.919-1.061) but not in high-grade gliomas (1.216; 95% CI, 1.074-1.356). Multiple-variable models showed statistically significant individual effects and superior diagnostic performance on ROC analysis.

CONCLUSION

TDLs can be diagnosed on preoperative MRI with a high degree of specificity; MRI features of incomplete rim enhancement, high ADC values, and a large number of lesions individually increase the probability and diagnostic confidence that a lesion is a TDL.

The Combined Performance of ADC, CSF CXC Chemokine Ligand 13, and CSF Interleukin 10 in the Diagnosis of Central Nervous System Lymphoma

BACKGROUND AND PURPOSE

CXC chemokine ligand 13 and interleukin 10 have emerged as CSF biomarkers for the diagnosis of CNS lymphoma. Our hypothesis is that the combined use of ADC, CXC chemokine ligand 13, and interleukin 10 will result in increased diagnostic performance compared with the use of ADC values alone.

MATERIALS AND METHODS

Eighty-seven patients were included in this study, including 43 with CNS lymphoma and 44 without CNS lymphoma (21 metastases, 14 high-grade gliomas, 9 tumefactive demyelinating lesions) who had undergone CSF proteomic analysis and had a new enhancing mass on brain MR imaging. Average ADC was derived by contouring the contrast-enhancing tumor volume. Group means were compared via t tests for average ADC, CXC chemokine ligand 13, and interleukin 10. Receiver operating characteristic analysis was performed for each individual variable. Multiple-variable logistic regression with receiver operating characteristic analysis was performed, and the multiple-variable receiver operating characteristic was compared with single-variable receiver operating characteristics.

RESULTS

The average ADC was lower and CSF CXC chemokine ligand 13 and interleukin 10 values were higher in CNS lymphoma (P < .001). Areas under the curve ranged from 0.739 to 0.832 for single-variable ROC. Multiple-variable logistic regression yielded statistically significant individual effects for all 3 variables in a combined model. Multiple-variable receiver operating characteristics (area under the curve, 0.928) demonstrated statistically significantly superior diagnostic performance compared with the use of single variables alone.

CONCLUSIONS

The combined use of ADC, CSF CXC chemokine ligand 13, and interleukin 10 results in increased diagnostic performance for the diagnosis of CNS lymphoma. This finding highlights the importance of CSF analysis when the diagnosis of CNS lymphoma is considered on the basis of MR imaging.

Primary central nervous system lymphoma: is absence of intratumoral hemorrhage a characteristic finding on MRI?

Background.

Previous studies have shown that intratumoral hemorrhage is a common finding in glioblastoma multi-forme, but is rarely observed in primary central nervous system lymphoma. Our aim was to reevaluate whether intratumoral hemorrhage observed on T2-weighted imaging (T2WI) as gross intratumoral hemorrhage and on susceptibility-weighted imaging as intratumoral susceptibility signal can differentiate primary central nervous system lymphoma from glioblastoma multiforme.

Patients and methods.

A retrospective cohort of brain tumors from August 2008 to March 2013 was searched, and 58 patients (19 with primary central nervous system lymphoma, 39 with glioblastoma multiforme) satisfied the inclusion criteria. Absence of gross intratumoral hemorrhage was examined on T2WI, and an intratumoral susceptibility signal was graded using a 3-point scale on susceptibility-weighted imaging. Results were compared between primary central nervous system lymphoma and glioblastoma multiforme, and values of P < 0.05 were considered significant.

Results.

Gross intratumoral hemorrhage on T2WI was absent in 15 patients (79%) with primary central nervous system lymphoma and 23 patients (59%) with glioblastoma multiforme. Absence of gross intratumoral hemorrhage could not differentiate between the two disorders (P = 0.20). However, intratumoral susceptibility signal grade 1 or 2 was diagnostic of primary central nervous system lymphoma with 78.9% sensitivity and 66.7% specificity (P < 0.001), irrespective of gross intratumoral hemorrhage.

Conclusions.

Low intratumoral susceptibility signal grades can differentiate primary central nervous system lymphoma from glioblastoma multiforme. However, specificity in this study was relatively low, and primary central nervous system lymphoma cannot be excluded based solely on the presence of an intratumoral susceptibility signal.

A vanishing lymphoma in the cheek

BACKGROUND

We describe the unusual case of a 66-year-old woman who presented with a cheek mass that completely abated with oral steroids.

CASE REPORT

Multiple separate biopsies of the mass were negative or inconclusive. MRI revealed a large mass, yet after a short steroid course, this mass was completely undetectable on clinical examination. A repeat biopsy eventually revealed follicular lymphoma.

DISCUSSION

Lymphomas are known to be steroid sensitive; the medication is an essential component of the common CHOP therapy. While known to occur in the central nervous system, to the best of our knowledge, the presence of a 'vanishing' lymphoma has not been documented in the head and neck. We discuss the likely physiology of the vanishing lymphoma, and the diagnostic difficulty it presents.

CONCLUSION

When a lymphoma is suspected, patient care may be optimized if biopsy is delayed until steroids have been discontinued.

Multiple sclerosis: diagnosis, differential diagnosis, and clinical presentation

The diagnosis of multiple sclerosis (MS) is based on demonstrating evidence of inflammatory-demyelinating injury within the central nervous system that is disseminated in both time and space. Diagnosis is made through a combination of the clinical history, neurologic examination, magnetic resonance imaging and the exclusion of other diagnostic possibilities. Other so-called "paraclinical" tests, including the examination of the cerebrospinal fluid, the recording of evoked potentials, urodynamic studies of bladder function, and ocular coherence tomography, may be helpful in establishing the diagnosis for individual patients, but are often unnecessary. Differential diagnosis in MS must be guided by clinical presentation and neurologic localization. While the list of conditions that can mimic MS clinically or radiologically is long, in clinical practice there are few conditions that truly mimic MS on both fronts. A positive test for a putative MS "mimic" does not unto itself exclude the diagnosis of MS. Typical symptoms of MS include discrete episodes ("attacks" or "relapses") of numbness, tingling, weakness, vision loss, gait impairment, incoordination, imbalance, and bladder dysfunction. In between attacks, patients tend to be stable, but may experience fatigue and heat sensitivity. Some MS patients go on to experience, or only experience, an insidious worsening of neurologic function and accumulation of disability ("progression") that is not associated with discrete relapse activity. Progression accounts for most of the long-term disability in MS. Diagnostic criteria for MS have evolved over the past several decades, with each revision impacting the apparent prevalence and prognosis of the disorder - the result has been to encourage earlier diagnosis without compromising accuracy.

Primary central nervous system lymphoma: a clinicopathological and cytomorpholgical study from a tertiary care centre in Chennai, India

BACKGROUND

The aim of this study was to analyze the clinicopathological and immunohistochemical features of primary central nervous system lymphoma (PCNSL) cases occurring in Indian patients and also study the utility of the crush smear preparation in intraoperative diagnosis.

MATERIALS AND METHODS

The immune status, clinical, radiological details, immunohistochemical profile, histopathological findings and cytological features in smear preparation of 32 cases of PCNSL were analyzed. Patients with systemic NHL and skull-base lymphomas were excluded.

RESULTS

The mean age of our patients was 52 years with a male: female ratio 1:1. A periventricular location was found in 62.5% of patients. None of our PCNSL cases were associated with AIDS. All cases except one were diffuse large B-cell lymphomas. Intraoperative diagnosis using crush smears allowed correct prediction in 93% of cases.

CONCLUSIONS

Our study shows that PCNSL is seen predominantly in immunocompetent patients in India .The age of presentation is relatively young as compared to the West. Our study also stresses the utility of crush smear preparation in establishing an intraoperative diagnosis.

A systematic approach to the diagnosis of suspected central nervous system lymphoma

Central nervous system (CNS) lymphoma can present a diagnostic challenge. Currently, there is no consensus regarding what presurgical evaluation is warranted or how to proceed when lesions are not surgically accessible. We conducted a review of the literature on CNS lymphoma diagnosis (1966 to October 2011) to determine whether a common diagnostic algorithm can be generated. We extracted data regarding the usefulness of brain and body imaging, serum and cerebrospinal fluid (CSF) studies, ophthalmologic examination, and tissue biopsy in the diagnosis of CNS lymphoma. Contrast enhancement on imaging is highly sensitive at the time of diagnosis: 98.9% in immunocompetent lymphoma and 96.1% in human immunodeficiency virus-related CNS lymphoma. The sensitivity of CSF cytology is low (2%-32%) but increases when combined with flow cytometry. Cerebrospinal fluid lactate dehydrogenase isozyme 5, β2-microglobulin, and immunoglobulin heavy chain rearrangement studies have improved sensitivity over CSF cytology (58%-85%) but have only moderate specificity (85%). New techniques of proteomics and microRNA analysis have more than 95% specificity in the diagnosis of CNS lymphoma. Positive CSF cytology, vitreous biopsy, or brain/leptomeningeal biopsy remain the current standard for diagnosis. A combined stepwise systematic approach outlined here may facilitate an expeditious, comprehensive presurgical evaluation for cases of suspected CNS lymphoma.

A prospective study of the safety and efficacy of frameless, pinless electromagnetic image-guided biopsy of cerebral lesions

BACKGROUND

In recent years, frameless navigation techniques have been reported to be safe and effective for biopsy of cerebral lesions.

OBJECTIVE

To evaluate the safety and efficacy of a technique of frameless, pinless electromagnetic-guided biopsy for brain lesions with the Medtronic Stealth AxiEM.

METHODS

Prospective data were collected on consecutive brain biopsies performed by a single surgeon (P.L.G.) with this technology between October 2007 and May 2010. One trajectory was made per lesion with multiple specimens taken for analysis. Outcome measures included measures of accuracy, histological yield, and complication rate.

RESULTS

A total of 150 biopsies were performed in 149 patients (84 male and 65 female patients; age range, 19.8-83.8 years). The consultant performed 49 procedures, supervising a trainee in the others. In only 1 case (0.7%) was there nondiagnosis consequent of a registration error and inaccurate trajectory. In 4 other cases (2.7%), no specific diagnosis was established, but abnormal tissue was identified histologically, and postoperative imaging confirmed accurate targeting of these lesions. There were no instances of intracranial hemorrhage or significant morbidity and no deaths directly attributable to the procedure. Four patients (2.7%) died within 30 days of the procedure but not of complications of surgery. One patient suffered a transitory neurological deficit.

CONCLUSION

Electromagnetic navigation is proven to be a simple, safe, and effective innovation for frameless and pinless biopsy of cerebral lesions. This technique is time efficient, and elimination of frame placement enhances patient comfort and facilitates the use of local anesthetic technique.

[Remission of lymphomatosis cerebri induced by corticosteroid and high-doses intravenous methotrexate]

Lymphomatosis cerebri (LC) is a rare form of primary central nervous system lymphoma characterized by subacute progressive dementia and unsteady gait. MRI study of LC typically reveals diffuse leukoencephalopathy without contrast enhancement. The clinical presentation and MRI features of LC can resemble infectious, inflammatory, toxic or vascular leukoencephalopathy. Hence diagnosis of LC is easily mistaken for other, more common diseases. In this report, we present a case of a 55-year-old man presenting with subacute progressive dementia and ataxic gait. Brain MRI showed diffuse hyperintense lesions in the cerebral white matter of both hemispheres, left amygdala, brainstem and cerebellar peduncles on FLAIR image. No contrast-enhanced lesion was observed. Cerebrospinal fluid analysis showed elevated levels of soluble interleukin-2 receptor and β2-microglobulin. Based on MRI findings and 123I-IMP SPECT, stereotactic biopsy targeting white matter of the left medial temporal lobe was performed (day 0). On the day after the brain biopsy, corticosteroid therapy was initiated and improved the patient's cognitive function and gait disturbance. Pathological diagnosis of large B-cell lymphoma was obtained on day 9. High-dose intravenous methotrexate chemotherapy was started on day 14 and led to complete remission by day 52. This case highlighted the importance of brain biopsy for diagnosis of LC. This report raises a possibility that timely and proper treatment leads to a favorable outcome of LC that has been regarded as an intractable disease with poor prognosis.

Glioblastoma presenting with steroid-induced pseudoregression of contrast enhancement on magnetic resonance imaging

Corticosteroid-induced reduction in contrast enhancement on radiographic imaging is most commonly associated with lymphoma but has been reported in other entities, including glioma. This finding may represent a diagnostic dilemma. Concern that steroid-induced cytotoxicity obscures histological diagnosis of suspected lymphoma may lead to postponement of a biopsy. If glioma is not considered in the differential diagnosis, reduction in tumor contrast enhancement may be misinterpreted as disease regression rather than a transient radiographic change. We report a case of a patient with an enhancing right temporoparietal mass adjacent to the atrium of the lateral ventricle. After treatment with dexamethasone was started, the mass exhibited marked reduction in contrast enhancement, with symptom improvement. The clinical course suggested lymphoma, and surgery was not performed. Subsequent screening for extra-axial lymphoma was negative. Two weeks later, the patient developed worsening symptoms, and repeat T1-weighted imaging showed interval increase in size and enhancement. The findings suggested a possible diagnosis of malignant glioma. The patient underwent a stereotactic-guided craniotomy for excision of the right temporoparietal mass lesion. Final histological diagnosis was glioblastoma multiforme, World Health Organization grade IV.

Alterations in the primary diagnosis of lymphomas pretreated with corticosteroid agents

Little is known of the role of preliminary corticosteroids in clinical and morphological modifications and in difficulties in reaching a diagnosis in patients with lymphoma. We identified 31 patients who were given steroids before biopsy for primary diagnosis. We looked for the reason for steroid pretreatment, its dose, and duration. We evaluated the difficulty in reaching the primary diagnosis and whether a secondary diagnosis was made. The patients' slides were reviewed to identify secondary histological changes. Our findings suggest a variable effect of prior glucocorticoids on the clinical and histopathological alterations developing in malignant lymphomas, as well as on the complexity of the process of reaching a diagnosis.

Splenic micronodular T-cell/histiocyte-rich large B-cell lymphoma: effect of prior corticosteroid therapy

We report on three patients who were treated with corticosteroids only prior to the diagnosis of splenic lymphoma. Corticosteroids were administered for different conditions, at different doses, and for various periods of time. The primary diagnosis was splenic micronodular T-cell/histiocyte-rich large B-cell lymphoma in the three cases, and it was reached with variable difficulty. We suggest that the corticosteroid treatment was one of the causes for the complications in reaching a diagnosis. The morphologic appearance of the microscopic splenic nodules was the most variable feature and may possibly reflect the dose and duration of the corticosteroid therapy. However, the histopathologic changes are probably not related with Epstein-Barr virus-induced immunosuppression.

CNS T-cell lymphoma: an under-recognized entity?

The incidence of CNS lymphoma has increased significantly in the past 30 years, primarily in the elderly and immunocompromised. While T-cell lymphomas comprise 15-20% of systemic lymphomas, they comprise less than 4% of primary CNS lymphomas, suggesting that they may be under-recognized compared to their systemic counterparts. To investigate this, we studied brain biopsies from three patients who were diagnosed with T-cell lymphoma confined to the brain. They had enhancing lesions by MRI, arising in the cerebellum and brainstem in one and temporal lobe in two. We compared these to biopsies from three patients who had reactive lymphoid infiltrates and who had clinical signs/symptoms and radiographic findings that were indistinguishable from the lymphoma group. Biopsies from both the lymphoma group and reactive group showed considerable cytomorphologic heterogeneity. Although one lymphoma case contained large atypical cells, the other two contained small, mature lymphocytes within a heterogeneous infiltrate of neoplastic and reactive inflammatory cells. Surface marker aberrancies were present in two lymphoma cases, but this alone could not reliably diagnose T-cell lymphoma. The proliferation index was not useful for differentiating lymphoma from reactive infiltrates. In five of the six cases the diagnosis was most influenced by clonality studies for T-cell receptor-gamma gene rearrangements. We conclude that because of the high degree of overlap in cytomorphologic and immunophenotypic features between T-cell lymphoma and reactive infiltrates, T-cell lymphoma may not be recognized unless studies for T-cell receptor gene rearrangements are performed for CNS lesions composed of a polymorphous but predominantly T-cell infiltrate.

Diagnosis of inflammatory demyelination in biopsy specimens: a practical approach

Multiple sclerosis is the most frequent demyelinating disease in adults. It is characterized by demyelination, inflammation, gliosis and a variable loss of axons. Clinically and histologically, it shares features with other demyelinating and/or inflammatory CNS diseases. Diagnosis of an inflammatory demyelinating disease can be challenging, especially in small biopsy specimens. Here, we summarize the histological hallmarks and most important neuropathological differential diagnoses of early MS, and provide practical guidelines for the diagnosis of inflammatory demyelinating diseases.

Surgical interventions for primary central nervous system lymphoma

Early diagnosis is central to proper management of primary central nervous system lymphomas (PCNSLs). Surgical intervention hinges on initial entertainment of a diagnosis of a PCNSL, based on acute neurological presentation and neuroimaging findings. Unless there is an urgent need for surgical decompression, a biopsy to obtain a diagnosis of PCNSL is the first step in surgical management. Repeated biopsy may be necessary in patients who have received preoperative steroid therapy. Patients with PCNSL may also present with leptomeningeal involvement, resulting in the need for an Ommaya reservoir for intrathecal chemotherapy. In cases in which hydrocephalus develops, placement of a ventriculoperitoneal shunt may be necessary. Two case studies are presented to highlight the role of surgical intervention in PCNSL.

Pathology of primary central nervous system lymphoma

✓ The understanding of primary central nervous system lymphoma (PCNSL) has lagged behind that of the much more common systemic, nodal lymphomas. Reasons for this include the relative rarity of PCNSL and the fact that these lesions differ in some ways from their histologically similar systemic counterparts. The purpose of this paper is twofold: first, the author provides concise descriptions of the pathological features of both common and uncommon types of PCNSL while discussing issues such as the confusion surrounding histological classification of PCNSLs, problems related to intraoperative diagnosis, and the appropriate diagnostic work up. Second, the author discusses a small number of molecular studies to demonstrate the great promise they offer. Such studies have already clarified some issues, including the category of lymphocyte from which the majority of PCNSLs are derived. Hopefully in the future these studies will help guide treatment decisions.

Primary CNS lymphoma in immunocompetent patients from 1989 to 2001: a retrospective analysis of 164 cases uniformly diagnosed by stereotactic biopsy

BACKGROUND

We present outcome data of a cohort of 164 immunocompetent PCNSL patients uniformly diagnosed at a single center for stereotactic neurosurgery, and evaluate the acceptance and impact of combination radiotherapy (RT) and chemotherapy (CHT) with high-dose methotrexate (HD-MTX) over time.

METHOD

We assessed choice of treatment and patient survival in a series of 164 PCNSL cases diagnosed from 1989 to 2001, and performed a re-evaluation of histopathology and pre-operative clinical data.

FINDINGS

From 1989 to 1993, RT was the predominant therapy, and additional CHT did not improve survival. After 1994, the use of combination CHT/RT increased continuously, consistently contained MTX, and was associated with longer survival than RT only: median survival was 14 months after CHT/RT (2-year survival 35.7%) and 10 months (2-year survival 26.2%) after RT only (not significant). Overall median survival remained poor, increasing from six (1989-1993) to nine months (1994-2001) (p = 0.008). Survival was variable, with a few patients surviving >4 years after diagnosis in the CHT/RT as well as in the RT only group.

CONCLUSIONS

Despite considerable improvement of PCNSL therapy, the overall benefit of combined CHT/RT versus RT only was lower than that expected from previous phase II clinical trials. The striking variability of survival in either treatment group may suggest a yet undefined biological heterogeneity of PCNSL, which may also include a more aggressive PCNSL subtype in the group of patients with rapidly progressive disease and not eligible for standard therapy.

[Diagnosis of an initial infratentorial central nervous system B-cell lymphoma during prolonged cortisone medication]

We present a patient with primary central nervous system B-cell lymphoma. He had suffered from slowly developing weight loss and presented to us with disorientation, seizures, and a supranuclear gaze disturbance. The patient was dismissed with the primary diagnosis of autoimmune encephalitis of the brainstem and put on oral corticosteroids. Four months later, his health status had deteriorated, and at that time diagnostic methods pointed to a cerebral lymphoma. Stereotactic biopsy with subsequent immunohistochemistry and polymerase chain reaction analysis revealed a highly malignant B-cell lymphoma of the CNS, despite prolonged corticosteroid treatment. The patient was treated with whole brain radiotherapy.

Neuroradiological findings in primary cerebral lymphomas of non-AIDS patients

Primary central nervous system lymphomas (PCNSL's) are rare tumours which generally accounted for 1.0-1.5% of all intracranial neoplasms. However, within the last decade the frequency of cerebral lymphomas has dramatically increased. We retrospectively analysed the neuroradiological findings (computed tomography (CT), MRI, angiography) in 37 patients with PCNSL. Thirty patients with the clinically and neuroradiologically suspected diagnosis of cerebral lymphoma underwent CT- or MRI-guided stereotactic biopsy. In seven cases an open surgical intervention was performed. Preoperatively, CT with and without contrast medium was performed in all but two cases. Twenty-eight patients received MRI (axial SE T2 weighted, triplanar SE T1 weighted, triplanar SE T1+Gadolinium). Additionally, in 9 patients cerebral angiography was performed. Typical neuroradiological patterns are: (1) iso- or hyper-density (85.5%) on unenhanced CT scan with marked contrast enhancement (87.7%); (2) infiltration/contact of leptomeningeal and/or ependymal spaces (97.3%); (3) hyperintensity on T2 with moderate oedema (80.3%). Histopathological work-up included conventional and immunohistochemical stains performed on formalin fixed and paraffin embedded bioptical specimen. Despite widely used preoperative dexamethasone treatment, an accurate histopathological diagnosis of PCNSL of B cell type was established in all cases except one. The high percentage of accurate histopathological diagnosis was based on: (1) great mean sample volume per biopsy site; (2) great number of biopsies in patients suspected to have cerebral lymphomas; and (3) MR-guided stereotactic procedures if the lesion was not clearly identifiable on CT scan.

Primary central nervous system lymphoma: from clinical presentation to diagnosis

Immunocompetent patients with primary central nervous system lymphoma (PCNSL) present with a median age of 55 years, immunosuppressed patients with a median age of 40 years. They show a broad range of signs and symptoms. Symptoms of increased intracranial pressure and personality change are most frequent, followed in frequency by ataxia and hemiparesis. The median time from onset of symptoms to diagnosis is 3-5 months in immunocompetent patients and 2 months in immunodeficient patients. The time to diagnosis can be considerably longer in patients with slowly developing personality change or fluctuating symptoms due to spontaneous or steroid-induced remission of so-called sentinel lesions. Native CT scans show iso- or hyperdense lesions with homogenous contrast enhancement. T1-weighted MRI scans show hypointense and T2-weighted scans hyperintense lesions. The definitive diagnosis of PCNSL requires biopsy. In some cases, however, the definitive diagnosis may exclusively be made by the demonstration of malignant B-lymphocytes in the cerebrospinal fluid.

Intracranial inflammatory tumors: a survey of their various etiologies by presentation of 5 cases

Due to similar clinical and neuroradiological features, intracranial inflammatory tumors (IITs) are frequently misdiagnosed as brain neoplasms, from which they notably differ in respect to therapy and prognosis. In this article, five cases of such tumors are presented. Three of the patients with brain tumors (cases 3, 4 and 5) presented a history of 'pararheumatic' syndromes but no diagnosis of defined immunopathies. On the basis of radiological findings, all processes were classified as genuine brain neoplasms, but histology showed reactive inflammatory features. The possible etiologies of these 'tumors' are discussed on the basis of all clinical and histological data of the patients. The spectrum of diseases potentially leading to the manifestation of an IIT is reviewed. Additionally, the presentation of case 5, who developed a highly malignant B-cell-lymphoma 6 months after the removal of an IIT without any histological signs of atypia, shows that this differential diagnosis always has to be kept in mind.

Primary non-Hodgkin's lymphoma of brachial plexus

We report the case of a 65-year-old man with non-Hodgkin's lymphoma (NHL) not only in the brachial plexus but also in the central nervous system and parotid gland. He was referred to our hospital for evaluation of a right parotid mass. He also presented with bilateral facial palsy and paralysis of the left superior limb. Computed tomography scan and magnetic resonance imaging revealed mass lesions in the right parapharyngeal space, the deep lobe of the right parotid gland. and the left brachial plexus. A gallium-67 citrate scan demonstrated abnormal uptake in the left brachial plexus. These symptoms and lesions improved during steroid therapy. However, the symptoms worsened again after steroid therapy was discontinued. We performed a right parotidectomy to confirm the diagnosis. Histopathological study revealed NHL. He was treated with combination chemotherapy, and most of the lesions and symptoms, except bilateral facial palsy, improved. Despite follow-up treatment, a brain metastasis occured, and he died 16 months after the onset of symptoms.

Glucocorticoid treatment of primary CNS lymphoma

Glucocorticoid therapy may result in the rapid resolution of cerebral mass lesions in patients with primary CNS lymphoma. Since glucocorticoids will obscure the histological diagnosis of primary CNS lymphoma upon biopsy, steroids should be withheld if primary CNS lymphoma is a likely diagnosis by neuroradiological criteria. The lympholytic effect of glucocorticoids is mediated by cytoplasmic steroid receptors which are translocated to the nucleus and signal apoptosis. Glucocorticoid-induced apoptosis of lymphoid cells does not require wild-type p53 activity, seems not to depend on caspase activation, but is attenuated by the bcl-2 protooncogene product. Longterm glucocorticoid therapy of primary CNS lymphoma is not recommended because relapse is probably inevitable and because of the prominent side effects of long-term glucocorticoid treatment. Further, long-term glucocorticoid treatment is contraindicated in immunocompromised patients with primary CNS lymphoma.

The effect of glucocorticoids in the normal cerebral hemisphere of brain tumour patients

OBJECTIVES

To study the potential effects of glucocorticoids (GC) in normal white matter (WM) of the contralateral cerebral hemisphere in brain tumour patients in a prospective protocol.

MATERIALS AND METHODS

Using MR relaxation time (RT) imaging (T1 and T2-maps), 190 different scanning sessions were performed on 42 brain tumour patients before and after initiation of GC-treatment. RT imaging correlates closely with in vivo tissue water content (reported estimation accuracy error <4%). Repetitive studies were performed in order to study changes as a function of time. RTs were measured in the contralateral frontal and occipital white matter (WM).

RESULTS

The mean change in T1 after initiation of GC treatment was 1.6+/-1.7% (P = 0.24), and 1.8+/-3.8% in T2. The mean coefficient of variation for the pooled data in all patients was 1.4% for both T1 and T2. There were no differences in effect between different histological types of tumours or sex.

CONCLUSION

GC treatment does not influence in vivo cerebral water content expressed as relaxation times of apparently normal WM. The neurological effects in brain tumour patients are normally evident within 24 h, but do not seem to correlate with changes in brain water content. The normal biological variation in RTs (and thereby in vivo tissue water content) in normal WM of brain tumour patients is very small and approaches the expected fluctuations in the MRI measurement technique.

Computerized tomography and magnetic resonance guided stereotactic brain biopsy in nonimmunocompromised and AIDS patients

BACKGROUND

The utility of stereotactic brain biopsy (SBB) in AIDS patients still remains controversial. The authors investigated SBB-related diagnostic accuracy, complications, and postoperative sequelae in nonimmunocompromised (NIC) patients and AIDS patients. The role of bioptic yield in treatment planning was also studied in AIDS patients.

METHODS

From 1990-95, 200 computerized tomography (CT) or magnetic resonance imaging (MRI)-guided SBBs were performed in our Department; 172 bioptic procedures were performed in NIC patients (169), and 28 SBBs in AIDS patients (27). The statistical significance was evaluated using the Fisher exact t-test.

RESULTS

SBB accuracy was very high in both NIC (94.8%) and AIDS (92.9%) patients. Statistical analysis indicated nonsignificant (NS) differences between the two study groups (P > 0.05). Diagnostic yield resulted higher in contrast-enhancing (CE) brain lesions (98.6% in NIC and 95.0% in AIDS patients; P > 0.05; NS), than in non-CE lesions (74.1% in NIC and 87.5% in AIDS patients; P > 0.05; NS). The overall complication rate was similar in both groups (17.2% in NIC and 14.8% in AIDS patients, P > 0.05, NS). The most frequent complication was hemorrhage, with statistically negligible differences between the two study groups (P > 0.05). The frequency of complications involving minor/major morbidity or mortality was very low in NIC (5.9%, 0.6%, and 2.4%, respectively), and in AIDS (3.7%, 7.4%, and 0.0%, respectively) patients. Regarding the therapeutic impact of bioptic diagnosis for neuro-AIDS patients, the preoperative treatment attitude was modified in 23/27 cases (85.2%), and the empiric anti-toxoplasmosis regimen was changed or withdrawn in 17/21 patients (81.0%).

CONCLUSION

Our experience demonstrated SBB to be an accurate, manageable, and reasonably safe diagnostic tool in both NIC and AIDS patients. These results suggest also that timely SBB indication in selected AIDS patients, reaching an early diagnosis, may on one side prevent unnecessary and potentially toxic empiric therapeutic regimens, and on the other address the appropriate treatment, thereby improving length and quality of life in such patients.

Glucocorticoid-induced long-term remission in primary cerebral lymphoma: case report and review of the literature

We report a 25-year old immunocompetent woman with a high grade primary non-Hodgkin's lymphoma of the central nervous system (PNHL-CNS) in whom the administration of dexamethasone alone during three months produced a complete clinical and radiological response lasting over four years. If complete remission of PNHL-CNS induced by glucocorticoids are well known, the opportunity to observe glucocorticoid-induced remission for a long period of time without radio- and chemotherapy is rare. Only nine other cases of PNHL-CNS with complete remission induced by glucocorticoids lasting from 6 to 60 months, were found in the literature and are summarized here. Duration of glucocorticoids therapeutic effect in PNHL-CNS is probably underestimated. Glucocorticoids cannot be recommended as sole initial treatment for PNHL-CNS. However, we suggest standard therapies to be delayed in those patients responding completely to glucocorticoids where radio- and chemotherapy should be contraindicated (kidney, liver, bone marrow failure, pregnancy).

Primary T-cell lymphoma of the cerebellum. A case report

Most primary CNS non-Hodgkin lymphomas are of B-cell lineage. Only a very few immunocytochemically well documented cases of T-cell lymphomas have been reported. We report a case of a high malignant T-cell lymphoma localized primarily to the vermis of the cerebellum and compare the characteristics of the clinicopathological presentation with those of B-cell lymphomas as well as with the other T-cell lymphomas reported.