Computed tomography of malignant lymphoma of the brain

Primary Lymphomas of the Brain: A Clinico-Pathologic Review of 37 Cases

The clinico-pathologic data of 37 primary lymphomas of the brain were retrospectively reviewed. The tumors were classified according to the Kiel classification and the Working Formulation System. They represented 1.02% of all primary intracranial tumors of our series. The radiologic prediction appeared to be difficult: the suspicion was maximal when the absence of pathologic vessels at angiography occurred in a meningioma-like lesion at CT. Median survival was 4.53 months in the 16 cases who underwent surgery only versus 25.7 months in the 8 cases operated and irradiated with 40-60 Gy (p < 0.01). The prognosis of lymphomas of the CNS, even if radioresponsive tumors, remains poor. Most patients relapse after treatment, most often locally in the brain, with a variable frequency of spinal or systemic localization.

Diffuse large B-cell lymphoma of the cerebellopontine angle in a patient with sudden hearing loss and facial palsy

Primary lymphoma of the cerebellopontine angle (CPA) is rare in the central nervous system. To our knowledge, there have only been 14 cases reported worldwide so far. Here, we report our findings in a 57-year-old man, who presented with bilateral sudden hearing loss followed by left facial palsy within 1 month. Radiologic study and magnetic resonance imaging showed a homogeneous enhancing mass, 1.6 x 0.5 x 1.1cm in size, in the left CPA cistern region with mild extension to the left internal auditory canal. The tumor was removed through left retromastoid craniectomy, and the histopathologic diagnosis of the tumor was confirmed as diffuse large B-cell type malignant lymphoma. After a series of tumor surveys, there was no evidence of other original lymphoma. The patient was treated with chemotherapy (including intra-Ommaya injection with methotrexate and Ara-C and systemic injection with vincristine, methotrexate and ifosfamide) for the primary CPA lymphoma. He was still alive 19 months after the initial treatment.

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 B-cell lymphoma of the CNS in an infant

Primary B-cell lymphoma of the CNS is a rare tumor representing 0.2 to 2% of all primary CNS malignancies. The usual age of presentation is in the 4th to 6th decades. Sporadic cases have been reported in the pediatric population. However, even in this age group the tumor is extremely rare under the age of 5. This is a report of a 3-year-old child with primary lymphoma of the CNS.

Cerebellopontine angle lymphoma: a case report and review of the literature

BACKGROUND

Although malignant lymphomas of the central nervous system have been reported to be increasing in frequency, cerebellopontine (CP) angle lymphoma is rare and only 13 cases have been reported previously in the literature.

CASE PRESENTATION

A 63-year-old woman had progressive dizziness and nausea for 2 months. Computed tomography scanning and magnetic resonance imaging (MRI) revealed a mass lesion in the left CP angle, that was compressing the lateral-dorsal aspect of the pons and the fourth ventricle. This tumor was avascular on angiography. The tumor was surgically removed through a left lateral suboccipital approach. It was considered to arise from the subarachnoid space of the CP angle cistern. For some reason, the histologic diagnosis was not definitively made, and therefore radiation therapy was not planned. The tumor recurred within 50 days after the tumor excision. Surgical excision of the recurrent tumor was performed again. The histologic diagnosis was B-cell type malignant lymphoma. Radiation therapy was performed. In the 27 months since irradiation, a recurrent tumor has not been detected on MRI.

CONCLUSIONS

Although erosion and expansion of the internal auditory canal suggest an acoustic neurinoma, CP angle lymphoma can, in rare circumstances, erode the internal auditory canal. There are three distinct patterns in which malignant lymphomas occupy the CP angle: (1) an extra-axial CP angle lymphoma, (2) an intra-axial lymphoma extending to the CP angle, and (3) a leptomeningeal lymphoma presenting as a CP angle lesion. Although malignant lymphomas rarely occupy the CP angle, it should be considered in the differential diagnosis of CP angle tumors. It is desirable to obtain a frozen section in all CP angle tumors during surgery to identify the tumor, because aggressive removal is not necessary, but radiation therapy should additionally be performed for malignant lymphomas.

Characterization of primary intracranial lymphoma by computed tomography: an analysis of 36 cases and a review of the literature with particular reference to calcification haemorrhage and cyst formation

Previous published series describing the appearances of primary central nervous system lymphoma (PCNSL) state that calcification, haemorrhage and cyst formation are rare, but generally fail to quantify or expand on this statement. We present the pre-treatment computed tomography (CT) findings of 36 patients with biopsy proven PCNSL. In this series, calcification was present in only one very atypical lesion and evidence of haemorrhage was not seen. Small intralesional cysts were present in four of the total of 50 lesions. PCNSL usually appeared as one or more well defined focal lesions, iso- or hyperdense to grey matter, with homogeneous enhancement following IV contrast injection. Less commonly the contrast enhancement was inhomogeneous, only one lesion failed to enhance. Disproportionately little oedema and mass effect compared with lesion size was noted on approximately half the CTs. Lesions usually touch either the ependymal lining of the ventricles or the leptomeningeal surface.

An instructive false diagnosis: steroid-induced complete remission of a CNS tumor--probably lymphoma

In recent years the incidence of primary cerebral lymphomas has increased. Diagnosis by imaging techniques (CCT, angiography, MRT) and stereotactic biopsy are considered as reliable diagnostic tools. Therapeutically a combination of radio-, steroid- and chemotherapy is recommended. We report a case of space-occupying CNS lesion in which the radiopaque enhancing process completely disappeared after biopsy and steroid therapy. A year later the tumor recurred on the other side and again regressed after steroid therapy. The first biopsy showed signs of a papillar tumor, so a choroid plexus papilloma was suspected. On examination of the treatment history, however, this diagnosis had to be revised. A primary CNS lymphoma seems most probable. The phenomenon of a tumor remission under steroid administration and the problems related to the differential diagnosis are discussed.

Leptomeningeal tumor in primary central nervous system lymphoma: recognition, significance, and implications

The true incidence of leptomeningeal tumor in primary central nervous system lymphoma is unknown. We studied prospectively the cerebrospinal fluid profile of 96 patients without acquired immunodeficiency syndrome but with primary central nervous system lymphoma at diagnosis, at completion of treatment, and at recurrence. Magnetic resonance images and pathology slides were examined for evidence of leptomeningeal tumor. Leptomeningeal tumor was diagnosed by (1) positive findings on cerebrospinal fluid cytology, (2) leptomeningeal or subependymal enhancement on magnetic resonance imaging, or (3) pathological evidence of leptomeningeal tumor. We recorded whether treatment directed against the leptomeninges was given. Cerebrospinal fluid was examined in 86 of 96 patients at diagnosis and 29 of 42 at recurrence. The incidence of leptomeningeal tumor was 42% at diagnosis and 41% at recurrence. Only elevated levels of protein and lactate dehydrogenase isoenzyme-5 were significantly associated with leptomeningeal tumor (p = 0.012, p = 0.016, respectively). Treatment against the leptomeninges was significantly associated with the probability of achieving a complete response and a longer freedom from relapse. Patients older than 50 years had a worse disease-specific survival but a similar probability of responding to therapy as younger patients. Our data show that leptomeningeal tumor in primary central nervous system lymphoma is more prevalent than originally thought, and indicate the need for therapy inclusive of the leptomeninges in all patients.

Primary central nervous system lymphoma in Japan--a retrospective, co-operative study by CNS-Lymphoma Study Group in Japan

This manuscript reports the results of the first cooperative study on primary central nervous system lymphoma (PCNSL) in Japan. Of 196 patients registered, 170 were judged as having PCNSL. No patients were immunocompromised. Of the 170 patients with PCNSL, 93 were males and 77 were females. The mean was 56.7 years. One hundred and nineteen tumors were confirmed histopathologically, and 51 were diagnosed by neuroimaging alone. All the tumors were non-Hodgkin's lymphoma. According to the Working Formulation for Clinical Usage (WF), 96 out of 119 tumors were classifiable: 53 were diffuse large cell type (55.2%), 17 immunoblastic type (17.7%), 9 diffuse small cleaved type (9.4%), 6 diffuse mixed type (6.3%), 5 polymorphous type (5.2%), 5 small lymphocytic type (5.2%) and 1 small non-cleaved type (1.0%). Of 21 tumors studied immunohistochemically, 18 were B-cell type and 3 were T-cell type. Irradiated patients (144) survived significantly longer than non-irradiated patients, (median survival time, MST: 19.2 and 2.7 months, respectively; p < 0.001). There was a remarkable difference in survival among patients of the intermediate lymphomas; MST (18 months) of patients with large cell lymphoma was significantly shorter than MST (over 96 months) of patients with other intermediate grade lymphomas (small cleaved and mixed) (p < 0.001) and had no significant difference from MST (9 months) of patients with high grade lymphomas. If patients were irradiated with more than 40 Gy, higher doses and different modes of irradiation brought no further survival advantage. Chemotherapy was performed in 87 of 144 irradiated patients (60.4%). No regimens were effective in prolonging survival. Of 144 irradiated patients, a complete or partial response to initial treatment was demonstrated in 91 (63.2%) and 43 patients (29.9%), respectively. Improvement in performance status was confirmed in 82 patients (57.0%). Despite a good response to initial treatments, 88 out of 144 evaluatble patients have died of PCNSL (MST: 19 months). Multivariate analysis based on the Cox hazard model revealed that histology of tumor, age at onset, performance status, and radiotherapy were prognostic factors. Neither chemotherapy nor mode of surgery was a beneficial factor.

Primary intracerebral malignant lymphoma associated with different histological types of carcinoma: report of two cases

Two rare cases with histologically proven multiple primary neoplasms are described: an association of intracerebral malignant lymphoma with hepatocellular carcinoma in one case and with squamous cell carcinoma of the uterine cervix in the other. Therapeutic problems pertinent to the coexistence of primary intracerebral malignant lymphoma and neoplasms of a different histological type are discussed.

Primary central nervous system lymphoma

Primary central nervous system lymphomas (PCNSL) are uncommon neoplasms accounting for less than 2% of brain tumours. Their incidence appears to be increasing across a wide age range, in both immunocompetent and immunosuppressed populations. Particular risk groups include those with congenital and acquired immunodeficiencies and transplant recipients. The spread of the AIDS epidemic has seen large numbers of complicating PCNSL develop. Epstein-Barr virus infection appears to play a role in the development of these lymphomas in the immunosuppressed population. The aetiology of these tumours in the immunocompetent is uncertain. Their tendency to remain within the nervous system is not well understood but may be a function of CNS binding molecules carried by lymphocytes. Clinically PCNSL may present with a wide variety of signs and symptoms and has a capacity to mimic many other neurological conditions. Radiologically they appear as hyperdense homogenous deposits in subcortical white matter. Although most lesions are intermediate or high grade B cell lymphomas, T cell lymphomas are being recognised with increasing frequency. Immunohistochemistry and genotypic analysis have an important role in accurately characterising PCNSL, particularly in stereotactic biopsies. Involvement of multiple areas of the neuraxis, the eye and multiple intracranial sites can occur in the absence of obvious systemic lymphoma. The role of surgery in their treatment is uncertain. A combination of radiotherapy and chemotherapy can increase the length of survival. The prognosis, however, remains poor in comparison with nodal lymphomas, and particularly so in those with AIDS.

Primary cerebral malignant non-Hodgkin's lymphomas: a retrospective clinical study

In this retrospective study a series of 54 patients (seen from 1982 to 1989) with sporadic primary cerebral malignant lymphomas (PCML), which were uniformly classified with the support of immunocytochemical data, is presented. The analysis shows that on CT PCML are shown as cirumscribed, homogeneous, contrast-enhanced multifocal (70%) or solitary (30%) mass lesions within the subcortical white matter; they were found mainly close to the ventricular system or the subarachnoid space. To prove the histological diagnosis and for the purposes of differential diagnosis, low-risk CT-stereotactic biopsy is necessary and is the method of choice. Immunomorphological techniques are valuable adjuncts to confirm the histological diagnosis of PCML. In the series presented these tumours have been predominantly classified as high-grade blastic B-cell lymphomas. For this reason, this type should be regarded as the prevalent variant of malignant brain lymphomas. The evaluation of possible prognostic factors suggests that age at admission and morphological features of regression are relevant determinants of survival time. A correlation between neuroradiological evidence of a decrease in tumour size, morphological signs of regression and glucocorticoid administration has been found. Thus, patients suspected of having PCML require rapid diagnosis prior to corticosteroid administration. PCML have been shown to be radioresponsive, but not curable. Because of the lack of uniformity in management of this rate brain neoplasm, the different treatment protocols are not comparable, and hence the optimum therapy has not been satisfactorily determined.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary cerebral lymphoma: report of 24 patients and review of the literature

A retrospective study of 24 patients with primary non-Hodgkin's cerebral lymphoma (non-immunocompromised) is presented. All patients were seen at the Royal Preston Hospital, Lancashire between 1976 and 1991. Fifteen patients were over the age of 50 years (range 27-84). The commonest clinical presentation, seen in 16 patients was of an expanding space-occupying lesion. The diagnosis was suspected from the radiological findings but confirmation in every case was by histological examination of biopsy or necropsy material. The tumours were treated either by surgical excision or by biopsy and radiotherapy. Chemotherapy was given in two patients. Despite these measures the mean survival time was 3.6 months. The clinical radiological and pathological features of these tumours are highlighted with particular emphasis on the use of stereotactic biopsy, immunohistochemistry and chemotherapy in diagnosis and treatment.

Primary central nervous system lymphomas--an update

Primary CNS lymphomas (PCNSL), until recently representing about 1% of all brain tumors, show dramatically increased incidence both in high-risk groups (immunocompromised, AIDS) and in the general population. They are extranodal diffuse non-Hodgkin's lymphomas, the morphology and classification of which are identical to those of systemic lymphomas, although PCNSL show different biological behavior and diagnosis according to the New Working Formulation and updated Kiel classification may be difficult. The majority are large B cell variants of high-grade malignancy; low-grade subtypes and T cell lymphomas are rare. Sixty per cent occur in the supratentorial space (hemispheres, periventricular) and 12% in the posterior fossa; 30% are multiple (50%-70% in AIDS). PCNSL show a male preponderance with a peak incidence in the 5th-7th decade (3rd-4th in AIDS). The duration of diffuse or focal clinical symptoms averages 1-2 months. Computed tomography and magnetic resonance imaging scans show single or multiple or diffuse, often typical lesions. Diagnosis is achieved by evaluation of stereotactic biopsy material or cerebrospinal fluid cytology using immunocytological markers. Current therapy in immunocompetent patients, radiation plus corticosteroids and pre- or postradiation polychemotherapy, shows response rates of 85% with a median survival of 17-44 months, a prognosis similar to that for glioblastoma. Meningeal PCNSL is treated with intrathecal methotrexate or cytosine arabinoside. Transliquoral seeding of PCNSL is frequent, distant metastases occurring in 6%-8%. Therapy of AIDS-related PCNSL makes use of radiation and corticosteroids, and rarely of chemotherapy. The pathogenesis of PCNSL is unknown, but Epstein-Barr virus may be a contributory factor.

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.

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.

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.

Unusual radiological presentation of a primary CNS lymphoma

The Authors report a case of primary cerebral lymphoma occurred in a 62 years old lady, who came to observation for headache and mood alterations. An enhanced CT showed a lesion recalling a meningeal sarcoma. Points of interest in this case are the unusual radiological appearance and the infrequent localization. Main anatomical and clinical characteristics of primary CNS non-Hodgkin lymphomas are recalled, even with regard to modern immunohistochemical techniques.

Prognostic factors in the diagnosis and treatment of primary central nervous system lymphoma

The authors describe the results of multimodality therapy in 27 patients with biopsy-proven primary central nervous system (CNS) lymphoma treated between 1976 and 1986. Treatment included surgical resection (15 patients), radiotherapy (27 patients), and chemotherapy (nine patients). Actuarial survival rates for the 27 patients at 1, 2, and 5 years after diagnosis were 70%, 54%, and 45%, respectively. Nine patients were recurrence-free at 8 to 106 months follow-up. A multivariate risk analysis identified five factors which had a favorable impact on survival: (1) age less than 60 years (P less than 0.02); (2) preoperative Karnofsky performance score greater than or equal to 70 (P less than 0.02); (3) presence of strictly hemispheric tumor (P less than 0.0003); (4) whole-brain radiation dose between 4000 and 5000 cGy (P less than 0.05); and (5) addition of chemotherapy to radiotherapy (P less than 0.002). Patients with complete tumor resolution on computed tomography 6 months after beginning treatment also had longer survival (P less than 0.01). The presence of malignant cells on cerebrospinal fluid cytologic examination correlated with an increased risk of distant metastasis (P less than 0.05). In those patients whose disease eventually recurred, the administration of an additional therapeutic modality significantly increased the length of postrecurrence survival (P less than 0.05). Although surgical resection provided no increase in survival, the addition of chemotherapy to postoperative cranial irradiation significantly enhanced the duration of survival. Our experience suggests that pretreatment clinical and diagnostic factors can help in predicting survival and in planning treatment.

Steroid-induced complete remission in a case of primary cerebral non-Hodgkin's lymphoma

A case of a primary non-Hodgkin's lymphoma of the CNS is reported in which a complete and stable disappearance of an enhancing mass lesion on the CT scan after treatment with dexamethasone was followed by the occurrence of a high-grade malignant lymphoma in the opposite hemisphere 18 months later. The long-lasting and stable remission suggests a direct oncolytic effect of corticosteroids on lymphoma cells. Furthermore, this case illustrates the usefulness of repeated CT examinations in patients with CNS lymphoma and steroid treatment.

Primary central nervous system lymphoma

Primary lymphoma of the central nervous system (CNS), including reticulum cell sarcoma, microglioma, and histiocytic lymphoma, represents less than 1% of all primary brain tumors. In the last 10 years, this tumor has tripled in frequency in the nonimmunosuppressed population. By 1991, the tumor will be the most common neurological neoplasm by virtue of the increase in sporadic occurrence and in the acquired immunodeficiency syndrome (AIDS) population. Three percent of AIDS patients will develop this tumor either prior to AIDS diagnosis or during their subsequent course. In addition to acquired immunosuppression, patients with inherited disorders (such as Wiskott-Aldrich syndrome, severe combined immunodeficiency, and X-linked immunodeficiency) and other acquired disorders of the immune system are predisposed to the development of CNS lymphoma. Immunological studies have suggested a role for Epstein-Barr virus in the production of this tumor. Although subtypes exist, non-Hodgkin's lymphoma of the CNS most commonly consists of histiocytic cells or large immunoblastic cells bearing B cell surface markers in close proximity to the lateral and third ventricles. Sixty percent of these deposits are multiple, and subarachnoid invasion is seen in one-quarter of patients. Vitreous involvement of the eye occurring prior to and during the course of CNS lymphoma has been noted in up to 25% of patients. The involvement of multiple areas of the neuraxis, the eye, and multiple intracranial sites often occurs in the absence of obvious systemic lymphoma. Therapeutic trials of brain radiation therapy are associated with median survivals of less than 1 year. Uniform complete responses of intracranial deposits are recorded following chemotherapy with high-dose intravenous methotrexate, CHOP (cyclophosphamide, hydroxydaunomycin/doxorubicin, Oncovin (vincristine), and prednisone), high-dose cytosine arabinoside, and intra-arterial methotrexate with barrier modification.

The radiology of lymphoma

The development of new imaging techniques over recent years has improved the accuracy with which the extent of the disease can be demonstrated in patients with lymphoma. These methods either complement or replace existing conventional radiological methods such as plain films, bariums, intravenous urograms or lymphography. CT in particular, and to a lesser extent ultrasound and radionuclides, now plays an important part in helping the clinician to manage patients with lymphoma. It is impractical and unnecessary to use all available imaging studies. More than ever, close co-operation between the clinician and radiologist is essential to derive the maximum amount of information from the studies and to use the techniques effectively and appropriately. This chapter has reviewed the advantages and limitations of each imaging method, stressing the role of each in staging the lymphomas and in monitoring response to treatment. The common radiological appearances of the effects of lymphoma on each organ system have been described. The possible contribution that other techniques may make in the future has been discussed.

Arterial occlusion due to Listeria meningoencephalitis in an immunocompromised boy

Sequential CAT scan studies of the brain were performed in a 7-year-old boy with Listeria monocytogenes serotype 1 meningoencephalitis. The infection occurred while he was receiving maintenance chemotherapy for T-cell non-Hodgkin lymphoma. A lesion in the right hemisphere during the infection resulted in an excessive enlargement of the right ventricle 10 months later, most probably caused by arterial occlusion.

Primary central nervous system lymphoma in acquired immune deficiency syndrome: a clinical and pathological study

Twenty cases of primary lymphoma of the central nervous system associated with acquired immune deficiency syndrome were seen over a period of four years and were studied clinically and pathologically. Biopsy established the diagnosis in 11 cases, and autopsy confirmed it in 9. Multicentricity was demonstrated in all cases for which there was adequate autopsy material. Both large-cell immunoblastic and small noncleaved lymphomas were seen, and marker studies in 5 patients established that the lymphomas were of B-cell origin. Neurological symptoms and signs, cerebrospinal fluid characteristics, and radiographic appearance were reviewed. The clinical and radiographic picture is nonspecific and histological confirmation is essential for diagnosis. Although the tumor appears to be radiosensitive, prognosis is extremely poor, with an average survival of less than two months.

Primary malignant lymphoma of the central nervous system. Results of treatment of 11 cases and review of the literature

Eleven patients with primary malignant lymphoma of the central nervous system (CNS) were treated at the Medical College of Wisconsin Affiliated Hospitals between 1964 and 1984. Three patients had a prior history of immunosuppressive therapy following renal transplantation. All patients had biopsy-proven disease and 10 of the 11 were treated with external radiation therapy. The doses to the primary tumor ranged from 34 to 59.4 Gray (Gy). Actuarial (life-table) survival rate was 82% at 1 year and 43% at 3 years. No recurrence was seen after 13 months. Eighty-six reports totaling 693 cases of primary malignant lymphoma of the CNS were found in the literature. Of these, 308 cases were treated with a combination of surgery and irradiation. Overall survival at 5 years for those patients who received more than 50 Gy compared with less than 50 Gy to the primary tumor was 42.3% versus 12.8% (p less than 0.05). Twenty-one patients survived longer than 5 years. Late relapse was notable, with 10 (47.6%) of 21 tumors recurring between 5 and 12.5 years after diagnosis. Based on this review, a minimum of 50 Gy radiation to the primary tumor is recommended. While no statement regarding the efficacy of craniospinal irradiation or chemotherapy can be made in view of the small numbers, the use of craniospinal irradiation and/or systemic chemotherapy should be considered for future trials.

Intracranial malignant lymphoma. Report of 30 cases and review of the literature

Although primary malignant lymphoma is a rare entity in the gamut of intracranial tumors, it is more frequently seen than the secondary intracranial spread of a primary extracranial lymphoma. In general, the occurrence of lymphomas seems to be provoked by immunosuppression, as with medication (predominantly after transplantation) or with immunodepressive disease such as acquired immunodeficiency syndrome (AIDS). The usual age of onset of this disease is 55 to 65 years; and the male:female patient distribution is roughly 2:1. Characteristically, computerized tomography (CT) scans of lymphomas show a mass which is often large with regular contours, moderate mass effect, and hyper- or isodensity with marked and often homogeneous enhancement. In the series of 30 patients reported, the locations of lesions, in order of decreasing frequency, were the frontocallosal and temporal regions, the basal ganglia, and the cerebellum. Multiple lesions were present in 15% of these cases (20% to 40% in the literature). The following features should raise the suspicion of intracranial lymphoma: mirror lesions of the basal ganglia, bilateral subependymal infiltration, and leptomeningeal involvement contiguous with an intracerebral mass. According to the literature, the angiographic finding typical of lymphoma is an avascular tumor. A blush or vascular encasement of the mass seems to be rare, and the present series was in accordance with other reports in this respect. Differential diagnostic consideration should include meningioma, glioblastoma, metastatic disease, and focal infectious lesions such as toxoplasmosis or multifocal progressive leukoencephalitis, particularly in immunodepressed subjects. Diagnosing lymphoma from CT scans offers the alternative of substituting stereotaxic biopsy and neuropathological diagnosis for the more aggressive open surgical approach, since radiation therapy and possibly chemotherapy usually prove to be the treatment of choice.

Diagnosis of a primary non-Hodgkin's lymphoma of the central nervous system by examination of the cerebrospinal fluid

This paper is a report on a case of primary Non-Hodgkin's lymphoma of the central nervous system, diagnosed by cytological and immunological examination of the cerebrospinal fluid. The relevant literature on the subject is reviewed. The importance of examination of the cerebrospinal fluid in cases suspected of this disease is stressed.