Early stage primary cranial vault lymphoma in a 50-year-old man: presenting as only sclerosis and mimicking osteoma

Primary Calvarial Lymphoma: A Case Report

Calvarial lymphoma is radiologically similar in many respects to meningiomas, solid fibrous tumours, osteomyelitis, and metastatic carcinomas. Even though it is an extremely rare phenomenon, the initial suspicion and detection of calvarial lymphoma are paramount to establishing a correct diagnosis which helps to determine an appropriate management strategy. We present an illustrative rare case of primary calvarial lymphoma along with a literature review focusing on the best management strategy for this rare entity. A 45-year-old female presented to our center in March 2022. She had a history of forehead swelling, which was progressively increasing in size over time. The metastatic workup and bone marrow biopsy were negative. Initially, extensive surgery was planned to resect the lesion, but after a discussion with the multidisciplinary team, a biopsy of the lesion was taken, which revealed a large B-cell lymphoma. It is prudent to consider calvarial lymphoma in the differential diagnosis of a progressively growing skull lesion, which may obviate the need for large resective surgery. A biopsy plus chemoradiation may be all that is required.

Successful CNS-Centric Therapeutic Management and Genomic Profiling of Primary Cranial Vault Diffuse Large B-Cell Lymphoma

Primary cranial vault lymphoma (PCVL) is a rare lymphoma involving the skull with or without extra- and intracranial extension. Most cases of PCVL are diffuse large B-cell lymphoma (DLBCL). We report a case of primary cranial vault diffuse large B-cell lymphoma (PCV-DLBCL) that was successfully treated with anthracycline-based chemoimmunotherapy (CIT) alternating with central nervous system (CNS)-directed CIT with high-dose methotrexate and high-dose cytarabine. CNS-centric therapy was given for suspected cerebral cortical involvement and presumed elevated risk of CNS recurrence. The patient has remained in complete remission for 4.25 years following treatment. We suggest that PCV-DLBCL is potentially curable with CNS-directed therapy. Additionally, we provide genomic profiling results indicating an indeterminate cell of origin and multiple genetic mutations which are not frequently seen in DLBCL.

Primary intraosseous meningioma with subcutaneous and dural invasion: A case report and literature review

Primary intraosseous meningiomas (PIOMs) are a rare subset of meningiomas, comprising fewer than 1% of all such tumors. Furthermore, PIOMs presenting as osteogenic lesions that invade both the dura and subcutaneous tissue are extremely rare. Unlike intracranial meningiomas, diagnosing and treating PIOMs are challenges due to their insidious clinical behavior and a lack of clear radiological diagnostic criteria. We report the case of a 60-year-old female with headache and a slightly outward protrusion of the parietal region of the skull. CT showed an osteogenic lesion in the right parietal bone. MR imaging indicated mild to moderate homogeneous enhancement with an intense dural reaction. The suggested clinical diagnosis was lymphoma, so we performed a skull biopsy, which revealed an intraosseous benign meningioma. A precise resection strategy was planned with a neuronavigation system accompanied by a one-step customized titanium mesh cranioplasty. The lesion was completely removed, and pathological analysis confirmed a meningothelial meningioma (WHO Grade I) of intraosseous layer origin invading the dura mater and subcutaneous tissue. This case highlights the need for an initial biopsy when the lesion is difficult to diagnose on imaging. Complete resection should be attempted to minimize the risk of recurrence.

Characteristics of cranial vault lymphoma from a systematic review of the literature

Background:

Cranial vault lymphomas are rare and their clinical features are often similar to those of cranial vault meningiomas. The objective of this review was to identify the features helpful for differentiating lymphomas of the cranial vault, from meningiomas which were the most common diagnosis before the definitive pathological diagnosis.

Methods:

The inclusion criterion was a histologically proven malignant lymphoma initially appearing in the calvarium. We conducted a literature search of the electronic PubMed and Ichushi-Web databases up to June 1, 2020. Cranial vault lymphoma that was diagnosed after an original diagnosis of lymphoma in a nodal or soft-tissue site was excluded from the study. Descriptive analyses were used to present the patient characteristics.

Results:

A total of 111 patients were found in 98 eligible articles. Almost all studies were case reports. The most common symptom was a growing subcutaneous scalp mass (84%) present for a mean duration of 5.9 months before the patient presented for treatment in analyzable cases; this fast growth may distinguish lymphomas from meningiomas. The tumor vascularization was often inconspicuous or poor, unlike well-vascularized meningiomas. A disproportionately small amount of skull destruction compared with the soft-tissue mass was observed in two-thirds of the analyzable cases.

Conclusion:

This qualitative systematic review identified several features of cranial vault lymphomas that may be useful in differentiating them from meningiomas, including a rapidly growing subcutaneous scalp mass, poor vascularization, and limited skull destruction relative to the size of the soft-tissue mass.

Optimal Management of Calvarial Lymphoma: A Meta-Analysis

BACKGROUND

Calvarial lymphoma is an exceedingly rare phenomenon; the clinical presentation and imaging pattern mimic many diseases of the central nervous system. Several treatment approaches have been undertaken with variable use of surgery plus adjuvant chemotherapy and radiation; an optimal treatment algorithm has yet to be defined. The aim of this study was to better characterize management strategies and patient outcomes.

METHODS

An illustrative case was presented and a meta-analysis was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. MEDLINE and Embase were searched for cases of calvarial lymphoma. Outcomes between patients who underwent open surgery and biopsy only were compared directly.

RESULTS

In an analysis from 1976 to 2019, 62 patients with a median age of 60 were included. The most common presentations were subcutaneous scalp mass (89%), headaches (26%), and focal neurological deficits (21%). Osteolytic changes on computed tomography were seen in 69% of patients with extension into either the intracranial or extracranial space in 97% of cases. Surgical excision was performed in 41 patients with a remission rate of 85% and a recurrence rate of 5%, which did not vary significantly from patients treated nonsurgically (remission in 75%, P = 0.479; recurrence in 0%, P = 1.000) CONCLUSIONS: In patients presenting with a progressively enlarging scalp mass, calvarial lymphoma should be in the differential diagnosis, as it can be effectively managed with a biopsy followed by chemotherapy and radiation. The role for open surgery may be limited.

Diffuse-primary-B-cell lymphoma of the cranial vault presenting as stroke

A rare case of diffuse-primary-B-cell lymphoma was misdiagnosed on emergency computed tomography because of blurred findings and a sclerotic appearance of the right parietal bone. In spite of computed tomography, magnetic resonance imaging provided a higher diagnostic yield, revealing more extensive diploic alterations and indicating the involvement of all of the cranial vault compartments. Therefore, a histologic examination of the surgical specimen was conducted to reach a conclusive diagnosis.