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Murthy NK, Amrami KK, Broski SM, Johnston PB, Spinner RJ. Perineural spread of peripheral neurolymphomatosis to the cauda equina. J Neurosurg Spine 2021:1-6. [PMID: 34598154 DOI: 10.3171/2021.4.spine21344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/28/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neurolymphomatosis (NL) is a rare manifestation of lymphoma confined to the peripheral nervous system that is poorly understood. It can be found in the cauda equina, but extraspinal disease can be underappreciated. The authors describe how extraspinal NL progresses to the cauda equina by perineural spread and the implications of this on timely and safe diagnostic options. METHODS The authors used the Mayo Clinic medical records database to find cases of cauda equina NL with sufficient imaging to characterize the lumbosacral plexus diagnosed from tissue biopsy. Demographics (sex, age), clinical data (initial symptoms, cerebrospinal fluid, evidence of CNS involvement, biopsy location, primary or secondary disease), and imaging findings were reviewed. RESULTS Ten patients met inclusion and exclusion criteria, and only 2 of 10 patients presented with cauda equina symptoms at the time of biopsy, with 1 patient undergoing a cauda equina biopsy. Eight patients were diagnosed with diffuse large B-cell lymphoma, 1 with low-grade B-cell lymphoma, and 1 with mantle cell lymphoma. Isolated spinal nerve involvement was identified in 5 of 10 cases, providing compelling evidence regarding the pathophysiology of NL. The conus medullaris was not radiologically involved in any case. Lumbosacral plexus MRI was able to identify extraspinal disease and offered diagnostically useful biopsy targets. FDG PET/CT was relatively insensitive for detecting disease in the cauda equina but was helpful in identifying extraspinal NL. CONCLUSIONS The authors propose that perineural spread of extraspinal NL to infiltrate the cauda equina occurs in two phases. 1) There is proximal and distal spread along a peripheral nerve, with eventual spread to anatomically connected nerves via junction and branch points. 2) The tumor cells enter the spinal canal through corresponding neural foramina and propagate along the spinal nerves composing the cauda equina. To diffusely infiltrate the cauda equina, a third phase occurs in which tumor cells can spread circumdurally to the opposite side of the spinal canal and enter contralateral nerve roots extending proximally and distally. This spread of disease can lead to diffuse bilateral spinal nerve disease without diffuse leptomeningeal spread. Recognition of this phasic mechanism can lead to identification of safer extraspinal biopsy targets that could allow for greater functional recovery after appropriate treatment.
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Affiliation(s)
| | | | | | - Patrick B Johnston
- 3Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Kuhlman JJ, Alhaj Moustafa M, Gupta V, Jiang L, Tun HW. Primary Cauda Equina Lymphoma Treated with CNS-Centric Approach: A Case Report and Literature Review. J Blood Med 2021; 12:645-652. [PMID: 34321945 PMCID: PMC8312505 DOI: 10.2147/jbm.s325264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/12/2021] [Indexed: 11/23/2022] Open
Abstract
Primary cauda equina lymphoma is an extremely rare entity previously documented in only 24 reported cases. Primary cauda equina lymphoma represents a subtype of neurolymphomatosis, which occurs when lymphoma cells with neurotropism infiltrate and destroy peripheral nerves, spinal nerve roots, nerve plexuses and cranial nerves. The cauda equina is an anatomic structure located in the lower part of the spinal canal consisting of multiple lumbar and sacral nerve roots. Herein, we report a unique case of primary cauda equina diffuse large B-cell lymphoma presenting as a tumor mass in the lower spinal canal, which was treated with a CNS-centric treatment approach followed by autologous hematopoietic stem cell transplantation.
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Affiliation(s)
- Justin J Kuhlman
- Department of Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Vivek Gupta
- Department of Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Liuyan Jiang
- Department of Pathology and Laboratory Medicine, Jacksonville, FL, USA
| | - Han W Tun
- Division of Hematology and Medical Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
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Marquardt RJ, Li Y. Lumbosacral Radiculoplexopathy as the Initial Presentation of Lymphoma: A Report of 4 Cases. J Clin Neuromuscul Dis 2018; 19:196-202. [PMID: 29794574 DOI: 10.1097/cnd.0000000000000213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To evaluate the clinical, laboratory, and radiological features of 4 cases of biopsy-proven lymphomatous lumbosacral radiculoplexopathy. METHODS Retrospective chart review. RESULTS All patients suffered from diffuse large B-cell lymphoma. A mean diagnostic delay of 10 months was encountered. Presenting symptoms in all 4 patients included back pain, radicular leg pain, and leg weakness, similar to spondylotic radiculopathy. Electrodiagnostic study showed axon loss radiculoplexopathy and magnetic resonance imaging of the lumbar spine or pelvis demonstrated nerve or nerve root enhancement. Increased uptake by lumbosacral roots/plexus on fluorodeoxyglucose-positron emission tomography aided diagnosis in 3 cases. Cytology was positive in 1 of 10 cerebrospinal fluid samples. Combined chemotherapy and radiation treatment led to clinicoradiological improvement, with residual neurological symptoms in all patients. CONCLUSIONS Lymphomatous lumbosacral radiculoplexopathy should be considered in patients with progressive lumbosacral radicular symptoms. Magnetic resonance imaging and fluorodeoxyglucose-positron emission tomography, but not cerebrospinal fluid, are helpful in achieving early diagnosis. Treatment responses seem favorable.
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Affiliation(s)
- Robert J Marquardt
- Department of Neurology, Neuromuscular Center, Neurological Institute, Cleveland Clinic Cleveland, OH
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Suzuki K, Yasuda T, Hiraiwa T, Kanamori M, Kimura T, Kawaguchi Y. Primary cauda equina lymphoma diagnosed by nerve biopsy: A case report and literature review. Oncol Lett 2018; 16:623-631. [PMID: 29928449 DOI: 10.3892/ol.2018.8629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/26/2018] [Indexed: 01/22/2023] Open
Abstract
Primary cauda equina lymphoma (CEL) is a rare malignant tumor among various neoplasms that affects the cauda equina nerve roots. The present case report described the case of a 65-year-old man who presented with cauda equina syndrome with progressive motor palsy in the legs and gait disturbance over the last 5 months. Magnetic resonance (MR) images showed enlargement of the cauda equina occupying the dural sac from the L1-S1 level with isointensity to the spinal cord signal on both T1- and T2-weighted imaging. Enhancement of the cauda equina was seen on contrast MR images. On F-18 2-fluoro-2-deoxy-glucose positron emission tomography examination, diffuse accumulation of 2-fluoro-2-deoxy-glucose was observed in the cauda equina with a maximum standardized uptake value of 4.9. Based on elevation of soluble interleukin 2 receptor in cerebrospinal fluid and a biopsy of the enlarging cauda equina, a diagnosis of CEL of the diffuse large B-cell type was made. The present case report provided a detailed case discussion and a review of the available literature on this rare entity, focusing on clinical characteristics and imaging of primary CEL.
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Affiliation(s)
- Kayo Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Toyama 930-0194, Japan
| | - Taketoshi Yasuda
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Toyama 930-0194, Japan
| | - Toshihito Hiraiwa
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Toyama 930-0194, Japan
| | - Masahiko Kanamori
- Department of Human Science 1, Faculty of Medicine, University of Toyama, Toyama, Toyama 930-0194, Japan
| | - Tomoatsu Kimura
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Toyama 930-0194, Japan
| | - Yoshiharu Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Toyama 930-0194, Japan
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Shin HK, Oh SK, Woo CG, Huh JR, Suh CW, Jeon SR. Cauda equina lymphoma mimicking non-neoplastic hypertrophic neuropathy of the cauda equina: A case report. Br J Neurosurg 2015; 30:678-680. [PMID: 26610022 DOI: 10.3109/02688697.2015.1111295] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Spinal cauda equina lymphoma (CEL) is very rare, with only about 14 cases reported in the English medical literature. Magnetic resonance image findings and the gross appearance of CEL at surgery are similar to those of non-neoplastic hypertrophic neuropathy of the cauda equina (HNCE); however, their prognosis and treatment are very different. We report a case of CEL and discuss the differences from non-neoplastic HNCE.
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Affiliation(s)
- Hong Kyung Shin
- a Department of Neurological Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Korea
| | - Sun Kyu Oh
- a Department of Neurological Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Korea
| | - Chang Gok Woo
- b Department of Pathology , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Korea
| | - Joo Ryung Huh
- b Department of Pathology , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Korea
| | - Cheol Won Suh
- c Division of Hemato-Oncology, Department of Internal Medicine , Asan Medical Center, University of Ulsan College of Medicine
| | - Sang Ryong Jeon
- a Department of Neurological Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Korea
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Taylor JW, Flanagan EP, O'Neill BP, Siegal T, Omuro A, Deangelis L, Baehring J, Nishikawa R, Pinto F, Chamberlain M, Hoang-Xuan K, Gonzalez-Aguilar A, Batchelor T, Blay JY, Korfel A, Betensky RA, Lopes MBS, Schiff D. Primary leptomeningeal lymphoma: International Primary CNS Lymphoma Collaborative Group report. Neurology 2013; 81:1690-6. [PMID: 24107866 DOI: 10.1212/01.wnl.0000435302.02895.f3] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate clinical presentation, optimal diagnostic evaluation and treatment, and outcome in primary leptomeningeal lymphoma, a rare form of primary CNS lymphoma without parenchymal or systemic involvement. METHODS The International Primary CNS Lymphoma Collaborative Group, a multidisciplinary group of physicians with a particular interest in primary CNS lymphoma, retrospectively identified cases of lymphoma isolated to the leptomeninges as diagnosed by CSF cytology, flow cytometry, or biopsy, without systemic or parenchymal brain/spinal cord lymphoma or immunodeficiency. RESULTS Forty-eight patients were identified, with median age at diagnosis of 51 years and median Eastern Cooperative Oncology Group performance status of 2. Presenting symptoms were multifocal in 68%. Leptomeningeal enhancement was seen in 74% and CSF profile was abnormal in all cases. CSF cytology detected malignant lymphocytes in 67%. Flow cytometry identified monoclonal population in 80%, as did receptor gene rearrangement studies in 71%. Sixty-two percent had B-cell lymphoma, 19% T-cell, and 19% unclassified. Treatment varied and included fractionated radiotherapy (36%), systemic chemotherapy (78%), and intra-CSF chemotherapy (66%), with 66% receiving ≥ 2 modalities. Seventy-one percent had a favorable clinical response; ultimately, 44% received salvage treatment. Median overall survival was 24 months, with 11 patients still alive at 50 months follow-up. CONCLUSION Primary leptomeningeal lymphoma is a rare form of primary CNS lymphoma. Patients usually present with multifocal symptoms, with evidence of leptomeningeal enhancement and diagnostic CSF analysis. Although treatment is highly variable, patients have a better prognosis than previously reported and a subset may be cured.
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Affiliation(s)
- Jennie W Taylor
- From the Massachusetts General Hospital (J.W.T., T.B., R.A.B.), Boston; Mayo Clinic (E.P.F., B.P.O.), Rochester, MN; Hadassah Hebrew University Medical Center (T.S.), Jerusalem, Israel; Memorial Sloan-Kettering (A.O., L.D.), New York, NY; Yale University (J.B.), New Haven, CT; Saitama Medical University (R.N.), Japan; Kings College Hospital (F.P.), London, UK; University of Washington (M.C.), Seattle; LOC National Expert Center (K.H.-X., A.G.-A.), APHP, UPMC, Pitie-Salpetriere, Paris; Centre Leon Berard (J.-Y.B.), Lyon, France; Campus Benjamin Franklin (A.K.), Charite Universitätsmedizin Berlin, Germany; Department of Biostatistics (R.A.B.), Harvard School of Public Health, Boston, MA; and University of Virginia (M.-B.S.L., D.S.), Charlottesville
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Abstract
We describe 2 patients with inexorably progressive pseudotumor syndrome (intracranial hypertension without mass lesion or ventriculomegaly) both initially misdiagnosed as having idiopathic intracranial hypertension and who were eventually found to have spinal leptomeningeal lymphoma. Neither had, at any time, any clinical signs of a spinal cord or root lesion. We discuss the possible implications of these observations regarding the diagnosis and mechanism of the pseudotumor syndrome.
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Nishida H, Hori M, Obara K. Primary B-cell lymphoma of the cauda equina, successfully treated with high-dose methotrexate plus high-dose cytarabine: a case report with MRI findings. Neurol Sci 2011; 33:403-7. [PMID: 21898094 DOI: 10.1007/s10072-011-0752-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 08/23/2011] [Indexed: 11/24/2022]
Abstract
Primary malignant lymphoma of the cauda equina is an extremely rare disease. Previously, there have been only 12 reported cases of malignant lymphoma of the cauda equina, and most cases relapsed early in the clinical course. So, the optimal treatment strategy for this condition has not been established yet and the prognosis is thought to be poor. We experienced a case of B-cell malignant lymphoma of the cauda equina, with rapid progression of the muscle weakness of the bilateral lower extremities, successfully treated with high-dose methotrexate plus high-dose cytarabine (Ara-C) chemotherapy, followed by radiotherapy and in complete remission without any recurrence signs, 1.5 years after the initial diagnosis. Intrathecal chemotherapy with MTX, Ara-C, and predonisolone was simultaneously performed. We should carefully continue to monitor the clinical course of our case, with the examinations of magnetic resonance imaging and cerebrospinal fluid in order not to overlook any subtle neurological changes or other clinical symptoms.
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Affiliation(s)
- Hiroko Nishida
- Department of Internal Medicine, Mito Red Cross Hospital, 3-12-48 Sannoaru, Mito, Ibaragi 310-0011, Japan.
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