Intracranial Nasal Natural Killer/T-cell Lymphoma: Immunopathologically-Confirmed Case and Review of Literature

Yolk sac tumor of the fourth ventricle in a 3-year-old boy: imaging features

PURPOSE

Yolk sac tumor (YST) is a rare malignant germ cell tumor and typically occurs in gonads. It is extremely rare in the brain, especially in the fourth ventricle.

METHODS

This study reported the case of a 3-year-old boy with intermittent vomiting for 11 days and then intermittent twitch for 5 h.

RESULTS

Brain computed tomography showed a slightly higher density mass in the fourth ventricle. Brain magnetic resonance imaging showed an irregular lobulated expansive mass in the fourth ventricle, appearing with the low intensity on T1-weighted images, and uneven hyperintensity on T2-weighted images. The enhanced scan showed inhomogeneous and strong enhancement, with multiple small cyst-like areas of no enhancement. Tortuous tumor vessel also can be seen. The pathological results after surgical resection showed an YST in the fourth ventricle.

CONCLUSION

When a mass is observed in the fourth ventricle in children, with uneven signal with hemorrhage and cystic change, inhomogeneous and strong enhancement, and facilitated diffusion on diffusion-weighted imaging, YST should be considered. The increase of α-fetoprotein value can help differential diagnosis.

Nasal-Type Extranodal Natural Killer/T Cell Lymphoma with Meningeal Involvement: A Case Report and Literature Review

Objectives

We report a case of a 26-year-old man diagnosed with nasal-type extranodal natural killer/T cell lymphoma (ENKTL) extending beyond the nasal cavity. Complete response was achieved after therapy, followed by rapid metastasis to the meningeal nerve fibres. The overall survival (OS) of the patient was 15 months. To better understand ENKTL with meningeal involvement, we summarized the clinical features of the 10 cases involving meningeal metastasis in ENKTL reported in the English literature.

Methods

The patient was admitted for the ENKTL diagnosis, and positron emission tomography-computed tomography showed the disease stage and response. When central nervous system (CNS) infiltration was suspected, magnetic resonance imaging (MRI) of the brain and spinal cord was performed, as well as cerebrospinal fluid (CSF) analysis with flow cytometric immunophenotyping.

Results

MRI of the brain and spinal cord revealed normal results. CSF analysis with flow cytometric immunophenotyping showed NK/T lymphoma cell infiltration.

Conclusion

Meningeal metastasis of ENKTL is rare; when patients present with nervous system symptoms, CNS metastasis should be considered as a possibility, even in the early stage. The OS of our patient was 15 months, which is the longest survival time reported in the literature, probably due to early diagnosis and comprehensive management, including intrathecal therapy, chemotherapy and radiotherapy of the whole brain and spinal cord.

Extranodal natural killer/T cell lymphoma, nasal type: a diagnostic challenge

Extranodal natural killer/T cell lymphoma, nasal type (ENKL) is a rare and aggressive tumour that can, clinically and histologically, mimic infectious and inflammatory conditions, presenting a diagnostic challenge. The authors report the case of a 69-year-old Portuguese woman previously misdiagnosed with chronic recurrent sinusitis. Despite maximal medical and surgical treatments, the disease was refractory and progressed. The patient had undergone multiple biopsies when the histopathological diagnosis of ENKL was made, 5 months after the initial complaints. Multiagent chemotherapy was offered, but during the first cycle, the patient developed severe infection and pancytopenia, which culminated in her death. This case highlights the need to consider a neoplastic cause when faced with aggressive sinonasal disease not responsive to maximal treatment and the difficulties in establishing the diagnosis of ENKL, with multiples biopsies of deep-tissue usually being required.

Extranodal natural killer/T-cell lymphoma nasal type with central nervous system involvement mimicked tuberculous meningitis: A case report

RATIONALE

Neurologic deficits are rare in patients with extranodal natural killer/T-cell lymphoma (NKTL), nasal type. We present a case that was initially suspected as tuberculous meningitis, but later diagnosed as central nervous system metastasis of NKTL, nasal type, which has never been published previously.

PATIENT CONCERNS

A 55-year-old Chinese man presented with persistent headache and fever. The initial head computed tomography and magnetic resonance imaging (MRI) scan was normal. Low glucose, elevated protein, and pleocytosis of cerebral spinal fluid led to a diagnosis of tuberculous meningitis. The patient did not respond to anti-tuberculosis treatment, and his symptoms aggravated. MRI showed abnormal lesions in the right hemisphere and a lesion in the maxillary sinus region.

DIAGNOSIS

Endoscopic biopsy of the maxillary lesion showed features consistent with NKTL. Positron emission tomography revealed a hypermetabolic mass involving the right maxillary sinus and brain.

INTERVENTIONS

The patient received chemotherapy.

OUTCOMES

The patient died 30 days after chemotherapy.

LESSONS

Lymphoma of the nasal cavity and paranasal sinuses is extremely rare and may be easily misdiagnosed. Nasal NKTL metastasis should be considered when a patient presents with symptoms of leptomeningeal involvement.

Primary Central Nervous System Extranodal Natural Killer/T-Cell Lymphoma, Nasal Type Colliding with Meningioma

BACKGROUND

Collision tumors are defined as coexistence of 2 histologically different neoplasms occurring in the same anatomic location. Such co-occurrence of tumors in the brain is uncommon. To our knowledge, meningioma colliding with extranodal natural killer/T-cell lymphoma has not been described previously.

CASE DESCRIPTION

A 50-year-old man presented with a 1-year history of progressive memory decline and 2 weeks of drowsiness, bradykinesia, and aphasia. Magnetic resonance imaging revealed a heterogeneously enhanced mass beside the left frontal cerebral falx resulting in midline shift. The left frontal lobe mass was resected. Pathologic examination showed the tumor consisted of whorled spindle cells and diffuse medium-sized lymphoid cells. The spindle cells were positive for epithelial membrane antigen and negative for S-100. The lymphoid cells expressed CD3ε, CD56, TIA-1, and granzyme B. Epstein-Barr virus encoded small RNAs were detected by in situ hybridization. No monoclonal T-cell receptor gamma gene rearrangement was detected. Four weeks after surgery, the patient was treated with polychemotherapy and intrathecal methotrexate, but he died 2 months later.

CONCLUSIONS

This is the first report of a unique brain collision tumor consisting of a meningioma and an extranodal natural killer/T-cell lymphoma. Diagnosis depends on histopathology. Awareness of this entity is important to distinguish it from other intracranial tumors.

Extranodal natural killer/T cell lymphoma, nasal type in the middle cranial fossa: A case report

INTRODUCTION

Extranodal natural killer (NK)/T cell lymphomas, nasal type, are aggressive, non-Hodgkin lymphomas. Extranodal NK/T cell lymphomas, nasal type, involving the central nervous system (CNS) are rare; therefore, delayed diagnosis easily occurs and is associated with a poor prognosis. Early diagnosis and patented systemic chemotherapy are necessary.

CASE PRESENTATION

We present a case of 34-year-old male with facial numbness and diplopia. He was diagnosed with extranodal NK/T cell lymphoma, nasal type, involving the CNS. The tumor, located in the right middle fossa, was subtotally removed, and 3 cycles of systemic chemotherapy were given. He later died of severe neutropenia and infection.

CONCLUSION

NK/T cell lymphomas should be considered to be a potential cause of facial numbness and diplopia. A L-asparaginase-based regimen resulted in reasonable tumor suppression, but adverse effects, including fatal neutropenia, should be carefully considered.

EBV driven natural killer cell disease of the central nervous system presenting as subacute cognitive decline

Brain biopsy in patients presenting with subacute encephalopathyis never straightforward and only undertaken when a ‘treatable condition’ is a realistic possibility.

This 63 year old right handed, immunocompetent Caucasian woman presented with an 8 month history of rapidly progressive right-sided hearing impairment, a 4 month history of intermittent headaches, tinnitus, ‘dizziness’, dysphagia, nausea and vomiting, with the subsequent evolution of progressive gait ataxia and a subacute global encephalopathy. The possibility of CJD was raised. Brain biopsy was carried out. Western blot for prion protein was negative. She died 9 days later and autopsy brain examination confirmed widespread subacute infarction due to an EBV positive atypical NK/T-cell infiltrate with positivity for CD3, CD56, granzyme B, perforin and EBER with absence of CD4, CD5 and CD8 expression. Molecular studies for T-cell clonality were attempted but failed due to insufficient DNA quality. Serology was consistent with past EBV infection (EBV VCA and EBNA IgG Positive). There was no evidence of disease outside the CNS. Primary central nervous system NK/T-cell lymphoma is extremely rare. The rare reported cases all present with a discrete intracranial mass, unlike the diffuse infiltrative pattern in this case. Whilst the diffuse interstitial pattern is reminiscent of chronic active EBV infection (CAEBV) seen in other organ systems such as the liver and bone marrow, the clinical presentation and epidemiologic profile are not typical for CAEBV.

Extranodal NK/T-cell lymphoma, nasal type, manifesting as rapidly progressive dementia without any mass or enhancing brain lesion

Among the many potential etiologies for rapidly progressive dementia (RPD), primary central nervous system extranodal NK/T-cell lymphoma, nasal-type (ENKL) is a rare entity. We present the first reported case of autopsy-proven RPD due to ENKL without any mass or enhancing lesion of the brain. A 54-year-old immunocompetent man presented with RPD, myoclonus and ataxia. The mini-mental state examination (MMSE) score was 22/30. His brain MRI revealed progressive brain atrophy without gadolinium enhancement or mass lesion. Five months after the initial evaluation, cognitive impairment further worsened with an MMSE score of 3/30. At the advanced stage, lumbar MRI showed swollen cauda equina with gadolinium enhancement. The number of Epstein-Barr virus (EBV) DNA in cerebrospinal fluid had gradually increased. Twelve months after onset, the patient died of respiratory failure. Pathological findings revealed that lymphoma cells had diffusely invaded the meninges, parenchyma of the brain, spinal cord and cauda equina. Cells were positive for CD3, CD56 and EBV-encoded small RNAs and negative for CD20. No evidence of malignancy was identified in the visceral organs. This report indicates that ENKL should be recognized as one of the rare causes of RPD. Early testing for EBV-DNA in cerebrospinal fluid and imaging of cauda equina would be useful diagnostic tools.

Orbital and central nervous system extension of nasal natural killer/T-cell lymphoma

BACKGROUND

To describe a case series of nasal natural killer (NK)/T-cell lymphoma (NKTL) with orbital and central nervous system extension.

METHODS

This is a retrospective study. The medical records of 9 patients with a diagnosis of NKTL were reviewed. All patients had a positive biopsy for CD3, CD56, T-cell-restricted intracellular antigen-1, and granzyme expression and CT imaging of nose, sinuses, orbits, and brain. Five patients were also examined with MRI.

RESULTS

Orbital extension occurred in 6 patients. All had extraocular muscle enlargement and 5 showed signs of perineural spread.

CONCLUSIONS

NKTL is a polymorphous disease. Extraocular muscle involvement and perineural spread are overlooked features that explain dissemination of the tumor to both the orbit and the central nervous system.

Extranodal nasal-type natural killer/T-cell lymphoma masquerading as recalcitrant sinusitis

BACKGROUND

Extranodal nasal-type natural killer (NK)/T-cell lymphoma is a very uncommon disease process often mimicking refractory sinusitis. The diagnosis may be discovered after an extensive exclusion process. Careful immunohistochemical evaluation is crucial to differentiate NK/T-cell lymphoma from other malignancies.

METHODS AND RESULTS

We describe a 46-year-old white man presenting with a 4-month history of refractory sinusitis and new onset visual field loss in his right eye, right facial tingling, and pain. Examination revealed right periorbital edema and scleritis, and necrotic appearing turbinates with purulence and fibrinous debris. CT/MRI delineated extensive paranasal sinus involvement. Immunohistopathology demonstrated extranodal nasal-type NK/T-cell lymphoma. Additional radiography revealed widespread involvement.

CONCLUSION

Severe recalcitrant sinusitis with orbital involvement may be the initial presentation of NK/T-cell lymphoma. Ulcerative or necrotic lesions in the midline of the head and neck should raise concern for this disease. In addition to radiographic and laboratory testing, large biopsies should be taken for immunohistochemical analysis to achieve diagnosis and guide further management.

Extranodal NK/T-cell lymphoma presenting as a pituitary mass. Case report and review of the literature

Primary pituitary lymphomas (PPLs) are rare tumors of the central nervous system, and most are of B-cell origin. Extranodal NK/T-cell lymphomas are uncommon neoplasms that are highly aggressive and show a strong association with Epstein-Barr virus. They most commonly affect the nasal cavity and paranasal sinuses; manifestation as a primary pituitary tumor has never been described. The authors report a case of NK/T-cell lymphoma of the pituitary gland and review 17 cases of PPL from the literature. All patients had been evaluated at presentation for clinical, neuroimaging, and histopathological findings. Patients who had systemic lymphoma with secondary involvement of the pituitary gland were excluded. The mean patient age was 55.5 years (range 26-86 years); the male/female ratio was 13:5. The most common presentation was pituitary insufficiency (72%), followed by headache (56%), diplopia (39%), visual loss (28%), and fever (22%). Thirteen patients (72%) exhibited anterior hypopituitarism and seven (39%) had diabetes insipidus at presentation. Magnetic resonance imaging demonstrated enhancing parasellar masses with diffuse enlargement of the pituitary gland (94%), suprasellar extension (44%), cavernous sinus extension (39%), and stalk thickening (22%). Thirteen patients (72%) had B-cell lymphoma, four (22%) had T-cell lymphoma, and one (6%) had NK/T-cell lymphoma. Primary pituitary lymphomas are rare entities with a range of clinical presentations and neuroimaging findings that are unique from those of patients who present with pituitary adenomas. The pathological entity of NK/T-cell lymphoma is distinct, and its course is very aggressive with a poor prognosis.

Extranodal NK/T-cell lymphoma, nasal type

Extranodal NK/T-cell lymphoma, nasal type (ENKTCL), previously known as lethal midline granuloma is a distinct clinico-pathological entity associated with Epstein-Barr virus that typically causes destruction of the midface, palatal and orbital walls. In addition, ENKTCL can involve the skin, soft tissue, testes, gastrointestinal and upper respiratory tract. ENKTCL neoplastic cells express some T-cell associated antigens, most commonly CD2 and cytoplasmic CD3epsilon and, in favour of an NK-cell origin, CD56. Early stage disease may respond to radiotherapy alone, however late stage disease does not respond well to any available therapies. Overall, patients with ENKTCL have a cumulative probability of survival at 5 years ranging from 37.9% to 45.3%.