Extranodal Lymphoma of the Central Nervous System and Spine

The Role of MRI in the Diagnosis of Spinal Cord Tumors

Spinal cord tumors are uncommon, and its multiple representatives not always have pathognomonic characteristics, which poses a challenge for both patients and caring physicians. The radiologist performs an important role in recognizing these tumors, as well as in differentiating between neoplastic and non-neoplastic processes, supporting clinical and surgical decision-making in patients with spinal cord injury. Magnetic Resonance Imaging (MRI) assessment, paired with a deep understanding of the various patterns of cord involvement allied to detailed clinical data can provide a diagnosis or significantly limit the differential diagnosis in most cases. In this article, we aim to review the most common and noteworthy intramedullary and extramedullary spinal tumors, as well as some other tumoral mimics, with an emphasis on their MRI morphologic characteristics.

Conventional and Advanced Imaging of Spinal Cord Tumors

Spinal cord tumors are best identified by conventional MR imaging with contrast. Most intramedullary spinal cord tumors have characteristic MR imaging features that allow an accurate preoperative diagnosis. The spinal cord tumors reviewed in this article include the most common tumors, ependymomas and astrocytomas, as well as the less common tumors such as hemangioblastomas and metastases. Rare tumors such as primary CNS lymphoma and melanocytic tumors are also described. Advanced imaging techqniques of more common intramedullary tumors are also reviewed.

Function in Cancer Patients: Disease and Clinical Determinants

Patients with cancer often experience changes in function during and after treatment but it is not clear what cancer types, and associated clinical factors, affect function. This study evaluated patient-reported functional impairments between specific cancer types and risk factors related to disease status and non-cancer factors. A cross-sectional study evaluating 332 individuals referred to cancer rehabilitation clinics was performed at six U.S. hospitals. The PROMIS Cancer Function Brief 3D Profile was used to assess functional outcomes across the domains of physical function, fatigue, and social participation. Multivariable modeling showed an interaction between cancer type and cancer status on the physical function and social participation scales. Subset analyses in the active cancer group showed an effect by cancer type for physical function (p < 0.001) and social participation (p = 0.008), but no effect was found within the non-active cancer subset analyses. Brain, sarcoma, prostate, and lymphoma were the cancers associated with lower function when disease was active. Premorbid neurologic or musculoskeletal impairments were found to be predictors of lower physical function and social participation in those with non-active cancer; cancer type did not predict low function in patients with no evidence of disease. There was no differential effect of cancer type on fatigue, but increased fatigue was significantly associated with lower age (0.027), increased body mass index (p < 0.001), premorbid musculoskeletal impairment (p < 0.015), and active cancer status (p < 0.001). Anticipatory guidance and education on the common impairments observed with specific cancer types and during specific stages of cancer care may help improve/support patients and their caregivers as they receive impairment-driven cancer rehabilitation care.

A Rare Occurrence of Primarily Extranodal Spinal Epidural Lymphoma With Spinal Cord Compression and Invasion to the Thoracic Cavity

A 41-year-old man suffered from progressive radiculomyelopathy caused by spinal epidural mass primarily encasing the spinal cord at the cervicothoracic vertebrae that extended into the thoracic cavity through the neural foramen. An urgent decompressive laminectomy and epidural tumor resection were performed to prevent neurological deterioration and effective spinal cord decompression. The histopathologic diagnosis was diffuse large B-cell lymphoma. As first-line treatment for stage II extranodal lymphoma, he received 6 cycles of R-CHOP (rituximab/cyclophosphamide, hydroxydaunorubicin, Oncovin, and prednisone) chemotherapy. Consequently, follow-up positron-emission tomography CT and MR images demonstrated a complete metabolic response (Deauville score 1). This rare occurrence of primarily extranodal spinal epidural lymphoma with limited disease will be presented in a literature review.

Amide proton transfer MRI differentiates between progressive multifocal leukoencephalopathy and malignant brain tumors: a pilot study

BACKGROUND

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nerve system caused by the John Cunningham virus. On MRI, PML may sometimes appear similar to primary central nervous system lymphoma (PCNSL) and glioblastoma multiforme (GBM). The purpose of this pilot study was to evaluate the potential of amide proton transfer (APT) imaging for differentiating PML from PCNSL and GBM.

METHODS

Patients with PML (n = 4; two men; mean age 52.3 ± 6.1 years), PCNSL (n = 7; four women; mean age 74.4 ± 5.8 years), or GBM (n = 11; 6 men; mean age 65.0 ± 15.2 years) who underwent APT-CEST MRI between January 2021 and September 2022 were retrospectively evaluated. Magnetization transfer ratio asymmetry (MTR_asym) values were measured on APT imaging using a region of interest within the lesion. Receiver operating characteristics curve analysis was used to determine diagnostic cutoffs for MTR_asym.

RESULTS

The mean MTR_asym values were 0.005 ± 0.005 in the PML group, 0.025 ± 0.005 in the PCNSL group, and 0.025 ± 0.009 in the GBM group. There were significant differences in MTR_asym between PML and PCNSL (P = 0.023), and between PML and GBM (P = 0.015). For differentiating PML from PCNSL, an MTR_asym threshold of 0.0165 gave diagnostic sensitivity, specificity, positive predictive value, and negative predictive value of 100% (all). For differentiating PML from GBM, an MTR_asym threshold of 0.015 gave diagnostic sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 90.9%, 80.0%, and 100%, respectively.

CONCLUSION

MTR_asym values obtained from APT imaging allowed patients with PML to be clearly discriminated from patients with PCNSL or GBM.

"Wrap-Around Sign" in Non-Hodgkin Lymphoma of the Spine: A Common yet Overlooked Imaging Feature?

BACKGROUND

Anecdotal cases of the so-called "wrap-around" appearance in non-Hodgkin lymphoma (NHL) of the spine exist in the medical literature. In this paper, we looked at the prevalence of this imaging feature in our institutional cases.

MATERIALS AND METHODS

We screened our institutional database for biopsy-proven NHL. Our inclusion criteria were the histologically confirmed diagnosis of NHL involving any vertebra, available magnetic resonance imaging of the affected site, and a positive wrap-around sign. Exclusion criteria included lymphoma cases without the wrap-around sign and/or histology other than NHL. We subdivided the cases into 3 groups: 1) lymphoma wrapped around the vertebral body; 2) the posterior elements alone; or 3) both the vertebral body and posterior elements.

RESULTS

Our search identified 147 cases of NHL in which a confirmatory biopsy at the primary tumor site was available. Of those, 23 cases fulfilled the inclusion criteria (16 men and 7 women with average age at diagnosis of 63.3 years), yielding prevalence of 15.6% in our series. Most commonly the lymphoma involved the vertebral body with or without some involvement of the posterior vertebral elements (n = 20, 86.9%), followed by posterior vertebral elements (n = 2, 8.7%). One remaining case (4.4%) had lymphoma involving the anterior vertebral body and posterior elements.

CONCLUSIONS

Findings of our pilot study indicated that the wrap-around sign in cases of NHL could be helpful diagnostically. This sign may be frequently under-recognized, leading to potential for a diagnostic dilemma on imaging. Larger studies are necessary to obtain more precise information about the prevalence of the wrap-around sign.

Methotrexate-associated lymphoproliferative disorder of the thoracic spine in a patient with rheumatoid arthritis receiving methotrexate: a case report

Methotrexate-associated lymphoproliferative disorder is recognized as a lymphoma that occurs following methotrexate administration. The lesion of the spine is extremely rare, and only one case of lesion in the lumbar spine has been reported so far. Here, we present a case of methotrexate-associated lymphoproliferative disorder of the thoracic spine in a 54-year-old woman with rheumatoid arthritis. The lesion formed an extra-skeletal tumor mass from lateral to the vertebral body to the paravertebral muscle extending posterior to the epidural space without bone destruction. Magnetic resonance imaging showed low signal intensities on both T1- and T2-weighted images and high signal intensity with short-tau inversion recovery. These radiological findings were similar to those for primary spinal lymphoma. The lesion rapidly paralyzed the patient, forcing her to be treated with posterior spinal decompression. The lesion could not be resected because it adhered to the dura. Following the histopathological diagnosis as methotrexate-associated lymphoproliferative disorder, methotrexate administration was terminated. The remaining mass lesion showed complete regression within 6 months. Methotrexate-associated lymphoproliferative disorder, which could be cured by the discontinuation of methotrexate, should be considered a differential diagnosis in spinal lesion cases showing lymphoma-like appearance with methotrexate treatment to avoid unnecessary treatments.

Traditional and Advanced Neuroimaging Contributions to the Diagnosis and Differential Diagnosis of Central Nervous System Lymphoma Patients Visiting a Comprehensive Medical Center

Introduction:

The diagnosis of Central Nervous System Lymphoma, especially the Primary Central Nervous System Lymphoma is carried out based on brain imaging, thus avoiding an unnecessary extend of surgery. But the traditional imaging techniques, such as Computed Tomography and Magnetic Resonance Imaging, were not satisfactory.

Aims:

This study was conducted to characterize the spectrum of advanced Neuroimaging, such as the advanced Magnetic Resonance Imaging features in the Central Nervous System Lymphoma patients in a comprehensive medical center in Lebanon, and compare them to what has been described in the literature review.

Methods:

It is a retrospective exploratory study of the clinical data and imaging features for patients admitted to the emergency and radiology departments with ages above 10 years, and who were diagnosed histopathologically with intracranial lymphoma. This study may be the first to make a Radiological evaluation of Central Nervous System Lymphoma on the local population of patients over 9 years .

Results:

Results showed that the study of the Computed Tomography and Magnetic Resonance Imaging data of 10 immunocompetent patients with Central Nervous System Lymphoma concurs with the previously described patient populations, except for the gender parameter. Tumors were mostly presented in the fifth or Sixth decade and they could be solitary or multi-focal. Lesions were typically located Preprint submitted to The Open Neuroimaging Journal May 14, 2020 in the supratentorial compartment. On the brain Computed Tomography, the lesions were hyperdense, and in pre-contrast Magnetic Resonance images, the lesions appeared hypointense on T1 and hyperintense on T2-Weighted images, but hypointense with respect to the grey matter. The lesions were also surrounded with a mild to moderate edema as compared to other intracranial neoplasms, such as glioblastomas. Evaluation results showed that on post-contrast Magnetic Resonance images, the majority of lesions exhibited a homogeneous enhancement of 50%. Majority of the lesions also showed a less common heterogeneous ring-like enhancement of 40%, and revealed the uncommon absence of enhancement of 10%. Calcifications, hemorrhage, and necrosis were rare findings and were present in only one patient.

Conclusion:

As a future prospect, studying whether the advanced imaging techniques may provide not only non-invasive and morphological characteristics but also non-invasive biological characteristics and thus accurate diagnosis could be considered.

Intramedullary Masses of the Spinal Cord: Radiologic-Pathologic Correlation

Spinal cord tumors are a challenge for patients and neurosurgeons because of the high risk of neurologic deficits from the disease process and surgical interventions. Spinal cord tumors are uncommon, and approximately 2%-3% of primary intra-axial tumors of the central nervous system occur in the spinal cord. Primary intra-axial tumors are usually derived from neuroepithelial tissue, especially glial cells. This often leads to a classic intramedullary mass differential diagnosis of ependymoma or astrocytoma, which together constitute up to 70% of spinal cord tumors. For example, ependymomas occur predominantly in adults, and astrocytomas (specifically pilocytic astrocytomas) occur predominantly in children. While that is an excellent starting point, in order to refine the differential diagnosis, the authors review the radiologic-pathologic features of specific neoplastic categories and entities recognized by the World Health Organization (WHO) in the 2016 WHO Classification of Tumours of the Central Nervous System and a few additional congenital-developmental entities. Radiologists can add value by providing a reasonable preoperative differential diagnosis for the patient and neurosurgeon, in many cases by favoring the most common conditions, and in other cases by identifying radiologic features that may point toward a less common entity. Some of the less common entities include intramedullary myxopapillary ependymoma, spinal subependymoma, and spinal hemangioblastoma. Whenever possible, the characteristic imaging features and locations of these tumors are explained or traced back to the underlying cell of origin and findings seen at histopathologic examination.See discussion on this article by Buch.

Posttransplant Lymphoproliferative Disorder in Children: A 360-degree Perspective

An earlier incorrect version of this article appeared online. This article was corrected on December 17, 2019.

Differentiation of Primary Central Nervous System Lymphoma From Glioblastoma: Quantitative Analysis Using Arterial Spin Labeling and Diffusion Tensor Imaging

OBJECTIVE

Differentiation of primary central nervous system lymphoma (PCNSL) from glioblastoma using arterial spin labeling perfusion and diffusion tensor imaging (DTI).

METHODS

We performed a prospective study of 31 patients with a provisional diagnosis of PCNSL and glioblastoma who underwent conventional magnetic resonance imaging, DTI, and arterial spin labeling of the brain. The tumor blood flow (TBF), mean diffusivity (MD) plus fractional anisotropy (FA) of the mass were measured. The final diagnosis was confirmed by pathological examination.

RESULTS

The TBF of PCNSL (26.41 ± 4.03 mL/100 g/minute) was significantly lower than that of glioblastoma (51.08 ± 3.9 mL/100 g/minute; P = 0.001). The TBF cutoff (35.73 mL/100 g/minute) used for differentiation showed area under the curve (AUC) of 0.93, accuracy of 95.2%, sensitivity of 91.7%, and specificity of 100%. The MD of PCNSL (0.87 ± 0.2X 10^-3 mm²/second) was significantly lower than that of glioblastoma (0.87 ± 0.2 × 10^-3 mm²/second; P = 0.01). The MD cutoff (0.935 × 10^-3 mm²/second) used for differentiation showed an AUC of 0.73 and accuracy of 66.7% and a sensitivity of 75% and specificity of 55.6%. The FA of PCNSL (0.253 ± 0.05) was significantly greater than that of glioblastoma (0.135 ± 0.06; P = 0.001). The FA cutoff (0.185) used for differentiation revealed an AUC of 0.944 and accuracy of 85.7% and a sensitivity of 83.3% and specificity of 88.9%. The combined TBF, MD, and FA cutoffs revealed an AUC of 0.96 and accuracy of 95.5% and a sensitivity of 83.3% and specificity of 100%.

CONCLUSION

The noninvasive imaging parameters using TBF and DTI might help in differentiating PCNSL from glioblastoma.

Management of extranodal lymphoma of the spine: a study of 30 patients

Extranodal lymphoma of the spine is often a late manifestation of systemic disease, and may result in symptoms of pain, neurologic compromise or spinal instability. Symptomatic relief is generally achieved by radiotherapy alone, but is not sufficient in addressing spinal instability. The indications for surgery remain controversial, but may be required for spinal stabilization, or refractory disease. Currently, there is a lack of studies that compare the indications and clinical outcomes of patients receiving surgical and nonsurgical management of spinal extranodal lymphoma. Medical records of 30 patients seen from March 2006 to August 2015, with histologically confirmed spinal lymphoma, were retrospectively reviewed. Demographic information, clinical factors, imaging, treatment and clinical outcomes were recorded. 19 patients were treated surgically and 11 nonsurgically (i.e., chemotherapy, radiation or combination). Surgery was performed for emergent neurological deterioration, mechanical stabilization, refractoriness to medical management or to perform an open biopsy for pathological diagnosis. Among those treated surgically, significantly fewer patients could carry on normal activities (KPS <70) at baseline, compared with those treated nonsurgically. However, there were no significant differences regarding pain medication use, functional status at 1 year, or mean survival (87.6 months) between groups. Surgery for extranodal lymphoma may be required in specific cases, resulting in favorable and similar outcomes compared with nonsurgical management.