Leptomeningeal lymphoma: perspectives on management

Neurologic complications of hematologic neoplasms

The new WHO classification of hematopoietic and lymphatic neoplasms was devised to offer pathologists, oncologists, and geneticists a system of classification based on histopathologic, clinical, and genetic features. From the neurologic standpoint, it offers an opportunity to consolidate the complications produced by leukemias, lymphomas, and plasma cell dyscrasias. This article summarizes such complications that occur as a result of direct infiltration or compression of nervous tissue by tumor or as a result of indirect effects such as infection, vascular disorders, iatrogenesis, and paraneoplasia.

Neuroblastoma-like epidural localization in non-Hodgkin's lymphoma

We report a case of non-Hodgkin's lymphoma with CNS involvement confined to the epidural space causing cranial suture diastasis. Cerebrospinal fluid and bone marrow were normal. Two cases only of cranial epidural lymphoma have been reported in the literature; in both cases, the leptomeninges were also involved but without suture diastasis.

Central nervous system metastases from non-Hodgkin's lymphoma: treatment and prophylaxis

Central nervous system (CNS) lymphoma was identified in 96 patients treated for non-Hodgkin's lymphoma at Memorial Sloan-Kettering Cancer Center between 1975 and 1981. During the same period, 68 other patients with non-Hodgkin's lymphoma but no CNS disease received prophylactic CNS chemotherapy. In the 156 total patients, the lymphomas were diffuse in 96 percent, and 67 percent were stage IV at diagnosis. CNS involvement was present at initial diagnosis in 27 percent, at relapse in 26 percent, and during the course of progressive systemic disease in 47 percent. CNS involvement was asymptomatic in 10 percent. Cytologic study of the cerebrospinal fluid was the most sensitive and specific laboratory test, but often (22 percent) more than one lumbar puncture was required to identify malignant cells. CNS lymphoma was treated in 85 patients, 46 by intracerebroventricular cannulae; 81 percent improved. Although median survival after the diagnosis of CNS disease was four months, there were seven long-term disease-free survivors and the CNS disease contributed to death in only 14 percent. In 52 percent of treated patients, there was no CNS lymphoma at autopsy. CNS prophylaxis was with methotrexate or cytosine arabinoside, usually by lumbar puncture; an intraventricular cannula was used in seven patients. Although this group of high-risk patients with non-Hodgkin's lymphoma had a high systemic response rate and the median projected survival was greater than five years, CNS lymphoma developed in eight patients (12 percent). In five, CNS lymphoma occurred as an apparently isolated relapse site. The role of CNS chemoprophylaxis in high-risk patients with non-Hodgkin's lymphoma is still uncertain.

Temporal bone pathology of metastatic T-cell lymphoma

Metastatic lymphoma involving the temporal bone is a rare tumour. A review of the English literature revealed only 13 reported cases. The common metastatic sites within the temporal bone are bone marrow and the internal auditory canal (IAC). Non-Hodgkin lymphoma has a tendency to infiltrate to the inner ear and middle ear, with bone marrow involvement. Recent advances in immunology have redefined the malignant lymphoma as a neoplasm of the immune system that has involved T and B cells. We present a case of non-Hodgkin T-cell lymphoma that metastasized to the temporal bone and central nervous system.

Combined intraommaya methotrexate, cytosine arabinoside, hydrocortisone and thio-TEPA for meningeal involvement by malignancies

Twenty-three adult patients with meningeal involvement by a variety of malignancies were treated with the intra-Ommaya combination of methotrexate, hydrocortisone, cytosine arabinoside, and thio-TEPA. Whole brain irradiation was also administered to most patients who had not previously received it. Most patients demonstrated improvement of cerebrospinal fluid parameters, but only 50% of the patients experienced neurological improvement. Patients who did not receive cranial irradiation and performance status 4 patients were less likely to respond than were patients who did receive cranial irradiation as part of their treatment and patients who were performance status 0-3. Four patients developed possible and 2 patients developed probable or definite serious neurological complications. Another 4 patients developed less severe, reversible neurological toxicity. It is possible (but still uncertain) that this regimen is more toxic than other less intensive regimens, and further studies should be undertaken cautiously.

Malignant lymphoma of the testis

Malignant lymphomas of the testis account for approximately 5 percent of testicular neoplasms, and they are the most common testicular malignancy between the ages of 60 and 80. Testicular lymphoma has a propensity to be associated with involvement of the skin, the central nervous system, Waldeyer's ring and adjacent structures, and the contralateral testicle. In general, essentially all patients with testicular lymphoma have been categorized as having "poor-risk" non-Hodgkin's lymphoma, with diffuse histiocytic lymphoma being the most common histologic subtype. All patients with testicular lymphoma should be treated with aggressive combination chemotherapy, with or without radiotherapy.