Rapid improvement of paraplegia caused by epidural involvements of Burkitt's lymphoma with chemotherapy

Lumbosacral epidural lymphoma: A case report and comprehensive review of literature

Key Clinical Message

Epidural lymphoma of the lumbosacral region is a rare condition that manifests with back pain and nonspecific neurological symptoms. Our case which was diagnosed with diffuse large B-cell lymphoma, highlights the importance of recognizing early lymphoma symptoms to enable timely treatment and improved outcomes.

Abstract

Lymphoma rarely presents in the lumbosacral epidural space. Initial presentations of lymphoma are of paramount importance in the timely diagnosis and management of the disease. We report a 42-year-old woman presented with 4 years of low back pain and progressive right lower extremity paresthesia. Lumbar MRI revealed an epidural soft tissue lesion compressing nerves at L4 to the coccyx. Laminectomy and tumor resection were performed. Pathologic findings confirmed diffuse large B-cell lymphoma. We systematically reviewed the literature on lymphomas with lumbar epidural space involvement reported since 1990. Twenty-four cases from 19 reports were identified. The mean age of lumbar epidural lymphoma cases was 39.5 ± 17.8 years, and 72% were male. The most common subtype was diffuse large B-cell lymphoma, and common presentations included back pain, lower extremity neurological deficits, and bowel/bladder dysfunction. Overall, lymphomas presenting in the spine can pose diagnostic challenges owing to nonspecific initial symptoms. Our case highlights the importance of recognizing early lymphoma symptoms to enable timely treatment and improved outcomes.

Primary epidural sporadic Burkitt lymphoma in a 3-year-old: Case report and literature review

Background:

Burkitt lymphoma (BL) is a common tumor of childhood that usually arises in the abdomen or pelvis in its sporadic form. In a minority of cases, BL can present with CNS involvement, usually as a secondary site. Rarely, BL can arise primarily in the epidural space and present with back pain, or less commonly, acute myelopathy. This presentation is a surgical emergency and requires vigilant management.

Case Description:

We describe a case of pediatric BL arising primarily within the epidural space and presenting with progressive difficulty walking in a 3-year-old boy. Progression to complete inability to walk, absent lower extremity deep tendon reflexes, and new urinary incontinence prompted MRI of the spine, which showed a lesion extending from T5 to T10 and wrapping around the anterior and posterior portions of the spine with evidence of spinal cord compression. The patient underwent decompressive laminectomies from T5 to T10 and partial debulking of the posterior portions of the tumor. Microscopic examination showed a prominent “starry sky” pattern with abundant mitotic figures. Immunohistochemistry confirmed the diagnosis of BL. The patient is 10 months post-op and continues to undergo chemotherapy with partial neurologic improvement. He was free of recurrence 10 months post-operative.

Conclusion:

This appears to be the youngest described patient presenting with acute myelopathy in primary paraspinal BL. Management should include surgical decompression of the spinal cord followed by one of the various described chemotherapeutic regimens. Preoperative staging and neurologic function correlate with prognosis.

Spinal Burkitt's Lymphoma Mimicking Dumbbell Shape Neurogenic Tumor: A Case Report and Review of the Literature

Non-Hodgkin's lymphoma (NHL), a disease which may involve the spine, is frequently associated with advanced disease. Radiculopathy caused by spinal root compression as the initial presentation in patients with NHL is very rare and thought to occur in less than 5% of cases. A 69-year-old woman complained of a history of low back pain with right sciatica for 1 month prior to admission. Computed tomography and magnetic resonance imaging of the lumbar spine showed a dumbbell-shape epidural mass lesion extending from L2 to L3, which was suggestive of a neurogenic tumor. After paraspinal approach and L2 lower half partial hemilaminectomy, total excision of the tumor was achieved, followed by rapid improvement of back pain and radiating pain. The lesion was confirmed to be Burkitt's lymphoma by histopathological examination. We then checked whole-body PET-CT, which showed multifocal malignant lesions in the intestine, liver, bone and left supraclavicular lymph node. Although a rare situation, Burkitt's lymphoma should be considered in the differential diagnosis for patients presenting with back and lumbar radicular pain without a prior history of malignancy. Burkitt's lymphoma could be the cause of dumbbell-shape spinal tumor.

Leukapheresis and low-dose chemotherapy do not reduce early mortality in acute myeloid leukemia hyperleukocytosis: a systematic review and meta-analysis

The role of leukapheresis and low-dose chemotherapy is unclear in decreasing early mortality in acute myeloid leukemia (AML) patients with hyperleukocytosis. This systematic review was conducted to describe early mortality (deaths during first induction) in patients with AML with an initial white blood count≥100×10(9)L(-1) stratified by the approach to leukapheresis and hydroxyurea/low-dose chemotherapy. Twenty-one studies were included. Weighted mean early deaths rate (20 studies, 1354 patients) was 20.1% (95% confidence interval 15.0-25.1). Neither leukapheresis strategy (p=0.67) nor hydroxyurea/low-dose chemotherapy (p=0.23) influenced the early death rate. Early mortality related to hyperleukocytosis in AML is not influenced by universal or selected use of leukapheresis or hydroxyurea/low-dose chemotherapy.

Spinal compression due to Burkitt lymphoma in a newly diagnosed HIV-infected child

We describe a newly diagnosed HIV-infected child, without prior history of AIDS-defining disease, who presented with Burkitt lymphoma-related cauda equina syndrome that rapidly progressed to a flaccid paraplegia. Diagnosis was confirmed on biopsy and magnetic resonance imaging of the spine showed multiple epidural masses with involvement of several vertebral bodies, cord edema and compression of the cord and cauda equina. The child's immune status was relatively preserved and Epstein-Barr serology proved negative. Chemotherapy (LMB 89 modified protocol) was initiated immediately after histopathologic confirmation, together with highly active antiretroviral therapy. A follow-up magnetic resonance imaging 6 weeks later showed segmental cord atrophy at the site of previous edema despite complete resolution of all the epidural masses. Unfortunately, the child's neurologic state did not improve beyond the recovery of sphincter control and lower limb sensation. The patient is the first reported case of Burkitt lymphoma-related spinal cord compression as an initial AIDS-defining illness, in a 10-year-old child. The outcome of the case highlights the importance of early diagnosis and prompt treatment of this aggressive tumor to avoid permanent neurologic deficits.

Paravertebral malignant tumors of childhood: analysis of 28 pediatric patients

PURPOSE

To evaluate the clinical features and treatment results of the primary paravertebral malignant tumors (PMTs) in our department.

METHODS

Medical records of 28 children with primary PMTs treated between 1988-2007 were analyzed retrospectively.

RESULTS

Primary PMTs constituted 4.8% of the cancer cases in our department. Tumor diagnoses were mostly neuroblastoma (46.4%) and soft tissue sarcomas (35.7%). These cases presented with pain (64.3%), motor dysfunction (42.8%), sphincter dysfunction (35.7%), palpable mass (32.1%), and sensory deficits (7.1%). All tumors were extradural. Physical examination revealed motor deficits (53.6%), deep tendon reflex alterations (53.6%), sphincter dysfunction (35.7%), pathologic reflexes (25%), abnormal cutaneous reflexes (25%), and sensory deficits (17.8%). Sixteen had cord compression (CC; 13 clinical, three radiological CC). Eleven of them presented with advanced disease. Seven were managed by surgical departments by primary surgery (three unresponsive). Others were managed by pediatric oncology: five with corticosteroids+/-chemotherapy (one unresponsive), one with radiotherapy (RT), and two with surgery for the clinical CC. Surgery was tumor excision in nine, laminectomy in nine, laminotomy in one, and delayed surgery after chemotherapy in two cases. In chemotherapy and surgery groups, there were neurologic sequela associated with the advanced disease at diagnosis in 38% and 37%, respectively. At 3-year median follow-up, nine patients died, 17 are alive (four with neurologic sequela), and two are lost of follow-up.

CONCLUSION

Majority of cases presented with advanced disease. Late referral is the major cause of morbidity and mortality. The CC caused by PMTs should be initially managed with corticosteroids +/- chemotherapy to avoid the adverse late effects of RT and surgery.

Diagnosis and Treatment of Central Nervous System Involvement in Non-Hodgkin's Lymphoma

The diagnosis of lymphoma of the central nervous system (CNS) has been facilitated by advances in neuroimaging and laboratory analysis of cerebrospinal fluid. The most common form of central nervous system CNS involvement in non-Hodgkin's lymphoma (NHL) is leptomeningeal disease. After a diagnosis is established, the use of intrathecal or systemic chemotherapy and radiotherapy can improve survival and palliate symptoms. High-dose systemic chemotherapy with hematopoietic stem cell transplantation is an important treatment option at central nervous system relapse of NHL and for primary CNS lymphoma. The prognosis for disease-free survival and cure is better for patients who have treatment of CNS disease before transplantation than for patients who have active central nervous system disease at the time of transplant.

Clinical trials and evidence-based medicine for metastatic spine disease

Treatment of metastatic epidural spinal disease has undergone significant changes over the last 20 years. No longer is indiscriminate decompressive laminectomy offered as the only surgical treatment. It carries all the risks associated with an invasive procedure and offers the patient little benefit unless it is used to remove disease isolated to the posterior elements. The existing literature suggests that surgery that frees the spinal cord at the site of compression in addition to reconstructing and stabilizing the spinal column is more effective at preserving and regaining neural function, notably ambulatory function and sphincter function, than conventional radiotherapy. It is also highly effective in relieving pain. The preliminary results ofa recent RCT provide the first class I evidence to support a reversal in the current philosophy of primary treatment for many patients with meta-static disease. Conventional radiotherapy has a clearly defined role as adjuvant therapy and as primary therapy in those who are unable to tolerate or benefit significantly from surgery. The role of nonconventional radiation therapy, such as IMRT and SRS, remains to be elucidated.