Radiation therapy for intracranial lymphoma

The Role of Radiation Therapy in the Management of Primary Non-Hodgkin Lymphomas of the Central Nervous System: Clinical Study of 10 Cases

A series of 10 patients with a primary non-Hodgkin lymphoma of the central nervous system were observed and treated by the authors. All were diagnosed after a pathologic examination of the surgical material; the lesions were supratentorial in all cases and unifocal in 9. In every case radiation therapy improved clinical conditions and in most cases even radiologic features of the patients. Four patients were alive and without evidence of disease many months after therapy. Four patients died with a relapse in the central nervous system; 3 of them had disseminated disease at the time of death. Two patients died for an unknown cause. Radiation therapy was performed with 60Co source with 2 opposed portals and the whole brain irradiation technique in all cases but 2. Doses ranged from 35 to 54 Gy. The recent literature on this uncommon disease and the most adequate therapeutic possibilities of radiation therapy and chemotherapy, or both, are discussed.

Primary Lymphomas of the Brain: A Clinico-Pathologic Review of 37 Cases

The clinico-pathologic data of 37 primary lymphomas of the brain were retrospectively reviewed. The tumors were classified according to the Kiel classification and the Working Formulation System. They represented 1.02% of all primary intracranial tumors of our series. The radiologic prediction appeared to be difficult: the suspicion was maximal when the absence of pathologic vessels at angiography occurred in a meningioma-like lesion at CT. Median survival was 4.53 months in the 16 cases who underwent surgery only versus 25.7 months in the 8 cases operated and irradiated with 40-60 Gy (p < 0.01). The prognosis of lymphomas of the CNS, even if radioresponsive tumors, remains poor. Most patients relapse after treatment, most often locally in the brain, with a variable frequency of spinal or systemic localization.

Variations in the presentation of primary intraocular lymphoma: case reports and a review

Primary intraocular lymphoma is a distinct subset of primary non-Hodgkin's lymphoma of the central nervous system (CNS). Diagnosis can be difficult and is often delayed, as the clinical presentation can mimic a number of other ocular conditions. This report describes four different presentations of intraocular lymphoma and focuses on its modes of clinical presentation. Primary intraocular lymphoma can present with a wide variety of manifestations frequently mimicking diffuse uveitis that is refractory to corticosteroids. Subretinal pigment epithelium tumors may be seen. However, other presentations may include multiple deep white dots in the retina secondary to tumor infiltration; retinal infiltration, causing a necrotizing retinitis; or infiltration of the retinal vasculature, causing arterial or venous obstruction. Finally, optic nerve invasion may be seen. CNS lymphoma develops in the majority of patients before, in conjunction with, or after the development of eye disease. Intraocular lymphoma often has a fatal outcome, but recognition of its modes of presentation facilitates early diagnosis and treatment that may improve prognosis.

Intracranial malignant lymphomas: clinicopathological study of 26 autopsy cases

We examined 26 autopsy-proven cases of intracranial malignant lymphoma (IML) in immunocompetent patients to determine the extent of neoplastic involvement of the central nervous system (CNS) and to evaluate the effects of radiation on the tumor and brain tissue. All tumors were identified as diffuse non-Hodgkin's lymphomas of B-cell origin. In six patients who had not received radiotherapy, the clinical course of the disease was short and extensive infiltration of the tumor was seen. The remaining 20 patients were treated with radiotherapy and had a longer survival time. Leptomeningeal involvement was common, but extensive subarachnoid proliferation of the tumor was seen in only two cases. The posterior, but not anterior, lobe of the pituitary was involved in 5 of 22 cases, and choroid plexus involvement was seen in 4 of 21. Direct invasion of the tumor into the spinal cord, which tended to occur in patients with posterior fossa masses, was observed in 5 of 21 cases. Following irradiation, coagulation necrosis was frequently found in the invading zone as well as in the tumor mass, and degeneration of the white matter was also seen. We suggest that IML can extensively infiltrate into the CNS, including the posterior lobe of the pituitary and spinal cord, and that radiation injury to the brain appears to occur relatively easily in this disease.

Radiotherapy in the treatment of primary central nervous system lymphoma (PCNSL)

The use of radiotherapy alone to treat primary central nervous system lymphoma (PCNSL) does not produce the high local control and survival rates that it does in limited extranodal non-Hodgkin's lymphoma outside the central nervous system (CNS). Even with doses of whole brain radiation therapy (WBRT) to 40+20 Gy boost, the Radiation Therapy Oncology Group (RTOG) reported a local control rate of 39%. Seventy-nine percent of recurrences were in the 60 Gy region. The median survival was 11.6 months. This response to local radiotherapy is quite different from the response of non-CNS Diffuse Large Cell Lymphoma where doses of 30-40 and >40 Gy have a 75-90% local control rate. Neither systemic lymphoma nor PCNSL have a classic radiotherapy dose response. For PCNSL there appears to be a threshold dose that ranges in the literature between 30 and > 50 Gy with a median of 40 Gy. Therefore, when radiotherapy is combined with chemotherapy that crosses the BBB, WBRT and/or boost doses may be able to be decreased, especially in patients achieving a complete response. Promising data from the Centre Leon Berard suggest that this is possible. When such chemotherapy was combined with intrathecal chemotherapy and 20 Gy WBRT, they obtained a 56% actuarial 5 year survival rate. Confirmation of single institution reports of favorable results such as these are needed. Cooperative group and intergroup trials are needed to define optimal therapy.

[Radiotherapy in primary cerebral lymphoma]

Primary cerebral lymphoma is a rare disease with an unfavorable prognosis. Whole brain radiotherapy has been the standard treatment, but neither the optimal radiation fields nor optimal dose level of the regimen are as yet firmly established. From this review of the literature, it seems that the whole brain must be treated, and a boost to the area of the primary site must be discussed. With regard to dose, the radiation dose-response relationship is not clearly proven. Yet, a minimum dose of 40 Gy is necessary, and the maximum dose is set at 50 Gy because of late neurological sequelae. Because of the poor prognosis of this disease and the risk of late sequelaes, other avenues have been explored. Chemotherapy has been studied, seem to have a survival advantage and combinations of radiotherapy and chemotherapy, especially with high-dose methotrexate. Because primary cerebral lymphoma is an uncommon disease, randomized clinical trials that compare radiotherapy alone to chemotherapy plus radiotherapy may not be feasible. Finally, even if chemotherapy seems to have a survival advantage, the regimen of chemotherapy is still a matter of debate.

Second-line treatment for primary central nervous system lymphoma

Failure after first-line treatment was reported in 35-60% of immunocompetent patients with primary central nervous system lymphoma (PCNSL). There are currently no reports focusing on salvage therapy. This review analyses prognostic factors and the efficacy of salvage therapy by focusing on data from papers reporting results of first-line treatment in 355 cases. The study group consisted of 173 patients presenting treatment failure. The interval between failure and death (TTD) was compared for age at relapse (< or =60 vs. >60 years), type of failure (relapse vs. progression), time to relapse (< or =12 vs. >12 months) and salvage treatment (yes vs no). Median TTD was similar in younger and older patients (P = 0.09). Relapsed patients had a longer TTD than patients with progressive disease (P = 0.002). Early relapse led to a shorter TTD than late relapse (P = 0.005). Median TTD was 14 months for patients who underwent salvage therapy and 2 months for untreated cases (P<0.00001). A multivariate analysis showed an independent prognostic role for salvage therapy and time to relapse. Age and type of failure had no predictive value. Salvage therapy significantly improves outcome and, possibly, quality of life. As many different treatments were used conclusions cannot be made regarding an optimal treatment schedule.

Therapeutic management of primary central nervous system lymphoma in immunocompetent patients: results of a critical review of the literature

BACKGROUND

The optimal treatment for primary central nervous system lymphomas (PCNSL) has not been defined.

PATIENTS AND METHODS

Therapeutic results of 1180 immunocompetent patients (pts) with PCNSL reported in 50 series published in English between 1980 and 1995 were analysed. The impact on survival of age, treatment strategy, radiation field and doses, systemic and intrathecal chemotherapy (CHT) and treatment sequence was evaluated.

RESULTS

Univariate analyses showed a longer survival in pts of < or = 60 years (P < 0.00001): pts treated with > 40 Gy to whole brain (WB) (P = 0.02): pts receiving > 50 Gy to the tumor bed after a WB dose > 40 Gy (P = 0.02): pts submitted to a combined treatment as opposed to CHT alone (P = 0.007) or radiotherapy alone (P < 0.00001): pts receiving CHT followed by radiotherapy rather than in the reverse sequence (P = 0.05); pts treated with high-dose methotrexate (HDMTX) (P = 0.04) and pts receiving intrathecal CHT (P = 0.03). Multivariate analysis confirmed the independent prognostic value of age, WB dose, HD-MTX and intrathecal CHT.

CONCLUSIONS

Current data confirm the prognostic value of age and appear to support the use of systemic CHT consisting of HD-MTX and intrathecal drug administration followed by 41-50 Gy to WB and > 50 Gy to the tumor bed in the treatment of PCNSL in immunocompetent pts.

Primary central nervous system lymphoma with systemic metastasis: case report and review

Primary central nervous system lymphoma (PCNSL) almost always remains confined to the nervous system. We report a patient with well documented PCNSL who responded to treatment, but subsequently developed pathologically confirmed systemic metastases without repeated local failure 35 months after initial diagnosis. In a review of the world's literature we identified 5 other cases of PCNSL with histologically confirmed antemortem systemic metastases and a total of 62 cases of central nervous system (CNS) lymphoma in some way associated with extraneural lymphoma. These cases are classified and discussed. Clinicians caring for PCNSL patients must remain alert to the possibility of systemic metastasis, especially as local control of PCNSL improves.

Primary central nervous system lymphoma in Japan--a retrospective, co-operative study by CNS-Lymphoma Study Group in Japan

This manuscript reports the results of the first cooperative study on primary central nervous system lymphoma (PCNSL) in Japan. Of 196 patients registered, 170 were judged as having PCNSL. No patients were immunocompromised. Of the 170 patients with PCNSL, 93 were males and 77 were females. The mean was 56.7 years. One hundred and nineteen tumors were confirmed histopathologically, and 51 were diagnosed by neuroimaging alone. All the tumors were non-Hodgkin's lymphoma. According to the Working Formulation for Clinical Usage (WF), 96 out of 119 tumors were classifiable: 53 were diffuse large cell type (55.2%), 17 immunoblastic type (17.7%), 9 diffuse small cleaved type (9.4%), 6 diffuse mixed type (6.3%), 5 polymorphous type (5.2%), 5 small lymphocytic type (5.2%) and 1 small non-cleaved type (1.0%). Of 21 tumors studied immunohistochemically, 18 were B-cell type and 3 were T-cell type. Irradiated patients (144) survived significantly longer than non-irradiated patients, (median survival time, MST: 19.2 and 2.7 months, respectively; p < 0.001). There was a remarkable difference in survival among patients of the intermediate lymphomas; MST (18 months) of patients with large cell lymphoma was significantly shorter than MST (over 96 months) of patients with other intermediate grade lymphomas (small cleaved and mixed) (p < 0.001) and had no significant difference from MST (9 months) of patients with high grade lymphomas. If patients were irradiated with more than 40 Gy, higher doses and different modes of irradiation brought no further survival advantage. Chemotherapy was performed in 87 of 144 irradiated patients (60.4%). No regimens were effective in prolonging survival. Of 144 irradiated patients, a complete or partial response to initial treatment was demonstrated in 91 (63.2%) and 43 patients (29.9%), respectively. Improvement in performance status was confirmed in 82 patients (57.0%). Despite a good response to initial treatments, 88 out of 144 evaluatble patients have died of PCNSL (MST: 19 months). Multivariate analysis based on the Cox hazard model revealed that histology of tumor, age at onset, performance status, and radiotherapy were prognostic factors. Neither chemotherapy nor mode of surgery was a beneficial factor.

A multivariate analysis of prognostic factors in management of pineal tumor

PURPOSE

A multivariate analysis of prognostic factors of treatment outcome of pineal tumor.

METHODS AND MATERIALS

From February 1979 to June 1987, 25 patients with primary pineal tumors were treated in our department. Patients were treated with either AECL Co-60 unit or 10 MV linear accelerator to the primary tumor with an adequate margin or to the whole brain (median dose of 36 Gy) with or without a cone-down boost of 10 to 20 Gy. Craniospinal irradiation was performed in two patients with positive CSF cytology. Minimum follow-up was 40 months. Patients were further stratified according to tumor type. Group I consisted of seven patients with pineal germinoma. Group II included nine patients with nongerminoma, and Group III represented nine patients treated without a histological verification but clinical diagnosis.

RESULTS

The relapse-free survival (RFS) of Group I patients was 100% and 86% at 2 and 5 years, respectively. Relapse-free survival was 55% and 21% at 2 and 5 years, respectively, for Group II patients. Six of 9 patients in Group II died of disease due to either local recurrence or tumor seeding. Eight of 9 patients in Group III remain no evidence of disease, and RFS was 89% at 2 and 5 years. Multivariate analysis revealed that tumor histology is the only significant prognosticator. Age, gender, type of surgical procedure, RT field, and tumor dose were not. Cox's regression model also failed to demonstrate a significant correlation of tumor seeding with the type of surgery.

CONCLUSION

The type of tumors in the pineal region dictates the treatment outcome. Definitive radiation therapy is effective in controlling germinoma, whereas a more aggressive approach is needed to improve local control for nongerminoma. For a localized pineal lesion, we advocate that treatment can be tailored to the primary tumor with adequate margins. However, for locally advanced tumors whole brain or craniospinal irradiation should be considered. No definitive correlation between type of surgery and the probability of tumor seeding was identified.

What's new in primary central nervous system lymphomas?

Primary central nervous system lymphomas (CNSL) are uncommon neoplasms accounting for about 1% of primary brain tumors. Patients with congenital or acquired immunodeficiencies including AIDS patients and transplant recipients represent the main high-risk population for CNSL occurrence. An important point emerging from the literature is that CNSL incidence has dramatically increased during the last years not only in HIV infected patients by virtue of the AIDS epidemic spread, but also for unclear reasons in immunologically normal persons. Although c-myc oncogene activation and Epstein-Barr virus infection are considered to play a role in CNSL development, the peculiar tendency of these lymphomas to occur and remain inside the CNS is not well understood and may involve putative CNS binding molecules carried by lymphocytes. The clinical presentation is characterized by a great variety of neurological disorders. Radiological features consist of hyperdense homogeneous deposits within the subcortical white matter with a pattern of marked enhancement after injection of contrast material. The tumor masses are usually ill-defined and multicentric. Although all cytological types can be observed, the most common types belong to the high-grade category of non-Hodgkin's lymphoma. Monoclonal antibodies reactive with formalin-fixed, paraffin-embedded sections can be used in conjunction with stereotactic needle biopsy to provide accurate immunological characterization of CNSL. The large majority of CNSL is of B-cell origin but T-cell lymphomas seem at the present time less exceptional than previously thought. Although radiotherapy and chemotherapy can increase length of survival, the prognosis of CNS remains dramatically poor, the shortest survival being observed in AIDS patients.

Primary intracranial lymphomas

We present 20 cases of primary intracranial lymphoma and review the most important published series on this subject. The clinical patterns and the differential diagnosis from other intracranial space-occupying lesions on the CT and angiographic evidence are discussed. Surgical treatment was given in 19 of our cases, followed in 17 cases by radiotherapy and in 4 by chemotherapy. One patient was treated by a ventriculo-peritoneal shunt. The effectiveness of the various modalities of treatment is discussed in the light of survival.

Primary central nervous system lymphoma in AIDS. Results of radiation therapy

Primary central nervous system (CNS) lymphoma is one of the clinical presentations of the acquired immune deficiency syndrome (AIDS). Ten patients had biopsy-proven high-grade lymphomas that were confirmed by further staging as limited to the CNS. All ten patients received cranial irradiation (total dose, 2200 to 5000 cGy). Six patients demonstrated complete response (CR) of the intracranial masses at the time of repeat computed tomography (CT) scan, whereas one attained a partial response (PR). Two of the CR patients died of multiple opportunistic infections, two experienced relapse of lymphoma, and died at 7 and 16 months from diagnosis, and two were alive without evidence of disease at 8 and 14 months from diagnosis. The median survival of the whole group was 5.5 months (range, 2 to 16 months). Patients with AIDS-related primary CNS lymphoma may respond to radiation treatment; however, response duration is usually short, and survival is influenced by refractory disease or systemic opportunistic infections.

Prognostic factors in the diagnosis and treatment of primary central nervous system lymphoma

The authors describe the results of multimodality therapy in 27 patients with biopsy-proven primary central nervous system (CNS) lymphoma treated between 1976 and 1986. Treatment included surgical resection (15 patients), radiotherapy (27 patients), and chemotherapy (nine patients). Actuarial survival rates for the 27 patients at 1, 2, and 5 years after diagnosis were 70%, 54%, and 45%, respectively. Nine patients were recurrence-free at 8 to 106 months follow-up. A multivariate risk analysis identified five factors which had a favorable impact on survival: (1) age less than 60 years (P less than 0.02); (2) preoperative Karnofsky performance score greater than or equal to 70 (P less than 0.02); (3) presence of strictly hemispheric tumor (P less than 0.0003); (4) whole-brain radiation dose between 4000 and 5000 cGy (P less than 0.05); and (5) addition of chemotherapy to radiotherapy (P less than 0.002). Patients with complete tumor resolution on computed tomography 6 months after beginning treatment also had longer survival (P less than 0.01). The presence of malignant cells on cerebrospinal fluid cytologic examination correlated with an increased risk of distant metastasis (P less than 0.05). In those patients whose disease eventually recurred, the administration of an additional therapeutic modality significantly increased the length of postrecurrence survival (P less than 0.05). Although surgical resection provided no increase in survival, the addition of chemotherapy to postoperative cranial irradiation significantly enhanced the duration of survival. Our experience suggests that pretreatment clinical and diagnostic factors can help in predicting survival and in planning treatment.

Primary malignant lymphoma of the central nervous system. Results of treatment of 11 cases and review of the literature

Eleven patients with primary malignant lymphoma of the central nervous system (CNS) were treated at the Medical College of Wisconsin Affiliated Hospitals between 1964 and 1984. Three patients had a prior history of immunosuppressive therapy following renal transplantation. All patients had biopsy-proven disease and 10 of the 11 were treated with external radiation therapy. The doses to the primary tumor ranged from 34 to 59.4 Gray (Gy). Actuarial (life-table) survival rate was 82% at 1 year and 43% at 3 years. No recurrence was seen after 13 months. Eighty-six reports totaling 693 cases of primary malignant lymphoma of the CNS were found in the literature. Of these, 308 cases were treated with a combination of surgery and irradiation. Overall survival at 5 years for those patients who received more than 50 Gy compared with less than 50 Gy to the primary tumor was 42.3% versus 12.8% (p less than 0.05). Twenty-one patients survived longer than 5 years. Late relapse was notable, with 10 (47.6%) of 21 tumors recurring between 5 and 12.5 years after diagnosis. Based on this review, a minimum of 50 Gy radiation to the primary tumor is recommended. While no statement regarding the efficacy of craniospinal irradiation or chemotherapy can be made in view of the small numbers, the use of craniospinal irradiation and/or systemic chemotherapy should be considered for future trials.

Intracranial malignant lymphoma. Report of 30 cases and review of the literature

Although primary malignant lymphoma is a rare entity in the gamut of intracranial tumors, it is more frequently seen than the secondary intracranial spread of a primary extracranial lymphoma. In general, the occurrence of lymphomas seems to be provoked by immunosuppression, as with medication (predominantly after transplantation) or with immunodepressive disease such as acquired immunodeficiency syndrome (AIDS). The usual age of onset of this disease is 55 to 65 years; and the male:female patient distribution is roughly 2:1. Characteristically, computerized tomography (CT) scans of lymphomas show a mass which is often large with regular contours, moderate mass effect, and hyper- or isodensity with marked and often homogeneous enhancement. In the series of 30 patients reported, the locations of lesions, in order of decreasing frequency, were the frontocallosal and temporal regions, the basal ganglia, and the cerebellum. Multiple lesions were present in 15% of these cases (20% to 40% in the literature). The following features should raise the suspicion of intracranial lymphoma: mirror lesions of the basal ganglia, bilateral subependymal infiltration, and leptomeningeal involvement contiguous with an intracerebral mass. According to the literature, the angiographic finding typical of lymphoma is an avascular tumor. A blush or vascular encasement of the mass seems to be rare, and the present series was in accordance with other reports in this respect. Differential diagnostic consideration should include meningioma, glioblastoma, metastatic disease, and focal infectious lesions such as toxoplasmosis or multifocal progressive leukoencephalitis, particularly in immunodepressed subjects. Diagnosing lymphoma from CT scans offers the alternative of substituting stereotaxic biopsy and neuropathological diagnosis for the more aggressive open surgical approach, since radiation therapy and possibly chemotherapy usually prove to be the treatment of choice.

Primary lymphoma of the central nervous system: a clinicopathologic analysis of 26 cases

We analyzed 26 cases of primary lymphoma of the central nervous system. There were 14 males and 12 females ranging in age from 5-76 years (median age 51 years, mean age 50.2 years). None had received organ transplantation or immunosuppressive therapy. The most common presenting symptoms were headache, mental changes, nausea, vomiting, and convulsions. The main neurological findings were hemiparesis, papilledema, visual field defects, and cranial nerve palsies. The most common finding in the cerebrospinal fluid (CSF) was high protein content; CSF cytology was positive in only one case. Computerized tomography was done in 14 cases; all showed a contrast-enhancing lesion. Angiography generally revealed an avascular mass. The most common location above tentorium was the frontal lobe; in four cases the tumor was infratentorial (cerebellum, 3 cases). In five cases there was diffuse involvement of the brain; all had severe dementia and diagnosis was not made until the autopsy. Histologically, the most common type was diffuse histiocytic or immunoblastic lymphoma according to Rappaport and the Working Formulation classification respectively. Radiation therapy alone in five patients gave a median survival of 17 months. Five patients received radiation and chemotherapy, and median survival was 16 months. Two patients developed ocular lymphoma 8 and 36 months later that was treated by radiation.

Primary malignant lymphoma of the central nervous system

Between 1960 and 1983, 19 patients with primary malignant lymphoma of the central nervous system (CNS) were seen at McGill University Hospitals. The diagnosis was made at autopsy in 3 patients, and by biopsy in 16. Results of treatment were poor. All four patient who underwent surgery alone died within 2 months of diagnosis. Of 12 patients who underwent surgery and postoperative radiotherapy, 11 died between 2 and 56 months (median, 12 months) following diagnosis, and one is alive with disease at 47 months. Patterns of involvement at first recurrence and/or at autopsy were analyzed for 13 patients. Failure at the original site of involvement was unusual after treatment consisting of surgery and radiotherapy. In contrast, failure in the brain at sites other than those originally involved was common in spite of the use of whole brain irradiation. Local leptomeningeal involvement was seen in one patient whose diagnosis was made at autopsy, and cerebral spinal fluid seeding was seen in two additional patients, one within 1 month of diagnosis and one at relapse at 6 months after diagnosis. No patient developed disease outside the CNS. The limitations of current therapy for this disease are discussed, and certain suggestions made regarding the management of future patients with this diagnosis.

Primary non-Hodgkin's lymphomas of the CNS

This paper reports on 10 patients (4 male, 6 female) with primary non-Hodgkin's lymphomas of the brain (CNS-NHL--mean age 46.8 years, mean postdiagnostic survival 10 months). Pathological CSF (cerebrospinal fluid) was found in all 8 patients examined (positive cytology in 7/8 cases). Solitary tumors, diffuse periventricular infiltration or diffuse cerebral infiltration were demonstrated in cerebral computer-assisted tomography (CAT). Angiographical findings were unspecific. The histologic subtypes were lymphoplasmacytoid immunocytoma (4), unclassified low grade (1), centroblastic (1), B-immunoblastic (1), T-immunoblastic (1), lymphoblastic convoluted T-cell type (1), unclassified high grade (1) NHL. Patients who had received radiotherapy (+/- surgery) in this group had a mean survival of 15.66 months (sigma = 7.63). In addition, an overview of 83 well-documented, cases of the literature tries to characterize main histological and topographical distributions, histology-, patient's age-, and therapy-related survival. Patients with primary CNS-NHL have a 5-year survival expectancy of 30% compared with 2.3% in secondary CNS-manifestations of systemic non-Hodgkin's lymphomas. In this report, the beneficial effect of radiotherapy (mean survival 30.3 months) compared to surgery or symptomatic treatment (3.6 or 3.3 months) could be confirmed. It is concluded that primary CNS-NHL frequently present with atypical neuropsychiatric syndromes; diagnosis should be established preferentially with CAT and CSF-examinations or stereotactic biopsies, whereas open surgery should be avoided. An approach to exact classification should be attempted, as survival is clearly related to histological subtypes.

Primary lymphoma of the central nervous system: Manitoba experience and literature review

We describe eight cases of primary cerebral lymphoma seen in Manitoba from 1980 to 1985. The clinical presentation is similar to other primary brain tumors. The diagnosis should be considered when single or multiple, often deep lesions, show dense enhancement on computerized tomographic (CT) scan, but are avascular at angiography. These tumors are histologically indistinguishable from non-Hodgkins lymphomas arising outside the CNS. The prognosis is poor. However, radiotherapy with or without surgery may offer significant palliation. Although there is no consensus on the value of chemotherapy, corticosteroids alone or multiagent chemotherapy have shown promise in a few cases. For these reasons, histologic diagnosis should be sought in all cases and surgery, radiotherapy, and chemotherapy should be considered, as prolonged survival is possible.

Radiation therapy of primary malignant lymphoma of the brain

Primary malignant lymphoma of the brain (PMLB) is uncommon. Between 1975 and 1982, the authors observed 11 patients with histologically confirmed PMLB. Mean survival after radiation therapy was 7 months with 5 patients surviving for more than 2 years. Multifocal lesions were seen in 9 patients and spontaneous regression was seen at computed tomography in 2 patients. Radiation doses in excess of 30 Gy controlled the primary tumor, but intracranial recurrences occurred even after whole brain irradiation to 40 Gy. Only one patient had a relapse outside the central nervous system, and none had clinical evidence of seeding to the spinal canal. The authors postulate that PMLB usually is a multifocal intracranial disease, and that whole brain irradiation of at least 30 to 40 Gy should be given to all patients with this disease.

Successful non-neurotoxic therapy (without radiation) of a multifocal primary brain lymphoma with a methotrexate, vincristine, and BCNU protocol (DEMOB)

A 3.5-year-old boy with a multifocal primary lymphoma of the brain was treated successfully without neurotoxicity with a treatment regimen that did not include radiation. The protocol of Dexacort (dexamethasone), methotrexate, Oncovin (vincristine), and BCNU (carmustine) (DEMOB), which was developed with the use of MTX pharmacokinetic studies, was given over 7.5 months, and resulted in tumor disappearance on computerized tomography scans and marked improvement in clinical status. The patient remains in good health 3 years after diagnosis (March 1985).

Primary central nervous system lymphoma

A retrospective analysis of 21 cases of primary central nervous system (CNS) lymphoma is reported. All patients presented with a solitary mass in the supratentorial region. None had previously received immunosuppressive therapy. Neuroradiological studies included technetium-99m-pertechnetate brain scanning in eight cases, cerebral arteriography in all 21 cases, and computerized tomography (CT) in 14 cases. The characteristic features were increased uptake in brain scans, mass effect in arteriograms, and marked contrast enhancement on CT scans. Abnormal tumor vessels were occasionally seen on arteriography, and subtraction films were usually required to appreciate tumor stain. All patients underwent craniotomy, and histological studies of the tumors showed a diffuse type of lymphoma in all cases. Immunoglobulin testing was performed in 19 cases and a monoclonal spike was verified in 10, suggesting a B cell origin. All patients were followed until their death except one who was still alive 12 months from onset of symptoms. Therapy included subtotal resection in all 21 cases, whole-brain irradiation in six cases, chemotherapy in two cases, and a combination of whole-brain irradiation and chemotherapy in nine cases. Three different forms of chemotherapy were used. The results suggest that chemotherapy is an important addition to subtotal resection and whole-brain irradiation in the treatment of primary CNS lymphoma.

Primary intracranial lymphomas

We reviewed the cases of 16 patients with primary intracranial lymphomas. The clinical and radiological data proved to be helpful in suggesting the diagnosis, but only tumoral biopsy provided unequivocal diagnosis. In our cases radiotherapy proved to be the most effective treatment.

Intracerebral lymphoma deposits: investigation and treatment

In a recently studied series of 12 patients with intracerebral lymphoma deposits, the following are noteworthy: Although most intracerebral lymphoma deposits are dramatically and homogenously enhanced on CT brain scan, this is not always the case; two patients with apparently necrotic centers are presented. Subtraction of enhanced CT brain scanning cuts before and after radiotherapy allow a quantitation of tumor response. The apparent paradox of deficient lymphoma deposit angiogenesis on angiography and good enhancement on CT scan was probed by positron emission tomography (ECAT) in the only patient who did not have a confounding prior craniotomy. ECAT and histopathological examination suggest that the microvasculature of intracerebral lymphoma deposits is rich. The ECAT data demonstrated that regional tumor blood flow was comparable to that in grey matter, but tumor oxygen metabolism was intermediate between grey and white matter. The interesting observation of coupled depression of cerebral blood flow and oxygen metabolism in the cerebrum overlying the tumor and its surrounding edema is discussed. A protracted radiotherapy prescription (with daily fractions of 175 cGy) is favored.

Primary lymphoma of the central nervous system. Clinicopathological study of experience at Stanford

The authors present 22 cases of primary lymphoma of the central nervous system (CNS) from Stanford University Medical Center. Fifteen other published series comprising 400 patients with this disease are also reviewed. Males were affected more often than females. The majority of patients were in the sixth decade of life. The most common presenting symptoms were headache, nausea, vomiting, and mental status changes. The most common presenting signs were hemiparesis and papilledema. An elevated protein concentration was the most common cerebrospinal fluid (CSF) abnormality. The CSF cytology was rarely positive prior to surgery. If a mass was seen on computerized tomography, it always enhanced with infusion of contrast material. On angiography, the tumor was generally seen as an avascular mass. The most and least common sites of involvement supratentorially were the frontal and occipital lobes, respectively. Infratentorially, the cerebellum was most often involved. Histologically, the most common tissue type according to the Rappaport and Working Formulation systems were diffuse histiocytic lymphoma and immunoblastic lymphoma, respectively. Therapy primarily involved surgery for biopsy or subtotal resection and radiation therapy. The majority of patients died, and the median survival time of those dying was distinctly shorter than the follow-up period of those patients still alive. This difference in survival time suggests that primary CNS lymphoma consists of more than one disease group. Statistical analysis of our series showed those patients with either a diffuse mixed lymphoma histology or an infratentorial location of disease had a poorer prognosis. These two factors cannot totally account for the division of cases into separate survival-related groups.

Primary lymphoma of the central nervous system. Computerized tomography scan characteristics and treatment results for 12 cases

A retrospective analysis of 12 patients with primary central nervous system non-Hodgkin's lymphoma seen from 1958 to 1980 was carried out with emphasis on diagnostic evaluation and treatment results. Computerized tomography (CT) scans were found to be the most valuable diagnostic tool both for initial evaluation as well as follow-up. Characteristic CT scan features were identified and are discussed. Three patients had a history of previous immunosuppression; two had preceding and concurrent uveitis. Nine of the 12 patients were treated primarily with radiation therapy. Three patients were diagnosed at autopsy and had not received definitive therapy. Size of lesion proved to be the most important prognostic factor and appeared to be related to location. Gross total excision of tumor did not appear to improve survival. Two patients were alive with no evidence of disease at 38 and 48 months, respectively. Recurrences were noted from 1 to 33 months after diagnosis (median, 14 months), suggesting the advisability of long-term follow-up prior to presumption of cure. From these results and a review of the literature, possible treatment approaches are presented.

Primary non-Hodgkin's lymphoma of the central nervous system. Results of radiotherapy in 15 cases

Primary non-Hodgkin's lymphoma (NHL) of the central nervous system is a rare disease. The number of cases reported in the literature does not exceed 200. The current series comprises 15 cases of primary NHL of the CNS. In 12 cases material for pathology was obtained at surgery. In the other three cases the diagnosis was established by cytologic examination of the cerebrospinal fluid (CSF). The type of lymphoma was predominantly the diffuse lymphocytic type. All the patients received irradiation on the whole brain by means of two opposite lateral fields. The administered total doses were 40 Gy in four weeks in ten cases, 50 to 60 Gy in 5 to 6 weeks in four cases and 30 Gy in three weeks in one case. All but three patients are dead although initially a good tumor response was obtained as confirmed in most of the cases by CT scan. The mean survival of the dead patients was 14.5 months. No relationship was found between the administered dose and the relapse-free time. In six cases (40%) evidence of seeding was observed. Because of the poor results obtained with irradiation either of only the tumor bearing area or whole brain and because of the high risk of seeding through the CSF, the irradiation of the entire CNS is recommended in patients with primary NHL of the brain.

Primary lymphoma of the central nervous system

Primary intracranial lymphoma usually remains localized to the central nervous system, and aggressive radiotherapy will prolong some patients' remission and perhaps cure them. Although the lesion is usually believed to arise from histiocytes or reticulum cells, at least some of the neoplasms are of B-lymphocyte origin. Provisional diagnosis occasionally may be possible by identifying lymphoma cells in the cerebrospinal fluid by using the cytocentrifuge. The use of computed tomography of the head may decrease the need of arteriography for tumor localization.

Central nervous system involvement in non-Hodgkin's lymphoma: an analysis of 105 cases

Records of 105 patients with central nervous system (CNS) lymphoma were analyzed in order to better define the incidence, setting, and management of CNS lymphoma and the role for CNS prophylaxis. Survival was best for patient under 30 years of age treated with whole-brain irradiation and intrathecal (IT) chemotherapy whose CNS involvement was an isolated event (median survival time, 1.8 years). Survival was worst for patients over 30 years of age whose CNS invasion occurred at a time of progressive systemic lymphoma (median time ten weeks if treated with whole-brain irradiation with or without IT chemotherapy). The risk of CNS invasion was greatest for those with lymphoblastic lymphoma. Among patients with Stage IIE, III, or IV histiocytic lymphoma, the risk of CNS involvement was greatest for those with progressive or relapsing disease or involvement of the testes, peripheral blood, or epidural space of the spinal cord.

Computed tomographic appearances in microgliomatosis

The computed tomography (CT) appearances of 11 patients with microgliomatosis have been reviewed, and as a result it is possible to suggest that there may be typical features for the recognition of such tumours. In this series three fairly distinctive patterns were encountered. In view of their reputed response to radiotherapy, there is a strong case for making the diagnosis of such lesions, and CT has given the opportunity of alerting the surgeon and the pathologist to the likelihood of their presence at an early stage.

Radiation therapy treatment of stage I and II extranodal non-Hodgkin's lymphoma of the head and neck

We have reviewed the records of 76 patients with Stage I or II extranodal non-Hodgkin's lymphoma who were referred to the Division of Radiation Oncology, Mallinckrodt Institute of Radiology, during the years 1964 through 1974. The histologic slides were reviewed in the 67 cases in which they were available. Forty-three percent of Ann Arbor Stage I and II patients relapsed after primary radiation treatment.Seventy-three percent of these failed in sites distant from the irradiated volume. Failures in the treated volume were infrequent (7%) except in those patients presenting with primary lesions of the brain (4/5). Those patients presenting with lesions of Waldeyer's ring experienced a decrease in survival with increasing tumor size. Because of the high rate of failure in distant sites with tumors in the lingual and palatine tonsils, we are recommending the study of adjuvant chemotherapy in these cases, after primary radiation treatment.

The role of radiation therapy in the management of ocular reticulum cell sarcoma

Nine patients with ocular lymphomas were seen in the Department of Ophthalmology and the Division of Radiation Oncology at UCSF and Ralph K. Davies Medical Center, San Francisco, from 1978 through 1974. Six of the 9 patients had visual symptoms as the first manifestation of their disease. Eight of the 9 patients developed intracranial lymphoma at some time during the course of the disease. Despite lymphoma work-up including bone marrow biopsies and lymphangiogram, only 1 patient was found to have documented systemic involvement. The diagnosis of ocular lymphoma was based on pathologic material from the eye in 5 cases or from central nervous system biopsy in 4 patients in association with tumor cell infiltrates in the retina and vitreous clouding. Radiation therapy to the eyes improved vision in 10 of 13 eyes treated in 8 patients. The usual dose was in the range of 3500 to 4500 rads given over 4-5 weeks. In addition, 7 patients received central nervous system irradiation. Review of the literature reinforced the findings of this series showing the frequent association of ocular lymphoma with intracranial lymphoma and the rare systemic dissemination. This disease process has previously been referred to as ocular reticulum cell sarcoma.

Successful therapy with methotrexate of a multicentric mixed lymphoma of the central nervous system

Primary lymphoma of the central nervous system (CNS) is extremely rare. A case of mixed histiocytic lymphocytic lymphoma of the CNS that initially occurred in the spinal cord is reported. Multicentric recurrence following radiotherapy was successfully treated with intrathecal methotrexate and the patient remains free of disease after 4 years. The role of intrathecal methotrexate as alternative therapy following irradiation failure is discussed.

Reticulum cell sarcoma of the brain. A review of the literature and a study of 19 cases

Reticulum cell sarcoma of the brain is a rare neoplasm. However, patients who have been recipients of transplants have had a much higher than expected incidence of this tumor; reticulum cell sarcomas of the brain may be seen more often in the future. Most of the information available in the literature deals with the pathology and clinical course of the disease. Although several authors have commented on the radioresponsiveness of the tumor, little detail as to the exact treatment methods has been provided. Furthermore, it has been assumed that the prognosis of this tumor, after some form of surgery and postoperative radiotherapy, may be fairly good. This paper presents 19 patients who have had surgery followed by postoperative radiotherapy. Although a few patients have had good relief of symptoms for 3 to 4 years, only 1 patient is alive and free of disease over 5 years. This patient is the sixth reported long-term survival in the literature. Suggestions for the management of this disease are provided. If possible, limited surgery to remove circumscribed tumors should be done, but extensive resection should be avoided. Postoperative irradiation should include the whole brain to at least 4500 rads at 1000 rads per week, with a boost to residual tumor, if present, of 500 to 1000 rads in two to five treatments.