Central nervous system lymphoma: primary lumbar nerve root infiltration

[A case of primary central nervous system lymphoma with marked cauda equina enlargement]

An 80-year-old woman presented with subacute right lower limb pain and bilateral lower limb weakness. MRI of the spine showed marked cauda equina enlargement with contrast enhancement. Cerebrospinal fluid (CSF) examination showed elevated cell count, decreased glucose, and elevated protein. Cytology of the CSF showed class V, which together with B-cell clonality by flow cytometry, led to the diagnosis of primary central nervous system lymphoma (PCNSL). The patient was treated with steroid, radiation, and chemotherapy. Despite the reduction in lesion size, her neurological symptoms revealed no improvement. PCNSL with cauda equina lesions are rare and often require highly invasive cauda equina biopsy for diagnosis. In recent years, some studies reported useful CSF biomarkers, but they may have some problems. Therefore, as in this case, the combination of cytology, flow cytometry and, CSF biomarkers could be a substitute method for invasive biopsies, and contribute to the early treatment of PCNSL.

Primary Cauda Equina Lymphoma Treated with CNS-Centric Approach: A Case Report and Literature Review

Primary cauda equina lymphoma is an extremely rare entity previously documented in only 24 reported cases. Primary cauda equina lymphoma represents a subtype of neurolymphomatosis, which occurs when lymphoma cells with neurotropism infiltrate and destroy peripheral nerves, spinal nerve roots, nerve plexuses and cranial nerves. The cauda equina is an anatomic structure located in the lower part of the spinal canal consisting of multiple lumbar and sacral nerve roots. Herein, we report a unique case of primary cauda equina diffuse large B-cell lymphoma presenting as a tumor mass in the lower spinal canal, which was treated with a CNS-centric treatment approach followed by autologous hematopoietic stem cell transplantation.

Cauda equina biopsy as a tool in the diagnosis of malignant tumors

The prevalence of malignant lymphoma is increasing. With the advent of novel therapeutic approaches, the distinct pathology of each type of malignant lymphoma is used to tailor its treatment for the most effective outcome. Therefore, analysis of the malignant cell pathophysiology within the cauda equina is important to devising a treatment strategy. In some cases, the tumor only invades the cauda equina. Composed of an uninterrupted bundle of nerve fibers, the cauda equina is more complex than the brain parenchyma; hence, the method for performing a biopsy of the cauda equina is relatively more challenging and requires improvement. The appropriate surgical procedure to confirm the posterior ramus, which consists of sensory roots, is mandatory. In the lumbar region, the denticulate ligaments that distinguish between the motor and sensory nerve roots do not exist. Microsurgical techniques and neurophysiological monitoring can aid with removal of posterior roots and allow for the reliable performance of a cauda equina biopsy. First, we determined where the spinal root pierces the dura mater, and then we performed electromyography. We performed cauda equina biopsy with this method for patients with malignant lymphoma and reviewed the efficacy of this procedure. This strategy prevented postoperative neurological impairments and provided detailed information to ensure optimal adjuvant therapy. Based on advances in personalized therapies for malignant tumors, opportunities for cauda equina biopsy are increasing. Our method using both morphological feature observation and neurophysiological monitoring may contribute to successful biopsy of the cauda equina.

Primary cauda equina lymphoma diagnosed by nerve biopsy: A case report and literature review

Primary cauda equina lymphoma (CEL) is a rare malignant tumor among various neoplasms that affects the cauda equina nerve roots. The present case report described the case of a 65-year-old man who presented with cauda equina syndrome with progressive motor palsy in the legs and gait disturbance over the last 5 months. Magnetic resonance (MR) images showed enlargement of the cauda equina occupying the dural sac from the L1-S1 level with isointensity to the spinal cord signal on both T1- and T2-weighted imaging. Enhancement of the cauda equina was seen on contrast MR images. On F-18 2-fluoro-2-deoxy-glucose positron emission tomography examination, diffuse accumulation of 2-fluoro-2-deoxy-glucose was observed in the cauda equina with a maximum standardized uptake value of 4.9. Based on elevation of soluble interleukin 2 receptor in cerebrospinal fluid and a biopsy of the enlarging cauda equina, a diagnosis of CEL of the diffuse large B-cell type was made. The present case report provided a detailed case discussion and a review of the available literature on this rare entity, focusing on clinical characteristics and imaging of primary CEL.

Cauda equina syndrome secondary to neurolymphomatosis: Case report and literature review

Neurolymphomatosis is a rare disorder characterised by infiltration of neoplastic lymphocytes into the peripheral nervous system. A wide variety of symptoms can manifest depending on its nature and location, making its diagnosis a real challenge. Treatment is based on methotrexate, although various chemotherapy regimens are currently available for patients with systemic disease. We present the case of a male patient with neurolymphomatosis of the cauda equina, together with a review of all cases published to date.

Neuropathies associated with lymphoma†

Neuropathy occurs with various manifestations as a consequence of lymphoma, and an understanding of the etiology is necessary for proper treatment. Advances in medical imaging have improved the detection of peripheral nerve involvement in lymphoma, yet tissue diagnosis is often equally important. The neoplastic involvement of the peripheral nervous system (PNS) in lymphoma can occur within the cerebrospinal fluid (CSF), inside the dura, or outside of the CSF space, affecting nerve root plexuses and peripheral nerves. The infiltration of either cranial or peripheral nerves in lymphoma is termed neurolymphomatosis (NL). These infiltrations can occur as mononeuropathy, multifocal neuropathy, symmetric neuropathies, or plexopathies. In rare cases, intravascular lymphoma (IL) can affect the PNS and an even rarer condition is the combination of NL and IL. Immune-mediated and paraneoplastic neuropathies are important considerations when treating patients with lymphoma. Demyelinating neuropathies, such as Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy, occur more frequently in non-Hodgkin's lymphoma than in Hodgkin's disease. Paraproteinemic neuropathies can be associated with lymphoma and paraneoplastic neuropathies are rare. While the treatment of lymphomas has improved, a knowledge of neurotoxic, radiotherapy, neoplastic, immune-mediated and paraneoplastic effects are important for patient care.

Malignant cell infiltration in the peripheral nervous system

The peripheral nervous system can be affected by malignancies involving different mechanisms. Neoplastic nerve lesion by compression, invasion, and infiltration is rare and occurs in particular in leukemia (neuroleukemiosis) and lymphoma (neurolymphomatosis). Its occurrence is much rarer in cancer, and even less so in sarcoma. The neoplastic infiltration of peripheral nerves by solid tumors is characterized by specific topographical sites such as the base of the skull, the ear, nose and throat region, and the cervico-brachial plexus as well as the lumbar and sacral plexus. Rarely malignant invasion affects the cranial nerves of the face where it can spread centripetally. Autonomic nerves and ganglia can also be affected. The retrograde spread of cancer in nerves is a bad prognostic sign. The clinical diagnosis is determined by tumor type, the pattern of involvement, and often pain.

Cauda equina lymphoma--a rare presentation of primary central nervous system lymphoma: case report and literature review

The spinal cord is an extremely rare site for primary central nervous system (CNS) lymphoma (< 1%). Very few cases of primary cauda equina (including conus) lymphoma were previously reported. We report such a case, and with literature review, discuss their clinical features, operative and histopathological findings. Although rare, with an increasing incidence of CNS lymphoma, they should be considered in the differential diagnosis of intradural lesions. Furthermore, with intraoperative smear to establish diagnosis, extensive surgery can be avoided. The controversial role of glucocorticoids in the management of these patients is also discussed.

Primary B-cell lymphoma of the cauda equina, successfully treated with high-dose methotrexate plus high-dose cytarabine: a case report with MRI findings

Primary malignant lymphoma of the cauda equina is an extremely rare disease. Previously, there have been only 12 reported cases of malignant lymphoma of the cauda equina, and most cases relapsed early in the clinical course. So, the optimal treatment strategy for this condition has not been established yet and the prognosis is thought to be poor. We experienced a case of B-cell malignant lymphoma of the cauda equina, with rapid progression of the muscle weakness of the bilateral lower extremities, successfully treated with high-dose methotrexate plus high-dose cytarabine (Ara-C) chemotherapy, followed by radiotherapy and in complete remission without any recurrence signs, 1.5 years after the initial diagnosis. Intrathecal chemotherapy with MTX, Ara-C, and predonisolone was simultaneously performed. We should carefully continue to monitor the clinical course of our case, with the examinations of magnetic resonance imaging and cerebrospinal fluid in order not to overlook any subtle neurological changes or other clinical symptoms.

Primary NK/T-cell lymphoma of the cauda equina: a case report and literature review

STUDY DESIGN

A case report with a review of the literature.

OBJECTIVE

To describe an unusual case of primary lymphoma of the cauda equina and provide a review of the literature of this condition.

SUMMARY OF BACKGROUND DATA

Primary lymphoma of the cauda equina is extremely rare, and has been reported in 8 cases previously. This report is the first to describe a case of primary nasal type NK/T-cell lymphoma of the cauda equina.

METHODS

We report the case of a 67-year-old man presenting the symptoms of cauda equina syndrome caused by primary lymphoma of the cauda equina.

RESULTS

After laminectomy and removal of the tumor, the patient recovered from the symptoms of cauda equina syndrome except for bladder and bowel dysfunction. Further investigations including immunohistochemical stains made a diagnosis of primary nasal type NK/T-cell lymphoma of the cauda equina, and the patient received radiotherapy to the lumbosacral area. Brain metastasis was detected 8 months after surgery, and the patient died 14 months after his initial clinical presentation despite additional treatments including whole-brain radiotherapy and oral chemotherapy.

CONCLUSION

Although primary lymphoma of the cauda equina is extremely rare, the prognosis of this condition is thought to be poor. Early definitive diagnosis with examination of the cerebrospinal fluid followed by combined treatment with radiotherapy and high-dose methotrexate should be considered.

Spinal cord biopsy: a review of 38 cases

OBJECTIVE

Neurosurgeons are frequently asked to evaluate patients for spinal cord biopsies when preoperative magnetic resonance imaging studies demonstrate nonspecific features. These lesions often appear unresectable, but surgeons must decide whether a biopsy is warranted. To determine the best approach to these cases, we evaluated the clinicopathological findings for patients with unknown spinal cord lesions who underwent spinal cord biopsies.

METHODS

Thirty-eight consecutive patients who underwent spinal cord biopsies at the Mayo Clinic (Rochester, MN) between August 1988 and July 1998 were studied. A detailed review of the case histories, radiological results, surgical notes, histological findings, and outcomes was performed.

RESULTS

Spinal cord biopsies were performed for 21 male and 17 female patients (mean age, 42.1 yr) with progressive neurological deficits related to spinal cord lesions. All patients underwent preoperative magnetic resonance imaging evaluations. High T2-weighted signal intensity and spinal cord expansion were identified in 92 and 87% of cases, respectively. After gadolinium infusion, the majority (94%) of the inflammatory lesions demonstrated patchy and often peripherally situated enhancement. This neuroradiological pattern was less common for neoplasms (50%) and benign lesions (40%). The most common pathological findings were inflammatory changes of demyelination or sarcoidosis, which together accounted for 13 cases (34%). Nonspecific changes or benign lesions were observed in 10 cases (26%). Neoplasms were identified in eight cases (21%). One case of tuberculosis and one of schistosomiasis were found. Overall, 47% of the preoperative diagnoses made by the attending surgeon were correct. For 26% of the patients, specific treatment was based on the biopsy results. The average follow-up period was 12 months (standard deviation, 14 mo; range, 0-50 mo).

CONCLUSION

Preoperative laboratory and imaging studies are often diagnostically inconclusive in cases of spinal cord lesions with nonspecific features. Biopsies should be considered for patients with progressive symptomatic lesions.

Lymphoma at uncommon sites

Lymphoma can often present in unusual situations. This article provides a comprehensive review of the literature in which both non-Hodgkin's lymphoma and Hodgkin's disease are discussed.

Primary lymphoma of the spinal cord

Non-Hodgkin's lymphomas arising in the spinal cord are extremely rare. Only eight single case reports have been well confirmed in the literature. Herein we describe a 59-year-old woman with symptoms attributable to a spinal cord lesion. Physical examination revealed neurologic deficits but no evidence of tumor elsewhere. Although several imaging studies were performed, only magnetic resonance imaging with use of gadolinium revealed the exact site and extent of the lesion. Laminectomy and direct examination of the spinal cord disclosed a discolored region at the level of the 11th thoracic vertebra. A biopsy specimen was obtained, and pathologic examination revealed an intermediate grade, mixed cell lymphoma of T-cell origin. Radiotherapy was administered to the lesion and adjacent region of the spinal cord with use of 6-MV photons and an anteroposterior-posteroanterior technique; the total dose was 45 Gy in 23 fractions. No chemotherapy was given. After 3 years of follow-up, the neurologic signs and symptoms were stable, and repeated magnetic resonance imaging with use of gadolinium showed no residual tumor. In addition to the case report, we review the literature on primary lymphomas of the central nervous system and discuss treatment recommendations.

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 spinal intramedullary malignant lymphoma. A case report

A rare case of primary malignant intramedullary lymphoma, localized in the cervical part of the spinal cord, is presented. The onset of clinical symptoms was associated with herpes zoster infection. Surgery led to the histological diagnosis. The clinical investigations excluded the presence of lymphoma in other sites in the central nervous system and in the extraneural organs. Postoperative irradiation and chemotherapy effected relict of neurological symptoms.