Central nervous system lymphoma

Contiguous Meningioma and B-Cell Lymphoma: A Scoping Review and Case Illustration

BACKGROUND

The diagnosis of a contiguous, synchronous meningioma and central nervous system B-cell lymphoma is rare and associated with paradoxical treatment paradigms. We performed a scoping review of contiguous meningioma and B-cell lymphoma and included an additional illustrative case.

METHODS

The OVID Medline and PubMed databases were systematically searched using the Preferred Reporting Items of Systematic Reviews and Meta-Analysis guidelines. Only human clinical reports of contiguous, synchronous meningioma and B-cell lymphoma were included. We concurrently detailed a representative case from our institution.

RESULTS

Nine case reports met our criteria, including the present case. The average age at diagnosis was 67.4 years. Patients showed a female-to-male predominance of 7:2. The diagnosis of synchronous intracranial tumors was not suspected or discovered until after surgical resection in 100% of cases. All meningiomas were grade I on histopathologic diagnosis, while lymphomas were distributed between diffuse large B-cell lymphoma (56%), metastatic lymphoma (22%), Burkitt lymphoma (11%), and follicular lymphoma (11%). All patients underwent surgical resection. Patients (n = 5) treated with adjuvant chemotherapy had evidence of longer progression-free survival (median 12 months; range, 3-18 months) than patients without adjuvant chemotherapy (n = 2; median 2 months; range, 1-3 months).

CONCLUSIONS

Contiguous, synchronous meningioma/B-cell lymphoma is a rare diagnosis that may appear as an inconspicuous solitary intracranial neoplasm on imaging. Based on the limited cases and current treatment of lymphoma, progression-free survival may be contingent on the prompt initiation of chemotherapy targeting the lymphoma rather than surgical resection of the meningeal mass. Providers should prioritize prompt medical management.

Inflammatory Brain Lesions as Omen of Primary Central Nervous System Lymphoma: A Case Report and Literature Review

We report a rare case that was initially diagnosed as an inflammatory lesion and ultimately confirmed as primary central nervous system lymphoma (PCNSL) in an immunocompetent patient who was not treated with corticosteroid prior to the initial biopsy. A 70-year-old female patient presented with numbness in the left side of face, arm, and leg. Brain magnetic resonance imaging (MRI) revealed a lesion with intense gadolinium (Gd)-enhancement in the ventral portion of the midbrain. A stereotactic biopsy demonstrated mixed T-cell and B-cell infiltrating inflammatory lesions without demyelination. Three months after postoperative treatment with steroid, the lesion markedly decreased on follow-up MRI. Twenty-six months after the initial attack, she complained of dysarthria and urinary incontinence. Repetitive MRI showed a lesion with homogeneous enhancement, extensively involving the bilateral cerebral hemisphere, corpus callosum, and the right middle cerebellar peduncle. The confirmed diagnosis was diffuse large B-cell lymphoma on the second biopsy. Despite our best efforts, she died 38 months after disease onset. Based on review of the literature and our case, preceding inflammatory lesions are not always demyelinating and T-cell dominant inflammatory lesions. When the initial biopsy reveals an inflammatory lesion in an old-aged patient, the clinician should keep in mind the development of PCNSL and perform close clinical and radiological observations for a timely diagnosis.

Comparative study on different therapies on patients with primary central nervous system lymphoma

Objective

To compare and analyze three therapies on patients with primary central nervous system lymphoma (PCNSL), aiming to provide evidences for future treatment and prognosis.

Methods

Clinical data of 26 cases of PCNSL with normal immune system confirmed by postoperative pathology were retrospectively analyzed. Among them there were six cases with operation only, nine cases with operation and radiotherapy, and 11 cases with operation, radiotherapy and chemotherapy, and their survival rate was compared as well.

Results

The survival time of patients with operation only, operation combined with radiotherapy and operation combined with radiotherapy and chemotherapy was 6–11 months, 15–24 months and 24–51 months, respectively. And their median survival time was only nine months, 21 months and 38 months, respectively.

Conclusions

Operation combined with radiotherapy and chemotherapy can dramatically extend PCNSL patients’ survival time, therefore, it can be regarded as the first-line therapy.

[A case of primary diffuse large B-cell lymphoma of the brain]

The paper describes a case of primary extranodal diffuse large B-cell lymphoma of the cerebral hemispheres, which was regarded as an inflammatory disease of the brain during life and diagnosed only posthumously in the microscopically examination of the autopsy material by immunohistochemical studies.

Demyelination as a harbinger of lymphoma: a case report and review of primary central nervous system lymphoma preceded by multifocal sentinel demyelination

BACKGROUND

Primary central nervous system lymphoma (PCNSL) may rarely be preceded by "sentinel demyelination," a pathologic entity characterized by histologically confirmed demyelinating inflammatory brain lesions that mimic multiple sclerosis (MS) or acute disseminated encephalomyelitis (ADEM). Interpreting the overlapping radiologic and clinical characteristics associated with each of these conditions-contrast-enhancing demyelination of white matter and relapsing and remitting steroid-responsive symptoms respectively-can be a significant diagnostic challenge.

CASE PRESENTATION

We describe a 57-year-old woman with an unusual clinical course who presented with multi-focal enhancing white matter lesions demonstrated to be inflammatory demyelination by brain biopsy. Despite a good initial response to steroids and rituximab for treatment of presumed tumefactive multiple sclerosis, the patient's condition rapidly deteriorated, and a repeat brain biopsy six months later was consistent with a diagnosis of diffuse large B-cell lymphoma.

CONCLUSIONS

Early clinical suspicion for PCNSL and awareness that biopsied lesions may initially show sentinel demyelination suggestive of alternate diagnoses may be essential for early initiation of appropriate therapies and mitigation of disease progression. Clinical, pathophysiological, and diagnostic aspects of sentinel demyelination and PCNSL are discussed.

Central nervous system lymphoma: a description and analysis of patients’ clinical and radiological features

Background: Central nervous system (CNS) lymphoma is a rare brain neoplasm. Its incidence has increased these years, so it should be considered in the differential diagnosis for mass lesions in the CNS. The aim of the study was to describe the radiological and clinical features of patients with CNS lymphoma.Methods: The study was a retrospective study. All patients histopathologically confirmed to have CNS lymphoma from November 2008 to December 2013 in Siloam Hospital Lippo Village were included in the study. Medical records and patients’ MRI results were retrieved to be analyzed.Results: 32 patients were histopathologically diagnosed to have CNS lymphoma. The patients, mean age was 54 ± 15.01 years with slight male predominance. No patient was immuno compromised (CD4 > 500 cells/µL and leukocyte 5,000-11,000 cells/µL). The median interval between the onset of the initial symptoms and diagnosis is 7 weeks. The most common presenting symptoms were headache, mental changes, and neurological deficits related to the location of lesion. MR images show that most lesions were enhanced with contrast, iso-hypointense in T1 weighted imaging (T1WI), iso- to hypointense with perifocal edema in T2 weighted imaging (T2WI), hyperintense in diffusion weighted imaging (DWI), with the most common location was white matter of cerebral hemisphere on one or more lobes and periventricular area, and the tumor could be single or multiple (24%) without clear edges.Conclusion: Short course of neurological worsening (within weeks) should lead a suspicion toward lymphoma. The characteristics of MR images are markedly enhanced by contrast, iso- to hypointense on T1WI and T2WI, and hyperintense in DWI, involving white matter of cerebral hemisphere and periventricular area.

Evaluation of microvascular permeability with dynamic contrast-enhanced MRI for the differentiation of primary CNS lymphoma and glioblastoma: radiologic-pathologic correlation

BACKGROUND AND PURPOSE

Dynamic contrast-enhanced MR imaging can provide in vivo assessment of the microvasculature in intracranial tumors. The aim of the present study was to evaluate the diagnostic performance of dynamic contrast-enhanced MR imaging derived vascular permeability parameters, including the volume transfer constant, the volume of extravascular extracellular space, and the flux rate constant between the extravascular extracellular space and plasma, for the differentiation of primary CNS lymphoma and glioblastoma.

MATERIALS AND METHODS

Sixty glioblastomas and 11 primary central nervous system lymphomas were included. Pretreatment T1-weighted dynamic contrast-enhanced MR imaging with a 3D T1-weighted spoiled gradient-echo sequence was performed on a 3T MR imaging scanner. Perfusion parameters (volume transfer constant, the volume of extravascular extracellular space, and the flux rate constant) were measured on the basis of the Tofts-Kernmode model. The Mann-Whitney U test and receiver operating characteristic analysis were used to compare those parameters between primary central nervous system lymphoma and glioblastoma. Histopathologic correlation of dynamic contrast-enhanced MR imaging findings was performed by using reticulin staining and CD31 immunohistochemistry.

RESULTS

Median volume transfer constant and flux rate constant values were significantly higher in primary central nervous system lymphoma (0.145 ± 0.057 and 0.396 ± 0.088) than in glioblastoma (0.064 ± 0.021 and 0.230 ± 0.058) (P < .001, respectively). Median volume of extravascular extracellular space values did not differ significantly between primary central nervous system lymphoma (0.434 ± 0.165) and glioblastoma (0.319 ± 0.107). On receiver operating characteristic analysis, volume transfer constant had the best discriminative value for differentiating primary central nervous system lymphoma and glioblastoma (threshold, 0.093; sensitivity, 90.9%; specificity, 95.0%). Histopathologic evaluation revealed intact vascular integrity in glioblastoma despite endothelial proliferation, whereas primary central nervous system lymphoma demonstrated destroyed vessel architecture, thereby promoting vascular disintegrity.

CONCLUSIONS

Primary central nervous system lymphoma demonstrated significantly higher volume transfer constant and flux rate constant values compared with glioblastoma, implying a higher vascular permeability in primary central nervous system lymphoma. These findings confirm initial observations from perfusion CT and dynamic contrast-enhanced MR imaging studies, correlating with underlying histopathologic features, and may be useful in distinguishing primary central nervous system lymphoma from glioblastoma.

Isolated secondary CNS relapse in a case of stage I diffuse large B-cell lymphoma

A 55-year-old woman was admitted to our hospital with a 10-day history of right arm weakness and numbness. The patient's medical history was notable for lobular carcinoma in situ of the right breast in 2008 and stage I diffuse large B-cell lymphoma of the left axilla. The patient had completed treatment with chemotherapy and radiation 2 months prior to presentation. Blood counts, metabolic panel and lumbar puncture were unremarkable. MRI of the brain revealed multiple enhancing masses. The patient was started on dexamethasone, with rapid symptom improvement. A stereotactic brain biopsy revealed CD20 diffuse large B-cell lymphoma. The patient was started on high-dose intravenous methotrexate. She has received 11 cycles and has regained near normal function of the right arm. The patient's most recent brain MRI showed near complete resolution of all previously seen abnormal foci of enhancement.

Neurological complication of non Hodgkin lymphoma in childhood: experience from a single center in Turkey

PURPOSE

Lymphomas are the third most common childhood malignant disease after leukemia and central nervous system (CNS) tumors. Early diagnosis of these complications will reduce mortality and morbidity. In this study we aimed to review the neurological complications of childhood non Hodgkin Lymphoma (NHL).

PATIENTS AND METHODS

Forty four children with NHL between 2006 and 2012 were investigated retrospectively and 14 cases with neurological complications were identified.

RESULTS

The most common symptom was alteration of the consciousness (10 patients, 71.4 %) followed by convulsion (5 patients, 35.7 %), and hallucination (4 patients, 28.5 %); headache, eye pain, neurogenic bladder, speech disability and facial paralysis, and hemiplegia, were less common and each of them was seen in 1 (7.1 %) of the patients. The neurological complications were mostly seen in children with precursor T lymphoblastic lymphoma followed by anaplastic large cell lymphoma. The complications were secondary to medications (Eight patients) infection (two patients); CNS relapse (two patients); or CNS involvement of the primary disease (two patients). Chemotherapy-related neurologic complications were secondary to intrathecal methotrexate, L-asparaginase, vincristine, and ifosfamide

CONCLUSION

Advanced disease and PTLL subtype can be suggested as predictors of neurological complication. The survival rates of neurological complications are fairly good unless it is secondary to involvement of the primary disease. In patients with drug-induced neurological complications, the treatment can be safely re-administered after controlling the neurological complications. Therefore, clinicians managing children with NHL must be informative about neurological complications.

The risk of CNS involvement in aggressive lymphomas in the rituximab era

The risk of CNS dissemination and CNS prophylaxis strategies in aggressive non-Hodgkin lymphoma (NHL) is still debated. CNS dissemination is a rare but fatal event. A CNS prophylaxis is common for Burkitt and B-cell lymphoblastic lymphoma; however, in other NHLs, prophylactic treatments are not systematically warranted. Current risk models showed low sensitivity in predicting CNS involvement, implying overtreatment in roughly 70% of high-risk patients. Risk models in the rituximab era were modulated for the detection of occult CNS disease at diagnosis using flow cytometry. The optimal regimen for CNS prophylaxis in aggressive lymphoma patients has not been established thus far and should be modulated at different levels of 'intensity' such as standard intrathecal chemotherapy, 'active' intrathecal chemotherapy with liposomal cytarabine or more aggressive systemic treatment with high doses of drugs having good CNS bioavailability reserved for patients who are truly at high risk of CNS dissemination.

Primary fourth ventricular B-cell lymphoma in an immunocompetent patient

Letter to the Editor.

Diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoid malignancy in adults accounting for 31% of all NHL in Western Countries. Following, morphological, biological and clinical studies have allowed the subdivision of DLBCLs into morphological variants, molecular and immunophenotypic subgroups and distinct disease entities. However, a large number of cases still remain biologically and clinically heterogeneous, for which there are no clear and accepted criteria for subclassification; these are collectively termed DLBCL, not otherwise specified (NOS). DLBCL-NOS occurs in adult patients, with a median age in the seventh decade, but the age range is broad, and it may also occur in children. Clinical presentation, behaviour and prognosis are variable, depending mainly of the extranodal site when they arise. These malignancies present in localized manner in approximately 20% of patients. Disseminated extranodal disease is less frequent, and one third of patients have systemic symptoms. Overall, DLBCLs are aggressive but potentially curable malignancies. Cure rate is particularly high in patients with limited disease with a 5-year PFS ranging from 80% to 85%; patients with advanced disease have a 5-year PFS ≈ 50%. The International Prognostic Index (IPI) and age adjusted IPI (aaIPI) are the benchmarks of DLBCL prognosis. First-line treatment for patients with DLBCL is based on the individual IPI score and age, and three major subgroups should be considered: elderly patients (>60 years, aaIPI=0-3); young patients with low risk (<60 years, aaIPI=0-1); young patients with high risk (<60 years, aaIPI=2-3). The combination of the anti-CD20 monoclonal antibody rituximab and CHOP chemotherapy, every 14 or 21 days, is the standard treatment for DLBCL patients. Recent randomized trials suggest that high-dose chemotherapy supported by autologous stem cell transplant (HDC/ASCT) should not be used as upfront treatment for young high-risk patients outside prospective clinical trials. HDC/ASCT is actually recommended in young patients who did not achieve CR after first-line chemotherapy. Consolidation radiotherapy should be reserved to patients with bulky disease who did not achieve CR after immunochemotherapy. Patients with high IPI score, which indicates increased LDH serum level and the involvement of more than one extranodal site, and patients with involvement of certain extranodal sites (a.e., testes and orbit) should receive CNS prophylaxis as part of first-line treatment. HDC/ASCT should be considered the standard therapy for DLBCL patients with chemotherapy-sensitive relapse. Overall results in patients who cannot be managed with HDC/ASCT due to age or comorbidity are disappointing. New effective and less toxic chemotherapy drugs or biological agents are also worth considering for this specific and broad group of patients. Several novel agents are undergoing evaluation in DLBCL; among other, immunomodulating agents (lenalidomide), m-TOR inhibitors (temsirolimus and everolimus), proteasome inhibitors (bortezomib), histone deacetylase inhibitors (vorinostat), and anti-angiogenetic agents (bevacizumab) are being investigated in prospective trials.

Influence of methotrexate exposure on outcome in patients treated with MBVP chemotherapy for primary central nervous system lymphoma

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Although treated using the same high-dose methotrexate (HD-MTX)-based multiagent chemotherapy, patients with primary central nervous system lymphoma (PCNSL) have significant differences in outcome. However, little information has been published about factors influencing outcome in PCNSL. As it is known that the pharmacokinetics of MTX vary considerably between subjects leading to different exposure in patients receiving the same dose, it is important to evaluate its role in response to chemotherapy.

WHAT THIS STUDY ADDS

This study is the first to evaluate the exposure-response relationship in patients treated with MBVP chemotherapy. We found that patients who were early non-responders to MBVP chemotherapy had poor survival, whatever the salvage regimen. Tumour response at early evaluation was not associated with MTX pharmacokinetics and increasing the dose would probably not improve results.

AIMS

Although the standard treatment for primary central nervous system lymphoma (PCNSL) consists of three cycles of MBVP (methotrexate, BCNU, VP16, methylprednisolone) and radiotherapy, early failure of treatment may require modification of the treatment. However, our understanding of the outcome in such patients and of the factors involved in early failure of treatment is poor. In addition to known prognostic factors, we evaluated the influence of methotrexate (MTX) exposure on the response to MBVP chemotherapy in patients treated for PCNSL after the first two cycles.

METHODS

We retrospectively analyzed all patients with PCNSL treated with the MBVP regimen over the previous 10 years. Clinical, personal data and known prognostic factors were studied. The parameters of MTX exposure were estimated using a population pharmacokinetic approach with NONMEM. Objective response (OR), overall survival (OS) and failure-free survival (FFS) were evaluated in all patients.

RESULTS

Thirty-seven patients were studied. We observed lower FFS and OS (0.49 years) in patients who were not able to receive the planned treatment (group 1, n=12) than in those who received three cycles (8.04 years) (group 2, n=25). Known prognostic factors were comparable in both groups, but mean dose of MTX and mean AUC tended to be lower in patients who failed prematurely or showed no response after two cycles.

CONCLUSIONS

We found that patients who were early non-responders to MBVP chemotherapy had poor survival, without major influence of MTX exposure. It is thus probably unlikely that increasing the dose of MTX would improve outcome.

Primary central nervous system lymphoma: immunohistochemical profile and prognostic significance

Primary central nervous system lymphoma (PCNSL) is a rare subtype of non-Hodgkin lymphoma (NHL) with extranodal location affecting only the CNS, meninges and eye, without visceral or lymph node involvement. Its incidence has increased sharply over the past three decades, especially in immunocompetent subjects. Most PCNSL cases are diffuse large B-cell lymphomas (DLBCLs). However, it differs from nodal DLBCL in that it has a worse prognosis. DLBCLs are a heterogeneous entity and according to new genomic discoveries, classifications into prognostic subgroups have been embarked upon. Two prognostic algorithms were then prepared using a panel of immunohistochemical markers (CD10, Bcl6, MUM1/IRF-4, and Bcl2), thus categorizing DLBCL into two subgroups, GCB (germinal centre B-cell-like) or non-GCB, and into Group 1 or Group 2. Our goal is to apply both of these two sub-classifications to 39 PCNSLs, in order to assess their usefulness and prognostic relevance. 74.3% of our PCNSLs were of a non-GCB phenotype, corresponding to an activated postgerminal origin. They were evenly distributed across G1 and G2. Two- and 5-year overall survival rates were 34.8% and 19.6%, respectively. Younger age (<65) and a therapeutic combination of chemotherapy and radiotherapy significantly improved our patients' survival rates. The other clinical or biological markers tested had no prognostic impact. The two classifications did not reveal any significant survival difference. The recent discovery of a specific "transcriptional signature" of PCNSL, marking them out of DLBCL could account for the irrelevance of such prognostic classifications to PCNSL.

Meningeal relapse by follicular lymphoma as a single mass

Follicular lymphoma is the second most common lymphoma throughout the world. Its course is usually indolent. Affection of Central Nervous System by a follicular lymphoma is usually as primary disease, and secondary affection is usually due to high-grade transformation. In this case-report we describe a young patient who presented a follicular lymphoma which secondary affected the central nervous system without high grade transformation.

CNS T-cell lymphoma: an under-recognized entity?

The incidence of CNS lymphoma has increased significantly in the past 30 years, primarily in the elderly and immunocompromised. While T-cell lymphomas comprise 15-20% of systemic lymphomas, they comprise less than 4% of primary CNS lymphomas, suggesting that they may be under-recognized compared to their systemic counterparts. To investigate this, we studied brain biopsies from three patients who were diagnosed with T-cell lymphoma confined to the brain. They had enhancing lesions by MRI, arising in the cerebellum and brainstem in one and temporal lobe in two. We compared these to biopsies from three patients who had reactive lymphoid infiltrates and who had clinical signs/symptoms and radiographic findings that were indistinguishable from the lymphoma group. Biopsies from both the lymphoma group and reactive group showed considerable cytomorphologic heterogeneity. Although one lymphoma case contained large atypical cells, the other two contained small, mature lymphocytes within a heterogeneous infiltrate of neoplastic and reactive inflammatory cells. Surface marker aberrancies were present in two lymphoma cases, but this alone could not reliably diagnose T-cell lymphoma. The proliferation index was not useful for differentiating lymphoma from reactive infiltrates. In five of the six cases the diagnosis was most influenced by clonality studies for T-cell receptor-gamma gene rearrangements. We conclude that because of the high degree of overlap in cytomorphologic and immunophenotypic features between T-cell lymphoma and reactive infiltrates, T-cell lymphoma may not be recognized unless studies for T-cell receptor gene rearrangements are performed for CNS lesions composed of a polymorphous but predominantly T-cell infiltrate.

A virtual tissue bank for primary central nervous system lymphomas in immunocompetent individuals

Primary central nervous system lymphoma (PCNSL) is a rare form of extranodal non-Hodgkin's lymphoma with continuously increasing incidence in both immunosuppressed and immunocompetent individuals. PCNSL is a very aggressive tumor with a poor outcome, and its clinical outcome is much worse than for nodal lymphomas. Differently from lymphomas arising in lymph nodes or in other extranodal sites, the treatment of PCNSL remains very unsatisfactory. Current biologic knowledge of PCNSL is still limited and several fundamental questions remain to be answered. This is mainly due to the paucity of PCNSL material for adequate translational research. With the aim of providing biologic material to investigators interested in PCNSL, we have implemented a virtual tissue bank (VTB) for PCNSL in immunocompetent patients. After registration, the VTB is accessible via any web browser at www.ielsg.org. Only anonymous data are centralized at the website of the International Extranodal Lymphoma Study Group, whilst the pathologic material is maintained at the local pathology institutes.

High-dose methotrexate and primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) is a rare disease that is managed differently from other primary brain tumors and other types of systemic lymphomas. The use of high-dose methotrexate (HD-MTX) has improved survival rates. This article describes the experience of a patient treated with HD-MTX and outlines the essential aspects of care for the bedside practitioner. An understanding of the diagnostic workup and principles of treatment can minimize complications and maximize patient function as nurses care for the unique physical and emotional needs of this population.

Peripheral nervous system involvement in patients with cancer

Involvement of the peripheral nervous system (PNS) is common in patients with cancer and any part, including motor neurons, sensory ganglia, nerve roots, plexuses, cranial and peripheral nerves, and neuromuscular junctions, can be affected. Different mechanisms can initiate damage associated with cancer-related PNS disorders. These include tumour infiltration, toxicity of treatments, metabolic and nutritional perturbations, cachexia, virus infections, and paraneoplastic neurological syndromes. The type of cancer, lymphoma, or solid tumour is a further determinant of a PNS disorder. In this Review we discuss the different causes and mechanisms of disorders of the PNS in patients with cancer and we will focus on their assessment and diagnosis.

Low-grade follicular lymphoma in the dura: Rare mimic of meningioma

Lymphomas rarely present as a localized mass within the dura. We report a case of a 72-year-old woman, normally fit and well, who presented with a sudden episode of grand mal seizure. Imaging studies showed an extra-axial mass arising from the dura, with radiologic features characteristic of a meningioma. The mass was surgically excised, and the histologic features were of a grade 1 follicular lymphoma. Analysis using fluorescent in situ hybridization (FISH) demonstrated t(14:18) translocation. A bone marrow aspirate showed focal infiltration of lumbar vertebra by low-grade follicular lymphoma. Intracranial meningeal involvement by non-Hodgkin lymphoma usually occurs in the form of diffuse leptomeningeal spread. It is seen in high-grade lymphomas, often in association with widespread systemic disease. The majority of cases of dural lymphomas reported in the literature have been primary mucosa-associated lymphoid tissue (MALT)-type lymphomas. Most of these presented as localized dural masses mimicking meningiomas. Low-grade follicular lymphoma, either primary or secondarily involving the dura, appears to be an exceedingly rare occurrence.

IRM de diffusion-perfusion dans l’évaluation des lymphomes cérébraux

Because of the increasing incidence of cerebral lymphoma, it is critical for patient management to recognize the MR features of this disease. We present the characteristic morphological and functional MRI features of this tumor. The findings on MRI studies, including morphological, diffusion and perfusion imaging, performed in 9 biopsy-proven cases of cerebral lymphoma with 13 lesions are presented and analyzed, and are discussed in comparison with published literature data. All patients underwent diffusion-weighted imaging with a single shot echo-planar pulse sequence. Dynamic susceptibility-contrast MRI was performed using a T2*-weighted gradient-echo echo-planar sequence after intravenous injection of chelates of gadolinium at the rate of 6 ml/s and a temporal resolution of 1 second. All cases of cerebral lymphoma appeared hypointense or isointense on T1-weighted images and in 75% of cases iso- or hypointense on T2-weighted images. All lesions enhanced except one in a patient receiving steroid therapy. On diffusion-weighted images, tumours were hyperintense with normal or decreased ADC values (0.717+/-0.152.10-3 mm2/sec, range: 0.550-1.014) and an ADC ratio tumour/normal white matter of 0.974+/-0.190 (range: 0.768-1.410). On perfusion, the signal intensity-time curve of each tumour showed a characteristic type of curve with a significant increase of the signal intensity above the baseline and a low maximum relative cerebral blood volume ratio (rCVBmax) of 1.43+/-0.64 (0.55-2.62). Due to their higher cellularity, the lack of neoangiogenesis, and the increased permeability of the blood-brain barrier related to the infiltration of blood vessels wall by lymphomatous cells, cerebral lymphoma presents characteristic diffusion and perfusion MRI features that should be useful for diagnosis and patient follow-up.

Central nervous system lymphoma in a patient with Sjogren's syndrome and autoimmune thyroiditis (Hashimoto's thyroiditis)

We present a case of central nervous system (CNS) lymphoma in a patient with Sjogren's syndrome (SS) and autoimmune thyroiditis (Hashimoto's thyroiditis) overlap. A 60-year-old woman, who had the diagnosis of SS for 16 years, had been admitted for visual loss, fever, weight and appetite loss for 3 months. Cranial magnetic resonance imaging was in accordance with CNS lymphoma, and biopsy from right parietal region showed diffuse large B-cell lymphoma of the CNS. This is the first report of diffuse large B-cell lymphoma of the CNS in SS and autoimmune thyroiditis (Hashimoto's thyroiditis) overlap.

Primary CNS lymphoma in immunocompetent patients from 1989 to 2001: a retrospective analysis of 164 cases uniformly diagnosed by stereotactic biopsy

BACKGROUND

We present outcome data of a cohort of 164 immunocompetent PCNSL patients uniformly diagnosed at a single center for stereotactic neurosurgery, and evaluate the acceptance and impact of combination radiotherapy (RT) and chemotherapy (CHT) with high-dose methotrexate (HD-MTX) over time.

METHOD

We assessed choice of treatment and patient survival in a series of 164 PCNSL cases diagnosed from 1989 to 2001, and performed a re-evaluation of histopathology and pre-operative clinical data.

FINDINGS

From 1989 to 1993, RT was the predominant therapy, and additional CHT did not improve survival. After 1994, the use of combination CHT/RT increased continuously, consistently contained MTX, and was associated with longer survival than RT only: median survival was 14 months after CHT/RT (2-year survival 35.7%) and 10 months (2-year survival 26.2%) after RT only (not significant). Overall median survival remained poor, increasing from six (1989-1993) to nine months (1994-2001) (p = 0.008). Survival was variable, with a few patients surviving >4 years after diagnosis in the CHT/RT as well as in the RT only group.

CONCLUSIONS

Despite considerable improvement of PCNSL therapy, the overall benefit of combined CHT/RT versus RT only was lower than that expected from previous phase II clinical trials. The striking variability of survival in either treatment group may suggest a yet undefined biological heterogeneity of PCNSL, which may also include a more aggressive PCNSL subtype in the group of patients with rapidly progressive disease and not eligible for standard therapy.

Secondary Central Nervous System Lymphoma

This review summarizes current knowledge of secondary central nervous system lymphoma (SCNSL) in adults. We define SCNSL as CNS involvement not obvious at the initiation of treatment for systemic lymphoma. Recently, polymerase chain reaction and flow cytometry assays of cerebrospinal fluid have become available for the correct diagnosis of SCNSL. We reviewed reports of patients treated without CNS prophylaxis to evaluate the incidence of SCNSL. Elevated serum lactate dehydrogenase levels, the involvement of more than one extranodal site, an advanced stage, a high age-adjusted International Prognostic Index score at presentation, and special anatomic sites of involvement such as the testis are important risk factors for SCNSL. Histologic evidence of aggressiveness is generally an indicator of risk for SCNSL. In addition to conventional treatment, stem cell transplantation, intrathecal administration of rituximab, and liposomal cytarabine have come into clinical use for the treatment of established SCNSL. Prevention of isolated CNS recurrence is thought to be the main target of CNS prophylaxis. The value of CNS prophylaxis according to histologic subtype, status of systemic lymphoma, and other risk factors is summarized. Although prophylaxis is fundamental for treating highly aggressive non-Hodgkin's lymphoma (NHL), it is beginning to be appreciated for the treatment of aggressive NHL. CNS involvement is almost always fatal; however, a CNS-active strategy could complement other approaches that have led to recent improvements in the prognosis for lymphoma.

Non Hodgkin's lymphoma involving the adrenal glands and the central nervous system (CNS): a particular evolution after chemotherapy

Adrenal lymphoma is extremely rare. The prognostic depends on involvement of other organs (such as the central nervous system) responsible for lower median survival. We report the case of a 51-year-old man with non Hodgkin's Diffuse Large B Cell Lymphoma (DLBCL) involving the central nervous system (CNS) and the adrenal glands simultaneously. The endocrine exploration revealed a partial adrenal insufficiency and ruled out a pheochromocytoma. Computerized tomographic (CT) scan directed needle biopsy of the adrenal gland allowed the diagnostic of non-Hodgkin lymphoma (NHL). CNS biopsies showed similar histopathologic lesions. After aggressive polychemotherapy and methotrexate intrathecal injection, a dissociated therapeutic response was observed with a decrease of the cerebral lesion and an increase of the adrenal mass. This result may be explained by the efficacy of corticosteroid therapy on cerebral edema. The prognosis was poor with tumor infiltration of the leptomeninges and death 16 months after diagnosis.

Isolated Cranial Nerve III Palsy as the Presenting Manifestation of HIV-related Large B-Cell Lymphoma: Clinical, radiological and Postmortem Observations: Report of a Case and Review of the Literature

Rarely can a neurologically isolated cranial nerve III palsy be the presenting manifestation of central nervous system lymphoma. We detail the clinical, radiological, and pathological features of a previously healthy 45-year-old man presenting with an isolated, pupil-involving, right cranial nerve III palsy due to human immunodefiency virus (HIV) related non-Hodgkin lymphoma. Magnetic resonance imaging demonstrated bilateral peripheral cranial nerve III enhancement with no brain parenchymal or leptomeningeal abnormalities. Cerebrospinal fluid analysis revealed a monocytic pleocytosis with an elevated protein concentration and depressed glucose level. Morphologic and flow cytometric analysis of the cerebrospinal fluid was compatible with a large B-cell lymphoma. Serologic tests for HIV were positive. Postmortem examination of the brain revealed malignant lymphomatous cell infiltration of both cranial nerve III, diffuse leptomeningeal disease and focal superficial subependymal and subpial invasion. Based on our review of the literature, we were able to find only 10 detailed cases of cranial nerve III palsy as the presenting manifestation of central nervous system lymphoma. Furthermore, none of the previously reported cases correlated the magnetic resonance imaging findings with the gross and histopathologic observations.