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Hasner MC, van Opijnen MP, van der Meulen M, Verdijk RM, Maas SLN, Te Boome LCJ, Broekman MLD. Diagnostics and treatment delay in primary central nervous system lymphoma: What the neurosurgeon should know. Acta Neurochir (Wien) 2024; 166:261. [PMID: 38858236 PMCID: PMC11164806 DOI: 10.1007/s00701-024-06138-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/19/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE The gold standard for diagnostics in primary central nervous system lymphoma (PCNSL) is histopathological diagnosis after stereotactic biopsy. Yet, PCNSL has a multidisciplinary diagnostic work up, which associated with diagnostic delay and could result in treatment delay. This article offers recommendations to neurosurgeons involved in clinical decision-making regarding (novel) diagnostics and care for patients with PCNSL with the aim to improve uniformity and timeliness of the diagnostic process for patients with PCNSL. METHODS We present a mini review to discuss the role of stereotactic biopsy in the context of novel developments in diagnostics for PCNSL, as well as the role for cytoreductive surgery. RESULTS Cerebrospinal fluid-based diagnostics are supplementary and cannot replace stereotactic biopsy-based diagnostics. CONCLUSION Histopathological diagnosis after stereotactic biopsy of the brain remains the gold standard for diagnosis. Additional diagnostics should not be a cause of diagnostic delay. There is currently no sufficient evidence supporting cytoreductive surgery in PCNSL, with recent studies showing contradictive data and suboptimal study designs.
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Affiliation(s)
- M C Hasner
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, The Netherlands.
| | - M P van Opijnen
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - M van der Meulen
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - R M Verdijk
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S L N Maas
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - L C J Te Boome
- Department of Hematology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - M L D Broekman
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
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Tosefsky K, Rebchuk AD, Martin KC, Chen DW, Yip S, Makarenko S. Preoperative Corticosteroids Reduce Diagnostic Accuracy of Stereotactic Biopsies in Primary Central Nervous System Lymphoma: A Systematic Review and Meta-Analysis. Neurosurgery 2024:00006123-990000000-01141. [PMID: 38865324 DOI: 10.1227/neu.0000000000002944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/12/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Despite general acceptance that corticosteroid therapy (CST) should be withheld before biopsy for suspected primary central nervous system lymphoma (PCNSL), there remains conflicting evidence surrounding the precise impact of preoperative CST on the histopathological diagnosis. The objective of this systematic review and meta-analysis was to describe and quantify the effects of preoperative CST on the diagnostic accuracy of biopsies for PCNSL. METHODS Primary articles were screened from Ovid MEDLINE, Embase, Web of Science, and Scopus databases. Meta-analysis was performed for immunocompetent patients with histologically confirmed PCNSL. Subgroup and regression analyses were performed to assess the effects of biopsy type, CST duration, dose, and preoperative taper on the diagnostic accuracy. In addition, the sensitivity of cerebrospinal fluid (CSF) analyses for PCNSL was assessed. RESULTS Nineteen studies, comprising 1226 patients (45% female; mean age: 60.3 years), were included. Preoperative CST increased the risk of nondiagnostic biopsy with a relative risk (RR) of 2.1 (95% CI: 1.1-4.1). In the stereotactic biopsy subgroup, the RR for nondiagnostic biopsy was 3.0 (95% CI: 1.2-7.5). CST taper, duration, and dose did not significantly influence diagnostic biopsy rates. The sensitivity of CSF cytology, including flow cytometry, for PCNSL was 8.0% (95% CI: 6.0%-10.7%). CONCLUSION Our results suggest that preoperative CST reduces the diagnostic yield of stereotactic biopsies for PCNSL. We found no evidence that tapering CST before biopsy improves diagnostic rates. CSF analysis currently has a poor sensitivity for the diagnosis of PCNSL.
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Affiliation(s)
- Kira Tosefsky
- MD Undergraduate Program, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexander D Rebchuk
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Karina Chornenka Martin
- Department of Pathology & Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David W Chen
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephen Yip
- Department of Pathology & Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Serge Makarenko
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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Kahraman A, Dirilenoğlu F, Güzeliş İ, Çetinoğlu K. Intraoperative pathologic diagnosis of central nervous system lymphomas: A comparison of frozen and permanent section diagnoses, and the significance of preoperative imaging. Ann Diagn Pathol 2024; 69:152246. [PMID: 38113550 DOI: 10.1016/j.anndiagpath.2023.152246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/09/2023] [Accepted: 12/10/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Central nervous system (CNS) lymphomas, either primary or secondary in origin, are rare malignant tumors affecting the brain, spinal cord, or leptomeninges. Diagnosis of CNS lymphomas is complicated by their diverse clinical presentations, radiological features, and histopathological characteristics. Although frozen section (FS) analysis is commonly employed for various CNS tumors, its role and accuracy in CNS lymphoma diagnosis are less explored. In this study, we conducted a comparative analysis to assess the impact of knowledge of preoperative imaging on enhancing the accuracy of FS diagnosis in CNS lymphomas. METHODS Data collection involved a retrospective review of CNS lymphoma patients from January 2009 to August 2021. Patients who underwent intraoperative consultation were included, excluding those with prior cortisone treatment. The dataset incorporated patient demographics, classification as primary or secondary lymphoma, radiological preliminary diagnoses, FS diagnosis, and permanent section diagnosis. We employed various archived materials, including FSs, touch imprint slides, crush cytology slides, H&E-stained sections, and immunohistochemical stains, and re-evaluated all slides for diagnostic validation. RESULTS Our study included 25 patients, of whom 60 % were female and had a mean age of 56.5 years. Preoperative radiology data were available for 80 % of cases, with preliminary diagnoses commonly including lymphoma and/or metastasis. Intraoperative consultation results indicated lymphoma in 18 (72 %) patients, with discordance observed in 28 % of cases when compared to permanent section diagnoses. Most permanent section diagnoses were diffuse large B-cell lymphomas (92 %), with the remainder being T-cell non-Hodgkin lymphoma (4 %) and follicular lymphoma (4 %). Intraoperative misdiagnoses were significantly associated with the absence of knowledge of preoperative imaging. CONCLUSION Our study demonstrates the reliability of FS diagnosis for CNS lymphomas during surgery, with a favorable complete concordance rate of 72 % when compared to permanent diagnoses. Importantly, lack of knowledge of preoperative imaging significantly impaired diagnostic accuracy in FS, emphasizing the need for close collaboration between pathologists and radiologists.
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Affiliation(s)
- Aslı Kahraman
- Department of Pathology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Türkiye
| | - Fikret Dirilenoğlu
- Department of Pathology, Faculty of Medicine, Near East University, Nicosia, Cyprus.
| | - İsmail Güzeliş
- Department of Pathology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Türkiye
| | - Kenan Çetinoğlu
- Department of Radiology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Türkiye
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Meira Goncalves J, Polónia P, Pereira J, Silva PA. Primary Central Nervous System Lymphoma Mimicking the Presentation of Pituitary Apoplexy: A Case Report. Cureus 2023; 15:e50912. [PMID: 38249173 PMCID: PMC10799692 DOI: 10.7759/cureus.50912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
Pituitary lymphoma is one of the rare variants of primary central nervous system lymphoma (PCNSL), mostly arising due to the metastatic spread of systemic lymphoma. We report the case of a 69-year-old woman who initially presented to her family physician with a headache but without any other symptoms. The MRI scan revealed a sellar mass consistent with a pituitary macroadenoma. When the patient was referred to our hospital, two weeks later, the symptoms had progressed, comprising complete right-sided ophthalmoplegia and ptosis, with left-sided amaurosis. A repeat MRI revealed an increased size of the sellar mass, consistent with pituitary apoplexy. A right pterional craniotomy with partial resection of the mass was performed and an intraoperative frozen section biopsy was carried out. The final pathology revealed diffuse large B-cell lymphoma. A systemic follow-up including a whole-body CT, bone marrow aspiration, and cerebrospinal fluid studies ruled out any systemic manifestation, and the patient was HIV-negative. The patient underwent treatment with methotrexate, cytarabine, thiotepa, and rituximab for PCNSL. Although rare, PCNSL can mimic pituitary apoplexy, which needs to be considered if conservative therapy or surgery is to be offered to a patient with a radiological and clinical diagnosis of pituitary apoplexy.
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Affiliation(s)
- Joao Meira Goncalves
- Neurosurgery Department, Centro Hospitalar Universitário de São João, Porto, PRT
- Faculty of Medicine, University of Porto, Porto, PRT
| | - Patricia Polónia
- Neurosurgery Department, Centro Hospitalar Universitário de São João, Porto, PRT
- Faculty of Medicine, University of Porto, Porto, PRT
| | - Josué Pereira
- Neurosurgery Department, Centro Hospitalar Universitário de São João, Porto, PRT
- Faculty of Medicine, University of Porto, Porto, PRT
- Neurosciences Centre, Hospital CUF, Porto, PRT
| | - Pedro Alberto Silva
- Neurosurgery Department, Centro Hospitalar Universitário de São João, Porto, PRT
- Faculty of Medicine, University of Porto, Porto, PRT
- Neurosciences Centre, Hospital CUF, Porto, PRT
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Ngo A, McGehrin K, Di Loreto C, Arora R, LaBuzetta JN. Clinical Reasoning: A 67-Year-Old Man With Multiple Intracranial Lesions. Neurology 2023; 101:e845-e851. [PMID: 37156616 PMCID: PMC10449443 DOI: 10.1212/wnl.0000000000207386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 03/21/2023] [Indexed: 05/10/2023] Open
Abstract
A wide variety of diseases present with intracranial lesions. In this case report, a 67-year-old man initially presented to an outside hospital with nausea, headache, and ataxia and was found to have multiple intracranial lesions. Diagnostic workup was ultimately unrevealing, and his condition improved after a course of steroids and antibiotics. Unfortunately, symptoms returned 3 months later. MRI of the brain revealed progression of his intracranial lesions. This case highlights a diagnostic approach and general management strategy for patients presenting with undifferentiated intracranial pathology. A final diagnosis is ultimately reached and raises further discussion.
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Affiliation(s)
- Angeline Ngo
- From the Department of Neurosciences (A.N., K.M., J.N.L.), University of California San Diego; Office of the Coroner Ada County (C.D.L.), Boise, ID; and Department of Neurology (R.A.), Keck School of Medicine of USC, Los Angeles, CA.
| | - Kevin McGehrin
- From the Department of Neurosciences (A.N., K.M., J.N.L.), University of California San Diego; Office of the Coroner Ada County (C.D.L.), Boise, ID; and Department of Neurology (R.A.), Keck School of Medicine of USC, Los Angeles, CA
| | - Christina Di Loreto
- From the Department of Neurosciences (A.N., K.M., J.N.L.), University of California San Diego; Office of the Coroner Ada County (C.D.L.), Boise, ID; and Department of Neurology (R.A.), Keck School of Medicine of USC, Los Angeles, CA
| | - Rajan Arora
- From the Department of Neurosciences (A.N., K.M., J.N.L.), University of California San Diego; Office of the Coroner Ada County (C.D.L.), Boise, ID; and Department of Neurology (R.A.), Keck School of Medicine of USC, Los Angeles, CA
| | - Jamie Nicole LaBuzetta
- From the Department of Neurosciences (A.N., K.M., J.N.L.), University of California San Diego; Office of the Coroner Ada County (C.D.L.), Boise, ID; and Department of Neurology (R.A.), Keck School of Medicine of USC, Los Angeles, CA
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Scheichel F, Popadic B, Pinggera D, Jaskolski DJ, Lubrano V, Foroglou N, Netuka D, Iliescu B, Novak L, Sherif C, Marhold F, Freyschlag CF. European survey on neurosurgical management of primary central nervous system lymphomas and preoperative corticosteroid therapy. BRAIN & SPINE 2023; 3:101791. [PMID: 38020980 PMCID: PMC10668066 DOI: 10.1016/j.bas.2023.101791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/29/2023] [Accepted: 08/11/2023] [Indexed: 12/01/2023]
Abstract
Introduction Preoperative corticosteroid therapy (CST) is common in primary central nervous system lymphoma (PCNSL) and may complicate histopathological diagnosis. There is an ongoing debate on the best management after preoperative CST. Research question We aimed to survey how different European neurosurgical units treat PCNSL patients after preoperative CST. Methods An English-language survey consisting of 21 questions addressing the management of patients with suspected PCNSL and preoperative CST was sent to European hospitals. The survey also included three clinical cases to assess the decision-making process in a clinical setting. Results The survey was completed by 74 European hospitals. There was no clear consensus on how to treat a patient with PCNSL after CST. Accordingly, 24.3% responded that they would generally defer surgery regardless of a possible radiological response, 47.3% would defer surgery only if there is regression in preoperative MRI and the remaining 28.4% would defer surgery only if the tumor had completely vanished. Furthermore, there were distinct discrepancies in responses of neurosurgical units regarding their general management approach and their case-based decision in the three example cases. The results of our survey also showed regional differences and differences in treatment decisions between high-, intermediate- and low-volume centers. Discussion and conclusion There was no clear consensus on how to treat patients with suspected PCNSL and preoperative CST. Furthermore, most centers also showed inconsistencies in their responses regarding their general approach as well as individual patient treatment. More high-quality evidence-based recommendations are needed to improve consensus and thus patient care.
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Affiliation(s)
- Florian Scheichel
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Branko Popadic
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Daniel Pinggera
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dariusz J. Jaskolski
- Department of Neurosurgery and Neurooncology Medical University of Lodz, Norbert Barlicki University Hospital, Lodz, Poland
| | - Vincent Lubrano
- Clinique de l'Union, Saint Jean, France
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Nicolas Foroglou
- Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - David Netuka
- Central Military Hospital, Prague, Czech Republic
| | - Bogdan Iliescu
- Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Laszlo Novak
- Department of Neurosurgery, Clinical Centre, University of Debrecen, Debrecen, Hungary
| | - Camillo Sherif
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Franz Marhold
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
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Jesser J, Bendszus M. [Imaging pathologies of the corpus callosum]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:209-219. [PMID: 36688985 DOI: 10.1007/s00117-022-01111-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The corpus callosum is the largest fiber bundle in the cerebral white matter in the human brain. A multitude of disorders including congenital malformations, acute and chronic traumatic lesions, ischemia, neoplasms, secondary manifestations of metabolic, toxic or degenerative diseases as well as chronic inflammatory and demyelinating diseases can primarily or secondarily affect the corpus callosum. This article presents magnetic resonance imaging (MRI) characteristics of the most relevant diseases affecting the corpus callosum.
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Affiliation(s)
- J Jesser
- Abteilung für Neuroradiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - M Bendszus
- Abteilung für Neuroradiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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Shen J, Liu J. Bruton's tyrosine kinase inhibitors in the treatment of primary central nervous system lymphoma: A mini-review. Front Oncol 2022; 12:1034668. [PMID: 36465385 PMCID: PMC9713408 DOI: 10.3389/fonc.2022.1034668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/31/2022] [Indexed: 09/19/2023] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a highly aggressive brain tumor with poor prognosis if no treatment. The activation of the NF-κB (nuclear factor kappa-B) is the oncogenic hallmark of PCNSL, and it was driven by B cell receptor (BCR) and Toll-like receptor (TLR) signaling pathways. The emergence of Bruton's tyrosine kinase inhibitors (BTKis) has brought the dawn of life to patients with PCNSL. This review summarizes the management of PCNSL with BTKis and potential molecular mechanisms of BTKi in the treatment of PCNSL. And the review will focus on the clinical applications of BTKi in the treatment of PCNSL including the efficacy and adverse events, the clinical trials currently being carried out, the underlying mechanisms of resistance to BTKi and possible solutions to drug resistance.
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Affiliation(s)
- Jing Shen
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
| | - Jinghua Liu
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Hematology, Northern Theater General Hospital, Shenyang, China
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Jesser J, Bendszus M. [Imaging pathologies of the corpus callosum]. DER NERVENARZT 2022; 93:844-853. [PMID: 35829754 DOI: 10.1007/s00115-022-01347-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 11/25/2022]
Abstract
The corpus callosum is the largest fiber bundle in the cerebral white matter in the human brain. A multitude of disorders including congenital malformations, acute and chronic traumatic lesions, ischemia, neoplasms, secondary manifestations of metabolic, toxic or degenerative diseases as well as chronic inflammatory and demyelinating diseases can primarily or secondarily affect the corpus callosum. This article presents magnetic resonance imaging (MRI) characteristics of the most relevant diseases affecting the corpus callosum.
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Affiliation(s)
- J Jesser
- Abteilung für Neuroradiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - M Bendszus
- Abteilung für Neuroradiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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