Primary lymphoma of the brain associated with AIDS. A study of one case

A Clinicopathological Study of Seven Cases of Primary High-Grade Malignant Non-Hodgkin's Lymphoma of the Central Nervous System

Seven cases of primary non-Hodgkin's lymphomas of the central nervous system are described. Six cases were diagnosed after pathologic examination of surgical material; in one case, a patient with acquired immunodeficiency syndrome, the diagnosis was made at autopsy. The mean age of the patients was 52 years. The lesions were supratentorial in all cases, and unifocal in 6: the autopsy case had multicentric lesions. The cytologic examination of the cerebrospinal fluid was performed in 3 cases and was negative. The most common histologic type was immunoblastic lymphoma. The mean postoperative survival time was 12 months; in 2 cases, surgery combined with radiotherapy prolonged the survival for more than 2 years. Leptomeningeal involvement was considered to indicate a poor prognosis.

Primary lymphoma of the central nervous system

Eleven patients with primary lymphoma of the central nervous system were seen in the King Faisal Specialist Hospital and Research Centre, Saudi Arabia, between 1986 and 1992. None had previously received immunosuppressive therapy. All cases were confirmed by biopsy and histopathological studies. Of the eleven patients, six had debulking of the tumour, seven received radiation therapy and six received chemotherapy. This report confirms the very poor prognosis for patients with primary lymphoma of the central nervous system, with only a few long-term survivors.

Primary cerebral lymphoma: report of 24 patients and review of the literature

A retrospective study of 24 patients with primary non-Hodgkin's cerebral lymphoma (non-immunocompromised) is presented. All patients were seen at the Royal Preston Hospital, Lancashire between 1976 and 1991. Fifteen patients were over the age of 50 years (range 27-84). The commonest clinical presentation, seen in 16 patients was of an expanding space-occupying lesion. The diagnosis was suspected from the radiological findings but confirmation in every case was by histological examination of biopsy or necropsy material. The tumours were treated either by surgical excision or by biopsy and radiotherapy. Chemotherapy was given in two patients. Despite these measures the mean survival time was 3.6 months. The clinical radiological and pathological features of these tumours are highlighted with particular emphasis on the use of stereotactic biopsy, immunohistochemistry and chemotherapy in diagnosis and treatment.

Review of the central nervous system cytopathology in human immunodeficiency virus infection

The human immunodeficiency virus (HIV) is a neurotropic retrovirus capable of producing a wide spectrum of central nervous system changes. Nearly 40% of HIV-infected patients demonstrate neuropathy ranging from dementia to the opportunistic infections and neoplasia seen in the acquired immunodeficiency syndrome (AIDS). Dramatic increases in the numbers of AIDS cases have allowed for the cytotechnologist and cytopathologist to become acquainted with the various pathologic manifestations of HIV infection. In this review, we are reporting the HIV-related diseases in the central nervous system and the role of diagnostic cytology.

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.

Simple and choice reaction time in patients with human immunodeficiency virus infection

The performance of 56 homosexual men infected with human immunodeficiency virus (HIV) was compared to that of 23 HIV antibody-seronegative controls on simple (SRT) and choice (CRT) reaction time tasks. Patients were classified into 3 groups according to Centers for Disease Control clinical criteria. There were 18 patients who had acquired immunodeficiency syndrome (AIDS), 18 who had AIDS-related complex (ARC), and 20 who were HIV antibody-seropositive but otherwise asymptomatic (HIV-Ab+). The SRT task consisted of 5 trials, each containing 10 target stimuli. The CRT task consisted of 10 trials, each containing 5 target stimuli randomly interspersed with 5 nontarget stimuli. The mean response latency of each of the patient groups on the SRT task was not significantly different from that of controls. However, the performance of patients with AIDS or ARC on the CRT task was significantly lower than that of controls, whereas that of HIV-Ab+ patients was not. Analysis of the quality of RT task performance also indicated that the impairment of processing efficiency at higher levels of task difficulty reflected a disruption of processing prior to the response selection stage.

Primary central nervous system lymphoma

Primary lymphoma of the central nervous system (CNS), including reticulum cell sarcoma, microglioma, and histiocytic lymphoma, represents less than 1% of all primary brain tumors. In the last 10 years, this tumor has tripled in frequency in the nonimmunosuppressed population. By 1991, the tumor will be the most common neurological neoplasm by virtue of the increase in sporadic occurrence and in the acquired immunodeficiency syndrome (AIDS) population. Three percent of AIDS patients will develop this tumor either prior to AIDS diagnosis or during their subsequent course. In addition to acquired immunosuppression, patients with inherited disorders (such as Wiskott-Aldrich syndrome, severe combined immunodeficiency, and X-linked immunodeficiency) and other acquired disorders of the immune system are predisposed to the development of CNS lymphoma. Immunological studies have suggested a role for Epstein-Barr virus in the production of this tumor. Although subtypes exist, non-Hodgkin's lymphoma of the CNS most commonly consists of histiocytic cells or large immunoblastic cells bearing B cell surface markers in close proximity to the lateral and third ventricles. Sixty percent of these deposits are multiple, and subarachnoid invasion is seen in one-quarter of patients. Vitreous involvement of the eye occurring prior to and during the course of CNS lymphoma has been noted in up to 25% of patients. The involvement of multiple areas of the neuraxis, the eye, and multiple intracranial sites often occurs in the absence of obvious systemic lymphoma. Therapeutic trials of brain radiation therapy are associated with median survivals of less than 1 year. Uniform complete responses of intracranial deposits are recorded following chemotherapy with high-dose intravenous methotrexate, CHOP (cyclophosphamide, hydroxydaunomycin/doxorubicin, Oncovin (vincristine), and prednisone), high-dose cytosine arabinoside, and intra-arterial methotrexate with barrier modification.

Neuropathology of acquired immunodeficiency syndrome (AIDS). Analysis of 22 Brazilian cases

The neuropathologic study of 22 Brazilian cases of acquired immuno-deficiency syndrome (AIDS) was performed. Thirteen cases (59%) showed neuropathologic lesions. These included infection by Toxoplasma (n = 4), Cryptococcus neoformans (n = 3), viral encephalitis (n = 4), primary lymphomas (n = 2), isolated cerebral infarct (n = 1), and reactive gliosis (n = 1). In 2 cases, primary lymphoma and viral encephalitis were associated. Axonal spheroids in the gracilis and cuneatus nuclei were present in a case of toxoplasmosis. Mammillary bodies lesions consistent with Wernicke's encephalopathy were found in a case of viral encephalitis. In addition, circulatory changes (focal cortical infarcts) were associated lesions in 3 cases. These findings were compared with the main series reported in American and European literature.

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.

Developments in the diagnosis and treatment of primary CNS lymphoma. A prospective series

Current experience with 12 patients studied prospectively suggests a new approach in the diagnosis and treatment of primary central nervous system (CNS) lymphoma, integrating the techniques of needle brain biopsy, immunohistochemical staining for monoclonal antibody and chemotherapeutic drug delivery in association with blood-brain barrier modification. Computed tomography (CT)-guided needle biopsy of deep parenchymal lesions contributed to the diagnosis in six patients. Immunohistochemical staining methods detected monoclonal immunoglobulins in those patients so tested. Following diagnosis, the patients have been treated with multi-agent chemotherapy in conjunction with osmotic blood-brain barrier modification (five without antecedent cranial irradiation) with an initial complete response rate by CT scan in nine patients, a median follow-up of 19 months from diagnosis, and a 1-year survival of 75%. This experience emphasizes the value of CT-guided stereotaxic or CT-guided needle biopsy, which limits the need for therapy without a diagnosis or the need for a major craniotomy in what are commonly deep, paraventricular lesions. Immunoperoxidase cytochemical stains can detect monoclonal immunoglobulin characteristic of CNS B-cell malignant lymphomas and provide an important diagnostic aid when only modest quantities of tissue or cells are obtained. Finally, chemotherapy administered in conjunction with osmotic blood-brain barrier modification results in a clinical response rate and survival that are at least as effective as radiotherapy as a primary therapeutic modality.

What's new in cerebral pathology in acquired immune deficiencies?

Over the last few decades, a new pathology has appeared, directly related to the modified immune status of the hosts. It presents several distinctive points. The central nervous system is particularly affected. The opportunistic pathogenic agents do not usually injure the brain parenchyma and are not known for their aggressiveness in normal adults (papovavirus). Diagnosis of these different diseases is often difficult, some biological tests being irrelevant because of alterations of the immune system (toxoplasmosis). The lesions may be exclusively located in the brain (tuberculosis, lymphomas) which is not usually affected by these agents. Response to therapy is frequently poor, the clinical course being rapid and fatal. However, therapy may be successful in some cases, justifying the use of somewhat aggressive procedures (biopsy) in order to obtain an accurate diagnosis. It is important to be aware of these data, and an understanding of them may help in managing these already difficult patients. They also make possible some interesting pathogenic hypotheses.