Clivus lymphoma

Endoscopic endonasal approach to the cavernous sinus Epstein-Barr virus-positive B cell non-Hodgkin lymphoma in a child: case report

Cavernous sinus (CS) lymphoma without paranasal sinuses involvement is extremely rare in pediatric population and remains a diagnostic challenge due to its similarity to other tumors located in this area. An 8-year-old boy presented with a 6-day history of gradually developing ptosis in the right eyelid. After admission, his symptoms progressed within 24 h to include right-sided ophthalmoplegia consisting of oculomotor and abducens nerve palsies. Endoscopic endonasal approach (EEA) was performed urgently to decompress the CS and to obtain a diagnosis. The postoperative course was uneventful, and there was no complication related to the surgical approach. No immunodeficiency was identified. The histopathological diagnosis was an Epstein-Barr virus (EBV)-positive high-grade mature B cell non-Hodgkin lymphoma. He was initiated chemotherapy according to COG ANHL01P1 protocol. Two months after surgery, the third and sixth nerve palsies had resolved completely. Currently, he is well and has no clinical or radiological recurrence. This is the first pediatric case with EBV-positive CS lymphoma that underwent EEA for the diagnosis and decompression. In the pediatric population, EEA enables minimally invasive access to the CS and can play an alternative role in the management of CS lesions, either through biopsy or debulking.

CT, conventional, and functional MRI features of skull lymphoma: a series of eight cases in a single institution

OBJECTIVE

With the hypothesis that the combination of CT, conventional, and functional MRI can indicate a possible diagnosis of skull lymphoma, this study aimed to systematically explore CT, conventional, and functional MRI features of this rare entity.

MATERIALS AND METHODS

This retrospective study included eight patients with pathologically confirmed skull lymphomas. CT and conventional MRI findings, including the location, size, attenuation/signal intensity, cystic/necrosis, hemorrhage, calcification, enhancement, skull change, brain parenchyma edema and adjacent structure invasion, were reviewed. We also reviewed multi-parametric functional MR imaging features obtained from diffusion-weighted imaging (DWI, n = 4), susceptibility-weighted imaging (SWI, n = 3) and dynamic susceptibility-weighted contrast-enhanced perfusion-weighted imaging (DSC-PWI, n = 1).

RESULTS

The eight patients in this series consisted of five males and three females, with a mean age of 51.1 years. All skull lymphomas showed the tumors extending to extra- and intra-cranial spaces with permeative destruction of the intervening skull. Intratumoral cystic/necrosis was seen in one case. Hemorrhage or calcification was absent. Dural mater infiltration was detected in all cases. Two clivus lymphomas encased internal carotid artery without narrowing the lumen. Three cases invaded brain parenchyma with moderate edema. The tumors demonstrated high signal on DWI with low ADC values comparing to muscles. SWI images showed little intratumoral hemorrhage and vessel. Low relative cerebral blood volume (rCBV) value was detected.

CONCLUSIONS

Skull lymphomas commonly presented as a homogenous solid tumor extending either intra- or extra-cranially with permeative bone destruction. Restricted diffusion, little intratumoral susceptibility signal, and lower perfusion may indicate a specific diagnosis. Multi-parametric functional MRI may be a promising tool for the diagnosis of skull lymphomas.

Primary Lymphoma of the Skull Base in the Chinese: Clinical, Radiological, Pathological, and Therapeutic Experience in a Series of 8 Patients

BACKGROUND

Primary lymphoma of the skull base (PLSB) is an extremely rare neoplasm and not much is known regarding the clinical features of, treatment strategies for, and prognoses of these lesions. We investigated the manifestations and clinical outcomes of Chinese patients with PLSB.

METHODS

We retrospectively reviewed the data from 8 consecutive patients with PLSB who had been treated at our center from October 2008 to December 2016 and analyzed their clinical features, treatment strategies, and prognoses.

RESULTS

Of the 8 patients, 3 were men and 5 were women, with a male/female ratio of 0.6. The median age was 53.5 years. In most instances, the onset was characterized by headache, followed by dysfunction of the cranial nerves. The most frequently affected region was the cavernous sinus. On magnetic resonance imaging, the main characteristic was that the internal carotid artery was encased by the tumor without an obvious tendency to be deformed, dislocated, or narrowed. All patients underwent surgical biopsy via a transsphenoidal or sublabial-transmaxillary approach. The pathological diagnosis was non-Hodgkin lymphoma for all 8 patients, with diffuse large B-cell lymphoma in 7 patients. The patients underwent chemotherapy and involved-field radiotherapy. The median overall survival was 52 months, and the 1-year progression-free survival rate was 87.5%.

CONCLUSIONS

PLSB is a rare disease and a diagnostic challenge, with most cases in the Chinese due to diffuse large B-cell lymphoma. We found that the incidence peaked in middle and old age, and the cavernous sinus was usually affected. Multidisciplinary treatment involving surgical biopsy, chemotherapy, and radiotherapy was an effective therapeutic strategy.

A slippery slope

A 74-year-old woman experienced chronic painless progressive binocular horizontal diplopia for 2 years. Initial examination showed a visual acuity of 20/20 OU. External and slit lamp examination was unremarkable. Orthoptic evaluation showed an incomitant esotropia, a small vertical strabismus, and a large degree of excyclotorsion. Investigation revealed a diagnosis of diffuse large B-cell lymphoma.

Multimodality Imaging Spectrum of the Extranodal Lymphomas in the Head and Neck-A Pictorial Review

Lymphoma is the second most common malignant neoplasm of the head and neck region, involving the nodal and/or extranodal sites or both in a variable fashion. Lymphoma may mimic a variety of tumors in this region depending on the subsite involved. The usual presentation of lymphomatous disease is presence of multiple enlarged, often conglomerate, lymph nodes without significant necrosis. Extranodal lymphomas demonstrate more complex radiologic features, but careful evaluation can identify distinct imaging patterns to suggest extranodal lymphomatous disease from other more common lesions. Knowledge of these imaging features can help raise suspicion for lymphoma as a differential consideration. This can be of critical importance since further work-up and management can be vastly different between lymphomatous disease and other disease entities. The authors present a pictorial review of the spectrum of imaging findings in extranodal head and neck lymphomas.

Stereotactic biopsy approach to the upper clivus through the middle fossa floor that avoids pneumatised cavities and the intradural compartment

BACKGROUND

Biopsies of clival lesions are usually performed, under general anaesthesia, through an anterior endoscopic approach or, alternatively, through a trans-nasal or trans-oral stereotactic approach.

METHODS

A 57-year-old man with a symptomatic osteolytical lesion of the clivus, who refused general anaesthesia, underwent a sterotactically guided biopsy of the lesion by an antero-lateral approach through the temporal and sphenoid bones.

RESULTS

Biopsy was successfully performed and the resulting diagnosis was myeloma. The patient was comfortable during and after surgery and there were no complications.

CONCLUSIONS

The present stereotactic antero-lateral approach to the biopsy of the upper clivus can be considered an useful adjunct to the current trans-oral and transnasal approaches that often require general anaesthesia.

Sixth cranial nerve palsy caused by gastric adenocarcinoma metastasis to the clivus

Tumors of the clivus and metastases to the clivus are very rare. Metastasis involving the clivus has previously been described in only two case reports. In skull metastasis, the breast and prostate are the most common primary foci, while metastasis from gastric carcinoma is extremely rare. A review of the English literature revealed only one published case of clivus metastases from gastric adenocarcinoma. There is no literature thoroughly explaining the differential diagnosis between chordoma and metastasis. Here we report a rare case of metastasis to the clivus from a gastric adenocarcinoma in a 42-year-old female patient with sudden blurry vision, presenting as bilateral cranial nerve VI palsy.

[Primary clivus diffuse large B cell lymphoma presenting with posterior neck pain and bilateral abducens nerve palsy]

Bilateral abducens nerve palsy is an unusual clinical presentation, which could be caused by stroke, aneurysm, trauma and malignant neoplasm. We describe here a patient with bilateral abducens nerve palsy caused by large B cell lymphoma originated from clivus. An 83-year-old woman admitted to our hospital because of diplopia and severe posterior neck pain. Her diplopia developed one month before and progressed to her admission. Neurological examination revealed bilateral abducens nerve palsy. Brain MRI with enhancement lesion in the clivus, suggesting that bilateral petroclival segment of the abducens nerves were affected by the lesion. Biopsied was performed via a transsphenoidal approach, and histological diagnosis was made as diffuse large B cell lymphoma. She received oral corticosteroid administration combined with radiation therapy. After initiation of the treatment, posterior neck pain was resolved and tumor size was reduced in the repeated brain MRI. However, diplopia and bilateral abducens nerve palsy were still unresolved. Although malignant lymphoma originated at the clivus is uncommon, according to a presenting case as well as previously reported cases, lymphoma can present as an isolated involvement in the clivus associated with headache, and bilateral abducens nerve palsy. It is suggested that the clivus tumor affected the petroclival segment of abducent nerve in our case.

Resolution of immune thrombocytopenic purpura associated with extranodal B-cell lymphoma of the petroclival region after radiotherapy

Background:

Secondary immune thrombocytopenic purpura (ITP) associated with extranodal B-cell non-Hodgkin’s lymphoma (NHL) is extremely rare. The optimal management is not established. We report a first case of ITP in association with extranodal B-cell NHL originating in the lower petroclival region, successfully managed by local tumor control using conventional radiotherapy.

Case Description:

A 75-year-old man presented with a two-month history of hearing loss, hoarseness, and dysphagia. Neuroimaging revealed a large enhanced lesion in the left lower petroclival bone near the jugular foramen. Isolated unilateral parotid lymphadenopathy was also noted. Preoperative laboratory findings were normal, except for elevation of serum soluble interleukin-2 receptor level. A suboccipital craniotomy was performed and a biopsy sample was taken. Histological and immunohistochemical examination confirmed small B-cell lymphoma with plasmacytic differentiation. After initiation of radiotherapy, thrombocytopenia (24,000/µl) rapidly developed. Serological and bone marrow examination confirmed ITP. Prednisone was given at 1 mg/kg/day and radiation therapy was continued. After more than 32Gy, platelet count rapidly normalized. Radiotherapy to the tumor site achieved local tumor control and ITP was resolved. No evidence of recurrence and normal platelet count were confirmed at the two-year follow-up examination.

Conclusion:

Local control of the tumor was considered important in the resolution of secondary ITP in association with extranodal NHL of the skull base region.

Metastatic skull tumors: MRI features and a new conventional classification

Skull metastases are malignant bone tumors which are increasing in incidence. The objectives of this study were to characterize the MR imaging features, locations, and extent of metastatic skull tumors to determine the frequency of the symptomatic disease, and to assess patient outcomes. Between September 2002 and March 2008, 175 patients undergoing routine head MR imaging were found to have metastatic skull tumors. Contrast-enhanced study with fat suppression was used in some cases when required. Classification of metastases was simplified to three yes/no questions: first, with regard to location (either in the calvarium or in the cranial base); second, with regard to distribution within the plane of the cranial bone (either “circumscribed” meaning clearly demarcated and confined to one bone, or “diffuse” and likely to spread across a suture to another bone); and third, with regard to invasion (“intraosseous” in cranial bones only, or “invasive” spreading from the skull, either out into the scalp or inward to the dura and perhaps further in). Primary sites were breast cancer (55%), lung cancer (14%), prostate cancer (6%), malignant lymphoma (5%), and others (20%). The mean time from primary diagnosis to skull metastasis diagnosis was 71 months for cases of breast cancer, 26 months for prostate cancer, 9 months for lung cancer, and 4 months for malignant lymphoma. Calvarial circumscribed intraosseous metastases were found most frequently (27%). The patients were mainly asymptomatic. However, some patients suffered from local pain or cranial nerve palsies that harmed their quality of life. Treatment, mainly for symptomatic cases, was by local or whole-skull irradiation. Metastatic skull tumors are not rare, and most are calvarial circumscribed intraosseous tumors. MR images contribute to understanding their type, location, and multiplicity, and their relationship to the brain, cranial nerves, and dural sinuses. Radiation therapy improved the QOL of patients with neurological symptoms.

Quality initiatives: blind spots at brain imaging

Radiologists face the daily challenge of analyzing and interpreting a high volume of images in a timely manner. Minimizing errors, whether perceptual or cognitive in nature, is paramount for high-quality diagnostics and patient care. There are certain areas within the head encountered at routine brain imaging in which the interpreting radiologist is most prone to make perceptual errors. These areas, or "blind spots," include the cerebral sulci, dural sinuses, orbits, cavernous sinuses, clivus, Meckel cave, brainstem, skull base, and parapharyngeal soft tissues. In addition, the use of an inappropriate window width and level for the evaluation of computed tomographic (CT) scans can be a virtual, rather than an anatomic, blind spot. The inclusion of a comprehensive checklist for evaluation of these blind spots as part of every brain imaging study is crucial for avoiding false-negative results. Knowledge of the anatomic features of these blind spots is also crucial, as well as familiarity with the normal CT and magnetic resonance imaging findings in these areas. In addition, the radiologist should be aware of possible interpretation pitfalls that may lead to false-positive results (eg, normal anatomic variants that may be mistaken for pathologic conditions). Finally, a well-developed differential diagnosis will help ensure correct interpretation and appropriate patient treatment.

Clivus metastases: report of seven patients and literature review

BACKGROUND

Tumours of the clivus are rare and metastases involving this area have been previously described only as single case reports or included in series with other skull base tumours. Here, we describe seven such examples and review the pertinent literature.

METHOD

Clinical, radiological and follow-up data of patients who had undergone surgery for clivus tumours at our Institution between January 1995 and December 2007 were retrospectively collected. A literature review was performed using PubMed.

FINDINGS

Of 46 patients who underwent surgery for clivus bone tumours, seven proved to harbour a metastasis. This figure represents 0.18% and 0.42% respectively of intracranial and skull base tumours which were treated in our Institution in the study period. The primary tumours associated were lung adenocarcinoma (n = 2), prostate carcinoma (n = 2), skin melanoma (n = 1), hepatocarcinoma (n = 1) and lung squamous cell carcinoma (n = 1). All patients presented with a sixth nerve palsy as the symptom. Histopathology was obtained via a trans-sphenoidal biopsy. In spite of radiotherapy and chemotherapy, the mean survival was 12 months. On literature review, 27 examples of metastases located in the clival bone were found. Including our series, the most common primary tumours were prostate cancer (26.4%), thyroid carcinoma (11.7%) and hepatocarcinoma (11.7%).

CONCLUSION

Though exceedingly rare, metastases involving the clivus should be considered in the differential diagnosis with clivus chordoma. The metastatic lesion might be a late and single expression of the primary tumour. The trans-sphenoidal approach is the ideal procedure to establish a histopathological diagnosis. Prognosis is poor.

Central skull base lymphoma in children: MR and CT features

BACKGROUND

Central skull base tumours are rare in children.

OBJECTIVE

To characterize the imaging features of central skull base lymphoma in children to aid its diagnosis.

MATERIALS AND METHODS

The authors reviewed the CT findings (available in three patients) and MR findings (available in four patients) in four patients (three boys, one girl; age 2-12 years) with pathologically proven lymphoma (two with Burkitt lymphoma, two with B-cell lymphoma) involving the central skull base. Tumour location and extent, MRI signal intensities, noncontrast CT attenuation, patterns of enhancement, and changes in adjacent structures were evaluated.

RESULTS

All four tumours involved the sphenoid bone. In three patients, the tumour extended to the ethmoid sinus and both cavernous sinuses. All lesions were isointense solid masses on T2-weighted images and showed avid enhancement, except for one lesion with a focal necrosis. All tumours were associated with adjacent dural thickening. Non-contrast CT showed highly attenuating masses and permeative bone destruction in the central skull base.

CONCLUSION

Lymphoma involving the central skull base in children is visualized as an isointense mass on T2-weighted MRI with marked contrast enhancement and adjacent dural thickening, and as a highly attenuating mass on noncontrast CT with permeative or erosive bone destruction patterns.

Primary non-Hodgkin lymphoma of the skull base presenting with Garcin syndrome: MRI manifestations

Primary non-Hodgkin lymphoma of the skull base is a rare disorder. We report a case of primary non-Hodgkin lymphoma of the skull base presenting with Garcin syndrome. MRI revealed peculiar lesions in the cavernous sinus, clivus, and occipital bone. Diagnosis was made by biopsy of the tumor in the cavernous sinus.

Burkitt lymphoma involving the clivus

Burkitt lymphoma (BL) is a rapidly dividing tumor that commonly presents itself in the jaw in its endemic form and the abdomen in the sporadic type. Central nervous system involvement at diagnosis is not uncommon, but there have been no previously published reports of BL involving the clivus. Increased tumor burden is associated with complications such as tumor lysis syndrome, and recognition of unusual presentations is important for timely management. We report 3 patients with BL involving the clivus at diagnosis.

Primary lymphoma of the skull base

This case demonstrates the rare finding of a primary malignant lymphoma of the frontobasis and ethmoidal cells in a patient presenting with progressive loss of vision. Computed tomography and MRI demonstrated a homogenously enhancing tumour with extensive bony destructions of the skull base. After transsphenoidal biopsy, histology revealed a highly malignant primary B-cell lymphoma. The patient was further treated with immunochemotherapy. Tissue diagnosis is, therefore, crucial before a definitive therapy is instituted.