Primary lymphoma of the cranial vault: case report and a systematic review of the literature

Primary Calvarial Lymphoma: A Case Report

Calvarial lymphoma is radiologically similar in many respects to meningiomas, solid fibrous tumours, osteomyelitis, and metastatic carcinomas. Even though it is an extremely rare phenomenon, the initial suspicion and detection of calvarial lymphoma are paramount to establishing a correct diagnosis which helps to determine an appropriate management strategy. We present an illustrative rare case of primary calvarial lymphoma along with a literature review focusing on the best management strategy for this rare entity. A 45-year-old female presented to our center in March 2022. She had a history of forehead swelling, which was progressively increasing in size over time. The metastatic workup and bone marrow biopsy were negative. Initially, extensive surgery was planned to resect the lesion, but after a discussion with the multidisciplinary team, a biopsy of the lesion was taken, which revealed a large B-cell lymphoma. It is prudent to consider calvarial lymphoma in the differential diagnosis of a progressively growing skull lesion, which may obviate the need for large resective surgery. A biopsy plus chemoradiation may be all that is required.

Successful CNS-Centric Therapeutic Management and Genomic Profiling of Primary Cranial Vault Diffuse Large B-Cell Lymphoma

Primary cranial vault lymphoma (PCVL) is a rare lymphoma involving the skull with or without extra- and intracranial extension. Most cases of PCVL are diffuse large B-cell lymphoma (DLBCL). We report a case of primary cranial vault diffuse large B-cell lymphoma (PCV-DLBCL) that was successfully treated with anthracycline-based chemoimmunotherapy (CIT) alternating with central nervous system (CNS)-directed CIT with high-dose methotrexate and high-dose cytarabine. CNS-centric therapy was given for suspected cerebral cortical involvement and presumed elevated risk of CNS recurrence. The patient has remained in complete remission for 4.25 years following treatment. We suggest that PCV-DLBCL is potentially curable with CNS-directed therapy. Additionally, we provide genomic profiling results indicating an indeterminate cell of origin and multiple genetic mutations which are not frequently seen in DLBCL.

Cranial vault lymphoma - A case report and characteristics contributing to a differential diagnosis

Background

Lymphomas of the cranial vault are rare and are often misdiagnosed preoperatively as presumptive meningioma with extracranial extension.

Case Description

A 58-year-old woman was referred and admitted to our department with a rapidly growing subcutaneous mass over the right frontal forehead of 2 months' duration. The mass was approximately 13 cm at its greatest diameter, elevated 3 cm above the contour of the peripheral scalp, and attached to the skull. Neurological examination showed no abnormalities. Skull X-rays and computed tomography showed preserved original skull contour despite the large extra and intracranial tumor components sandwiching the cranial vault. Digital subtraction angiography showed a partial tumor stain with a large avascular area. Our preoperative diagnostic hypothesis was meningioma. We performed a biopsy and histological findings were characteristic of a diffuse large B-cell lymphoma. A very high preoperative level of soluble interleukin-2 receptor (5390 U/mL; received postoperatively) also suggested lymphoma. The patient received chemotherapy but died of disease progression 10 months after the biopsy.

Conclusion

Several preoperative features of the present case are clues to the correct diagnostic hypothesis of cranial vault diffuse large B-cell lymphoma rather than meningioma, including a rapidly growing subcutaneous scalp mass, poor vascularization, and limited skull destruction relative to the size of the soft-tissue mass.

A Rare Case of a Primary Leiomyoma of the Clivus in an Immunocompetent Patient and a Review of the Literature Regarding Clival Lesions

Leiomyomas are common lesions that are usually located in the genitourinary and gastrointestinal tracts. Primary leiomyomas at the skull base are uncommon. They are composed of well-differentiated smooth muscle cells without cellular atypia. The diagnosis of a leiomyoma has to be confirmed by immunohistochemistry. The tumor tissue is immunoreactive for SMA, S100 and cytokeratin. Leiomyomas mainly occur in immunocompromised patients. Most tumor tissues are positive for EBV. The presented case is that of a 56-year-old immunocompetent woman with a tumor on the clivus. The radiological images suggested chordoma or fibrous dysplasia. Transnasal transsphenoidal surgery was performed. The tumor tissue consisted of well-differentiated smooth muscle cells with elongated nuclei. Immunohistochemistry revealed a positive reaction for desmin, SMA and h-Caldesmon and a negative reaction for S100, beta-catenin, PGR and Ki67. The leiomyoma diagnosis was subsequently established. To the best of our knowledge, the case of a primary leiomyoma on the clivus of an immunocompetent patient is the first to be described. We also extensively reviewed the literature on the immunohistopathological and radiological differential diagnosis of clival lesions.

COVID19-induced immunosuppression and aggressive progression of primary cranial vault lymphoma presenting as a management challenge, a case report, and a literature review

Background

We needs to study Primary Large cell Non-Hodgkin’s Lymphoma of the cranial vault, which is rare, and its association with COVID19 has not been reported, which may have an immunosuppressive effect to aggravate its progression.

Patient details

Our patient, a 53-year-old male, noticed fast growth of posterior cranial vault lesion from 2 to 10 cm size in last 6 months after COVID 19 affliction. MRI brain with contrast revealed lesions suggesting meningioma. The whole-body PET scan was normal. Following Subtotal excision of the mass, histopathology revealed large B-cell Non-Hodgkin’s lymphoma (DLBCL). Immunohistochemistry showed positive results for CD10, CD20, CD45 (LCA), ALK, and BCL-VE with a Ki-67 index of 90–95%. Following radiotherapy and chemotherapy patient is disease-free on imaging and doing well at 5 months of follow-up.

Conclusions

Early intervention with excisional biopsy and timely chemo and radiotherapy in favorable immunostaining may add survival benefits even in malignant features induced by immunosuppressing diseases such as COVID19 in diffuse large B-cell lymphoma (DLBCL) of the scalp.

Characteristics of cranial vault lymphoma from a systematic review of the literature

Background:

Cranial vault lymphomas are rare and their clinical features are often similar to those of cranial vault meningiomas. The objective of this review was to identify the features helpful for differentiating lymphomas of the cranial vault, from meningiomas which were the most common diagnosis before the definitive pathological diagnosis.

Methods:

The inclusion criterion was a histologically proven malignant lymphoma initially appearing in the calvarium. We conducted a literature search of the electronic PubMed and Ichushi-Web databases up to June 1, 2020. Cranial vault lymphoma that was diagnosed after an original diagnosis of lymphoma in a nodal or soft-tissue site was excluded from the study. Descriptive analyses were used to present the patient characteristics.

Results:

A total of 111 patients were found in 98 eligible articles. Almost all studies were case reports. The most common symptom was a growing subcutaneous scalp mass (84%) present for a mean duration of 5.9 months before the patient presented for treatment in analyzable cases; this fast growth may distinguish lymphomas from meningiomas. The tumor vascularization was often inconspicuous or poor, unlike well-vascularized meningiomas. A disproportionately small amount of skull destruction compared with the soft-tissue mass was observed in two-thirds of the analyzable cases.

Conclusion:

This qualitative systematic review identified several features of cranial vault lymphomas that may be useful in differentiating them from meningiomas, including a rapidly growing subcutaneous scalp mass, poor vascularization, and limited skull destruction relative to the size of the soft-tissue mass.

Peripheral T-Cell Lymphoma Presenting as a Scalp Mass

Peripheral scalp T-cell lymphoma is a very rare disease. We report a case of a 22-year-old man who presented an indolent large scalp mass in the right frontal scalp region. The patient's physical examination demonstrated no palpable mass in the chest, abdomen, and extremities. The brain CT revealed a high-density large scalp mass of the subgaleal layer in the right frontal and a small scalp mass of the subgaleal layer in the left frontal. The brain MRI showed multifocal enhancing masses in the bilateral dura, the subgaleal layer of the scalp, and the skull. The patient underwent removal of the tumor found in the right frontal scalp. The histologic diagnosis was peripheral T-cell lymphoma. Bone marrow aspiration showed the involvement of T-cell lymphoma. The patient received chemotherapy with cyclophosphamide, vincristine, doxorubicin, and prednisolone (CHOP protocol) for 3 cycles. The patient was discharged without neurological deficit. The patient showed no evidence of recurrence 15 months after surgery. We report a rare case of peripheral T-cell lymphoma mimicking benign scalp tumors.

Primary Cranial Vault Lymphoma Extending between Subcutaneous Tissue and Brain Parenchyma without Skull Destruction after Mild Head Trauma: A Case Report and Literature Review

Malignant lymphoma of the head rarely arises outside of the brain parenchyma as primary cranial vault lymphoma (PCVL). A case of PCVL that invaded from subcutaneous tissue into the brain, passing through the skull, and occurred after mild head trauma is reported along with a review of the literature. The patient was a 75-year-old man with decreased activity. One month before his visit to our hospital, he bruised the left frontal area of his head. Magnetic resonance imaging showed homogeneously enhanced tumors with contrast media in the subcutaneous tissue corresponding to the head impact area and the cerebral parenchyma, but no obvious abnormal findings in the skull. A biopsy with craniotomy was performed under general anesthesia. The pathological diagnosis was diffuse large B-cell lymphoma. On histological examination, tumor cells grew aggressively under the skin. Tumor cells invaded along the emissary vein into the external table without remarkable bone destruction and extended across the skull through the Haversian canals in the diploe. Tumor cells were found only at the perivascular areas in the dura mater and extended into the brain parenchyma. Considering the history of head trauma and the neuroimaging and histological findings, the PCVL in the present case arose primarily under the skin, passed though the skull and dura mater, and invaded along vessels and reached the brain.

Primary diffuse large B-cell lymphoma of the cranial vault with Trousseau syndrome: a case report

Background

It is extremely rare for primary non-Hodgkin’s lymphomas to occur singly in the cranial vault. One case diagnosed as primary diffuse large B-cell lymphoma is reported, initially misdiagnosed as metastatic skull tumor, complicated with Trousseau syndrome.

Case description

The patient was a 60-year-old Japanese woman with no particular previous medical history. In a head computed tomography examination for vertigo, bone destructive skull tumor covering the right frontal, parietal, and temporal bones was incidentally discovered. As positron emission tomography indicated an abnormal accumulation in the large intestine and multiple cerebral infarctions suspicious of Trousseau syndrome were observed on magnetic resonance images, a metastatic skull tumor due to colorectal cancer was first considered. However, various tumor markers were negative, and colonoscopic biopsy indicated no colorectal abnormality. After pathological examination of the resected tumor, it was diagnosed as diffuse large B-cell lymphoma. The tumor affected muscles and skin but did not develop in the brain or the dura mater. As further general examination revealed no other abnormalities, we considered that it was primary diffuse large B-cell lymphoma in the cranial vault associated with Trousseau syndrome. Treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone and high-dose methotrexate reduced the residual lesion; coagulation abnormalities, which are frequently associated with Trousseau syndrome, also improved.

Conclusions

Skull tumors can result from a variety of malignancies, and their diagnosis may be complicated with Trousseau syndrome. However, even in cases of a single lesion in the cranial vault without invasion of the central nervous system, diffuse large B-cell lymphoma should be considered as a differential diagnosis.

Optimal Management of Calvarial Lymphoma: A Meta-Analysis

BACKGROUND

Calvarial lymphoma is an exceedingly rare phenomenon; the clinical presentation and imaging pattern mimic many diseases of the central nervous system. Several treatment approaches have been undertaken with variable use of surgery plus adjuvant chemotherapy and radiation; an optimal treatment algorithm has yet to be defined. The aim of this study was to better characterize management strategies and patient outcomes.

METHODS

An illustrative case was presented and a meta-analysis was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. MEDLINE and Embase were searched for cases of calvarial lymphoma. Outcomes between patients who underwent open surgery and biopsy only were compared directly.

RESULTS

In an analysis from 1976 to 2019, 62 patients with a median age of 60 were included. The most common presentations were subcutaneous scalp mass (89%), headaches (26%), and focal neurological deficits (21%). Osteolytic changes on computed tomography were seen in 69% of patients with extension into either the intracranial or extracranial space in 97% of cases. Surgical excision was performed in 41 patients with a remission rate of 85% and a recurrence rate of 5%, which did not vary significantly from patients treated nonsurgically (remission in 75%, P = 0.479; recurrence in 0%, P = 1.000) CONCLUSIONS: In patients presenting with a progressively enlarging scalp mass, calvarial lymphoma should be in the differential diagnosis, as it can be effectively managed with a biopsy followed by chemotherapy and radiation. The role for open surgery may be limited.

Primary Cranial Vault Non-Hodgkin's Lymphoma Mimicking Meningioma With Positive Angiography

Primary non-Hodgkin’s lymphoma of the bone remains an uncommon presentation of non-Hodgkin’s lymphoma. Primary lymphoma of the cranial vault is exceptionally rare. Here, we present a 62-year-old immunocompetent male presenting with the rapid growth of a left parietal scalp lesion and new-onset seizure. In addition to his imaging, which showed an extracranial, cranial, and intracranial mass with bony destruction, sagittal sinus involvement, and parenchymal invasion, his diagnostic angiogram demonstrated extensive vascular supply from both the right and left external carotid branches. Intraoperatively, we confirmed a frank invasion of the posterior sagittal sinus. After subtotal resection followed by R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone therapy, the patient continues to be disease-free at the 10-month follow-up. We report here a case of primary cranial vault lymphoma that very closely mimicked meningioma in many ways, with positive angiography and intraoperatively confirmed venous sinus invasion.

Large solitary lytic skull vault lesions in adults: radiological review with pathological correlation

The diagnosis of a large solitary lytic skull vault lesion in adults is a challenge due to variable aggressiveness and overlapping features. The purpose of this article is to demonstrate the use of an imaging approach to narrow the differential diagnosis when a large solitary lytic skull vault lesion is encountered. The initial imaging assessment using computed tomography (CT) is invaluable in determining lesion aggressiveness based on bony margins and skull tables involvement. Further assessment with magnetic resonance (MR) imaging including diffusion weighted imaging (DWI) aids in soft tissue characterization. We present cases of large solitary lytic skull vault lesions in adults, emphasizing on salient and atypical imaging features, with pathological correlation for better understanding of the disease processes that underlie the imaging features.

Primary Low-Grade B-Cell Lymphoma of Skull With Translocation Between Immunoglobulin and Interferon Regulatory Factor 4 Genes

Low-grade B-cell lymphoma with immunoglobulin ( IG) and interferon regulatory factor 4 ( IRF4) gene rearrangement is extremely rare, with only 4 cases being previously reported. In this article, we report one additional case that arises from the skull and review the literature. The patient was a 69-year-old man who presented with recurrent and disabling vertigo and was found to have a 5.0 × 1.7 cm lesion within the left posterior parietal bone. Histological examination revealed a bone lesion with diffuse lymphoid infiltrate comprising of mostly small lymphocytes with scant cytoplasm, slightly irregular nuclei and inconspicuous nucleoli, and scattered larger cells resembling prolymphocytes and paraimmunoblasts. Immunohistochemical studies showed that the neoplastic cells were positive for CD20, CD79a, PAX5, CD23, CD43, BCL-2, BCL-6, MUM-1, LEF-1, and IgM and negative for CD5, CD10, cyclinD1, SOX11, and IgD. Flow cytometric analysis identified CD5 negative and CD10 negative monoclonal B cells with lambda light chain restriction. Fluorescence in situ hybridization analysis revealed del(13q) abnormality, but was negative for IGH/BCL2, IGH/CCND1, and BIRC3/MALT1 translocations. Next-generation sequencing identified IGK-IRF4 rearrangement and BRD4 E1113 del abnormalities. Given a low clinical stage (IE) of the disease, the patient did not receive additional treatments and was free of disease at 1 year after the diagnosis.

Characteristics of Bone Destruction in Cranial Vault Lymphoma Compared with Other Skull Tumors

Cranial vault lymphomas are rare and challenging to diagnose. We present herein two cases of cranial vault lymphoma. The first patient was a 72-year-old woman who presented with a large mass in the parietal bone found incidentally following a head injury. The second patient was a 63-year-old man who presented with an occipital subcutaneous mass associated with visual disturbance and occipital headaches. The diagnosis of a malignant tumor in the second patient was straightforward due to his symptoms and considerable bone destruction, but the first patient was more difficult to diagnose due to a lack of symptoms and only slight bone destruction detected by computed tomography (CT). Both were histophathologically diagnosed with diffuse large B cell lymphoma (DLBCL) in the cranial vault. We also investigated the clinical features, including initial symptoms and patterns of bone destruction, in 23 patients with other types of skull tumors. This comparison showed that cranial vault lymphomas cause large masses on the scalp and lead to characteristic incomplete bone destruction, indicating that cranial bone is destroyed very slowly despite the expanding subcutaneous mass. This feature is unique compared with other benign and malignant skull tumors. In addition, cranial vault lymphoma can be confirmed via bone window CT.

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.

Head trauma complicated with primary cranial vault lymphoma: A case report

RATIONALE

Primary cranial vault lymphoma (PCVL) is an extremely rare extranodal lymphoma in the skull. This case study investigates the clinical features, so as to improve the understanding of the diagnosis and therapy.

PATIENT CONCERNS

A 31-year-old male presented painful scalp mass at the site of 1-month-old head trauma.

DIAGNOSIS

The final diagnosis was plasma cell lymphoma, which is a rare subtype of diffuse large B-cell lymphoma based on biopsy and immunohistochemistry findings.

INTERVENTIONS

The patient received total tumor resection in combination with chemotherapy OUTCOMES:: The patient survived without signs of systemic dissemination for 12 months after surgery at the time of last follow-up.

LESSONS

Trauma may be one of the factors that induce PCVL. The final diagnosis of PCVL depends on pathology and immunohistochemistry findings. A combined treatment of surgery, chemotherapy, and radiotherapy can achieve favorable outcomes.

A Missed Differential in an Extra-Axial Lesion with Calvarial Involvement

Extra-axial central nervous system lesions can occasionally involve the overlying calvarium. The involvement may be due to longstanding pressure effects or secondary to the aggressive behaviour of the lesion. The spectrum of such dural-based lesions varies from infectious/inflammatory to neoplastic etiology. We present a dural-based lesion with the erosion of the overlying calvarium in a young lady. In view of the short history with heterogenous enhancement on magnetic resonance imaging and bony erosion, hemangiopericytoma or malignant meningioma was suspected. The histopathology, however, proved it to be an anaplastic (grade III) ependymoma. Extra-axial ependymomas though uncommon have been reported. However, these extra-axial ependymomas presenting with calvarial erosion are unknown. The bony erosion, as in the present case, may suggest an aggressive tumour behaviour. The reported extra-axial supratentorial ependymomas along with their salient radiological/operative features are shortly reviewed. Also, the differentials of extra-axial lesions with calvarial involvement are touched upon.

Diffuse-primary-B-cell lymphoma of the cranial vault presenting as stroke

A rare case of diffuse-primary-B-cell lymphoma was misdiagnosed on emergency computed tomography because of blurred findings and a sclerotic appearance of the right parietal bone. In spite of computed tomography, magnetic resonance imaging provided a higher diagnostic yield, revealing more extensive diploic alterations and indicating the involvement of all of the cranial vault compartments. Therefore, a histologic examination of the surgical specimen was conducted to reach a conclusive diagnosis.

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.

[Primary lymphoma of the skull: Case report and literature review]

Primitive lymphomas of the bone are exceptional tumors, representing 4% of all non-Hodgkin lymphomas. The location at the skull remains the rarest. We report the case of a 56 year old patient with lytic lesions in the skull of a small cell lymphoma B, treated with primary chemotherapy and intensity-modulated radiotherapy in arctherapy with a dose of 30Gy in 15 fractions. With a follow-up time of 18 months after the end of treatment, the patient has no sign of disease evolution.

Bone regeneration after chemotherapy for vault lymphoma

A 76-year-old woman presented with a mass in the left frontal region of the scalp. On admission, neurological examination found no deficits. CT revealed an osteolytic mass lesion in the left frontal cranial vault. She underwent open biopsy of the subcutaneous lesion. Histological examination identified cells with pleomorphic nuclei and marked nucleoli, and immunohistochemical staining showed these cells were positive for CD20, but negative for CD3. The histological diagnosis was diffuse large B-cell lymphoma. The patient received chemotherapy consisting of rituximab, cyclophosphamide, adriamycin, vincristine and prednisolone. Fluorine-18 fluorodeoxyglucose positron emission tomography demonstrated complete response. Follow-up CT revealed that the tumour had completely disappeared, with regeneration of the destroyed bone. The regenerated skull bone had adequate strength without significant deformity, so cranioplasty was unnecessary. The present case demonstrates the regeneration of destroyed skull bone after chemotherapy for cranial vault lymphoma.

Primary malignant lymphoma of the cranial vault with extra- and intracranial extension

Bone involvement is a common finding in many types of lymphomas, particularly in advanced stages. However, cranial vault affliction has been regarded as an exceedingly rare presentation. Here, we report the case of a patient with cranial vault lymphoma who presented with a scalp mass. An 81-year-old woman presented with a gradually growing and non-painful frontal scalp mass that she noticed one month before admission. It was a flatly elevated, round mass measuring about 6×4×4 cm. Computed tomography and magnetic resonance imaging of the brain revealed a contrast-enhancing intracranial extradural mass at the counter-location of the scalp mass. The superior sagittal sinus was involved at the tumor site. Cerebral angiography showed that the tumor feeding vessels originated from the bilateral external carotid arteries. An operation was performed and the tumors were removed together with the involved bone. The pathologic diagnosis was malignant diffuse large B-cell type lymphoma. The patient was transferred to the Hemato-Oncology department for chemotherapy. Primary lymphoma of the cranial vault with scalp mass is very rare but it should be considered in the differential diagnosis of scalp masses. Although the results of reported cases are variable, the combination of surgery, radiation, and chemotherapy appears to offer favorable outcomes.