Low-grade primary meningeal lymphoma: case report and review of the literature

Extranodal Marginal Zone Lymphoma of the Central Nervous System

Extranodal marginal zone lymphoma of the central nervous system (CNS EMZBL) is a rare disease. We present a review of the literature and describe its presentation, differential diagnosis, treatment options, and outcomes. Systematic search of PubMed, Medline, and Embase databases via the Ovid engine for primary articles and case reports yielded 37 unduplicated peer-reviewed articles of CNS EMZBL. We identified 69 cases in these articles and 1 unreported case at our institution, which were included for this review's analysis. Median age at diagnosis was 55 years (range, 18-78 years), with a female preponderance of 77% (n = 54). Most common presenting symptoms were headache in 43% (n = 30), seizures in 31% (n = 22), and visual defects in 27% (n = 19). The most common treatment modalities were localized therapies, which were provided to 67% (n = 47) of cases. These included radiotherapy in 27% (n = 19), radiotherapy with surgery in 24% (n = 17), and surgery alone in 16% (n = 11). Ninety percent (n = 63) of patients had a median follow-up of 23 months. Complete remission was experienced by 77% (n = 49) patients, and 22% (n = 14) were alive with disease. Three patients had evidence of relapse, and one patient died. CNS EMZBL is an indolent, low-grade, radiosensitive lymphoma with good treatment outcomes and prognosis. It is an important differential to consider in extra-axial dural-based masses. Individualized management plans, with preference given to localized treatment options, should be considered after factoring in the site and extent of disease, its resectability, and the expected adverse effects of systemic therapy.

Primary diffuse large B-cell lymphoma of the dura with skull and scalp involvement: A case report and brief review of the literature

Primary dural lymphoma (PDL) refers to a lymphoma with epidural or subdural involvement and is a rare subtype of primary central nervous system lymphoma. Diffuse large B-cell lymphoma (DLBCL) presenting as PDL is extremely rare. The present study reports a case of PDL with skull and scalp involvement in a 56-year-old man. Magnetic resonance imaging (MRI) revealed that the tumor was located under the right parietal inner plate and was attached to the dura mater. Following contrast-enhanced MRI, markedly enhanced tumor signals were observed, and mild homogeneous enhancement was observed in the diploë and soft tissues under the scalp, near the parietal bone. Under general anesthesia, the patient underwent craniotomy and tumor resection. The postoperative pathological diagnosis was DLBCL. Tumors were additionally identified inside the skull and subcutaneous tissues. The patient was administered chemotherapy postoperatively, and the prognosis subsequent to the 4-year follow-up was favorable. Primary malignant lymphoma should be considered in the differential diagnosis of scalp masses and meningeal lesions. Early diagnosis and individualized treatment is closely associated with a favorable outcome.

Primary dural lymphoma: a novel concept of heterogeneous disease

Spinal primary dural lymphoma (PDL) is uncommon with a total of 37 previous well-documented cases reported, including one diagnosed in the authors' institution. More recently we encountered an additional case of spinal PDL that, similarly to our previous case, was grade 1-2 follicular B-cell PDL. Our two cases were diagnosed over a 3-year interval in a 72-year-old female and a 74-year-old male, respectively. An exhaustive literature review on PDL was performed consequently to reveal that: (i) spinal and cerebral sites of involvement by PDL are constantly mutually exclusive; and (ii) unlike cerebral PDL, which is usually of marginal zone B-cell type, only two of the 38 cases of spinal PDL were diagnosed as such, diffuse large B-cell lymphoma being the most commonly encountered type in the spine. This divergence infers that, in contrast to the prevailing concept that PDL is a unique disease group, PDL appears to be rather heterogeneous with a difference in predilection of lymphoma type for the anatomical site of dural involvement. Such a site-specific lymphoma-type predilection phenomenon, well-recognized in other organ systems, has not been acknowledged in PDL. This report brings new insights into PDL, and may contribute to a better understanding of nervous system pathophysiology and lymphoma classification.

Dural MALT lymphoma with disseminated disease

Central nervous system (CNS) lymphoma involving the dura mater is very rare and histologically is usually a subtype of non-Hodgkin's lymphoma (NHL) termed mucosa-associated lymphoid tissue (MALT) lymphoma. We present a case of a 46-year old woman with dural MALT lymphoma that was found to also involve a lacrimal gland, inguinal lymph nodes, and bone marrow. Magnetic resonance imaging of the brain showed an extra-axial enhancing mass approximately 6 cm in maximum diameter along the right frontotemporal convexity. Histopathology of the resected dural mass showed MALT lymphoma expressing CD20, CD52, CD19, and CD38. Molecular studies of the B-cell receptor heavy chain demonstrated monoclonality at the involved sites. The patient was treated with four cycles of fludarabine, mitoxantrone, and rituximab with complete remission. She had recurrence in the subcutaneous tissue of the back at 12 months but has remained free of intracranial disease for 31 months. A review of the literature reveals 57 cases of dural MALT lymphoma. Only 4 had extra-CNS involvement at presentation, and only 3 had local recurrence of the dural tumor. Because of the indolent behavior of this tumor, the intracranial portion can be treated conservatively after resection with or without chemotherapy. Deferral of brain radiation can be considered with close clinical and neuroimaging follow up.

Primary central nervous system marginal zone B-cell lymphoma of the Basal Ganglia mimicking low-grade glioma: a case report and review of the literature

Primary central nervous system (CNS) marginal zone B-cell lymphoma (MZBL) is very rare and shows an indolent disease course with potential of being cured. It seems to originate from meningothelial cells, and the most common site of occurrence is the dura of the cerebral convexity. Primary CNS MZBL is often misdiagnosed as meningioma because of its similar tumor locations and appearances on magnetic resonance imaging (MRI). Surgery, radiation therapy, chemotherapy, and combinations of these are considered treatment modalities depending on the case. Herein, we describe an 18-year-old man who presented with acute onset of right-sided central facial nerve palsy, right-sided hemiparesis with motor power grade 4+, dizziness, and dysarthria. After an MRI scan of the brain, wherein he was first diagnosed with high-grade glioma, a biopsy sample showed that he had primary CNS MZBL arising in the left basal ganglia. He was treated with radiation therapy, which resulted in complete remission for 1 year and 10 months up to the date of this case report. It is important to diagnose primary CNS MZBL correctly because it is curable without unnecessary invasive treatment in cases of localized disease.

PRIMARY MENINGEAL T-CELL LYMPHOMA IN A HARBOR SEAL (PHOCA VITULINA)

A 15-year-old female harbor seal (Phoca vitulina) was referred to the Nantes Veterinary School, Nantes, France, with a clinical history of anorexia, seizures, and left hemiplegia. Cerebrospinal fluid analysis revealed large numbers of neoplastic lymphoid cells. After injection of a contrast agent into the cerebrospinal space, radiographs demonstrated an asymmetry of the right lateral ventricle. Necropsy examination revealed a marked edema of the right frontal lobe, extending to the basal nuclei and thalamus in the brain. Histological examination of the brain revealed leptomeningeal lymphoma. Immunohistochemical labeling demonstrated that the neoplasm was of T-cell origin. No significant macroscopic or microscopic lesions were observed in the other organs examined, including lymphoid organs. This is the first report of primary leptomeningeal lymphoma in a harbor seal.

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.

Primary meningeal Burkitt-type lymphoma presenting as the first clinical manifestation of acquired immunodeficiency syndrome

The purpose of this study is to report a rare case of primary meningeal high grade Burkitt-type lymphoma presenting as the first clinical manifestation of acquired immunodeficiency syndrome. A 38-year-old Caucasian man, with a negative past medical history, sought treatment after experiencing global headache for five days. CT-Scan revealed a right front-temporo-parietal hyperdense subdural expansive mass. A craniotomy was performed and a hard white subdural was microsurgically dissected. Some hours after the surgery, the patient developed hemispheric cerebral edema and intracranial hypertension syndrome. Decompressive craniotomy was performed and the patient had an excellent recovery. Screening blood tests diagnosed human immunodeficiency virus infection. Further investigation ruled out systemic diseases. Eleven days after the initial surgery, the patient developed an acute respiratory failure and sepsis, dying on that day. Pathological studies diagnosed Burkitt-type lymphoma.

Intracranial non-Hodgkin's MALT lymphoma mimicking a large convexity meningioma

Primary presentation of an intradural Non-Hodgkin's lymphoma is rare. Recently these B cell lymphomas of mucosa associated lymphoid tissue (MALT) have gained acceptance as an important pathological subtype and are distinguishable from other primary CNS lymphomas that exhibit aggressive behaviour. Over the past decade a number of these lesions have been reported to resemble a meningioma both intra-operatively and radiologically. The authors outline such a case of marginal zone B cell lymphoma that clinically and radiologically resembled a meningioma. This case illustrates the rare occurrence of low grade dural B cell lymphoma and the need to consider this entity in the differential diagnosis of CNS lesions, if appropriate targeted therapy is to be administered.

Clinicopathologic and genetic profile of intracranial marginal zone lymphoma: a primary low-grade CNS lymphoma that mimics meningioma

PURPOSE

Although rare overall, marginal zone B-cell lymphoma (MZBCL) is the most common primary low-grade CNS lymphoma reported in the literature. The aim of this study is to elucidate the biology and genetic features of this unusual tumor.

PATIENTS AND METHODS

Fifteen CNS MZBCLs were studied clinically, pathologically, and genetically, including fluorescent in situ hybridization analyses with commercially available MALT1 and IgH break-apart and centromere 3, 7, 12, and 18 probes.

RESULTS

CNS MZBCLs preferentially affect middle-aged women (female-to-male ratio, 4:1), with 93% presenting as dural-based masses mimicking meningioma. Ten patients with 1 to 7.6 years of follow-up after diagnosis showed no evidence of disease after radiation and/or chemotherapy. Like MZBCLs outside of the CNS, they consisted of CD20+, CD3- small B lymphocytes with varying degrees of plasmacytic differentiation and predominantly kappa light-chain restriction (78%). Lymphoid follicles with follicular colonization were seen in three patients and deposition of amyloid was noted in samples from two patients, one of which was tumefactive. Neither Bcl-6 protein nor Epstein-Barr virus-encoded RNA was expressed. Trisomy 3 was detected in six of 12 patients, with no rearrangements of MALT1 or IgH and no trisomies of 7, 12, or 18 detected.

CONCLUSION

Our data suggest that intracranial MZBCL is an indolent primary CNS lymphoma that typically presents as a meningioma-like dural-based mass. Trisomy 3, but not MALT1 or IgH translocation, is a common genetic abnormality that may contribute to the pathogenesis of this CNS lymphoma.