A case of primary spinal intramedullary lymphoma

Primary intramedullary spinal cord lymphoma misdiagnosed as longitudinally extensive transverse myelitis: a case report and literature review

BACKGROUND

Primary intramedullary spinal cord lymphoma (PISCL) is rare and easily misdiagnosed with the lack of typical clinical features and non-specific imaging manifestations.

CASE PRESENTATION

A 49-year-old man was admitted to our hospital because of persistent limbs numbness, pinprick-like pain in the posterior neck and unsteady gaits. He has brisk tendon reflexes and positive Babinski's sign. Magnetic resonance imaging (MRI) of the cervical spine showed an abnormal signal with aberrant reinforcement at medulla oblongata and the level of C1-C7. He was clinically diagnosed as longitudinally extensive transverse myelitis (antibody-negative). Steroid pulse therapy was administered and resulted in reduced symptoms. One month later, his situation was exacerbated compared to the onset. We launched a new cascade of steroid pulse therapy. But it did not improve his symptoms. Finally, the biopsy pathology confirmed PISCL. Chemotherapy, radiotherapy and zanubrutinib were administered and until now about 3 years into treatment the patient is still survival.

CONCLUSIONS

Based on our case and literature review, we recommend that spinal onset patients react ineffectively to standard immunoglobulins or hormonal treatments or experience a relapse after a short time relief should take PISCL into consideration.

B-Cell Lymphoma Intramedullary Tumor: Case Report and Systematic Review

Intramedullary tumors represent the major cause of spinal cord injuries, and its symptoms include pain and weakness. Progressive weakness may concomitantly occur in the upper and lower limbs, along with lack of balance, spine tenderness, sensory loss, trophic changes of extremity, hyperreflexia, and clonus. The study protocol was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of the MEDLINE electronic database was performed to identify the studies reporting the clinical features of children and adults who presented with an intramedullary lymphoma. Twenty-one studies were included, reporting 25 cases. Manuscripts were excluded if the full-text article was not available, original data were not reported (e.g., review articles), or if the main disease was not intramedullary lymphoma. A structured data extraction form was employed to standardize the identification and retrieval of data from manuscripts. To enlighten the discussion, a case is also presented. An 82-year-old woman with Fitzpatrick skin type II, diagnosed and treated for non-Hodgkin's lymphoma 7 years ago, was admitted with mental confusion and memory loss for the past 2 months-evolving with recurring falls from her own height. One day before admission, she displayed Brown-Séquard syndrome. An expansive lesion from C2 to C4 in the cervical spinal cord was found and a hypersignal spinal cord adjacent was described at the bulb medullary transition to the C6-C7 level. A primary spinal cord tumor was considered, as well as a melanoma metastasis, due to the lesion's flame pattern. The patient presented a partial recovery of symptoms and a reduction of the spinal cord edema after being empirically treated with corticosteroids, but the lesion maintained its extent. Subsequently, a large diffuse B-cell lymphoma with nongerminal center was found in open body biopsy, infiltrating neural tissue. The main objective of the present study is to report a surgical case treated for a large diffuse B-cell lymphoma, in addition to presenting the results of a systematic review of primary intramedullary spinal cord lymphoma.

Nomograms Predict Survival Outcome of Primary Intramedullary Spinal Cord Lymphoma Patients

Background

Primary intramedullary spinal cord lymphoma (PISCL) is a rare cause of myelopathies. Considering its poor prognosis, it is essential to determine the appropriate treatment strategies and to develop nomograms to predict survival outcome for PISCL patients.

Material/Methods

Data were collected from the Surveillance, Epidemiology and End Results (SEER) database. We used 364 patients to investigate overall survival (OS) and 289 patients for cancer-specific survival (CSS). Kaplan-Meier method was to evaluate correlations of survival with different treatment strategies and clinicopathologic factors. Univariate and multivariable analyses were conducted to assess OS and CSS based on different variables. Risk factors were integrated to build nomograms.

Results

Most of the 414 PISCL patients diagnosed with positive histology had diffuse B cell lymphoma, were under 60 years old, were male, were of white race, had 1 primary tumor, were married, were low stage, and had previously undergone chemotherapy. We found that radiation therapy had no effect on patient OS and CSS, and patients receiving chemotherapy alone tended to have better OS and CSS in comparison with other groups. In addition, we showed that clinicopathologic factors, including histologic type, age, stage, and marital status, could serve as independent prognostic factors for PISCL patient OS and CSS. These factors were utilized to construct nomograms. The calibration curves demonstrated good agreement. The concordance indexes for OS and CSS were 0.672 (P=0.024) and 0.683 (P=0.029), respectively.

Conclusions

Practical nomograms were established for patients’ OS and CSS. Besides, this study can guild clinician to make the right decision for appropriate treatment of PISCL patients.

Primary intraspinal non-Hodgkin's lymphoma: Case report and review of literature

We present the unique case of an 67-year-old female patient with primary intraspinal B-cell non-Hodgkin's lymphoma without cerebral manifestation mimicking myelitis in clinical presentation and neuroradiological diagnostic. It illustrates the broad spectrum of differential diagnoses for paraplegia and the importance of rapid interdisciplinary diagnostic work-up since the neurologic status after treatment mainly depends on the delay of treatment. Review of existing literature suggests combined radio- and chemotherapy as well as high-dose intravenous methotrexate or rituximab. The rising incidence of spinal lymphomas especially in patients with acquired immunodeficiency underlines the importance of fast diagnosis and initiation of treatment of this rare entity.

Primary Intramedullary Malignant Lymphoma in the Cervical Cord with a Presyrinx State

A 79-year-old man presented with primary intramedullary malignant lymphoma with a presyrinx state in the cervical cord manifesting as left hemiparesis and hemidysesthesia. The magnetic resonance imaging (MRI) scan showed an intramedullary mass in the cervical spinal cord at the level of C1 and T2-weighted image prolongation from the medulla to the level of C5. According to the progression of hemiparesis, he underwent an emergency removal of the tumor under general anesthesia. The tumor was totally removed, and the peritumoral signal abnormality was not present in the postoperative MRI. Histological examination revealed diffuse large B cell lymphoma. While brain MRI, bone marrow puncture, and ¹⁸F-fluorodeoxy-glucose positron emission tomography (18FDG-PET) of the whole body were performed to find out a primary lesion, there were no abnormalities. He underwent a high-dose methotrexate-based chemotherapy and a local irradiation therapy (40Gy). He has been alive for more than two years since the symptom onset, and without any evidence of recurrence. This case suggests that malignant lymphoma, as an infiltrating and rapidly progressive tumor, may be accompanied by syrinx.

Primary intramedullary spinal cord lymphoma: a population-based study

Background

Primary intramedullary spinal cord lymphoma (PISCL) is a rare diagnosis with poorly understood disease progression. Clarification of the factors associated with survival in PISCL patients is warranted.

Methods

We conducted a population-based cohort study utilizing prospectively collected data from the Surveillance, Epidemiology, and End Results (SEER) database. Patients with histological diagnosis of primary lymphoma in spinal cord (C72.0) from 1973 to 2012 in the SEER database were included. Multivariable survival analysis between patient, lesion characteristics, and PISCL-related death was performed to adjust for confounding factors.

Results

We included 346 PISCL patients in our study. Average age was 56.5 ± 17.8 years, with 62.7% being male. Racial distribution of these patients was white (87.6%), black (8.0%), and other (4.3%). More than half (55.8%) of patients were married. The most prevalent histology of PISCL was diffuse B-cell (46.2%), and the majority (55.2%) were low stage (Ann Arbor stage I/II). Most patients (67.9%) received radiation therapy. Average survival interval of patients with PISCL-related death (n=135, 39.0%) was 27.8 months. General cumulative survival probability at 1 year, 2 years, and 5 years was 73.8%, 67.9%, and 63.1%, respectively. Multivariable accelerated failure time (AFT) regression showed follicular lymphoma (HR:0.25, P=.008) and more recent diagnosis (HR:0.96, P<.001) was positively associated with PISCL-related survival. Conversely, nonwhite race (HR:1.69, P=.046), older age (HR:1.02, P<.001), unmarried status (HR:2.14, P<.001), and higher stage (HR:1.54, P=.022) were negatively associated with survival.

Conclusions

Age, race, marital status, tumor histology, tumor stage, and year of diagnosis were associated with survival of PISCL. While most PISCL-related deaths occur within a 1-year period, subsequent slow progression was observed after the first year of survival.

Primary Non-Hodgkin's Lymphoma of the Spine: A Case Report and Literature Review

Primary non-Hodgkin’s lymphoma (NHL) of the spine is a rare form of extranodal lymphoma. This entity constitutes a diagnostic challenge due to its mimicking of other spinal diseases and the difficulty in establishing a tissue diagnosis. In fact, core biopsy can be inconclusive, oftentimes requiring surgical biopsy. Definitive evidence is lacking regarding the treatment of choice. As a result, the prognosis remains unfavorable. We present the case of an adult female who presented with back pain and was found to have a spinal NHL. We also review the literature regarding this rare occurrence.

Primary intramedullary non-Hodgkin's lymphoma in an immunocompetent child

STUDY DESIGN

Case report.

OBJECTIVES

Primary intramedullary spinal cord lymphoma is a rare entity. Studies have shown that there is a recent increase in the number of patients regardless of the status of the immunity. High index of suspicion should be kept in all patients with intramedullary tumors. Multidisciplinary approach at the earliest is required for best outcomes.

SETTING

Department of Neurosurgery, Medical Oncology, Pathology and Radiation oncology. Nizam's Institute of Medical Sciences, Hyderabad, India.

METHODS

We describe the case of an 11-year-old boy who presented with paraparesis and sensory loss below T10 level. On imaging, the dorsal spine showed intramedullary lesion mimicking an astrocytoma.

RESULTS

Surgical decompression of the tumor was done and histopathology showed non-Hodgkin's lymphoma, diffuse large B-cell type. There were no findings suggestive of congenital or acquired immunodeficiency. After complete staging evaluation, we instituted chemotherapy with modified DeAngelis protocol. At 2 years post treatment, he is in complete remission with near normal neurological status.

CONCLUSIONS

Intramedullary spinal cord diffuse B-cell lymphoma in a pediatric age group is very rare and hence requires a high index of suspicion in patients presented with myelopathy. The outcomes are encouraging with current multidisciplinary approach.

Primary cauda equina lymphoma treated with high-dose methotrexate

A 69-year-old man presented with a very rare case of primary central nervous system lymphoma originating in the cauda equina manifesting as progressive paraparesis. The patient underwent a biopsy, and was treated with intravenous high-dose (3.5 g/m(2)) methotrexate chemotherapy and local irradiation. Histological study revealed large B cell type lymphoma. Follow-up magnetic resonance imaging showed complete remission of the lesion, but the patient died of pneumonia at 18 months after the initial onset without tumor recurrence, so the efficacy of this strategy remains unknown.

Primary intramedullary histiocytic sarcoma

Intramedullary primary central nervous system lymphoma (PCNSL) is a rare central nervous system (CNS) malignancy affecting mostly the brain, but it may also involve the leptomeninges, eyes, and spinal cord. A 71-year-old woman presented with back pain and progressive unilateral lower extremity weakness owing to an intramedullary primary histiocytic sarcoma of the spine, a rare PCNSL subtype. To the authors' knowledge, this is the first case of an intramedullary PCNSL caused by histiocytic sarcoma.

Adult primary spinal cord tumors

Primary spinal cord tumors represent 2-4% of all neoplasms of the CNS. Primary spinal cord tumors are anatomically separable into two broad categories: intradural intramedullary and intradural extramedullary. Intramedullary tumors are comprised predominantly of gliomas (infiltrative astrocytomas and ependymomas). Resective surgery can usually be accomplished with spinal ependymomas owing to separation of tumor from spinal cord and, when complete, require no further therapy. By contrast, spinal cord gliomas infiltrate the myelon and, consequently, surgery is nearly always incomplete. Involved-field radiotherapy is most often administered after partial resection. Intradural extramedullary tumors are either peripheral nerve sheath tumors (neurofibromas or schwanommas) or meningiomas. In either instance, complete resection may be accomplished and is often curative. Radiotherapy is reserved for rare malignant variants and for patients in whom surgery is contraindicated. Chemotherapy is administered for recurrent primary spinal cord tumors without other options, that is, reoperation or re-irradiation. Problematic, however, is the lack of clinical trials in general for these CNS tumors and for spinal cord tumors in particular. Consequently, treatment is similar to that for intracranial tumors with a similar histology. Early recognition of the signs and symptoms of primary spinal cord tumors allows for early treatment, potentially minimizes neurologic morbidity and improves outcome. Primary treatment is surgery in essentially all spinal cord tumors, and predictors of outcome include preoperative functional status, histological grade of tumor and extent of surgical resection.

Intramedullary lesions of the conus medullaris: differential diagnosis and surgical management

The medullary conus represents a distinct entity of the spinal cord regarding its anatomical, clinical and microsurgical features. An overview of the pathologic processes of this region is provided. Epidemiological, clinical and neuroradiological characteristics of neoplastic (glial tumors, non-glial tumors, metastasis, primary melanomas) and non-neoplastic lesions (granulomatous lesions, abscess, parasitic infections, vascular, demyelinating and dysembryogenetic lesions) are discussed. Main MR imaging characteristics used to differentiate neoplastic from non-neoplastic lesions consist in pathological spinal cord expansion, gadolinium-enhancement and tumoural cyst formation. Management strategies differ substantially, depending on the kind of lesion. According to the suspected pathological entity radical resection, biopsy or conservative treatments are reasonable options. Intraoperative electrophysiological monitoring is a fundamental part of the surgical setting.

[Primary intramedullary lymphoma. Case report]

A 66-year-old female presented primary intramedullary spinal cord lymphoma. This patient was referred for lower limbs weakness, which had developed six weeks earlier and right C5 radiculalgia. Physical examination revealed a medullary syndrome with Claude-Bernard-Horner syndrome. The diagnosis was established after MRI and biopsy (dorsal myelotomy). The patient was given chemotherapy and craniospinal adjuvant radiotherapy (30 Grays). The clinical, radiological and therapeutic features are discussed.

An Update on Primary Central Nervous System Lymphoma

The most important recent advance in treatment of primary central nervous system lymphoma has been the introduction of high-dose methotrexate-based chemotherapy. Convincing data demonstrate that the regimens of such chemotherapy improve survival compared with historical controls treated with radiotherapy alone. However, the optical treatment approach is still unclear and therapy can be associated with long-term neurotoxicity. Current research focuses on maximizing survival while minimizing neurologic sequelae.

Primary spinal tumors in children

Nine patients, 16 years of age or younger with primary spinal cord tumors, diagnosed between 1991 and 2003 at The Kaohsiung University Hospital, were reviewed retrospectively. There were 2 female and 7 male patients. Two tumors were located primarily in the cervical cord (1 meningioma, 1 neurofibroma), five were predominantly thoracic (1 lymphoma, 1 meningioma, 1 astrocytoma, 1 fibrosarcoma and 1 osteoblastoma), one lumbar (ependymoma), and one sacral (Ewing's sarcoma). The most common clinical presentation was limb weakness (100%) followed by back pain (44.4%). All the patients underwent laminectomy for removal of their tumors. Five children with benign tumors improved postoperatively. At discharge, these 5 children could walk without assistance and have remained stable with long-term of follow-up. Radical surgery should be considered in benign primary spinal cord tumors. As would be expected, patients diagnosed and treated early and in whom a total resection was achieved had a better prognosis.