Non-Hodgkin's lymphoma presenting with spinal involvement

Aggressive B-Cell Lymphoma with Metastatic Spinal Cord Compression: Treat the Patient, Not the Disease

INTRODUCTION

The management of metastatic spinal cord compression (mSCC) is a demanding task. The main challenges of mSCC include various manifestations and unpredictable outcomes with indiscriminate treatment recommendations. Because of attendant urgency with potentially devastating health consequences, the SCC is an emotionally disturbing experience whose management could take an impulsive rather than rational approach. The treatment strategy is particularly problematic when mSCC is caused by a malignant lymphoma with its protean attributes.

CASE REPORT

A 68-year-old female presented with generalized body pain and weight loss. Imaging studies revealed a vast bulk of the disease involving lymph nodes, spleen, visceral organs, musculature, marrow, and bones including vertebrae with extension into the spinal canal. A biopsy of the chest wall mass showed high-grade diffuse large B-cell lymphoma. A magnetic resonance imaging (MRI) of the spine demonstrated diffuse marrow replacement by the tumor of the thoracic and lumbar spine with compression of the cord. The prompt treatment with corticosteroids and immunochemotherapy (ICT) was recommended, but the patient elected to seek a second opinion. After two doses of radiation therapy, the patient's general condition rapidly deteriorated and she was hospitalized for systemic ICT. Despite the treatment, her condition continued to deteriorate, and she died 3 weeks after the presentation.

CONCLUSION

The presented case demonstrates some hitherto unaddressed challenges in evaluation and treatment of mSCC caused by aggressive non-Hodgkin lymphoma (LSSC). The case scrutinizes the role of MRI in uncommon clinical situations. The case has also exposed some ethical issues associated with the proper management of LSCC.

Miliary pattern in secondary central nervous system T-cell lymphoma

BACKGROUND

Secondary central nervous system lymphoma may manifest in a variety of ways on imaging, but most commonly presents with leptomeningeal disease, isolated parenchymal lesions, or both. We present a case of secondary central nervous system T-cell lymphoma with miliary pattern of spread noted on imaging.

CASE DESCRIPTION

Our patient had known systemic T-cell lymphoma involving the gastrointestinal and respiratory tracts and underwent stereotactic biopsy confirming secondary cerebral metastasis. This spread pattern is an uncommon manifestation of disease and in our experience carries a very poor prognosis.

CONCLUSION

We highlight the need to maintain a broad differential diagnosis that includes other metastatic disease and infectious etiologies, including toxoplasmosis and tuberculosis. High clinical suspicion and timely confirmatory testing including biopsy or cerebrospinal fluid flow cytometry are critical to treatment.

Development of Primary Diffuse Large B-Cell Lymphoma Around an Internal Fixation Implant After Lumbar Fusion Surgery: A Case Report and Review of the Literature

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL) is the most commonly diagnosed primary non-Hodgkin lymphoma of the spine and can induce spinal compression. Reports of lymphoma arising in bone adjacent to metallic prostheses are increasing. However, to our knowledge, DLBCL arising from a scar after lumbar fusion surgery has not been reported previously.

CASE DESCRIPTION

A 63-year-old man complained of a 2-month history of severe pain in the back and both legs, radiating down to the ankle, similar to sciatica with a past history of L2-S1 decompression and fusion 7 years ago. Imaging revealed an irregular mass in the epidural space and around the internal fixation surgical site, which was initially diagnosed as an epidural infectious abscess. Most of the lesion was completely excised and a detailed immunohistopathologic analysis was performed revealing the diagnosis of a DLBCL. After surgery and chemotherapy, he was discharged without complications. Unfortunately, he died 2 years later because of brain metastasis.

CONCLUSIONS

This case highlights the need to consider malignancy in the differential diagnosis and carefully examine surgical specimens in revision surgery. Further understanding of the role of metal implants in the development of lymphoma is required.

Uncommon Disorders Masquerading as Acute Flaccid Paralysis in Children

The syndrome of acute flaccid paralysis (AFP) is a common medical emergency in children. In the era of poliomyelitis eradication, the common causes of AFP include Guillain-Barré syndrome (GBS), transverse myelitis and traumatic neuritis. However, many common diseases can uncommonly present as AFP and some uncommon diseases may also masquerade like it. Uncommon causes of AFP seen at a tertiary care pediatric hospital are discussed along with relevant points in diagnosis and management. Also, common pitfalls in diagnosis of pediatric AFP and an approach to investigations are discussed.

Clinical outcomes of treatment for spinal cord compression due to primary non-Hodgkin lymphoma

BACKGROUND CONTEXT

Primary non-Hodgkin lymphoma of the spine (PNHLS) with spinal cord compression is an extremely rare disease in clinical practice. The optimal treatment options for this disease have been controversial and pose a challenge for the clinicians.

PURPOSE

To provide some useful insight into the treatments, outcomes, and prognostic factors of PNHLS.

STUDY DESIGN

Retrospective analysis.

PATIENT SAMPLE

The authors collected 40 patients' data with primary non-Hodgkin lymphoma at the mobile spine, and these patients presented with spinal cord compression as a first symptom between 1998 and 2010.

OUTCOME MEASURES

The posttreatment neurologic status, general status, local recurrence, and survival were noted according to the telephone calls, letters, or follow-up visits in the outpatient department.

METHODS

Multidisciplinary treatments, including surgical intervention, chemotherapy, and radiotherapy, were performed in this series. Follow-ups regarding treatment outcomes, local recurrence, and survival rates were carried out and analyzed. The prognostic factors including age, neurologic status, general status, vertebrae involvement, and treatment outcomes were determined.

RESULTS

The median age of the patients was 52 years (range, 13-79 years). After treatments, 30 patients (75%) reached a complete remission (CR). The 5-year overall survival (OS) of all patients was 72.9%. Patients who were younger than 60 years, with single vertebra involvement, or had CR after treatment had higher 5-year OS (p<.05). In multivariate analysis, CR after treatment and involvement of a single vertebra were identified as favorable prognostic factors for OS.

CONCLUSIONS

Patients with PNHLS with neurologic compression had distinct clinical features. Regarding treatment, the authors emphasized the importance of multidisciplinary management and the optimal operating juncture. Patients with excellent response to the treatment and single vertebra involvement had better survival.

Surgical decompression improves recovery from neurological deficit and may provide a survival benefit in patients with diffuse large B-cell lymphoma-associated spinal cord compression: a case-series study

BACKGROUND

Malignancy-associated spinal cord compression is generally treated by surgical decompression, radiotherapy or a combination of both. Since diffuse large B-cell lymphoma (DLBCL) is highly sensitive to both chemotherapy and radiotherapy, the role of surgical decompression in the treatment of DLBCL-associated spinal cord compression remains unclear. We therefore conducted a retrospective review to investigate the impact of surgical decompression on recovery from neurological deficit caused by DLBCL-associated spinal cord compression and patients' overall survival.

METHODS

Between March 2001 and September 2011, 497 newly diagnosed DLBCL patients were reviewed, and 11 cases had DLBCL-associated spinal cord compression. Six cases were treated surgically and five cases nonsurgically.

RESULTS

The rates of complete recovery from neurological deficit were 100% (6/6) and 20% (1/5) for patients in the surgical and nonsurgical groups, respectively (P = 0.015), while the median survival for patients in the surgical and nonsurgical groups was 48.6 months and 17.8 months, respectively (P = 0.177).

CONCLUSIONS

We conclude that surgical decompression can improve recovery from neurological deficit in patients with DLBCL-associated spinal cord compression, possibly providing these patients a survival benefit.

Primary non-Hodgkin's lymphoma presenting as radicular syndrome: report of two cases

We report two cases of primary Non-Hodgkin's Lymphoma in the spine leading to radicular compression secondary to infiltration of lumbar body vertebras. The two patients were free of either nodular or other extra-nodular disease. Treatment consisted of chemotherapy alone, one patient have had a cauda equina syndrome and surgical decompression was performed in emergency. The patients were in remission for 20 months after diagnosis. A review is given for the incidence of primary vertebral localization of lymphoma, its diagnosis, treatment and prognosis.