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Ge H, Xu L, Gao H, Ji S. Primary intramedullary spinal cord lymphoma misdiagnosed as longitudinally extensive transverse myelitis: a case report and literature review. BMC Neurol 2023; 23:352. [PMID: 37794313 PMCID: PMC10548565 DOI: 10.1186/s12883-023-03383-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
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.
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Affiliation(s)
- Huizhen Ge
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Li Xu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Huajie Gao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Suqiong Ji
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Younger DS. Spinal cord motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:3-42. [PMID: 37620076 DOI: 10.1016/b978-0-323-98817-9.00007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Spinal cord diseases are frequently devastating due to the precipitous and often permanently debilitating nature of the deficits. Spastic or flaccid paraparesis accompanied by dermatomal and myotomal signatures complementary to the incurred deficits facilitates localization of the insult within the cord. However, laboratory studies often employing disease-specific serology, neuroradiology, neurophysiology, and cerebrospinal fluid analysis aid in the etiologic diagnosis. While many spinal cord diseases are reversible and treatable, especially when recognized early, more than ever, neuroscientists are being called to investigate endogenous mechanisms of neural plasticity. This chapter is a review of the embryology, neuroanatomy, clinical localization, evaluation, and management of adult and childhood spinal cord motor disorders.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Lo YT, Lim VY, Ng M, Tan YH, Chiang J, Chang EWY, Chan JY, Poon EYL, Somasundaram N, Bin Harunal Rashid MF, Tao M, Lim ST, Yang VS. A Prognostic Model Using Post-Steroid Neutrophil-Lymphocyte Ratio Predicts Overall Survival in Primary Central Nervous System Lymphoma. Cancers (Basel) 2022; 14:cancers14071818. [PMID: 35406590 PMCID: PMC8997514 DOI: 10.3390/cancers14071818] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Ratios of differential blood counts (hematological indices, HIs) had been identified as prognostic variables in various cancers. In primary central nervous system lymphomas (PCNSLs), higher baseline neutrophil-lymphocyte ratio (NLR) in particular was found to portend a worse overall survival. However, it was often observed that differential counts shift drastically following steroid administration. Moreover, steroids are an important part of the arsenal against PCNSL due to its potent lymphotoxic effects. We showed that the effect of steroids on differential blood cell counts and HIs could be an early biomarker for subsequent progression-free (PFS) and overall survival (OS). Methods: This study retrospectively identified all adult patients who received a brain biopsy from 2008 to 2019 and had histologically confirmed PCNSL, and included only those who received chemoimmunotherapy, with documented use of corticosteroids prior to treatment induction. Different blood cell counts and HIs were calculated at three time-points: baseline (pre steroid), pre chemoimmunotherapy (post steroid) and post chemoimmunotherapy. Tumor progression and survival data were collected and analyzed through Kaplan−Meier estimates and Cox regression. We then utilized selected variables found to be significant on Kaplan−Meier analysis to generate a decision-tree prognostic model, the NNI-NCCS score. Results: A total of 75 patients who received chemoimmunotherapy were included in the final analysis. For NLR, OS was longer with higher pre-chemoimmunotherapy (post-steroid) NLR (dichotomized at NLR ≥ 4.0, HR 0.42, 95% CI: 0.21−0.83, p = 0.01) only. For platelet-lymphocyte ratio (PLR) and lymphocyte-monocyte ratio (LMR), OS was better for lower post-chemoimmunotherapy PLR (dichotomized at PLR ≥ 241, HR 2.27, 95% CI: 1.00 to 5.18, p = 0.05) and lower pre-chemoimmunotherapy (post-steroid) LMR (dichotomized at LMR ≥25.7, HR 2.17, 95% CI: 1.10 to 4.31, p = 0.03), respectively, only. The decision-tree model using age ≤70, post-steroid NLR >4.0, and pre-steroid (baseline) NLR <2.5 and the division of patients into three risk profiles—low, medium, and high—achieved good accuracy (area-under-curve of 0.78), with good calibration (Brier score: 0.16) for predicting 2-year overall survival. Conclusion: We found that post-steroid NLR, when considered together with baseline NLR, has prognostic value, and incorporation into a prognostic model allowed for accurate and well-calibrated stratification into three risk groups.
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Affiliation(s)
- Yu Tung Lo
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore;
- Department of Neurosurgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Vivian Yujing Lim
- Translational Precision Oncology Lab, Institute of Molecular and Cell Biology (IMCB), A*STAR, 61 Biopolis Dr, Proteos, Singapore 138673, Singapore;
| | - Melissa Ng
- Singapore Immunology Network (SIgN), A*STAR, 8A Biomedical Grove, Immunos, Singapore 138648, Singapore;
| | - Ya Hwee Tan
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore; (Y.H.T.); (J.C.); (E.W.Y.C.); (J.Y.C.); (E.Y.L.P.); (N.S.); (M.F.B.H.R.); (M.T.); (S.T.L.)
| | - Jianbang Chiang
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore; (Y.H.T.); (J.C.); (E.W.Y.C.); (J.Y.C.); (E.Y.L.P.); (N.S.); (M.F.B.H.R.); (M.T.); (S.T.L.)
| | - Esther Wei Yin Chang
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore; (Y.H.T.); (J.C.); (E.W.Y.C.); (J.Y.C.); (E.Y.L.P.); (N.S.); (M.F.B.H.R.); (M.T.); (S.T.L.)
| | - Jason Yongsheng Chan
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore; (Y.H.T.); (J.C.); (E.W.Y.C.); (J.Y.C.); (E.Y.L.P.); (N.S.); (M.F.B.H.R.); (M.T.); (S.T.L.)
- Oncology Academic Clinical Program, Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
| | - Eileen Yi Ling Poon
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore; (Y.H.T.); (J.C.); (E.W.Y.C.); (J.Y.C.); (E.Y.L.P.); (N.S.); (M.F.B.H.R.); (M.T.); (S.T.L.)
| | - Nagavalli Somasundaram
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore; (Y.H.T.); (J.C.); (E.W.Y.C.); (J.Y.C.); (E.Y.L.P.); (N.S.); (M.F.B.H.R.); (M.T.); (S.T.L.)
- Oncology Academic Clinical Program, Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
| | - Mohamad Farid Bin Harunal Rashid
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore; (Y.H.T.); (J.C.); (E.W.Y.C.); (J.Y.C.); (E.Y.L.P.); (N.S.); (M.F.B.H.R.); (M.T.); (S.T.L.)
- Oncology Academic Clinical Program, Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
| | - Miriam Tao
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore; (Y.H.T.); (J.C.); (E.W.Y.C.); (J.Y.C.); (E.Y.L.P.); (N.S.); (M.F.B.H.R.); (M.T.); (S.T.L.)
- Oncology Academic Clinical Program, Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
| | - Soon Thye Lim
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore; (Y.H.T.); (J.C.); (E.W.Y.C.); (J.Y.C.); (E.Y.L.P.); (N.S.); (M.F.B.H.R.); (M.T.); (S.T.L.)
- Oncology Academic Clinical Program, Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
| | - Valerie Shiwen Yang
- Translational Precision Oncology Lab, Institute of Molecular and Cell Biology (IMCB), A*STAR, 61 Biopolis Dr, Proteos, Singapore 138673, Singapore;
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore; (Y.H.T.); (J.C.); (E.W.Y.C.); (J.Y.C.); (E.Y.L.P.); (N.S.); (M.F.B.H.R.); (M.T.); (S.T.L.)
- Oncology Academic Clinical Program, Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
- Correspondence:
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Schäfer N, Glas M, Herrlinger U. Primary CNS lymphoma: a clinician's guide. Expert Rev Neurother 2013; 12:1197-206. [PMID: 23082736 DOI: 10.1586/ern.12.120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Primary CNS lymphoma is a high malignant disease of the brain which can lead rapidly to death if diagnosis and/or the start of treatment is delayed. The age at time of diagnosis is a strong factor influencing prognosis so that in younger patients <65 years of age long-term survival may be achieved in a substantial percentage of patients, while in elderly patients long-term survival is seen much more rarely. First-line therapy consists of high-dose methotrexate-based (poly)chemotherapy. This review provides an overview of clinical presentation, steps to diagnosis, detailed information about current treatment concepts and specific information for particular clinical situations.
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Affiliation(s)
- Niklas Schäfer
- Division of Clinical Neurooncology, Department of Neurology, University Hospital of Bonn, Bonn, Germany
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Herrlinger U, Schabet M, Bitzer M, Petersen D, Krauseneck P. Primary central nervous system lymphoma: from clinical presentation to diagnosis. J Neurooncol 1999; 43:219-26. [PMID: 10563426 DOI: 10.1023/a:1006298201101] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Immunocompetent patients with primary central nervous system lymphoma (PCNSL) present with a median age of 55 years, immunosuppressed patients with a median age of 40 years. They show a broad range of signs and symptoms. Symptoms of increased intracranial pressure and personality change are most frequent, followed in frequency by ataxia and hemiparesis. The median time from onset of symptoms to diagnosis is 3-5 months in immunocompetent patients and 2 months in immunodeficient patients. The time to diagnosis can be considerably longer in patients with slowly developing personality change or fluctuating symptoms due to spontaneous or steroid-induced remission of so-called sentinel lesions. Native CT scans show iso- or hyperdense lesions with homogenous contrast enhancement. T1-weighted MRI scans show hypointense and T2-weighted scans hyperintense lesions. The definitive diagnosis of PCNSL requires biopsy. In some cases, however, the definitive diagnosis may exclusively be made by the demonstration of malignant B-lymphocytes in the cerebrospinal fluid.
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Affiliation(s)
- U Herrlinger
- Department of Neurology, University of Tübingen, Germany
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Abstract
Glucocorticoid therapy may result in the rapid resolution of cerebral mass lesions in patients with primary CNS lymphoma. Since glucocorticoids will obscure the histological diagnosis of primary CNS lymphoma upon biopsy, steroids should be withheld if primary CNS lymphoma is a likely diagnosis by neuroradiological criteria. The lympholytic effect of glucocorticoids is mediated by cytoplasmic steroid receptors which are translocated to the nucleus and signal apoptosis. Glucocorticoid-induced apoptosis of lymphoid cells does not require wild-type p53 activity, seems not to depend on caspase activation, but is attenuated by the bcl-2 protooncogene product. Longterm glucocorticoid therapy of primary CNS lymphoma is not recommended because relapse is probably inevitable and because of the prominent side effects of long-term glucocorticoid treatment. Further, long-term glucocorticoid treatment is contraindicated in immunocompromised patients with primary CNS lymphoma.
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Affiliation(s)
- M Weller
- Laboratory of Molecular Neuro-Oncology, Department of Neurology, University of Tübingen, Germany.
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