A Rare Case of Malignant Lymphoma Occurred at Spinal Epidural Space: A Case Report

Surgical Intervention for Primary B-cell Lymphoma of the Spine: A Systematic Review and Meta-analysis of Clinical Presentation, Treatment, Postoperative Outcomes, and Histologic Markers

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To perform a systematic review of the clinical symptoms, radiographic findings, and outcomes after spinal decompression in B-cell lymphoma.

SUMMARY OF BACKGROUND DATA

B-cell lymphoma is a potential cause of spinal cord compression that presents ambiguously with nonspecific symptoms and variable imaging findings. Surgical decompression is a mainstay for both diagnosis and management, especially in patients with acute neurological deficits; however, the efficacy of surgical intervention compared with nonoperative management is still unclear.

METHODS

The databases of Medline, PubMed, and the Cochrane Database of Systemic Reviews were queried for all articles reporting spinal B-cell lymphoma. Data on presenting symptoms, treatments, survival outcomes, and histologic markers were extracted. Using the R software "survival" package, we generated bivariate and multivariate Cox survival regression models and Kaplan-Meier curves.

RESULTS

In total, 65 studies were included with 72 patients diagnosed with spinal B-cell lymphoma. The mean age was 56.22 (interquartile range: 45.00-70.25) with 68% of patients being males and 4.2% of patients being immunocompromised. Back pain was the most common symptom (74%), whereas B symptoms and cauda equina symptoms were present in 6% and 29%, respectively. The average duration of symptoms before presentation was 3.81 months (interquartile range: 0.45-3.25). The most common location was the thoracic spine (53%), with most lesions being hyperintense (28%) on T2 magnetic resonance imaging. Surgical resection was performed in 83% of patients. Symptoms improved in 91% of patients after surgery and in 80% of patients treated nonoperatively. For all 72 patients, the overall survival at 1 and 5 years was 85% (95% CI: 0.749-0.953; n = 72) and 66% (95% CI: 0.512-0.847; n = 72), respectively.

CONCLUSION

Although surgery is usually offered in patients with acute spinal cord compression from B-cell lymphoma, chemotherapy and radiation alone offer a hopeful alternative to achieve symptomatic relief, particularly in patients who are unable to undergo surgery.

Spinal Meningeal Mass Lesion: A Rare Presentation of Primary Dural Follicular Lymphoma

INTRODUCTION

The differential diagnosis of a spinal intradural extramedullary mass lesion is broad and includes meningioma, schwannoma, neurofibroma, leptomeningeal metastasis, and myxopapillary ependymoma. Though rare, lymphoma should be included in the differential diagnosis of a dural mass lesion.

CASE REPORT

A 38-year-old man presented with back pain that progressed over 1 month with associated focal tenderness over his mid to lower thoracic spine. He developed intermittent numbness of the bilateral lower extremities, nuchal rigidity, difficulty sleeping, and night sweats. A magnetic resonance imaging of the thoracic spine demonstrated a dorsal intradural extramedullary enhancing lesion from T7 to T10 extending outside the spinal canal. Dural thickening across the entire circumference of the spinal cord was noted. Computed tomography (CT)-guided biopsy of the thoracic lesion was performed, and pathology was consistent with follicular lymphoma. Fluorodeoxyglucose positron emission tomography:CT demonstrated no systemic disease. Bone marrow biopsy was negative for malignancy. Symptoms resolved with dexamethasone therapy. He was treated with bendamustine and rituximab with follow-up positron emission tomography:CT 2 months later demonstrating a complete response.

CONCLUSIONS

Lymphoma can rarely present as an isolated dural lesion and should be considered in the differential diagnosis of intradural extramedullary spinal mass lesions. Prompt diagnosis and initiation of treatment can lead to complete response and resolution of symptoms.

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.

Primary Spinal Epidural Diffuse Large B-cell Lymphoma: Case Report and Literature Review

Primary spinal epidural lymphoma (PSEL) comprises a group of tumors present only in the spinal epidural space with a histopathological picture of lymphoma and negative diagnostic workup for lymphoma at other sites. We present the case of an older male adult with primary spinal diffuse large B-cell lymphoma (DLBCL) presenting with spinal cord compression who was treated with surgery followed by high dose methotrexate in combination with RCHOP (rituximab, cyclophosphamide, prednisone, vincristine, and doxorubicin). This case report and review of literature on DLBCL limited to the spine provide a novel chemotherapy regimen and a comprehensive perspective on the optimal management of these patients.

A Conservative Approach to the Treatment of a Rare Case of Cervical Spine Double Expressor Diffuse Large B-cell Lymphoma: A Case Report

Non-Hodgkin's lymphomas are a group of lymphoid neoplasms, with diffuse large B-cell lymphoma (DLBCL) being the most common subtype. Genetic alterations involving c-MYC, BCL-2, and BCL-6 have been implicated in the pathogenesis of subtypes of DLBCL with poor prognostic implications. This case report demonstrates a retropharyngeal mass with extension through the bilateral neuroforamina into the epidural space and posterior elements of the cervical spine (C2-C3), for which biopsy revealed diffuse large B-cell lymphoma. Here we present a unique case as it provides a solution for the dilemma on how to treat a patient with a known prior malignancy (gastrointestinal [GI] melanoma) with a retropharyngeal mass with epidural extension (dumbbell-shaped tumor) with an inconclusive initial CT-guided needle-core biopsy. A CT-guided biopsy only yielded that the mass was neoplasm; we had a choice between attempting gross total resection of the mass or open biopsy. Attempting gross total resection would have entailed an anterior approach (transoral with possible odontoidectomy or endoscopic endonasal with possible odontoidectomy) along with posterior instrumentation and fusion from occiput to C3, which is a rather morbid procedure that would subject the patient to a decreased quality of life as well as risks of vascular injury, dysphagia, and infection. We elected to perform an open biopsy of the epidural component of the mass through a decompressive laminectomy, which allowed for decompression of the spinal cord as well as a sampling of the mass. This provided treatment for possible increasing epidural compression from the mass, as well as diagnostic tissue. A multidisciplinary team discussed the case and developed a treatment plan for the patient with systemic and intrathecal chemotherapy in combination with radiotherapy. 

Dural Follicular Lymphoma: Case Report and Literature Review

Follicular lymphoma (FL) usually has an indolent course and presents with painless, waxing and waning lymphadenopathy in the absence of systemic symptoms. It is uncommon for FL to present outside of lymph nodes, although it can develop in the gastrointestinal tract, skin, thyroid, and testes. Central nervous system (CNS) involvement in FL is rare. Most CNS lymphomas are diffuse large B-cell lymphoma, although Burkitt lymphoma, lymphoblastic lymphoma, and peripheral T-cell lymphoma are also observed. These tumors usually involve white matter but may also involve gray matter. Lymphomas of the dura are very uncommon and are usually mucosa-associated lymphoid tissue lymphomas. Here, we present a case of FL of the dura arising in a 62-year-old woman that was responsive to chemotherapy. According to a literature review, there have been 15 previously reported cases of FL of the dura. Dural FL has been most frequently treated with radiation and chemotherapy. Patients were still alive in all cases in which follow-up was reported. Although the sample size is small, these data suggest that dural FL, like other forms of FL, is an indolent disease that is associated with prolonged survival despite usually being incurable.

A Great Mimicker in Thoracic Spine: Spinal Double Expressor Lymphoma

Diffuse large B-cell lymphoma (DLBCL) is one of the most common causes of non-Hodgkin’s lymphoma (NHL). Some of these DLBCLs can have genetic mutations as well as protein overexpression. The genes involved are MYC, BCL-2 and BCL-6. These are very aggressive and do not respond well to standard chemotherapy regiment. Lymphomas usually show classic signs and symptoms but rarely can present with little or no symptoms or even mimic other disease processes. Here we will present a case where a spinal lymphoma mimicked a hematoma and the patient developed signs and symptoms only after mechanical fall and hitting his back.

A case report of primary central nervous system lymphoma with intestinal obstruction as the initial symptom

RATIONALE

Primary central nervous system lymphoma (PCNSL) with initial manifestations of constipation and intestinal obstruction (IO) is rare.

PATIENT CONCERNS

A 50-year-old Chinese male patient was admitted to the gastroenterology department due to constipation and abdominal distention for 8 days. He had experienced intermittent back pain for 3 years prior to admission. Based on abdominal radiography, he was initially diagnosed with IO and treated with meal restriction and enemas. However, his symptoms worsened, and progressive lower limb weakness was observed.

DIAGNOSES

A colonoscopy was inconclusive due to the IO. Computed tomography and magnetic resonance imaging revealed space-occupying lesions near centrums 9-11 of the thoracic vertebrae. The patient underwent spinal decompression surgery, and pathologic examination led to a diagnosis of PCNSL (diffuse large B cell lymphoma).

OUTCOMES

The symptoms of the IO improved postoperatively, and the patient partially recovered his lower limb muscle strength. He returned to his homeland for chemotherapy.

LESSONS

IO can be an initial, unspecific symptom of spinal cord compression in patients with PCNSL.

Primary Spinal Epidural Lymphoma As a Cause of Spontaneous Spinal Anterior Syndrome: A Case Report and Literature Review

Background Primary spinal epidural lymphoma (PSEL) is one of the rarest categories of tumors. Spinal cord compression is an uncommon primary manifestation and requires to be treated with surgery for the purpose of diagnosis and decompression. Case Presentation A 45-year-old man presented with a new onset thoracic pain and progress to an anterior spinal syndrome with hypoesthesia and loss of thermalgesia. Magnetic resonance image showed a paravertebral mass that produces medullary compression at T3. The patient was taken up to surgery, where the pathology examination showed a diffuse large B-cell lymphoma. Conclusions PSEL is a pathological entity, which must be considered on a middle-aged man who began with radicular compression, and the treatment of choice is decompression and biopsy. The specific management has not been established yet, but the literature suggests chemotherapy and radiotherapy; however, the outcome is unclear.

Primary spinal intradural extramedullary lymphoma: A novel management strategy

Primary spinal intradural extramedullary lymphoma remains a very rare entity in spinal oncology. In this case report, we present the first treatment of a PSIEL diagnosed by cytopathologic analysis alone followed by urgent radio- and chemotherapy in the literature. At 18-month follow-up, our patient was ambulatory with near total imaging resolution of the lesion. In conclusion, surgical excision or biopsy may not be necessary when suspicion for PSIEL exists, and may delay prompt medical and radiation treatment due to necessity for wound healing. Further research into the management of extramedullary lymphoma treatment strategies is warranted.

Diagnostic challenge in a patient with primary bilateral Dumbbell-shaped lumbar non-Hodgkin’s lymphoma

Objective: Primary bilateral dumbbell-shaped lumbar non-Hodgkin lymphomas with epidural and extraspinal involvement, are rare occurrences. Patients presenting at advanced stages and rapid evolution towards neurological impairment lead to diagnostic dilemmas for which only immunohistochemistry can provide a correct, although delayed solution.

Case report: We report the first case of a bilateral, dumbbell-shaped, lumbar lymphoma in a 65-year-old man with a medical history of chronic viral hepatitis type B and D under interferon treatment. The patient presented with back pain radiating down the right leg, with rapid progression to paraplegia and sphincter dysfunction. CT and MRI revealed a large dumbbell mass (approx. 5/5/10 cm) in the right paraspinal musculature, at the L4-L5 level, with intraspinal epidural extension. A similar mass of smaller size was described on the left side, almost mirroring the first lesion, the imagistic aspect suggesting a neural sheath tumor. Intraoperatively, in the right lumbar paraspinal musculature, a soft, yellowish region was discovered, the macroscopic appearance being rather suggestive for a diffuse infection. Clinical, imagistic and surgical findings were not conclusive, nor was the histological examination in light microscopy of the surgical specimen or of the bone marrow biopsy. Immunohistochemistry identified the presence of large B cells, leading to the diagnosis of B cell lymphoma. Although the patient was treated with systemic chemotherapy, his condition rapidly deteriorated and he died within 3 months.

Conclusions: In the case of a lumbosacral, dumbbell shaped mass, developed both epidural and extraspinal, the differential diagnosis must include lymphoma. The histological examination, especially immunohistochemistry provided the final diagnosis. Delays in establishing a diagnosis, associated with a malignant evolution of lymphoma, diminish the chances of determining and applying a treatment strategy that could prolong survival.