Presentation
Progressive paraparesis.
Patient Data
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A fusiform mass involves the cauda equina with a further nodule more inferiorly filling the thecal cul de sac. Much of the cauda equina and exiting nerve roots are thickened and enhancing. These regions are isointense on T1 and T2 weighted images with homogeneous and vivid contrast enhancement. No evidence of cyst formation. No evidence of hemorrhage. Bone marrow appears normal. Conus appears normal.
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A large enhancing mass ( * ) located just bellow the conus is associated with extensive thickening and enhancement of the cauda equina (blue arrows) and enhancing tissue in the thecal cul-de-sac (yellow arrow).
Multiple enlarged retroperitoneal lymph nodes (red arrows) are also present.
MICROSCOPIC DESCRIPTION: Nerve root infiltrated by a neoplastic lymphoid infiltrate. The tumor cells are large, with fairly small amounts of cytoplasm and large irregular nuclei, often with prominent nucleoli. The neoplastic cells show strong membrane enhanced cytoplasmic staining with the antibody to CD20. There is an accompanying infiltrate of small lymphocytes, of both B and T-cell lineage. The features are those of infiltration of nerve root by diffuse large B-cell non-Hodgkin lymphoma.
Case Discussion
Intradural involvement by lymphoma is uncommon compared to epidural / vertebral body, but can be the presenting feature in some patients, who sometimes have disease limited to the central nervous system.
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