Primary CNS lymphoma
Left sided weakness.
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There is a 46 x 34 mm homogeneously enhancing mass centred in the right posterior temporal lobe. There is surrounding vasogenic oedema, that extends predominately into the right frontal and temporal lobes but also into the right internal capsule, into the right mid brain, as well as into the hypothalamus and optic chiasm. There is 5 mm midline shift, obstruction of the foramen of Monro, with dilation of the left lateral ventricle, and descending trans-tentorial herniation, that distorts the right cerebral peduncle.
Incidental empty sella. No further abnormal contrast enhancement.
The patient went on to have a biopsy.
Paraffin sections show cores of cerebral white matter. These show aggregation of large atypical lymphoid cells in cuffs around small calibre blood vessels. Invasion of vessel walls by atypical cells is noted. Atypical cells are also dispersed in white matter between vessels. The atypical cells have large round, oval and angulated vesicular nuclei and a narrow rim of pale cytoplasm. Scattered mitotic figures are identified. Intervening white matter is oedematous and shows astrocytic gliosis. The featurs are of non Hodgkin's lymphoma.
Immunohistochemistry shows strong membrane staining for CD20 and CD79a and strong perinuclear staining for bcl-2 with weaker staining for bcl-6. There is also strong nuclear staining for MUM-1. Moderate numbers of small CD3+ T lymphocytes are mixed with the atypical large B cells. There is no staining for cyclin D1 or CD23. The features are of non Hodgkin's large B cell lymphoma.
Brain biopsies: non Hodgkin's lymphoma