Spinal cord lymphoma

Case contributed by A.Prof Frank Gaillard

Presentation

Past history of non-Hodgkin's lymphoma, in remission. Now two months low back pain; one week increased weakness and sensory loss leg/perineum.

Patient Data

Age: 35 years
MRI

MRI spine

Multifocal regions of  the cord demonstrate signal abnormality with increased T2 cord signal, cord expansion and enhancement.

At T10/T11 the spinal cord is expanded with 4.2cm length of vivid contrast-enhancement and a much greater extent of T2 hyperintensity. Incompletely imaged expansile and T2 hyperintense lesion at the cervicothoracic junction.

Multiple low T1 signal and enhancing lesions within vertebra: T2, T6 body, T9 body, T10 body, 2 in T11 body, T12 body, inferior endplate L1, superior end plate and spinous process L2, inferior end plate L4. Filling the spinal canal at S2 is contrast-enhancing lesion, which is hypointense on T2 to CSF, and is consistent with drop metastases. 

Distal to this are prominent Tarlov cysts. Conus terminates at L1. 

Conclusion: Multifocal, enhancing lesions within the cord with associated cord expansion, most consistent with tumour infiltration. In the setting of lymphoma this is consistent with secondary CNS lymphoma. 

MRI

MRI brain

In the region of the pineal gland, there is a well-circumscribed, 10 mm, lesion which returns isointense intrinsic T1 signal intensity and isointense T2 signal characteristics. The lesion demonstrates moderate, homogeneous contrast enhancement.

There are no regions of FLAIR signal abnormality. The ventricular configuration is symmetrical with no evidence of hydrocephalus. The posterior fossa content is unremarkable. There are no remote regions of intra or extra-axial pathological contrast enhancement.

Conclusion: In the setting of ongoing PET +ve stage IV lymphoma elsewhere, the pineal lesion, which was not present on prior CT, is likely a manifestation of systemic lymphoma. An incidental pineocytoma or pineoblastoma is less likely.

Case Discussion

The patient went on to have a biopsy. 

Histology

MICROSCOPIC DESCRIPTION:

The sections show a densely cellular malignant infiltrate, forming sheets. Many of the tumour cells have plasmacytoid appearance. Mature plasma cells are seen. Other cells are medium to large in size and they are more atypical and pleomorphic with enlarged clefted and hyperchromatic nuclei, focal conspicuous nucleoli, clumped chromatin, perinuclear hofs and some eosinophilic cytoplasm. There are no granulomas. The atypical cells show kappa light chain restriction, confirming malignancy. Scattered large cells are CD20 positive and they have infiltrative pattern, most probably representing malignant B-cells. Some cells are also CD138 and EMA positive. Most of the cells in this biopsy are bcl-2, CD79a and MUM1 positive. The Ki-67 index is about 20%. PAX-5, CD10, CD30, CD56 and EBER-CISH are negative.

Comment: Given the presence of CD20 positivity and past history of lymphoma, this tumour is interpreted as diffuse large B-cell lymphoma. The plasmacytoid features are very prominent which can be seen in DLBCL.

DIAGNOSIS: Diffuse large B-cell lymphoma with prominent plasmacytoid features.

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Case information

rID: 44722
Case created: 3rd May 2016
Last edited: 9th May 2016
Inclusion in quiz mode: Excluded

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