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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 5  |  Page : 532-534

Primary spinal epidural diffuse large B-cell lymphoma


1 Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
2 Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
3 Department of Imaging Sciences and Intervention Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

Date of Submission18-Jul-2013
Date of Decision03-Sep-2013
Date of Acceptance20-Oct-2013
Date of Web Publication22-Nov-2013

Correspondence Address:
Sujit Abajirao Jagtap
Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.121940

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How to cite this article:
Jagtap SA, Patil AS, Kesavdas C, Radhakrishnan N, Soni H, Satish KS. Primary spinal epidural diffuse large B-cell lymphoma. Neurol India 2013;61:532-4

How to cite this URL:
Jagtap SA, Patil AS, Kesavdas C, Radhakrishnan N, Soni H, Satish KS. Primary spinal epidural diffuse large B-cell lymphoma. Neurol India [serial online] 2013 [cited 2022 May 26];61:532-4. Available from: https://www.neurologyindia.com/text.asp?2013/61/5/532/121940


Sir,

A 32-year-old female patient presented with progressive ill-defined pain at the level of left infra mammary region with a tight band like sensation of 3 weeks duration followed by progressive asymmetric weakness of both lower limb with decreased pain and temperature sensation without any bowel or bladder involvement 1 week before admission. Neurologic examination demonstrated, bilateral lower limb spasticity with asymmetric pyramidal pattern of weakness (right > left) with impaired vibratory and proprioceptive sensation below T4 level. Thoracic magnetic resonance imaging showed T1 hypo and T2 mild hyperintense well defined epidural lesion at T3-T4 level with diffusion restriction and moderate enhancement on contrast with small paraspinal component extending along T3-T4 neural canal on the right side [Figure 1]. The radiologic differential diagnosis included lymphoma, granuloma and bone metastasis. Extensive work-up for malignancy was negative, including bone marrow examination. Open lesion biopsy demonstrated diffuse large B-cell lymphoma with MIB index of 50% and CD20 and bcl-6 positive cells [Figure 2]. Patient underwent partial laminectomy with decompression of the lesion followed by improvement in symptom. She received chemotherapy during follow up.
Figure 1: Well defined epidural soft tissue mass at T3-T4 level (a) T1 hypointense, (b) T2 mildly hyperintense (c) contrast enhancing, (d and e) showing diffusion restriction (f and g) axial image at T3-4 levels showing small paraspinal component extending along T3-T4 neural canal on the right side

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Figure 2: (a) H and E, ×100, (b) H and E, ×400, showing highly cellular small round cell neoplasm with cells having, round dark nuclei in sheets, vesicular nuclei, scanty cytoplasm and mitotic figures, (c) leukocyte common antigen (LCA) ×400, the tumor cells showing strong membrane positivity for LCA immunomarker

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"Primary spinal epidural lymphoma" (PSEL) is subset of lymphomas primarily occurring in the epidural space with no other recognizable sites of disease at the time of diagnosis. [1] The origin of PSEL is still unknown, but thought to be derived from lymphatic tissue along the venous plexus in the epidural space or the paravertebral lymphoid rests or the vertebral body, which later extends to the epidural space. [2] It usually present in fifth or sixth decade although childhood presentation has been described. The thoracic spine is the most common site involved followed by the cervical, lumbar and lumbosacral regions. PSEL is more common than intramedullary lymphoma and presents as an isointense, homogeneous tumor spanning multiple segments and may extend through the neural foramina with contrast enhancement and diffusion restriction. [3] It is differentiated from spinal epidural or subdural hematoma by the presence of hyperintense blood products and peripheral rather than solid enhancement on contrast in epidural abscess. Hyperintense T2 signal greater than that of adjacent fat with adjacent expansile bone disease differentiate epidural metastases from lymphoma. [3] Surgery is the main stay of treatment for cord decompression with aggressive chemotherapy in conjunction with radiotherapy is associated with good functional outcome. [4]

PSEL should be suspected in patients with spinal cord compression with imaging showing isointense, homogeneous extradural contiguous level compressive soft-tissue lesion without bony involvement and previous history of cancer or history suggestive of any systemic involvement.

 
  References Top

1.Cugati G, Singh M, Pande A, Ramamurthi R, Balasubramanyam M, Sethi SK, et al. Primary spinal epidural lymphomas. J Craniovertebr Junction Spine 2011;2:3-11.  Back to cited text no. 1
[PUBMED]    
2.Mora J, Wollner N. Primary epidural non-Hodgkin lymphoma: Spinal cord compression syndrome as the initial form of presentation in childhood non-Hodgkin lymphoma. Med Pediatr Oncol 1999;32:102-5.  Back to cited text no. 2
[PUBMED]    
3.Haque S, Law M, Abrey LE, Young RJ. Imaging of lymphoma of the central nervous system, spine, and orbit. Radiol Clin North Am 2008;46:339-61, ix.  Back to cited text no. 3
[PUBMED]    
4.Monnard V, Sun A, Epelbaum R, Poortmans P, Miller RC, Verschueren T, et al. Primary spinal epidural lymphoma: Patients' profile, outcome, and prognostic factors: A multicenter rare cancer network study. Int J Radiat Oncol Biol Phys 2006;65:817-23.  Back to cited text no. 4
[PUBMED]    


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