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Metastatic Intracranial Lymphoma


KEY FACTS

Terminology

  • Secondary CNS involvement in patients with systemic lymphoma (SCNSL)

Imaging

  • Secondary CNS lymphoma: Skull, dura, leptomeninges > > parenchymal mass

  • Best diagnostic clue: Diffusely enhancing dural mass ± bone involvement

    • May see leptomeningeal enhancement or nonsupression of cerebrospinal fluid on FLAIR; CT hyperdensity

  • Lower relative cerebral blood volume than other tumors

Top Differential Diagnoses

  • Meningioma

  • Meningeal metastases

  • Primary CNS lymphoma

  • “Tumefactive” demyelinating disease (MS, ADEM)

Clinical Issues

  • Prognostic markers suggestive of CNS relapse

    • Elevated serum lactate dehydrogenase levels

    • Presence of B symptoms

    • Extranodal involvement at > 1 site

    • Advanced stage

  • Aggressive histologic features increase risk for SCNSL

  • Involvement of liver, bladder, testis, or adrenals also increases risk of CNS spread

  • CNS involvement of lymphoma almost always fatal

  • Prophylactic CNS chemotherapy recommended for patients considered at high risk of CNS recurrence

Diagnostic Checklist

  • Occult lymphoma found in 8% of patients presenting with CNS lymphoma

  • SCNSL commonly mimics meningioma or other metastatic disease

Axial CECT shows extensive dural enhancement
related to metastatic intracranial lymphoma. Secondary lymphoma has a propensity for the meninges. About 1/3 of systemic lymphoma patients develop CNS disease.

Axial T1 C+ MR shows an enhancing central skull base mass
with associated dural
and leptomeningeal enhancement
within the internal auditory canals. The clivus is often involved by metastatic disease, particularly breast cancer and lymphoma.

Axial T1 C+ MR in a 54-year-old man with systemic lymphoma shows multiple enhancing masses. Some lesions involve the dura
, whereas others are parenchymal
. Metastatic intracranial lymphoma often involves the dura and may mimic a meningioma.

Axial T1WI C+ FS MR shows enhancement along the maxillary division (V2) of CN5
, extending from the cavernous sinus into the pterygopalatine fossa
, in this patient with systemic lymphoma and new facial paresthesias.

TERMINOLOGY

Synonyms

  • Secondary CNS lymphoma (SCNSL)

Definitions

  • Secondary involvement of CNS in patients with systemic lymphoma

IMAGING

General Features

  • Best diagnostic clue

    • Enhancing dural mass ± bone involvement

  • Location

    • Typically involves dura or leptomeninges

    • Parenchymal lesions may occur

    • Peripheral nerve = neurolymphomatosis

    • Spine involvement: ~ 3-5%

  • Morphology

    • Solitary mass or multiple lesions

    • May be circumscribed or infiltrative

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