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Lymphoma


KEY FACTS

Terminology

  • Lymphoreticular neoplasms with myriad of specific diseases and cellular differentiation

Imaging

  • Multiple types with variable imaging manifestations

  • Epidural lymphoma: Thoracic > lumbar > cervical

    • Enhancing epidural mass ± vertebral involvement

  • Osseous lymphoma: Long bones > spine

    • Bone destruction (“ivory” vertebra, rare), vertebra plana

  • Lymphomatous leptomeningitis

    • Smooth/nodular pial enhancement

  • Intramedullary lymphoma: Cervical > thoracic > lumbar

    • Poorly defined, enhancing mass

  • Secondary > primary involvement

  • Extradural > intradural > intramedullary

  • FDG PET useful for staging, monitoring treatment response, predicting treatment outcomes, and risk stratifying lymphoma patients

Pathology

  • Lymphoma is most common malignancy of epidural space

  • Non-Hodgkin lymphoma (NHL) > > Hodgkin disease; 80-90% are B cell

    • CNS lymphoma > 85% NHL (B cell > > > T cell)

  • CNS lymphoma may be primary or secondary (hematogenous or direct geographic extension)

Clinical Issues

  • Most common presenting symptom = back pain

  • Intramedullary = myelopathy (weakness, numbness)

  • Cord compression occurs in up to 5-10% of systemic lymphomas

  • Generally poor prognosis for CNS lymphoma

  • Markedly sensitive to chemotherapy/XRT

  • Depressed humoral and cell-mediated immunity leads to opportunistic infections

Sagittal T2WI MR demonstrates a discrete hypointense mass in the posterior epidural space with a cap of epidural fat
. The spinal cord is displaced anteriorly
. Biopsy disclosed B-cell lymphoma.

Sagittal T2WI MR (L) shows amorphous hypointense tumor mass insinuating along the cauda equina
. Sagittal T1WI C+ MR (R) reveals enhancing lymphoma within the leptomeninges surrounding the distal conus and involving the nerve roots diffusely
.

Coronal PET (L) shows FDG uptake in the left cervical lymph node mass
that was clinically evident. PET/CT fused image (R) shows abnormal activity at T11
. This is an example of osseous metastases from cervical Hodgkin lymphoma primary tumor.

Sagittal CT (L) demonstrates a pathologic compression fracture of a midthoracic vertebral body
. Sagittal T1WI C+ MR (R) confirms abnormal marrow enhancement
and a ventral paraspinal mass
.

TERMINOLOGY

Definitions

  • Lymphoreticular neoplasms with a myriad of specific diseases and cellular differentiation

IMAGING

General Features

  • Location

    • Multiple types with variable imaging manifestations

      • –

        Epidural lymphoma: Thoracic > lumbar > cervical

        • □

          Epidural extension from adjacent vertebral/paraspinous disease

      • –

        Osseous lymphoma: Long bones > spine

      • –

        Lymphomatous leptomeningitis

      • –

        Intramedullary lymphoma: Cervical > thoracic > lumbar

    • Secondary > primary involvement

      • –

        30% of systemic lymphomas have skeletal involvement

      • –

        Primary osseous lymphoma = 3-4% of all malignant bone tumors

    • Extradural > intradural > intramedullary

  • Best imaging clues

    • Epidural: Enhancing epidural mass ± vertebral involvement

    • Osseous: Bone destruction (“ivory” vertebra rare)

    • Leptomeningitic: Smooth/nodular pial enhancement

    • Intramedullary: Poorly defined enhancing mass

    • Angiotropic lymphoma (AL): Early signal intensity abnormalities

Radiographic Findings

  • Radiography

    • Epidural: May see bony erosion

    • Osseous

      • –

        Bone destruction (30-40%)

      • –

        Rare “ivory” vertebral body, vertebra plana

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