1、12 Case 1: Female, 66y3 Case 1: PLAIN MRI4 Case 1: POST-CONTRAST MRI5Case 2: F 66Y6 Case 2: POST-CONTRAST MRI7CASE 3: M 58Y, NHL was diagnosed 2.5 years ago, now feel headache(2008-1-25)-C+C82008-1-309102008-5-1511LYMPHOMA Primary central nervous system lymphoma (PCNSL) is a rare form of lymphatic c
2、ancer arising in the brain, eye, nerves, spinal fluid surrounding the brain and spinal cord, and the covering of the brain, called dura Secondary: metastases to the nervous system in lymphoma affecting other organs12PCNSL: Epidemiology O n ce r a r e ( 1 % ) , n o w b e c o m i n g increasingly more
3、 common Incidence has risen dramatically in past few decades, as PCNSL now accounts for 4-7% (16%) of all newly diagnosed primary brain tumors I n c i d e n c e h a s r i s e n i n t h e i m m u n o c o m p r o m i s e d a n d a l s o immunocompetent population13PCNSL: EpidemiologyImmunocompromised
4、Congenital causes of immunodeficiency 1.Wiskott-Aldrich syndrome 2.IgA deficiency 3.X-linked lymphoproliferative syndrome acquired causes 1. HIV infection and AIDS 2.immunosuppressive regimen after organ transplantation 14PCNSL: Epidemiology M e d i a n a g e o f o n s e t 5 5 y e a r s i n immunoco
5、mpetent, incidence rises with age Greatest rise has occurred among the elderly Male is more commonly seen compare to female (2:1)15Diagnosis History Focal neurologic deficit (i.e. hemiparesis, aphasia) present in 50% of all patients with PCNSL Altered mental status (memory loss, confusion, etc.) fou
6、nd in 33% - may be insidious onset Headache, nausea (from increased ICP) in 33% May present with new-onset seizure in 10% Blurred vision if ocular lymphoma is present Radiologic imaging Head CT detects most lesions (90%) Brain MRI may detect lesions missed on CT16Diagnosis Primary CNS lymphoma may a
7、rise from different parts of the brain deep hemispheric periventricular white matter being the most common corpus callosum, cerebellum, orbits, and cranial nerves may also harbor the tumor Histology: intermediate- to high-grade extranodal non-Hodgkins lymphoma of B-cell origin 17Radiologic ImagingTy
8、pical Appearance in Immunocompetent PatientsUsually solitary, non-hemorrhagic lesion in deep white matter, near ventriclesLesion is isodense to hyperdense (70%)surrounding vasogenic edema h o m o g e n e o u s l y enhancing massSurrounding edema is typically less profound than in metastatic brain le
9、sions or gliomas1864-year-old woman with left-sided weakness.Axial unenhanced CT scan shows typical hyperdense mass (arrows) in right parietal lobe surrounded by low-density zone, consistent with vasogenic edema. Axial contrast-enhanced CT scan shows homogeneous enhancement (arrows) of lesion near m
10、idline. 19Radiologic ImagingTypical Appearance in Immunocompetent Patientsintermediate- to low-signal-intensity tumor on T1-weighted imagesIsointense to hypointense signal relative to the gray matter on T2-weighted imagesA classic presentation is the lesion that crosses the corpus callosum in a butt
11、erfly pattern E n h a n c e s d e n s e l y a n d homogenously with gadolinium contrastMay also reveal leptomeningeal diseaseHigh signal on DWI2064-year-old woman with left-sided weakness Axial T2-weighted MR image shows heterogeneous mass (black arrows) of predominantly low signal intensity. Note c
12、entral linear T2 hyperintensity (arrowhead), likely representing necrosis. Also note surrounding vasogenic edema (white arrows). Axial gadolinium-enhanced T1-weighted MR image shows marked contrast enhancement of lesion (arrows). Note mass effect on adjacent right lateral ventricle. 21 Post-contrast
13、 Coronal T1 Wtd MRIPost-contrast Axial T1 Wtd MRIHomogeneously enhancing tumor is seen involving the splenium of the corpus callosum (arrows) spreading across the midline.2272-year-old immunocompetent woman with primary CNS non-Hodgkins B-cell lymphoma who presented with progressive motor weakness.
14、Axial FLAIR MR image shows isointensity of lesions to brain parenchyma and surrounding edema. The masses involve deep white and gray matter. Axial contrast-enhanced T1-weighted MR image shows homogeneous enhancement of multiple bilateral tumors. 2350-year-old immunocompetent man with primary CNS non
15、-Hodgkins B-cell lymphoma. Axial T2-weighted MR image shows infiltrative hyperintense mass expanding genu and splenium of corpus callosum in butterfly pattern. contrast-enhanced axial T1-weighted MR image shows homogeneous enhancement of lesion. 24头痛伴口周麻木头痛伴口周麻木2个月个月 25Radiologic ImagingAtypical App
16、earance in Immunocompetent Patients isodensity or even hypodensity on CT In the setting of a periventricular low-density lesion, lymphoma may easily be misdiagnosed as chronic small vessel ischemia or encephalomalacia Diffusely infiltrative lymphomas may not exhibit parenchymal enhancement at all269
17、0-year-old woman with normal immune status who presented with right-sided weakness and difficulty finding words.Axial T2-weighted MR image shows ill-defined T2 hyperintensity (arrows) surrounding left internal capsule and adjacent left temporal lobe. Axial gadolinium-enhanced MR image reveals barely
18、 discernible parenchymal enhancement in corresponding region. Axial contrast-enhanced CT scan obtained 4 months later shows marked expansion of left basal ganglia and thalamus caused by infiltrating neoplasm, with loss of normal anatomic boundaries (arrows). 2763-year-old woman with primary meningea
19、l lymphoma who presented with frequent falls and vertigo. Axial FLAIR image shows hyperintensity (arrow) involving sulci and leptomeninges of parietotemporal convexity. Contrast-enhanced T1-weighted axial (B) and coronal (C) MR images show focal thickening and homogeneous enhancement of leptomeninge
20、s of parietotemporal convexity (arrows). 28Male 54y. right side weakness with headache and vomitting for 2 months29Radiologic ImagingAtypical LocationsA r a r e p r i m a r y lymphoma of the pineal gland appears similar to a primary neoplasm of pineal origin C r a n i a l n e r v e s , b r a i n s t
21、 e m , cavernous sinus, or tuber cinereum may have lymphomatous involvement30Metastatic CNS Lymphoma In 59% of systemic non-Hodgkins lymphoma, secondary spread involves the CNS, usually in the form of leptomeningeal infiltrates, and has a poor prognosis Parenchymal lesions, when present, typically r
22、esult from secondary involvement from the leptomeninges via infiltration of the perivascular spaces 31Post-contrast Axial T1 Wtd MRIFigure. Linear enhancement of the cerebellar sulci (yellow arrows) and left temporal sulci (red arrow).Diagnosis: Secondary Lymphoma with subarachnoid tumor seeding (ar
23、rows).32Post-contrast Coronal T1 Wtd MRIDiagnosis: Secondary Lymphoma with calvarial involvement (green arrow) and associated epidural tumor (yellow arrows) / scalp tumor (red arrow)33Radiologic ImagingTypical Appearance in HIV Patientsa cerebral mass is detected in a supratentorial parenchymal loca
24、tion (55%) with frequent involvement of the corpus callosum, basal ganglia, and other deep cerebral nuclei Contrast enhancement is variable, commonly of an inhomogeneous or bizarre pattern. Solitary ringlike enhancement is more likely seen in this group necrosis develops in the tumor (64%)Multiple l
25、esions may be seen (50%) Periventricular lesions frequently invade the ventricular surface, causing ependymal seeding (38%) However, meningeal enhancement is surprisingly not frequent.3438-year-old man with HIV who presented with disorientation and confusion. Axial gadolinium-enhanced T1-weighted MR
26、 image shows solitary ringlike enhancement of mass and peripheral low-signal-intensity halo (arrows). 3535-year-old man with HIV who presented with lower extremity weakness. Note atypical lymphoma presented as nonenhancing low-density lesion in right basal ganglia on CT, initially thought to be a la
27、cunar infarct. Axial proton density-weighted MR image obtained 3 months after A shows hyperintense lesion (arrows) with irregular borders at same location. Coronal gadolinium-enhanced T1-weighted MR image reveals interval growth and enhancement of pallidal mass (arrows). Subtle enhancement (arrowhea
28、d) is also seen in ependymal surface. Biopsy revealed primary lymphoma. atypical lymphoma36Other considerations Steroids can significantly alter appearance on imaging by decreasing tumor size, edema, and enhancement Tumors are highly radiosensitive and chemosensitive37References Erdag N, Bhorade RM,
29、 Alberico RA, Yousuf N, Patel M. Primary lymphoma of the central nervous system: typical and atypical CT and MR imaging appearances. AJR Am J Roentgenol 2001; 176 :1319 1326 H. Wayne Slone1, Joseph J. Blake, Rajul Shah, CT and MRI Findings of Intracranial Lymphoma. AJR 2005; 184:1679-1685 38Differen
30、tial diagnosis Gliomablastoma multiforme Metastasis Encephalitis Other multiple focal white matter disease Meningitis结束语当你尽了自己的最大努力时，失败也是伟大的，所以不要放弃，坚持就是正确的。When You Do Your Best, Failure Is Great, So DonT Give Up, Stick To The End感谢聆听不足之处请大家批评指导Please Criticize And Guide The Shortcomings演讲人：XXXXXX 时 间：XX年XX月XX日
