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Cerebral Lymphoma

Michael Dignazio, MD
Amir Zamani, MD

February 12, 1997

Presentation

A 62-year-old man presented with headache.

Imaging Findings

CT of the brain
T1-weighted MR of the brain
T2-weighted MR of the brain

Computed tomography (CT) images of the brain (without contrast material) demonstrate a 3x3x4 cm high-attenuation mass (arrows) within the right temporal lobe, extending superiorly to the level of the frontal horns. Note the mass effect and the right-to-left midline shift of approximately 1cm. Surrounding low-attenuation vasogenic edema (arrows) extends to the high parietal area. A similar, smaller high-attenuation lesion (arrows) is visible in the right basal ganglia, also with surrounding vasogenic edema and mass effect.

On T1-weighted magnetic resonance (MR) images, right temporal and basal ganglia lesions enhance strongly with gadolinium and are surrounded by low signal edema. On T2-weighted MR, lesions are mixed in signal but predominantly isointense to grey matter.

Differential Diagnosis

Primary cerebral lymphoma (PCL) is most likely. Although most PCL is focal, it can be diffuse and infiltrative, in which case it may mimic gliomatosis cerebri. Because of the variable appearance of PCL, differential diagnosis based on imaging studies may include glioma, metastasis, melanoma, and even meningioma or progressive multifocal leukoencephalopathy.

Diagnosis

Diffuse, large cell non-Hodgkin's lymphoma of B-cell origin (primary cerebral lymphoma)

Discussion

PCL is uncommon in adults, comprising only 1-2% of all intracranial neoplasms and approximately 1% of primary non-Hodgkin's lymphoma. A slightly higher incidence is seen in the setting of AIDS. The average age at presentation is 60 years for immunocompetent individuals, and 33 years in those afflicted with AIDS.

PCL tends to occur centrally, with a predilection for deep basal ganglia, periventricular areas, and the corpus callosum. Symptoms are those usually associated with intracranial mass lesions, and the histologic findings are usually non-Hodgkin's of the B-cell variety. Although the tumors are exquisitely radiosensitive, recurrence is the rule, and median survival is 13.5 months.

On CT images, most PCL will be isodense to moderately hyperdense on unenhanced imaging, and show strong uniform enhancement with contrast. Ring enhancement is more commonly associated with immunocompromised patients.

On MR images, most focal PCL will be slightly hypointense to isointense to grey matter on T1-weighted images, isointense to slightly hyperintense on T2. Gadolinium will generally cause marked, uniform enhancement. In AIDS-related PCL, heterogenoeous patterns occur more frequently.

References

1. Osborn AG. Diagnostic neuroradiology. St Louis, MO: Mosby, 1994: 620-622.

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