CASE 10541 Published on 03.12.2012

Primary bone lymphoma presenting with extradural spinal cord compression

Section

Neuroradiology

Case Type

Clinical Cases

Authors

Eleonora Gaspari, Angela Lia Scarano, Gisele Kabunda Dembele, Valentina Cama, Silvia Arduini, Giovanni Simonetti

Policlinico Tor Vergata,
v.le Oxford 81,
Roma, Italy
Patient

60 years, female

Categories
Area of Interest Spine ; Imaging Technique MR
Clinical History
Onset of pain in sacrococcygeal region that rapidly worsened and radiated into the buttock and posterior thigh and leg bilaterally. Reflexes were symmetrically elicited in the upper limb, reduced in the left lower limb; preserved sensitivity; right limb Lasègue test was positive at 60° flexure; pain, (not weakness) prevented ambulation.
Imaging Findings
The X-ray examination of lumbar column was normal; after 2 months of pain the patient underwent a contrast-enhanced magnetic resonance imaging. The study documented the presence of a homogeneous T1 hypointense mass localised within the spine canal between L3 and L4, arising from the posterior epidural space, with compression of the dural sac (Figure 1). The mass had a longitudinal extension of up to 5 cm, with invasion of the L3 left spinal foramen and also extended through the adipose tissue interposed between the spinous process and the left para-vertebral muscle between L3 and L4. The cortical disruption was limited to the left peduncle and lamina of L3. The T2 STIR sequence showed the hyperintense signal of the L3 spinous process (Figure 1). After administration of contrast medium the mass presented a homogeneous enhancement with pseudo-capsule aspect. The mielo-MR sequence defined the grade of compression (Figure 2).
Discussion
Primary bone lymphoma (PBL) is an uncommon disease [1]. The incidence of PBL is 7% of all malignant bone tumours, 4-5% of all extranodal non-Hodgkin Lymphoma and less than 1% of all malignant lymphomas [2, 3]. Men are affected more frequently than are women by primary lymphoma of bone. All ages are affected, although lymphoma of bone is uncommon in childhood. Most patients are in the fifth to seventh decade of life. Some authors reported neurologic compression as occurring rarely in primary NHL of the spine [4]. PBL can arise in any part of the skeleton, but long bones (femur, tibia, humerus) are the most common sites of presentation. Vertebral localisation is an unusual site of presentation. Paravertebral neoplasms (lymphoma, neuroblastoma, sarcoma), which spread through the intravertebral foramina without bone involvement, represent 10-15% of cases [5]. The pain by epidural spinal cord compression has the same features of pain caused by degenerative disc disease, but contrary to what is observed in patients with herniated discs, pain related to epidural masses might even increase in the supine position.
Diagnostic imaging allows detecting the presence and the severity of spinal cord compression. However, traditional X-ray examinations are normal in 60-70% of patients with lymphoma, sarcoma and paediatric cancers with a posterior or posterolateral compression without bone lesions [6]. Contrast enhanced MRI of the spine is the gold standard in suspected spinal cord compression because it allows the identification of the lesion, the dural sac compression and its relationship with adjacent structures [7]. Low signal intensity on T1-weighted images and high signal intensity on T2 weighted images is typically present. The presence of a dense fibrosis pattern of the lesion may cause a low T2 signal intensity. T2 STIR (short inversion-time inversion recovery) images distinguish pathological bone marrow where oedema is present. T1 post-gadolinium sequences show a homogeneous high enhancing lesion.
Although chemotherapy and/or radiotherapy are considered the most effective therapies [2], in our case the surgical approach was considered to be more appropriate in order to obtain decompression of the dural sac and remove the mass. In consideration of the lesion shape and its pseudo-capsulated morphology the excision was performed with therapeutic and diagnostic proposals (Figure 3). The histologic evaluation diagnosed diffuse large B-cell lymphoma.
Differential Diagnosis List
Primary bone lymphoma (diffuse large B-cell lymphoma)
Osteosarcoma
Schwannoma
Neurofibroma
Metastases
Final Diagnosis
Primary bone lymphoma (diffuse large B-cell lymphoma)
Case information
URL: https://www.eurorad.org/case/10541
DOI: 10.1594/EURORAD/CASE.10541
ISSN: 1563-4086

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