Eur. Radiol. (2002) 12:329340 DOI 10.

1007/s003300101037

NE UR O

A. Coulon F. Lafitte K. Hoang-Xuan N. Martin-Duverneuil K. Mokhtari J. Blustajn J. Chiras

Radiographic findings in 37 cases of primary CNS lymphoma in immunocompetent patients

Received: 10 November 2000 Revised: 8 December 2000 Accepted: 11 June 2001 Published online: 21 September 2001  Springer-Verlag 2001

A. Coulon F. Lafitte ( ) N. MartinDuverneuil J. Chiras Department of Neuroradiology, Hpital de la Salptrire, 4783 Boulevard de l'Hpital, 75651 Paris, France E-mail: flafitte@aol.com or flafitte@fo-rothschild.fr Phone: +33-1-42 16 19 01 Fax: +33-1-42 16 19 06 K. Hoang-Xuan Department of Neurology, Hpital de la Salptrire, 4783 Boulevard de l'Hpital, 75651 Paris, France K. Mokhtari Department of Anatomopathology, Hpital de la Salptrire, 4783 Boulevard de l'Hpital, 75651 Paris, France J. Blustajn Department of Radiology, Fondation Rothschild, Paris, France

Abstract Because of the increasing incidence of primary central nervous system lymphoma (PCNSL), it is essential to recognize this disease in order to start appropriate treatment. We present the characteristic CT and MRI features of this tumour. The findings of 32 CT and 31 MR of 37 immunocompetent patients with biopsy-proved PCNSL are reviewed. The main features are presented and analysed, and are discussed in comparison with proven literature data. Primary central nervous system lymphoma presents as supratentorial solitary lesions in approximately 80 % of the patients and multiple lesions in 20 %. In contrast to classical data, the lesions are located in deep structures only in one-third of the cases, and involve posterior fossa in 10 % of cases. Most of the lesions are hyperdense or isodense (92 %) on CT, hypointense or isointense on T1-weighted images, and only about 40 % are hyperintense on T2-weighted images. Nearly all the lesions enhance, except after corticosteroid administration. They produce mild oedema

and mass effect. Meningeal or ventricular enhancement are rare but suggestive. Calcification, haemorrhage or necrosis are scarce. Although PCNSL in immunocompetent patients have a variable CT and MR appearance, the imaging data often suggest the diagnosis. Keywords MR imaging CT imaging Brain tumours Brain lymphoma Immunocompetent patient

Introduction
Primary central nervous system (CNS) lymphoma represents approximately 6 % of all intracranial neoplasms and approximately 1 % of all lymphomas. It usually presents as a brain tumour, but may also involve the leptomeninges (12 %), eyes, and spinal cord (1 %). The in-

cidence has been steadily increasing in the past 20 years, in both immunocompromised and immunocompetent patients. The pathogenesis remains unknown. Most primary central nervous system lymphoma (PCNSL) are composed of diffuse large lymphomatous cells with a B phenotype, and cannot be histologically differentiated from systemic extra-nodal non-Hodgkin's lymphomas.

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Table 1 The CT data of the 39 lesions (for the 37 patients) in percent Density Hypodense Isodense Hyperdense Heterogeneous Calcification Enhancement Absent Moderate Important Ventriculitis Mass effect Moderate Important 5 46 46 3 3 0 20 80 11 44 41

Table 3 The MRI features of the 45 lesions in percent Cystic Necrosis Haemorrhage Margins Irregular Oedema Absent Moderate Important Mass effect Absent Moderate Important Signal T1 Isointense Hypointense Signal T2 Hyperintense Isointense Enhancement Absent Moderate Important Heterogeneous Homogeneous Meningitis Ventriculitis 2 7 2 73 15.5 47 38 31 44.5 24.5 36 53 42 38 0 33 67 50 50 5 13

Table 2 The MRI number and location of the 45 lesions for the 37 patients in percent Unifocal forms Multifocal forms Posterior fossa Supratentorial level Lobar involvement Deep structures involvement Both Isolated ventriculitis 80 20 18 80 35 33 12 2

The CT and MR features of these lesions have already been described, but mostly in small series. The aim of our study is to present a pictorial overview of the PCNSL.

Results
The interval between the clinical onset and the histological diagnosis was approximately 8 weeks (range 120 weeks). According to the REAL classification, 25 patients (67.5 %) had diffuse large B-cell lymphoma, T-cell lymphoma was found in 3 patients (8.1 %) and 9 patients (24.3 %) presented unclassified subtype. Computed tomography demonstrated 39 lesions in 32 patients. Detailed results concerning the different characteristics of the lesions are presented in Table 1. Magnetic resonance imaging showed 45 lesions in 31 patients. Eight lesions (18 %) were located in the posterior fossa. Thirty-six lesions (80 %) were supratentorial, with isolated lobar involvement in 16 lesions (35 %), isolated deep structure involvement in 15 lesions (33 %), and associated lobar and deep structure involvement in 5 lesions (12 %). One lesion (2 %) appeared as isolated diffuse ventriculitis. We observed two cases of skull base involvement. The detailed analysis of the different locations of the lesions stemmed from the MR data, which is more precise than CT (Table 2). Detailed results concerning the characteristics of the lesions are presented in Table 3. Seven patients (20 %) presented a multifocal form, with a total of 20 lesions on MRI. The mean age was

Materials and methods

The clinical data and initial radiographic findings of 37 patients (19 women and 18 men, mean age 62 years, age range 2480 years) who presented in our institution with PCNSL between December 1991 and June 1998 were retrospectively reviewed. All of our patients had no known immunodeficiency, neither congenital nor acquired (AIDS, haematological disease, immunosuppressive treatment). They all had a negative extra-neural staging (including physical examination, bone marrow aspiration and biopsy, chest and abdominal CT, testicular sonography and ophthalmological exam (slit-lamp)), necessary to differentiate PCNSL from secondary CNS lymphoma. The CT (32 exams) and MRI studies (31 exams) were analysed by two neuroradiologists. The diagnosis was histologically confirmed in all cases. The histological diagnoses were obtained by stereotactic or surgical brain biopsy for 32 patients (86.5 %), vitrectomy for 3 patients (8 %), and lumbar puncture with cerebrospinal fluid (CSF) analysis for 2 patients (5.5 %). All the imaging findings were analysed and compared with literature data.

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Fig. 1 ad A 58-year-old man presenting with intracranial hypertension. a, b Axial CT scan before and after contrast medium administration show area of subtle hyperdensity around the third ventricle (arrow), with strong enhancement after injection. c Axial postcontrast T1-weighted MR image shows the lesion enhancing strongly and surrounding the third ventricle. Note the diffuse ventriculitis. d Axial T2-weighted image demonstrates the isointense lesion, surrounded with hyperintense oedema

62.5 years (age range 3473 years) . There were 4 women and 3 men (gender ratio was 0.4). According to MRI results, 7 (35 %) of these 20 lesions were located in the posterior fossa and 13 lesions (65 %) were supratentorial, with isolated lobar involve-

ment in 7 cases (35 %), isolated deep structure involvement in 5 cases (25 %), and both lobar and deep structure involvement in 1 case (5 %). The comparison of multifocal with monofocal PCNSL allowed to detect statistical differences:

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Fig. 2 ac A 70-year-old woman presenting with aphasia and amnesia. CT scan in axial plane a before and b after contrast media administration: left posterior hemispheric lesion with high density prior contrast administration, yielding important enhancement. c T2-weighted axial slice: the lesion appears isointense; oedema and mass effect are slight in comparison with the important size of the lesion

fusion and balance disorders. Initial seizures are uncommon, probably because the PCNSL, unlike metastasis, often occur in a deep location, sparing the cortical areas. Number and location of the lesions In agreement with the literature, the majority of patients in our study (80 %) had a solitary lesion [4, 5, 6]. The higher rate of multiple lesions is classically found in patients with AIDS lymphomas (ranging from 41 to 81 %) [7, 8]. A large majority of lesions were supratentorial (80 % in our series, 70 % in other series) [7, 8, 9, 10]. The posterior fossa location is rare (18 % in our study) with a preference for the cerebellar hemispheres [9, 10, 11]. Combined supra- and infratentorial involvement is also rare, but estimated to be 14.5 % by Canaple [1]. Only 3 cases (8 %) of multiple cerebral lymphoma involved both sides of the tentorium in our studies. However, the characteristic features of the disease may be changing: it has been suggested that there is an increasing trend for the PCNSL to present with multifocal intracranial lesions, and to involve both infra- and supratentorial levels. The cause of this increase of multifocal lymphoma is unclear but could be partially explained by improved radiological detection of small lesions due to technical advances. It is generally reported that the PCNSL preferentially involve the deep cerebral parenchyma (Fig. 1), and especially the basal ganglia; however, in our studies only 33 % were strictly located to the deep central

1. On CT, necrosis was more frequent for multifocal lymphomas (p = 0.028) and the mass effect appeared weaker or absent (p = 0.021). 2. On MR, the lesions were more frequently hyperintense on T2-weighted spin echo (SE; p < 0.001), the oedema and the mass effect were weaker or absent (p = 0.005), and ventricular involvement was less frequent (p = 0.022). The ophthalmological exams were normal in 30 patients (81 %), and uveitis or retinitis were present in 3 patients (8 %). No ophthalmological exam was performed in 4 patients (11 %). The mean age in our cohort is similar to that of other reported series of patients with primary CNS lymphomas. The disease usually occurs in the sixth decade. A male predominance is generally recognized, but in agreement with recent studies, our series had a female preponderance, with 0.94 male-to-female ratio. In agreement with previous studies [1, 2, 3], the delay between onset of clinical symptoms and histological diagnosis is relatively short, with a median at 2 months for our study (2.5 months in the literature). Their presenting symptoms vary and the most common are focal sensory motor loss, signs of intracranial hypertension, con-

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Fig. 3 ae A 26-year-old man presenting with intracranial hypertension. a, b Axial CT scan before and after contrast medium administration show a hyperdense mass of the right part of the posterior fossa, strongly enhanced after injection (arrows), with adjacent skull base erosion. c Noncontrast sagittal T1-weighted MR image demonstrates the hypointense lesion. d Coronal postcontrast T1-weighted image shows the extra-axial mass, and the associated involvement of the adjacent skull base and soft tissues (curved black arrows). e Axial T2-weighted image show the isointense lesion without marked oedema (asterisk)

structures. Our results confirm some more recent findings where 5060 % of lesions are located in the peripheral brain matter [9, 10, 11], and only 1733 % of PCNSL occur in a deep location [10]. According to the literature, the deep midline structures are rarely in-

volved, particularly the corpus callosum (10 %). The classical butterfly pattern or mirror image (when the lesion involves the frontal lobes and the genu of the corpus callosum) was found in only 1 case of our study. This location seems to be more frequent in lymphomas of patients with AIDS [12], or in malignant gliomas. The optic chiasm and pineal gland are also rarely involved (only 1 case in our study). Unlike secondary CNS lymphoma, bone and dural involvement are rare (2 patients with a skull involvement in our study). Such lesions may mimic meningioma.

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Fig. 4 ac Extra-axial lymphoma mimicking a falx meningioma. CT scan in axial plane a before and b after contrast media administration: extra-axial mass involving the cerebral fax: the lesion appears hyperdense prior contrast administration, and strongly enhances. Important associated oedema. c T1-weighted coronal slice after gadolinium administration: the corpus callosum is displaced downwards by the extra-axial mass

found in metastasis or glioblastoma. In fact, 26 % of metastatic lesions yield necrotic or haemorrhagic components [12]. On MRI, there is a relation between necrosis and hyperintense signal on T2-weighted images and annular or heterogeneous enhancement [16]. Necrotic and haemorrhagic lesions are more frequent in patients with AIDS-related lymphomas [10, 17, 18, 19]. Density (CT) and signal (MRI) of the lesions According to the literature, PCNSL on CT usually appears hyperdense (46 %) or isodense (46 %) before contrast medium administration (Figs. 1, 2, 3, 4). The hypercellularity may be responsible for the hyper- or isodensity of the tumoral mass [20]. This feature is important in distinguishing PCNSL from metastasis or gliomas, which are more frequently hypodense [12, 21]. Only few cases of hypodense lymphomatous lesions have been described [4]. On MRI, in agreement with the literature [1, 10, 13, 16, 22, 23, 24, 25], on T1-weighted images the lesions were most frequently hypointense (53 %) or isointense (37 %). On T2-weighted images, the lesions were more commonly hyperintense (42 %) or isointense (37 %). Less commonly, the lesions may show a hypointense central area surrounded by peripheral hyperintense oedema in T2-weighted sequences [10, 14, 16]. When presenting with iso- or hypointense signal on T2weighted images (58 % of cases), PCNSL can usually be distinguished from gliomas and demyelinating diseases, which are more commonly hyperintense; however, such hypointensity could be seen in gastrointesti-

General pattern of the lesions Classically [10, 13], most of the lesions are well demarcated, particularly on MRI. Calcification, cyst formation and haemorrhage are accepted as being uncommon features of PCNSL prior to treatment. We found only one cystic lesion in MRI; however, Jenkins and Ogata described approximately 8 % of cystic lesions as hypodense areas. Calcifications occur most frequently after radiotherapy or chemotherapy. Jenkins and Colquhoun reported one case of gyral calcification in a diffuse infiltrative form of lymphoma [14]. We therefore agree that calcifications are indeed rare in PCNSL at presentation, and to our knowledge, the single case in our series is the second to be reported of a calcified untreated PCNSL. Calcifications are far more frequent in primary glial tumours, particularly oligodendrogliomas. We observed only two haemorrhagic lesions. These haemorrhagic lymphomas are very scarce but are described in literature on MRI [15]. The differential diagnosis includes metastasis (e.g. melanoma, renal and lung cancers, choriocarcinoma) and glioblastoma which bleeds frequently. Necrotic lesions are also rare (four cases detected by CT and two cases by MRI). They are preferentially

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Fig. 5 a, b A 79-year-old patient with meningeal syndrome. a Axial postcontrast T1weighted image shows enhancing lesions involving the lateral ventricles (ventriculitis). b Axial T2-weighted image shows the isointense involvement of the lateral ventricles (black arrows)

nal tract adenocarcinoma metastasis (tumour hypercellularity, and mucine hypersecretion). In the case of PCNSL, it probably reflects the increased nuclear-cytoplasmic ratio in these densely packed highly cellular tumours [15]. Contrast enhancement After gadolinium administration, significant enhancement was observed in all the lesions of our series, and was strong and homogeneous in 70 % of the cases on CT (Figs. 1, 2). Classically, on MRI, enhancement is also usually homogeneous [13, 16, 24, 26, 27, 28], but it was heterogeneous in 50 % of our cases. This could be explained by the better spatial resolution of MRI, which can detect more heterogeneous areas than CT. The lack of enhancement of the lesions prior to treatment is very uncommon but has been described in some series in a proportion of 10 % of the lesions [16, 29, 30, 31], which seems overestimated. Corticosteroids can also modify and anul the enhancement pattern, and should not be administered prior to CT and MR imaging (except in case of severe intracranial hypertension). Oedema and mass effect Marked oedema and mass effect are uncommon features of PCNSL, probably because of the infiltrative

nature of the tumour [1, 6, 32]. In our series, the mass effect was moderate on CT and MRI. Although oedema was usually described as weak on MRI, it was often considered to be severe on CT. Similar data have already been described [33]. It is obvious that the peripheral hypodensity on CT (usually considered as oedema) is non-specific and may correspond either to peritumoral oedema or tumoral non-enhancing infiltration. Although the hyperintense areas on T2-weighted images are also not specific, they seem to be more reliable in analysing the peritumoral oedema. Ventriculitis One of the most characteristic features of CNS lymphoma is its tendency to involve the ventricular ependyma, the meninges, or both (in 6080 % of the cases on imaging modalities, and 100 % on autopsies) [4, 9, 17, 25]. This feature supports the theory that the lesion originates from the periadventitial cells of penetrating arterioles in the perivascular Virchow-Robin spaces [34]. Results from our series show that 50 % of the lesions were in contact with the meninges on CT and MRI, with a meningeal enhancement in 10 % on CT and 20 % on MRI. The lower sensitivity of CT in detecting meningeal enhancement could be explained by the proximity between meningeal structures and bone. Even if a ventricular contact was observed in 56 % of CT and 38 % of MRI, ventricular enhancement was

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Fig. 6 a, b A 70-year-old patient presenting gait disturbance and diplopia. CT scan in axial plane a before and b after contrast media administration: right capsulo-lenticular lesion, isodense with mild oedema and mass effect, with strong and sharply delimitated enhancement, mimicking a stroke in the deep territory of the middle cerebral artery

found in only 20 % (on CT and MRI) and preferentially observed in the lesions involving the deep brain matter [26, 35, 36]. Classically, the meningeal and ventricular involvement is contiguous with a parenchymatous lesion (Fig. 1), but a diffuse radiological meningitis or ventriculitis may exist (Fig. 5) [26, 37]. While CT and MRI are highly sensitive in detecting diffuse meningeal involvement, cerebrospinal fluid (CSF) examinations, however, are often negative [37]. Our study confirms the lack of correlation between radiological and cytological data. Cerebrospinal fluid examination was normal when a diffuse meningitis was present (9 % of our patients); however, in cases of diffuse ventriculitis, CSF examination was positive (presence of lymphomatous cells) in 2 cases (out of 5 patients). Moreover, a positive CSF examination in these patients allowed the diagnosis of PCNSL and obviated the need for an invasive cerebral biopsy. Atypical presentations and differential diagnosis The type of enhancement is sometimes atypical and can be mistaken for another disease: 1. We noted a frontorolandic gyra-like enhancement in one of our patients. Lee et al. [5] reported three similar cases. The main differential diagnosis is an enhancingresolving infarction (Fig. 6).

2. The frequency of rim enhancement is rare in such immunocompetent patients before treatment and was seen in 1340 % on CT in the literature [5, 33, 38]. We observed only two supratentorial lesions with rim enhancement. This pattern of enhancement is more frequently seen in the posterior fossa and immunocompromised patients [7, 33]. The main differential diagnoses in these cases include other neoplasms such as brain metastasis or malignant glioma, abscess, or sometimes resolving haematoma. 3. We also reported one case of diffuse periventricular enhancement without a cerebral mass associated (Fig. 5). This atypical presentation has already been described [33, 34]. The enhancement was strong and homogeneous. This pattern of ventriculitis is also encountered in other tumours or in infectious diseases. 4. Some atypical PCNSL infiltrate the brain parenchyma diffusely with no mass formation [24, 29, 39, 40]. These lesions appear as relatively symmetrical areas of hypodensity on CT and hypointensity on T1weighted images, with lack or slight oedema and mass effect. There is no enhancement after contrast media administration. The diagnosis of PCNSL is very difficult and often delayed. In these cases the tumoral cells sparsely infiltrate the brain parenchyma, sparing the blood-brain barrier [24, 26]. The differential diagnoses are demyelinating diseases, low grade astrocytomas, gliomatosis cerebri and progressive multifocal leucoencephalopathy in immunocompromised patients. In old patients, this feature

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Fig. 7 ad A 38-year-old patient with intracerebral haemorrhage and aphasia. a T2weighted axial slice: left temporal hyperintense and heterogeneous lesion. b T1-weighted sagittal slice: the lesion contains haemorrhagic components in hypersignal. T1-weighted sequence after gadolinium injection in c axial and d coronal planes: mild parenchymatous and meningeal enhancement. The features are close to those observed in herpes meningoencephalitis, but the clinical presentation is different

may not be distinguished from leucoaraiosis; however, the involvement of the deep or superficial grey matter may help to exclude demyelinating diseases. 5. Occasionally, PCNSL appears as an extra-axial mass involving dura matter and sometimes the adjacent skull [11, 41, 42, 43, 44, 45]. These lesions may mimic meningioma but also dural metastasis, plasmocytoma, dural inflammatory pseudotumours and Castleman's disease (Figs. 3, 4). 6. Meningeal enhancement (without intracerebral mass associated) is rare in PCNSL [6, 9] but is more fre-

quently encountered in secondary lymphomas (e.g. Hodgkin's). 7. In our series, we report a case of a cerebral lymphoma (involving only the left temporal lobe) which closely mimicked herpes encephalopathy (Fig. 7). 8. Multiple lesions (Fig. 8) are known to occur in approximately 1147 % of cases of PCNSL. Their prevalence is higher in immunocompromised patients, and seems to increase. In our study they represented approximately 20 % of all PCNSL.

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Fig. 8 ad An 80-year-old woman presenting with sensory loss. a Axial postcontrast T1weighted image shows a strong enhancing area involving the frontal lobes and the genu of the corpus callosum. bd Several other locations are visible in the posterior fossa (arrow)

Isolated lobar involvement is very frequent (70 %), especially for the frontal and parietal lobes. Posterior fossa involvement is frequent (35 %). In comparison with monofocal PCNSL, these lesions demonstrate a higher frequency of heterogeneous enhancement and

areas of necrosis, but little oedema and mass effect, unlike metastasis. The differential diagnoses are metastases (but they are often located at the whitegrey matter junction), multifocal glioblastoma and abscess.

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9. Ocular lymphoma is known to be associated with PCNSL in 610 % of cases, and to precede the disease in 10 % [46]. Furthermore, 1020 % of relapse occurs in the eyeball [9]. We report 3 cases (8 %) of PCNSL with ocular location in our series. For one of these 3 cases, the diagnosis was established 1 year before the onset of PCNSL. The presence of lymphomatous cells in the vitreous could be explained by the direct propagation of tumoral cells from the brain to the eyeball via the subarachnoid spaces of the optic nerve sheath.We recommend an ophthalmological exam in all cases of suspected PCNSL in order to search for uveitis or hyalitis, since half of the cases with ocular involvement are not symptomatic. In case of suggestive abnormalities (uveitis or hyalitis), a vitreous biopsy can be performed and may obviate performing an invasive brain biopsy, especially in elderly patients.

bral lymphoma from infectious lesion in AIDS patients, but this technique does not seem relevant in immunocompetent patients [47]. Diffusion-weighted imaging (DWI) and MR spectroscopy may provide additional information [48], since PCNSL often present high-intensity signal on DWI; however, further studies are needed to define the different patterns of brain tumours, especially in DWI. Histological diagnosis is always necessary, using brain biopsy, or, in some cases, CSF examination after lumbar puncture or vitreous biopsy in case of suggestive uveitis or hyalitis. The histological diagnosis is often difficult, leading sometimes to false diagnoses, especially with gliomas. The administration of corticosteroids (sometimes performed to assist the differential diagnosis with imaging modalities) must be avoided, because it may cause difficulties with regard to performing a biopsy.
Acknowledgements The authors thank G. Podevins for the iconography and A. Bissery for the statistics.

Diffusion-weighted imaging and nuclear studies

Some papers emphasize the interest of thallium-201 brain single photon emission CT in differentiating cere-

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