顱內(nèi)淋巴瘤影像診斷課件

CASEDISCUSSIONWANGLIJUN2008-7-141CASEDISCUSSIONWANGLIJUN1Case1:Female,66y2Case1:Female,66y2Case1:PLAINMRI3Case1:PLAINMRI3Case1:POST-CONTRASTMRI4Case1:POST-CONTRASTMRI4Case2:F66Y5Case2:F66Y5Case2:POST-CONTRASTMRI6Case2:POST-CONTRASTMRI6CASE3:M58Y,NHLwasdiagnosed2.5yearsago,nowfeelheadache(2008-1-25)-C+C7CASE3:M58Y,NHLwasdiagnos2008-1-3082008-1-308992008-5-15102008-5-1510LYMPHOMAPrimarycentralnervoussystemlymphoma(PCNSL)isarareformoflymphaticcancerarisinginthebrain,eye,nerves,spinalfluidsurroundingthebrainandspinalcord,andthecoveringofthebrain,calledduraSecondary:metastasestothenervoussysteminlymphomaaffectingotherorgans11LYMPHOMAPrimarycentralnervouPCNSL:EpidemiologyOncerare(~1%),nowbecomingincreasinglymorecommonIncidencehasrisendramaticallyinpastfewdecades,asPCNSLnowaccountsfor4-7%(16%)ofallnewlydiagnosedprimarybraintumorsIncidencehasrisenintheimmunocompromisedandalsoimmunocompetentpopulation12PCNSL:EpidemiologyOncerare(PCNSL:EpidemiologyImmunocompromisedCongenitalcausesofimmunodeficiency1.Wiskott-Aldrichsyndrome2.IgAdeficiency3.X-linkedlymphoproliferativesyndrome

acquiredcauses1.HIVinfectionandAIDS2.immunosuppressiveregimenafterorgantransplantation13PCNSL:EpidemiologyImmunocomprPCNSL:EpidemiologyMedianageofonset55yearsinimmunocompetent,incidenceriseswithageGreatestrisehasoccurredamongtheelderlyMaleismorecommonlyseencomparetofemale(2:1)14PCNSL:EpidemiologyMedianageDiagnosisHistoryFocalneurologicdeficit(i.e.hemiparesis,aphasia)presentin>50%ofallpatientswithPCNSLAlteredmentalstatus(memoryloss,confusion,etc.)foundin~33%-maybeinsidiousonsetHeadache,nausea(fromincreasedICP)in~33%Maypresentwithnew-onsetseizurein<10%BlurredvisionifocularlymphomaispresentRadiologicimagingHeadCTdetectsmostlesions(~90%)BrainMRImaydetectlesionsmissedonCT15DiagnosisHistory15DiagnosisPrimaryCNSlymphomamayarisefromdifferentpartsofthebraindeephemisphericperiventricularwhitematterbeingthemostcommoncorpuscallosum,cerebellum,orbits,andcranialnervesmayalsoharborthetumorHistology:intermediate-tohigh-gradeextranodalnon-Hodgkin'slymphomaofB-cellorigin16DiagnosisPrimaryCNSlymphomaRadiologicImaging

TypicalAppearanceinImmunocompetentPatientsUsuallysolitary,non-hemorrhagiclesionindeepwhitematter,nearventriclesLesionisisodensetohyperdense(70%)surroundingvasogenicedemahomogeneouslyenhancingmassSurroundingedemaistypicallylessprofoundthaninmetastaticbrainlesionsorgliomas17RadiologicImaging

TypicalApp64-year-oldwomanwithleft-sidedweakness.AxialunenhancedCTscanshowstypicalhyperdensemass(arrows)inrightparietallobesurroundedbylow-densityzone,consistentwithvasogenicedema.Axialcontrast-enhancedCTscanshowshomogeneousenhancement(arrows)oflesionnearmidline.1864-year-oldwomanwithleft-siRadiologicImaging

TypicalAppearanceinImmunocompetentPatientsintermediate-tolow-signal-intensitytumoronT1-weightedimagesIsointensetohypointensesignalrelativetothegraymatteronT2-weightedimagesAclassicpresentationisthelesionthatcrossesthecorpuscallosuminabutterflypatternEnhancesdenselyandhomogenouslywithgadoliniumcontrastMayalsorevealleptomeningealdiseaseHighsignalonDWI19RadiologicImaging

TypicalApp64-year-oldwomanwithleft-sidedweaknessAxialT2-weightedMRimageshowsheterogeneousmass(blackarrows)ofpredominantlylowsignalintensity.NotecentrallinearT2hyperintensity(arrowhead),likelyrepresentingnecrosis.Alsonotesurroundingvasogenicedema(whitearrows).Axialgadolinium-enhancedT1-weightedMRimageshowsmarkedcontrastenhancementoflesion(arrows).Notemasseffectonadjacentrightlateralventricle.2064-year-oldwomanwithleft-siPost-contrastCoronalT1WtdMRIPost-contrastAxialT1WtdMRIHomogeneouslyenhancingtumorisseeninvolvingthespleniumofthecorpuscallosum(arrows)spreadingacrossthemidline.21Post-contrastCoronalT1Wtd72-year-oldimmunocompetentwomanwithprimaryCNSnon-Hodgkin'sB-celllymphomawhopresentedwithprogressivemotorweakness.AxialFLAIRMRimageshowsisointensityoflesionstobrainparenchymaandsurroundingedema.Themassesinvolvedeepwhiteandgraymatter.Axialcontrast-enhancedT1-weightedMRimageshowshomogeneousenhancementofmultiplebilateraltumors.2272-year-oldimmunocompetentwo50-year-oldimmunocompetentmanwithprimaryCNSnon-Hodgkin'sB-celllymphoma.AxialT2-weightedMRimageshowsinfiltrativehyperintensemassexpandinggenuandspleniumofcorpuscallosuminbutterflypattern.contrast-enhancedaxialT1-weightedMRimageshowshomogeneousenhancementoflesion.2350-year-oldimmunocompetentma頭痛伴口周麻木2個月24頭痛伴口周麻木2個月24RadiologicImaging

AtypicalAppearanceinImmunocompetentPatientsisodensityorevenhypodensityonCTInthesettingofaperiventricularlow-densitylesion,lymphomamayeasilybemisdiagnosedaschronicsmallvesselischemiaorencephalomalaciaDiffuselyinfiltrativelymphomasmaynotexhibitparenchymalenhancementatall25RadiologicImaging

AtypicalAp90-year-oldwomanwithnormalimmunestatuswhopresentedwithright-sidedweaknessanddifficultyfindingwords.AxialT2-weightedMRimageshowsill-definedT2hyperintensity(arrows)surroundingleftinternalcapsuleandadjacentlefttemporallobe.Axialgadolinium-enhancedMRimagerevealsbarelydiscernibleparenchymalenhancementincorrespondingregion.Axialcontrast-enhancedCTscanobtained4monthslatershowsmarkedexpansionofleftbasalgangliaandthalamuscausedbyinfiltratingneoplasm,withlossofnormalanatomicboundaries(arrows).2690-year-oldwomanwithnormal63-year-oldwomanwithprimarymeningeallymphomawhopresentedwithfrequentfallsandvertigo.

AxialFLAIRimageshowshyperintensity(arrow)involvingsulciandleptomeningesofparietotemporalconvexity.Contrast-enhancedT1-weightedaxial(B)andcoronal(C)MRimagesshowfocalthickeningandhomogeneousenhancementofleptomeningesofparietotemporalconvexity(arrows).2763-year-oldwomanwithprimaryMale54y.rightsideweaknesswithheadacheandvomittingfor2months28Male54y.rightsideweaknessRadiologicImaging

AtypicalLocationsArareprimarylymphomaofthepinealglandappearssimilartoaprimaryneoplasmofpinealoriginCranialnerves,brainstem,cavernoussinus,ortubercinereummayhavelymphomatousinvolvement29RadiologicImaging

AtypicalLoMetastaticCNSLymphomaIn5~9%ofsystemicnon-Hodgkin'slymphoma,secondaryspreadinvolvestheCNS,usuallyintheformofleptomeningealinfiltrates,andhasapoorprognosisParenchymallesions,whenpresent,typicallyresultfromsecondaryinvolvementfromtheleptomeningesviainfiltrationoftheperivascularspaces30MetastaticCNSLymphomaIn5~9%Post-contrastAxialT1WtdMRIFigure.Linearenhancementofthecerebellarsulci(yellowarrows)andlefttemporalsulci(redarrow).Diagnosis:SecondaryLymphomawithsubarachnoidtumorseeding(arrows).31Post-contrastAxialT1WtdMRIPost-contrastCoronalT1WtdMRIDiagnosis:SecondaryLymphomawithcalvarialinvolvement(greenarrow)andassociatedepiduraltumor(yellowarrows)/scalptumor(redarrow)32Post-contrastCoronalT1WtdMRadiologicImaging

TypicalAppearanceinHIVPatientsacerebralmassisdetectedinasupratentorialparenchymallocation(55%)withfrequentinvolvementofthecorpuscallosum,basalganglia,andotherdeepcerebralnucleiContrastenhancementisvariable,commonlyofaninhomogeneousorbizarrepattern.Solitaryringlikeenhancementismorelikelyseeninthisgroupnecrosisdevelopsinthetumor(64%)Multiplelesionsmaybeseen(50%)Periventricularlesionsfrequentlyinvadetheventricularsurface,causingependymalseeding(38%)However,meningealenhancementissurprisinglynotfrequent.33RadiologicImaging

TypicalApp38-year-oldmanwithHIVwhopresentedwithdisorientationandconfusion.Axialgadolinium-enhancedT1-weightedMRimageshowssolitaryringlikeenhancementofmassandperipherallow-signal-intensityhalo(arrows).3438-year-oldmanwithHIVwhop35-year-oldmanwithHIVwhopresentedwithlowerextremityweakness.Noteatypicallymphomapresentedasnonenhancinglow-densitylesioninrightbasalgangliaonCT,initiallythoughttobealacunarinfarct.Axialprotondensity-weightedMRimageobtained3monthsafterAshowshyperintenselesion(arrows)withirregularbordersatsamelocation.Coronalgadolinium-enhancedT1-weightedMRimagerevealsintervalgrowthandenhancementofpallidalmass(arrows).Subtleenhancement(arrowhead)isalsoseeninependymalsurface.Biopsyrevealedprimarylymphoma.atypicallymphoma35