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Magnetic Resonance Imaging Spectrum of Cauda Equina and Conus Lymphoma: Keys to Unravel the Differential Diagnosis with a Review of the Literature
, Pallavi Gogoi2, Bidyut B. Gogoi3, Kalyan Sarma1, Gautam Sarma4, Karuna Hazarika5, Augstine A.6, Halimuddin Ahmed5
This article was originally published by Thieme Medical and Scientific Publishers Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Central nervous system lymphoma is not an uncommon condition, but spinal lymphoma with isolated involvement of the conus medullaris and cauda equina is a rare entity. Our study aims to evaluate the various magnetic resonance imaging (MRI) features of cauda equina and conus lymphoma. This retrospective study was carried out on nine patients with histopathologically proven cauda equina and conus lymphoma, who were presented at a tertiary care hospital between January 2018 and June 2020. All patients underwent lumbar spine MRI scans using a 1.5 Tesla MR scanner. The clinical data and different MRI findings were analyzed with an independent sample t-test and paired-samples t-test. Among the nine patients with cauda equina and conus lymphoma, three had primary lymphoma and six had secondary lymphoma. Six patients (66.7%) showed a diffuse pattern of involvement of cauda equina and conus medullaris, while three patients (33.3%) showed a focal pattern. T2-weighted imaging (T2WI) hypo to isointense signal intensity lesions were observed in six patients (66.7%) and T2WI iso to slight hyperintensities in three patients (33.3%). Diffuse sheet-like thickening and postcontrast enhancement of the thickened cauda equina nerve roots were observed in two patients of primary and one patient with secondary lymphoma. The diagnosis of cauda equina and conus lymphoma especially primary lymphoma is challenging and requires a high index of clinical suspicion as distinguishing this entity from similar conditions is difficult solely on MRI. Early diagnosis of this entity is important for early institution of treatment for increasing the chances of survival and improvement of symptoms.
Keywords
Introduction
The intradural and intramedullary spinal lymphomas, whether primary or secondary, have been an uncommon entity. Central nervous system (CNS) lymphoma is rather common but spinal lymphoma is a rare entity.1 Primary CNS lymphoma accounts for 1 to 2% of all non-Hodgkin lymphoma.2 Of the CNS lymphoma, spinal cord lymphoma occurs in less than 1%.3 Among the spinal cord lymphoma, cauda equina lymphoma is the rarest one.3
The primary cauda equina and conus lymphomas are uncommon extranodal non-Hodgkin lymphoma. Secondary cauda equina and conus lymphomas occur due to secondary involvement of systemic lymphoma, either from hematogenous, direct invasion, venous spread through Batson's plexus, or drop metastasis from brain involvement.4
B cell type of lymphoma dominantly affects the cauda equina in both primary and secondary forms.2 The aggressive form of B cell lymphoma secondarily affects the CNS in up to 25% of patients. Human immunodeficiency virus (HIV)-infected, organ-transplanted, and congenital immunodeficiency patients are more prone to the development of CNS lymphoma.5 There has been an increasing incidence of primary CNS lymphoma in immune-competent individuals also. The frequency of spinal lymphomas in decreasing order are intraosseous, epidural, intradural extramedullary, and intramedullary depending on their location.6
Leptomeningeal seeding of lymphoma manifests as abnormal shaggy to nodular enhancement over the spinal cord surface and nerve roots.4 The intravascular form of B cell lymphoma presents with progressive cauda equina syndrome, skin lesions, or other systemic features7 where nasal mucosal, skin, or bone marrow biopsy helps in its diagnosis.
Intraosseous and epidural lymphomas have a better prognosis than intradural or intramedullary lymphoma,4 so knowledge of various magnetic resonance imaging (MRI) appearances of intradural lymphoma of cauda equina and conus medullaris is of utmost importance for early diagnosis and early treatment for better patient outcomes.
This study aims to evaluate the various MRI features of cauda equina and conus lymphoma.
Materials and Methods
A retrospective study was conducted in our institute on histopathologically proven nine patients of cauda equina and conus lymphoma presented between January 2018 and June 2020. This study was approved by the institutional ethics review committee.
Inclusion Criteria
Only intradural extramedullary and intramedullary forms of spinal lymphoma affecting cauda equina and conus medullaris.
Exclusion Criteria
Isolated spinal epidural lymphoma
Lymphoma involving contiguous vertebra and or retroperitoneum
MRI Protocols
All patients underwent an MRI scan of the spine, using a 1.5 Tesla MR scanner, Siemens Magnatom Avanto (Siemens Medical Systems, Erlangen, Germany). The conventional MRI sequences of the spine includes sagittal T1-weighted imaging (T1WI), T2WI, short tau inversion recovery (STIR), diffusion-weighted imaging, coronal STIR, and axial T1WI, T2WI. Postgadolinium T1WI sequences were obtained in all three planes. The parameters of the various sequences used are shown in (Table 1).
|
MRI sequence |
TE (ms) |
TR (ms) |
Matrix |
Field of view (FOV) |
Slice thickness (mm) |
Flip angle |
Others |
|---|---|---|---|---|---|---|---|
|
T1W sagittal |
9–15 |
450–500 |
256 × 256 |
200-220 |
4 |
90° |
|
|
T2W sagittal |
110–120 |
3400–4600 |
256 × 256 |
200-220 |
4 |
90° |
|
|
STIR sagittal |
25–28 |
4500–4900 |
256 × 256 |
200-220 |
4 |
90° |
TI = 160ms |
|
STIR coronal |
25–28 |
4500–4900 |
256 × 256 |
200-220 |
4 |
90° |
TI = 160ms |
|
DWI sagittal |
86–100 |
2500–3000 |
128 × 128 |
200-220 |
4 |
90° |
b = 1000sec/mm2 |
|
T1W axial |
9–15 |
450–500 |
256 × 256 |
200-220 |
3 |
90° |
|
|
T2W axial |
110–120 |
3400–4600 |
256 × 256 |
200-220 |
3 |
90° |
|
|
Fat-suppressed postcontrast T1WI axial, coronal and sagittal |
9–15 |
450–500 |
256 × 256 |
200-220 |
3 |
90° |
after injecting I.V. Gadopentetate Dimeglumine at a dose of 0.1mmol/kg body weight. |
Abbreviations: DWI, diffusion-weighted imaging; MRI, magnetic resonance imaging; STIR, short tau inversion recovery; T1WI, T1-weighted imaging; TE, time of echo; TI, inversion time; TR, repetition time.
MRI evaluation: The patients were evaluated for the involvement of conus medullaris, cauda equina nerve roots, superior or inferior extensions, and pattern of contrast enhancement.
Laboratory test and histopathological examination: All patients were evaluated with complete blood count, enzyme-linked immunosorbent assay for HIV, cerebrospinal fluid (CSF) analysis, bone marrow aspiration cytology, and posteroanterior view of chest X-rays. Confirmation of lymphoma was established by histological confirmation of postoperative resected specimen of thickened cauda equina nerve roots in three patients of primary Lymphoma, lymph nodal biopsy in five patients, and associated leg mass biopsy in one patient with secondary lymphoma.
Treatment: Four patients were treated with only multidrug chemotherapy and five patients with combined chemoradiotherapy. Clinical, hematological, or radiological follow-up was done in all patients.
Statistical analysis: All statistical analysis was performed by using Statistical Package for the Social Science (SPSS programs, version 16). The clinical data and different MRI findings were analyzed with an independent sample t-test and paired-samples t-test.
Results
Patient and clinical data: In this study sample, nine patients (n = 4 male, n = 5 female) of cauda equina and conus lymphoma were included with a male: female ratio of 1:1.25 and mean age of 48.89 ± 1.84 (standard deviation, SD) years (range: 18–80 years). The demography, clinical and MRI findings were summarized in (Table 2). Primary lymphoma was identified in three patients (33.3%) and secondary lymphoma in six patients (66.7%). Patients with secondary lymphoma had cervical lymphadenopathy in two patients, mediastinal lymphadenopathy in two patients, retroperitoneal lymphadenopathy in one patient, and leg mass with tibial involvement in another one patient.
|
S/N |
Age (y) /sex |
Clinical presentation |
Clinical findings |
CSF analysis findings |
Blood cell count |
MRI appearance of the lesion |
Other site involvement |
Diagnosis |
Treatment |
Survival |
|||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
T2WI |
DWI |
Postgadolinium |
Extension of lesion |
||||||||||
|
1. |
50/F |
LBA with saddle perianal anesthesia |
b/l lower limb muscle power 3/5, decreased tone, absent deep tendon reflexes in lower limbs |
Elevated protein—68 mg/dL and lymphocytic pleocytosis—92 cells/µL with many large-sized atypical lymphoid cells |
TLC—5,400, N79, L13 |
Iso to slight hyperintense |
Restricted |
Sheet-like Homogenous enhancing lesions over conus, cauda equina and along the thickened and clumped lumbar and upper sacral nerve roots |
D12 to S1 vertebral level |
No |
Primary lymphoma |
Chemotherapy +radiotherapy |
Died after 4 months of therapy |
|
2. |
53/M |
LBA with radicular pain, paraparesis |
b/l lower limb muscle power 2/5, decrease tone, absent deep tendon reflexes in lower limbs |
Elevated protein-76mg/dL, lymphocytic pleocytosis- 143 cells/µL with many large atypical lymphoid cells |
TLC— 5,800, N73, L15 |
Hypo to isointense |
Restricted |
Sheet-like homogenous enhancement D12 to L5 vertebral level |
D12 to L5 vertebra l level |
No |
Primary lymphoma |
Chemotherapy |
Died after 7 months of therapy |
|
3. |
50/F |
LBA with paraparesis and bladder and bowel dysfunction |
b/l lower limb muscle power 1/5, decreased tone, absent deep tendon reflexes in lower limbs |
Elevated protein: 102 mg/dL, lymphocytic pleocytosis—178 cells/µL with many atypical lymphoid cells |
TLC—7,820 N- 69, L17 |
Hypo to isointense with plaque like lesion |
Restricted |
Segmental plaque-like homogenously enhancing lesions in conus, cauda equina, and along the thickened and clumped lumbar nerve roots |
L1 to S1 Vertebra l level |
Retroperitoneal lymphadenopathy |
Secondary lymphoma |
Chemotherapy +radiotherapy |
Died after 3 months of therapy |
|
4. |
60/F |
LBA with radicular pain |
b/l lower limb muscle power 3/5 |
Elevated protein—87 mg/dL, lymphocytic pleocytosis—101 cells/µL |
TLC—6,430, N 71,L16 |
Hypo to isointense |
Restricted |
Sheet-like homogenously enhancing lesions in cauda equina fibers and lumbar nerve roots |
L2 to L5 vertebral level |
Mediastinal lymphadenopathy |
Secondary lymphoma |
Chemotherapy +radiotherapy |
Died after 8 months of therapy |
|
5. |
50/F |
Paraparesis and bladder and bowel dysfunction |
b/l lower limb muscle power 2/5 |
Protein—112 mg/dL, lymphocytic pleocytosis—89 cells/µL |
TLC—5,780 N-67, L14 |
Hypo to isointense |
No restriction |
Mild sheet-like homogenously enhancing lesions over conus with enhancing cauda equina fibers |
D6 to D12 vertebra l level |
Cervical lymphadenopathy |
Secondary lymphoma |
Chemotherapy |
Died after 9 months of therapy |
|
6. |
80/M |
Paraparesis and bladder and bowel dysfunction |
b/l lower limb muscle power 3/5 |
Protein—77 mg/dL, lymphocytic pleocytosis—89 cells/µL |
TLC—5,800 N-68, L14 |
Iso to Slight hyperintense |
No restriction |
Patchy plaque-like and nodular enhancing lesions within conus medullaris and over surface. No cauda equina fibers affected |
D10 to L1 vertebral level |
No |
Primary lymphoma |
Chemotherapy |
Died after 6 months therapy |
|
7. |
24/M |
Paraparesis and Bladder and bowel dysfunction |
b/l lower limb muscle power 1/5 |
Protein—97 mg/dL, lymphocytic pleocytosis—95 cells/µL |
TLC—6,700 N-71, L 16 |
Iso to slight hyperintense nodular lesion in conus with dorsal cord T2 hyperintense edema |
Restricted |
Patchy irregular nodular enhancing lesion in conus medullaris |
D11 to D12 vertebral level |
Mediastinal lymphadenopathy |
Secondary lymphoma |
Chemotherapy +radiotherapy |
Died after 4 months |
|
8. |
18/M |
Para paresis and bladder and bowel dysfunction |
b/l lower limb muscle power 2/5 |
Protein—107 mg/dL, lymphocytic pleocytosis—89 cells/µL |
TLC—6,300 N-69, L19 |
Hypo to isointense |
No restriction |
Sheet-like enhancement over conus with enhancing nodules within conus |
D2 to L1 vertebral level |
Cervical lymphadenopathy |
Secondary lymphoma |
Chemotherapy +radiotherapy |
Died after 9 months |
|
9. |
55/F |
LBA and paraparesis and bladder and bowel dysfunction |
b/l lower limb muscle power 3/5 |
Protein—123 mg/dL, lymphocytic pleocytosis—108 cells/µL |
TLC—6,200 N 70, L 17 |
Iso to slight hyperintense |
Restricted |
Intradural mass-like enhancement over the conus medullaris with displacement of conus towards left side. |
D11 to L2 vertebra l level |
Right leg mass lesion with tibial involvement with cortical destruction |
Secondary lymphoma |
Chemotherapy |
Died after 10 months of therapy |
Abbreviations: CSF, cerebrospinal fluid; DWI, diffusion-weighted imaging; LBA, low back ache; MRI, magnetic resonance imaging; T2WI, T2-weighted imaging; TLC, total leuckocyte count.
The most common clinical presentation was chronic paraparesis with bladder and bowel dysfunction in five patients (55.56%), chronic low backache with radiculopathy in two patients (22.2%), and chronic low backache with dissociative anesthesia in one patient (11.1%) and chronic low backache in another 1 patient (11.1%). The mean duration between neurological symptoms onset and MRI examination was 4.78 ± 2.11 (SD) months.
MRI findings: Six patients (66.7%) showed a diffuse pattern (Figs. 1 and 2) and three patients (33.3%) showed a focal pattern of involvement of cauda equina and conus medullaris (Figs. 345). T2WI hypo to isointense signal intensities were observed in six patients (66.7%) and T2 iso to slight hyperintensities in three patients (33.3%). Diffusion restriction with a low apparent diffusion coefficient value was observed in four patients (44.4%) with the diffuse pattern of lymphoma and two patients (22.2%) with focal lymphoma.
Diffuse sheet-like postcontrast enhancement of the cauda equina fibers and sheet-like thickened nerve roots was observed in two patients (22.2%) of primary (Figs. 1 and 2) and one patient (11.1%) with secondary lymphoma. Plaque to focal mass-like postcontrast enhancement within or around the conus medullaris and cauda equina fibers was found in four patients (44.4%) (Figs. 3 and 5), focal (intradural mass-like) postcontrast enhancement over conus in one patient (11.1%) (Fig. 4), and isolated conus surface enhancement in another one patient (11.1%).
Clumping of cauda equina nerve roots was observed in six patients (66.7%) (Figs. 1 and 2). Intramedullary enhancing conus lesion observed in one patient (11.1%) (Fig. 5), sheet-like conus surface enhancement in four patients (44.4%), and both intramedullary lesion and conus surface enhancement in four patients (44.4%) (Fig. 3). The salient differences between the primary and secondary lymphoma in our study sample were shown in Table 3.
|
Parameters |
Primary lymphoma (n = 3) |
Secondary lymphoma (n = 6) |
p-Value |
||
|---|---|---|---|---|---|
|
Age (years) |
61 ± 16.5 (SD) |
42.8 ± 17.4 (SD) |
0.178 |
||
|
Sex |
M: F = 2:1 |
M: F = 1:2 |
0.407 |
||
|
Radiological |
T2WI appearance |
0.170 |
|||
|
Hypo to isointense (n = 6) |
1 (11.1%) |
5 (55.6%) |
|||
|
Iso to slight hyperintense (n = 3) |
2 (22.2%) |
1 (11.1%) |
|||
|
DWI characteristics |
1.000 |
||||
|
No DWI restriction (n = 3) |
1 (11.1%) |
2 (22.2%) |
|||
|
DWI restriction (n = 6) |
2 (22.2%) |
4 (44.4%) |
|||
|
Form of disease |
1.000 |
||||
|
Focal form (n = 3) |
1 (11.1%) |
2 (22.2%) |
|||
|
Diffuse form (n = 6) |
2 (22.2%) |
4 (44.4%) |
|||
|
Pattern of conus involvement on postcontrast images |
0.050 |
||||
|
Intramedullary enhancing lesion (n = 1) |
0 |
1(11.1%) |
|||
|
Surface/mass-like enhancement (n = 4) |
2(22.2%) |
2(22.2%) |
|||
|
Both intramedullary and conus surface enhancement (n = 4) |
1(11.1%) |
3(33.3%) |
|||
|
Cauda equina nerve roots on postcontrast images |
0.111 |
||||
|
Not thickened |
1 |
2(22.2%) |
|||
|
Thickened |
0 |
3(33.3%) |
|||
|
Sheet like diffuse thickenings and clumping |
2(22.2%) |
1(11.1%) |
|||
|
Extraspinal involvement |
No |
Yes, lymphadenopathy: cervical 2, mediastinal 2, retroperitoneum 1, 1-right leg mass with tibial involvement |
|||
|
Prognosis |
Survival (months) |
5.67 ± 1.53 (SD) |
7.17 ± 2.93 (SD) |
0.442 |
|
Abbreviations: DWI, diffusion-weighted imaging; MRI, magnetic resonance imaging; SD, standard deviation.
Four patients of conus and cauda equina lymphoma were treated with only multidrug chemotherapy and five patients with combined chemoradiotherapy. The mean patient survival was 6.67 ± 2.55 (SD) months after the treatment.
Discussion
Previous literature showed various case reports of lymphomatous involvement of conus and cauda equina in the localized8 as well as a disseminated form of non-Hodgkin lymphoma. Recurrent lymphoma of spinal cord can cause cauda equina syndrome.9 The intramedullary form of lymphoma commonly affects the thoracic cord followed by the conus medullaris and cervical cord.10
Primary adrenal lymphoma may be presented with cauda equina syndrome with secondary deposits in cauda equina nerve roots.11 Patients with cauda equina lymphoma usually presented with nonspecific symptoms like low backache, radiculopathy, paraparesis, or saddle anesthesia.1213
Increased CSF protein level, hypoglycemia, or pleocytosis was observed in cauda equina lymphoma.11 Lachance et al14 found malignant lymphocytes in CSF in 66% of patients with cauda equina lymphoma. Accurate diagnosis of cauda equina lymphoma is usually achievable with surgical resection of the affected nerve root and confirmation on histopathological or immune histopathological examinations.15
Cauda equina lymphoma on MRI appears as a focal increase in the volume of cauda equina or nerve roots, sheet-like thickening, and homogenous moderate-to-intense postcontrast enhancement of the thickened nerve roots.812 In our study, sample of 66.7% of patients showed a diffuse pattern and 33.3% showed a focal pattern of involvement of cauda equina and conus medullaris. In our study sample, diffuse sheet-like postcontrast enhancement of the cauda equina fibers and sheet-like thickened nerve roots was observed in 33.3% of patients, while previous case reports by Broen et al13 and Biasi et al16 showed similar findings of cauda equina lymphoma. A few previous case reports by Teo et al,3 Nakashima et al,12 and Shin et al17 showed focal intradural mass lesions around the conus medullaris and cauda equina but in our study sample, only 1 patient showed an intradural mass.
Focal plaque-like enhancing cauda equina mass can be encountered in cauda equina lymphoma and in such a situation tumors like schwannoma, ependymoma, neurofibroma, meningioma, dermoid, epidermoid, paraganglioma, hemangioblastoma and metastasis needed to be differentiated with their characteristics MRI features.12 Usually, schwannoma shows T1W isointense and T2W hyperintensity with irregular postcontrast enhancement with or without cystic degeneration and commonly having neural exit foraminal extension. Meningioma showed T1W isointense and T2W iso to hypointense signal intensity with moderate to intense homogenous postcontrast enhancement and the presence of a dural tail. Ependymoma showed T1W isointense and T2W hyperintense signal intensity with intense postcontrast enhancement with or without intratumoral hemorrhage and cystic changes. Neurofibroma shows the dumbbell shape of the mass with neural exit foraminal extension.
Sheet-like cauda equina nerve root thickenings can be encountered in acute inflammatory demyelinating polyradiculoneuropathy, chronic inflammatory demyelinating polyradiculoneuropathy, Landry-Guillain-Barre syndrome, hereditary sensory-motor neuropathies (Charcot-Marie Tooth disease), sarcoidosis, arachnoiditis, tuberculous pachymeningitis, schistosomiasis,81118 tumor with CSF drop metastasis (glioblastoma, ependymoma, medulloblastoma, ependymoma, pineal tumor), and extracranial metastasis from breast and lung cancers.1819 There is difficulty in distinguishing these conditions from cauda equina lymphoma on MRI. Even though few salient MRI findings were shown in Table 4 for their differentiation.
|
Parameter |
Conus and cauda equina lymphoma |
Leptomeningeal metastasis |
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) |
Neurosarcoidosis |
Inflammatory arachnoiditis |
Guillain–Barre syndrome |
|---|---|---|---|---|---|---|
|
Probable etiology |
-Most commonly non-Hodgkin lymphoma |
-Hematogenous metastasis -CSF drop metastasis from brain tumors.23 -Extracranial metastasis (from breast and lung cancers) |
-Neurological disorder of peripheral nerve causing peripheral neuropathy.24 -Demyelination of peripheral nerves |
-Systemic granulomatous disease25 -Noncaseating granulomas |
-Infectious meningitis -Postoperative failed back -Postirradiation -Hemorrhage -Degenerative spondylosis |
-Acute inflammation demyelinating polyradiculoneuropathy -Postinfectious/ postvaccinal demyelination |
|
Salient MRI features |
Various MRI patterns can be seen111719 -Enlarged cauda equina with iso to slight hyper or hypointensities on T1WI and T2WI -Focal or diffuse homogenous enhancement over conus and cauda equina nerve roots -Diffuse sheet like postcontrast enhancement of the cauda equina nerve roots |
4 MRI pattern can be seen26 -Solitary focal at bottom of thecal sac or along cord surface -Diffuse sheet-like coating of spinal cord/ nerve roots -Rope-like thickening of cauda equina nerves -Multifocal, discrete nodules along the spinal cord/ nerve roots |
-Enhancement of the cauda equina nerve roots -Affected nerve roots are enlarged -Most commonly enlarged in extra- foraminal segment27 |
Smooth postcontrast enhancement over conus surface and cauda equina nerve roots28 |
3 MRI patterns cauda nerve roots29 - Central clumping - Peripheral clumping with empty sac sign -Central mass-like clumping with decreased thecal sac diameter |
-Ventral nerve roots dominantly affected -Normal on T1W and T2W images -Smooth enhancement over conus and cauda equina nerve roots |
Abbreviations: CSF, cerebrospinal fluid; MRI, magnetic resonance imaging; T1WI, T1-weighted imaging.
Most of patients with cauda equina lymphoma usually respond to chemotherapy, radiotherapy or combined chemoradiotherapy. In treated cauda equina lymphoma patients, the common symptoms like pain and motor weakness are usually relieved after treatment; however, bladder and bowel incontinence usually remain.320 Combined chemotherapy and radiotherapy had survival rates ranging from 16 to 44.5 months in cauda equina lymphoma patients3 however, in our study sample, the survival period is less at 6.67 ± 2.55 (SD) months.
However, combined chemoradiotherapy is more effective than isolated radiotherapy or chemotherapy in the management of primary CNS lymphoma.21 Isolated radiotherapy is initially effective, but its response is short-lived.21 Aggressive surgical resection is not effective in primary CNS lymphoma.21 But treatment protocol including initial radiotherapy or chemotherapy with or without surgical intervention is the mainstay of treatment in cauda equina lymphoma presenting with radiculopathy22Table 5 shows the literature review of cauda equina and conus lymphoma in the last decade.
|
Series/year |
Number |
Age/mean age (y) |
Sex/sex ratio |
Salient MRI findings |
Form of lymphoma |
Cell type of lymphoma |
Treatment |
Outcome |
|---|---|---|---|---|---|---|---|---|
|
Iwasaki et al 201227 |
1 |
69 |
M |
Enhancing lesion in conus medullaris and cauda equina with old collapse of L1 vertebra |
Primary |
DLBCL |
Chemotherapy (MTX) + RT |
Initially improved but died after 18 months |
|
Biasi et al 201516 |
1 |
67 |
F |
Thickening of cauda equina nerve roots with intense postcontrast enhancement |
Primary |
DLBCL |
Chemotherapy |
Improved |
|
Nishida et al 201220 |
1 |
47 |
M |
Swelling of cauda equina with marked diffuse enhancement |
Primary |
DLBCL |
Chemotherapy +RT |
Improved |
|
Broen et al 201413 |
2 |
75,71 |
F:2 |
Enhancement along cauda equina fibers in first case. Thickening and enhancement of multiple lumbosacral nerves in second case |
Primary |
DLBCL |
First case- steroid second case—chemotherapy |
First case –not improved and died Second case improved |
|
Nakashima et al 201412 |
1 |
59 |
M |
Intradural lesion from D12 to S1 level |
Primary |
DLBCL |
RT and MTX |
Improved |
|
Teo et al 20123 |
1 |
58 |
M |
Minimally enhancing intradural mass from D12 to L4 level |
Primary |
DLBCL |
Chemotherapy + RT+ steroid |
Improved |
|
Shin et al 201517 |
1 |
79 |
F |
Segmental intradural mass from L3 to L5 level with leptomeningeal enhancement over cord and Conus. |
Primary |
DLBCL |
Chemotherapy +RT |
Improved |
|
Ogilvie et al 201028 |
1 |
58 |
M |
Intraspinal mass from D11 to L4 encasing spinal cord, conus medullaris, and cauda equina |
Primary |
DLBCL |
Laminectomy + chemotherapy |
Improved |
|
Piyatanont et al 201029 |
1 |
77 |
M |
Cauda equina enhancement |
Primary |
IVL |
ND |
ND |
|
Tajima et al 200711 |
1 |
67 |
F |
Cauda equina edema, enhancement, mass |
Primary |
DLBCL |
RT +CT |
Improved |
|
Present study |
9 |
48.89 ± 1.84 (SD) |
M: F = 1:1.25 |
-Enhancement within and over the conus -Intradural plaque-like or mass-forming type -Thickenings and enhancement of the cauda equina nerve roots -Diffuse Sheet like thickenings and clumping of nerve roots, especially in primary lymphoma |
Primary—3 Secondary—6 |
B cell lymphoma |
Chemotherapy RT |
All patient died up to 10 months of follow-up |
Abbreviations: CT, chemotherapy; DLBCL, diffuse large B cell lymphoma; IVL, intravascular lymphoma; ND, not defined; RT, radiotherapy; SD, standard deviation.
In conclusion, the diagnosis of cauda equina lymphoma especially primary lymphoma is challenging and requires a high index of suspicion. Early diagnosis of cauda equina and conus lymphoma is important as early treatment may be beneficial and increase the chances of survival and improvement of symptoms.
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