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Findings

Multiple lesions

Posterior body, splenium of corpus collosum, periventricular deep white matter

Isointense on T1WI

Hyperintense on FLAIR

Homogenous enhancement on T1 post gad

Differential Diagnosis

Primary CNS Lymphoma

Demyelinating disease

GBM

Metastatic disease

Neurosarcoid

PML

Primary CNS Lymphoma

MR findings in immunocompetent patients

T1WI

Homogenous hypo / isointense to cortex

T2WI (and FLAIR)

Homogenous hypo / isointense to cortex

Related to increased N/C ration

DWI

May show restricted diffusion with low ADC

T1 + Gad

Strong homogenous enhancement

Steroids can significantly alter the imaging findings.

Signs / symptoms

Altered mental status, focal neurological deficits, headache, seizure

CSF shows elevated protein and decreased glucose

Cytology is typically negative for lymphoma

Age

Immunocompetent: 6th to 7th decades

Immunocompromised

AIDS: mean age 39 yrs

Transplant recipients: mean age 37 yrs

Inherited immunodeficiency syndromes: mean age 10 yrs

Male predominance

Treatment

Avoidance of steroids and early neurosurgical consultation for stereotactic biopsy.

Whole brain radiation therapy (WBRT) alone is insufficient for durable tumor control, and is associated with a high risk of neurotoxicity in patients over 60.

Chemotherapy and WBRT together improve tumor response rates and survival compared with WBRT alone.

Methotrexate based multi-agent chemotherapy alone without WBRT is associated with similar tumor response rates and survival.

Batchelor T, Loeffler JS: Primary CNS Lymphoma. Journal of Clinical Oncology; 24(8):1281-8, 2006.