PMC9911714_01
Preoperative MRI findings. A-C: The fat suppression with gadolinium (Gd) enhancement showed that consecutive epidural mass extended into both intervertebral foramina from C3 to T7 vertebrae lesions (white arrows) on sagittal and coronal sections. D and E: The spinal cord was encased by diffuse homogenously enhancing mass lesions (white arrows) on axial T1-weighted imaging with Gd enhancement at T1 and T4 vertebra.
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F1
The epidural mass was extending into bilateral intervertebral foraminal spaces to spread to the left pleural space diffusely with pleural thickening. There was also an enhanced lesion in the epidural space with bilateral foraminal involvement, the right side of C6-T3 and the left side of C5-T6 (Fig. 1).
PET CT scan on staging workup. A and B: PET-CT indicates that extranodal spinal epidural lymphoma extended into the unilateral mediastinal cavity through the left pleura spread (sagittal and coronal image, white arrows). C and D: The multiple lymph node invasion in the left supraclavicular (C, white arrows) and mediastinal lymph nodes along with ribs suggests metastasis (D, white arrows). PET, positron-emission tomography.
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F2
FDG uptake suggesting pleural metastasis (Fig. 2). For pathological diagnosis and spinal cord decompression, he underwent elective surgical resection of the tumor encasing the upper thoracic spinal cord via the decompressive laminectomy
Intraoperative photos of initial and surgical resection and histologic features. A and B: Upon exposing the spinal cord, avascular amorphous encasing mass was continuously compressed the spinal cord. C: Following adequate surgical decompression, the spinal cord was satisfactorily expanded from tumor decompression. D: On histologic findings, H&E staining (x200) demonstrates atypical round-shaped large cells in scanty cytoplasm with basophilic or vesicular nuclei that are compatible with diffuse large B-cell lymphoma.
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F3
T1, 2, 3, 4 (Fig. 3). The mass compressed spinal cord was a consecutive avascular band-like mass with the finding of reactive inflammation. Histological findings demonstrated diffuse proliferation of atypical small round cells, which were large cells with scanty cytoplasm and basophilic or vesicular nuclei on H&E staining (x200) (Fig. 3).
Immunohistochemistry findings and chemoport insertion. A and B: Immunohistochemistry findings reveal a high Ki-67 proliferative index of 40% (A) and a strong positive CD20 as a B-cell marker (B). C: Chemoport was inserted into the right subclavian vein for R-CHOP (rituximab/cyclophosphamide, hydroxydaunorubicin, Oncovin, and prednisone) chemotherapy.
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F4
Immunohistochemistry findings showed a 40% of Ki-67 proliferative index and strong positive CD20 as a B-cell marker (Fig. 4). According to National Comprehensive Cancer Network (NCCN) guidelines, chemo port was inserted on the right subclavian vein (Fig. 4) for chemotherapy.
Radiographic imaging follow-up after 6 cycles of R-CHOP chemotherapy. A and B: Follow-up MR image of fat suppression Gd enhancement demonstrates complete radiographic and metabolic response (Deauville score 1) at 6 months. C and D: PET scan images also define initial extranodal spinal epidural lymphoma with left supraclavicular and mediastinal lymph node invasion that has completely disappeared. R-CHOP, rituximab/cyclophosphamide, hydroxydaunorubicin, Oncovin, and prednisone; Gd, gadolinium; PET, positron-emission tomography.
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F5
The chemoport was removed after the confirmation of complete remission in imaging studies (Fig. 5).