PMC3604819_01
Isodose curve showing the radiation coverage for the anterior mediastinal lymphadenopathy
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F1
In November 2001, he underwent focal irradiation for a residual anterior mediastinal lymphadenopathy, consisting of a total of 30 Gy in 20 fractions, with a maximum dose of 37.8 Gy and mean dose of 9.2 Gy to the spinal cord [Figure 1]. In February 2002, he underwent a peripheral blood stem cell transplantation using cells donated by his identical twin, resulting in complete remission. Gadolinium-enhanced magnetic resonance (MR) imaging of the spine revealed an intramedullary tumor with irregular enhancement extending from the C6 to the T6 level, corresponding to the previous radiation portal [Figures 1 and 2a]. However, gadolinium-enhanced brain MR imaging revealed periventricular enhanced lesions [Figures 1b and c] and diffuse enhancement of the ventral surface of the pons and the medulla oblongata.
(a-c) Gadolinium-enhanced T1-weighted MR images showing an irregularly enhanced intramedullary lesion at the C6-T6 spinal level with enhancement along the dorsal surface of the spinal cord (a) and intracranial enhanced lesions located along the ventricular surface (b, c)
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F2
Gadolinium-enhanced magnetic resonance (MR) imaging of the spine revealed an intramedullary tumor with irregular enhancement extending from the C6 to the T6 level, corresponding to the previous radiation portal [Figures 1 and 2a].
(a) May-Giemsa staining of the CSF sediment showing atypical cells, (b, c) Immunocytochemistry of the CSF sediment showing atypical cells (white arrowheads) with enlarged hyperchromatic delicate irregular nuclei that are positive for Olig2, (b) and negative for LCA (c), The surrounding lymphocytes (black arrowheads) are positive for LCA, (c) and negative for Olig2 (b) (100 x objective), (d, e) Paraffin sections of the biopsy of the intracranial lesion. H and E staining, (d) and Olig2 immunostaining, (e) Scale bars = 50 mum
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F3
Cytological examination of the CSF obtained by lumbar puncture revealed large atypical cells with nuclear grooves or clefts [Figure 3a], suggesting the recurrence of lymphoblastic lymphoma. Histopathological examination of this sample showed diffuse proliferation of anaplastic glioma cells with hyperchromatic nuclei on a fibrillary background, along with a tendency for perivascular accumulation [Figure 3d]. These assays revealed that the atypical cells with enlarged hyperchromatic delicate irregular nuclei in the CSF were positive for Olig2 [Figure 3b] but negative for LCA [Figure 3c]. In contrast, the LCA+/Olig2- lymphocytes showed relatively uniform, smaller roundish nuclei [Figures 3b and c], suggesting that the LCA+ cells in the CSF were nonneoplastic lymphocytes such as reactive lymphocytes rather than lymphoma cells.
(a-c) Gadolinium-enhanced T1-weighted MR images showing marked reduction in the size of the enhanced lesion of the spinal cord (a) and the disappearance of the periventricular dissemination (b, c)
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F4
After radiotherapy, the spinal tumor was markedly reduced in size, and the dissemination disappeared [Figure 4].