颅内淋巴瘤影像诊断课件

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头痛伴口周麻木2个月24头痛伴口周麻木2个月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.atypicallymphoma3535-year-oldmanwithHIVwhopOtherconsiderationsSteroidscansignificantlyalterappearanceonimagingbydecreasingtumorsize,edema,andenhancementTumorsarehighlyradiosensitiveandchemosensitive36OtherconsiderationsSteroidscReferencesErdagN,BhoradeRM,AlbericoRA,YousufN,PatelM.Primarylymphomaofthecentralnervoussystem:typicalandatypicalCTandMRimagingappearances.AJRAmJRoentgenol2001;176:1319–1326

H.WayneSlone1,JosephJ.Blake,RajulShah,

CTandMRIFindingsofIntracranialLymphoma.AJR2005;184:1679-1685

37ReferencesErdagN,BhoradeRM,DifferentialdiagnosisGliomablastomamultiformeMetastasisEncephalitisOthermultiplefocalwhitematterdiseaseMeningitis38DifferentialdiagnosisGliomabl结束语当你尽了自己的最大努力时，失败也是伟大的，所以不要放弃，坚持就是正确的。WhenYouDoYourBest,FailureIsGreat,SoDon'TGiveUp,StickToTheEnd结束语感谢聆听不足之处请大家批评指导PleaseCriticizeAndGuideTheShortcomings演讲人：XXXXXX时间：XX年XX月XX日

感谢聆听演讲人：XXXXXX时间：XX年CASEDISCUSSIONWANGLIJUN2008-7-1441CASEDISCUSSIONWANGLIJUN1Case1:Female,66y42Case1:Female,66y2Case1:PLAINMRI43Case1:PLAINMRI3Case1:POST-CONTRASTMRI44Case1:POST-CONTRASTMRI4Case2:F66Y45Case2:F66Y5Case2:POST-CONTRASTMRI46Case2:POST-CONTRASTMRI6CASE3:M58Y,NHLwasdiagnosed2.5yearsago,nowfeelheadache(2008-1-25)-C+C47CASE3:M58Y,NHLwasdiagnos2008-1-30482008-1-3084992008-5-15502008-5-1510LYMPHOMAPrimarycentralnervoussystemlymphoma(PCNSL)isarareformoflymphaticcancerarisinginthebrain,eye,nerves,spinalfluidsurroundingthebrainandspinalcord,andthecoveringofthebrain,calledduraSecondary:metastasestothenervoussysteminlymphomaaffectingotherorgans51LYMPHOMAPrimarycentralnervouPCNSL:EpidemiologyOncerare(~1%),nowbecomingincreasinglymorecommonIncidencehasrisendramaticallyinpastfewdecades,asPCNSLnowaccountsfor4-7%(16%)ofallnewlydiagnosedprimarybraintumorsIncidencehasrisenintheimmunocompromisedandalsoimmunocompetentpopulation52PCNSL:EpidemiologyOncerare(PCNSL:EpidemiologyImmunocompromisedCongenitalcausesofimmunodeficiency1.Wiskott-Aldrichsyndrome2.IgAdeficiency3.X-linkedlymphoproliferativesyndrome

acquiredcauses1.HIVinfectionandAIDS2.immunosuppressiveregimenafterorgantransplantation53PCNSL:EpidemiologyImmunocomprPCNSL:EpidemiologyMedianageofonset55yearsinimmunocompetent,incidenceriseswithageGreatestrisehasoccurredamongtheelderlyMaleismorecommonlyseencomparetofemale(2:1)54PCNSL:EpidemiologyMedianageDiagnosisHistoryFocalneurologicdeficit(i.e.hemiparesis,aphasia)presentin>50%ofallpatientswithPCNSLAlteredmentalstatus(memoryloss,confusion,etc.)foundin~33%-maybeinsidiousonsetHeadache,nausea(fromincreasedICP)in~33%Maypresentwithnew-onsetseizurein<10%BlurredvisionifocularlymphomaispresentRadiologicimagingHeadCTdetectsmostlesions(~90%)BrainMRImaydetectlesionsmissedonCT55DiagnosisHistory15DiagnosisPrimaryCNSlymphomamayarisefromdifferentpartsofthebraindeephemisphericperiventricularwhitematterbeingthemostcommoncorpuscallosum,cerebellum,orbits,andcranialnervesmayalsoharborthetumorHistology:intermediate-tohigh-gradeextranodalnon-Hodgkin'slymphomaofB-cellorigin56DiagnosisPrimaryCNSlymphomaRadiologicImaging

TypicalAppearanceinImmunocompetentPatientsUsuallysolitary,non-hemorrhagiclesionindeepwhitematter,nearventriclesLesionisisodensetohyperdense(70%)surroundingvasogenicedemahomogeneouslyenhancingmassSurroundingedemaistypicallylessprofoundthaninmetastaticbrainlesionsorgliomas57RadiologicImaging

TypicalApp64-year-oldwomanwithleft-sidedweakness.AxialunenhancedCTscanshowstypicalhyperdensemass(arrows)inrightparietallobesurroundedbylow-densityzone,consistentwithvasogenicedema.Axialcontrast-enhancedCTscanshowshomogeneousenhancement(arrows)oflesionnearmidline.5864-year-oldwomanwithleft-siRadiologicImaging

TypicalAppearanceinImmunocompetentPatientsintermediate-tolow-signal-intensitytumoronT1-weightedimagesIsointensetohypointensesignalrelativetothegraymatteronT2-weightedimagesAclassicpresentationisthelesionthatcrossesthecorpuscallosuminabutterflypatternEnhancesdenselyandhomogenouslywithgadoliniumcontrastMayalsorevealleptomeningealdiseaseHighsignalonDWI59RadiologicImaging

TypicalApp64-year-oldwomanwithleft-sidedweaknessAxialT2-weightedMRimageshowsheterogeneousmass(blackarrows)ofpredominantlylowsignalintensity.NotecentrallinearT2hyperintensity(arrowhead),likelyrepresentingnecrosis.Alsonotesurroundingvasogenicedema(whitearrows).Axialgadolinium-enhancedT1-weightedMRimageshowsmarkedcontrastenhancementoflesion(arrows).Notemasseffectonadjacentrightlateralventricle.6064-year-oldwomanwithleft-siPost-contrastCoronalT1WtdMRIPost-contrastAxialT1WtdMRIHomogeneouslyenhancingtumorisseeninvolvingthespleniumofthecorpuscallosum(arrows)spreadingacrossthemidline.61Post-contrastCoronalT1Wtd72-year-oldimmunocompetentwomanwithprimaryCNSnon-Hodgkin'sB-celllymphomawhopresentedwithprogressivemotorweakness.AxialFLAIRMRimageshowsisointensityoflesionstobrainparenchymaandsurroundingedema.Themassesinvolvedeepwhiteandgraymatter.Axialcontrast-enhancedT1-weightedMRimageshowshomogeneousenhancementofmultiplebilateraltumors.6272-year-oldimmunocompetentwo50-year-oldimmunocompetentmanwithprimaryCNSnon-Hodgkin'sB-celllymphoma.AxialT2-weightedMRimageshowsinfiltrativehyperintensemassexpandinggenuandspleniumofcorpuscallosuminbutterflypattern.contrast-enhancedaxialT1-weightedMRimageshowshomogeneousenhancementoflesion.6350-year-oldimmunocompetentma头痛伴口周麻木2个月64头痛伴口周麻木2个月24RadiologicImaging

AtypicalAppearanceinImmunocompetentPatientsisodensityorevenhypodensityonCTInthesettingofaperiventricularlow-densitylesion,lymphomamayeasilybemisdiagnosedaschronicsmallvesselischemiaorencephalomalaciaDiffuselyinfiltrativelymphomasmaynotexhibitparenchymalenhancementatall65RadiologicImaging

AtypicalAp90-year-oldwomanwithnormalimmunestatuswhopresentedwithright-sidedweaknessanddifficultyfindingwords.AxialT2-weightedMRimageshowsill-definedT2hyperintensity(arrows)surroundingleftinternalcapsuleandadjacentlefttemporallobe.Axialgadolinium-enhancedMRimagerevealsbarelydiscernibleparenchymalenhancementincorrespondingregion.Axialcontrast-enhancedCTscanobtained4monthslatershowsmarkedexpansionofleftbasalgangliaandthalamuscausedbyinfiltratingneoplasm,withlossofnormalanatomicboundaries(arrows).6690-year-oldwomanwithnormal63-year-oldwomanwithprimarymeningeallymphomawhopresentedwithfrequentfallsandvertigo.

AxialFLAIRimageshowshyperintensity(arrow)involvingsulciandleptomeningesofparietotemporalconvexity.Contrast-enhancedT1-weightedaxial(B)andcoronal(C)MRimagesshowfocalthickeningandhomogeneousenhancementofleptomeningesofparietotemporalconvexity(arrows).6763-year-oldwomanwithprimaryMale54y.rightsideweaknesswithheadacheandvomittingfor2months68Male54y.rightsideweaknessRadiologicImaging

AtypicalLocationsArareprimarylymphomaofthepinealglandappearssimilartoaprimaryneoplasmofpinealoriginCranialnerves,brainstem,cavernoussinus,ortubercinereummayhavelymphomatousinvolvement69RadiologicImaging

AtypicalLoMetastaticCNSLymphomaIn5~9%ofsystemicnon-Hodgkin'slymphoma,secondaryspreadinvolvestheCNS,usuallyintheformofleptomeningealinfiltrates,andhasapoorprognosisParenchymallesions,whenpresent,typicallyresultfromsecondaryinvolvementfromtheleptomeningesviainfiltrationoftheperivascularspaces70MetastaticCNSLymphomaIn5~9%Post-contrastAxialT1WtdMRIFigure.Linearenhancementofthecerebellarsulci(yellowarrows)andlefttemporalsulci(redarrow).Diagnosis:SecondaryLymphomawithsubarachnoidtumorseeding(arrows).71Post-contrastAxialT1WtdMRIPost-contrastCoronalT1WtdMRIDiagnosis:SecondaryLymphomawithcalvarialinvolvement(greenarrow)andassociatedepiduraltumor(yellowarrows)/scalptumor(redarrow)72Post-contrastCoronalT1WtdMRadiologicImaging

TypicalAppearanceinHIVPatientsacerebralmassisdetectedinasupratentorialparenchymallocation(55%)withfrequentinvolvementofthecorpuscallosum,basalganglia,andotherdeepcerebralnucleiContrastenhancementisvariable,commonlyofaninhomogeneousorbizarrepattern.Solitaryringlikeenhancementismorelikelyseeninthisgroupnecrosisdevelopsinthetumor(64%)Multiplelesionsmaybeseen(50%)Periventricularlesionsfre