Imaging Changes and Cognitive Outcome in Primary CNS Lymphoma after Enhanced Chemotherapy Delivery
Edward A. Neuwelta,b,
Paul E. Guastadisegnia,
Péter Várallyaya and
Nancy D. Doolittlea
a Department of Neurology, Oregon Health Sciences University, Portland, OR
b Department of Neurosurgery, Oregon Health Sciences University, Portland, OR
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FIG 1. A 61-year-old woman with PCNSL (patient 12 in Table 1). Demonstration of zones I and II. (See also serial image for this patient in Figure 4.)
A, Baseline axial T1-weighted image, after left frontal craniotomy. There is heterogeneous increased T1 signal intensity, consistent with subacute blood due to biopsy, in the center of the left frontal parasagittal hypointense lesion (arrow).
B, Baseline axial gadolinium-enhanced T1-weighted image. There is an intense enhancing mass (i.e., zone I) in the left frontal parasagittal region (arrow).
C, Baseline axial T2-weighted image. The mass (arrowhead) is of relative low signal intensity, characteristic of PCNSL due to the high cellularity of the tumor. The central portion has high T2 signal intensity, which is consistent with subacute blood secondary to prior biopsy. The surrounding larger area of increased T2 signal intensity represents edema or infiltrating tumor and is referred to as zone II (arrows).
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FIG 2. A 37-year-old man with PCNSL (patient 5 in Table 1). Change of zone II abnormality with partial resolution. Baseline Z score –3.00; end of treatment Z score –.44. (This patient had multiple enhancing tumor foci, consequently with multiple zone II abnormalities, some of them partially, some of them completely resolved. See also Figure 3.)
A, Baseline axial T2-weighted image demonstrates large zone II areas in the bilateral parietal periventricular white matter (arrows). The heterogeneous low signal intensity areas directly adjacent to the posterior aspect of the ventricles represent the solid tumor mass (arrowheads).
B, End-of-treatment axial T2-weighted image shows only small, residual zone II in the bilateral parietal periventricular white matter (arrows).
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FIG 3. A 37-year-old man with PCNSL (patient 5 in Table 1). Change of zone II abnormality with complete resolution. Baseline Z score –3.00; end-of-treatment Z score –.44 (This patient had multiple enhancing tumor foci, consequently with multiple zone II abnormalities, some of them partially, some of them completely resolved. See also Fig 2.)
A, Baseline axial T2-weighted image shows three distinct areas of zone II in the centrum semiovale on both sides.
B, End-of-treatment axial T2-weighted image. No T2 signal intensity abnormality is seen (i.e., the zone II areas have completely resolved).
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FIG 4. A 61-year-old woman with PCNSL (patient 12 in Table 1). Change of T2 signal intensity abnormality that was not associated with enhancing tumor at baseline. Baseline Z score –.46; end of treatment Z score –.26.
A, Baseline axial T2-weighted image demonstrates linear as well as tiny ovoid areas of T2 signal intensity abnormality bilaterally in the parietal periventricular white matter (arrows). This may represent small areas of chronic small vessel ischemic changes and probably enlarged Virchow-Robin spaces. Also note a large left frontal zone II abnormality (arrowhead).
B, End-of-treatment axial T2-weighted image shows enlarged and more intensive T2 signal intensity abnormality bilaterally in the parietal periventricular white matter (arrows). This may either represent aging with advanced ischemic changes but more likely represents changes secondary to chemotherapy, which is supported by the fact that multiple, new, partially confluent T2 foci appeared bilaterally in the periventricular white matter (curved arrows). Note the much smaller left frontal residual zone II abnormality (arrowhead).
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FIG 5. A 36-year-old woman with PCNSL (patient 4 in Table 1). Appearance of new T2 signal intensity abnormality. Baseline Z score –2.03; end-of-treatment Z score –.79.
A, B, Baseline axial T2-weighted images demonstrate no signal intensity abnormality in the periventricular white matter and centrum semiovale.
C, D, End-of-treatment axial T2-weighted images show diffuse high signal intensity in the periventricular white matter and centrum semiovale bilaterally (arrows).
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