Stereotactic Brain Biopsy in the Diagnosis of Malignant Lymphoma

ANATOMIC PATHOLOGY
Original Article
Stereotactic Brain Biopsy in the Diagnosis
of Malignant Lymphoma
MARK E. SHERMAN, M.D., YENER S. EROZAN, M.D., RISA B. MANN, M.D.,
ASHOK A. J. KUMAR, M.D., JUSTIN C. McARTHUR, M.B.B.S., M.P.H.,
WALTER ROYAL, M.D., SUMIO UEMATSU, M.D.,
AND HARING J. W. NAUTA, M.D.
onstrated by immunohistochemical techniques in six patients,
and positivity for B-cell markers was observed in an additional
case. In one instance, two stereotactic biopsy specimens were
interpreted as being suggestive of lymphoma, but necrosis and
inflammation prevented a definitive diagnosis. Nine patients had
no known risk factors for cerebral lymphoma, and the diagnosis
often was unsuspected clinically. (Key words: Nervous system
neoplasms; Computed tomography; Immunoenzyme techniques;
Malignant lymphoma) Am J Clin Pathol 1991;95:878-883
Computed tomography (CT) -guided stereotactic biopsy
of the brain is gaining acceptance rapidly as an effective
diagnostic technique. Cytologic and histologic specimens
obtained through stereotactic guidance often permit a definitive diagnosis to be made, thus eliminating the need
for craniotomy. Because radiation therapy is the treatment
of choice for many cerebral neoplasms, avoidance of an
open biopsy may be highly desirable.
The accuracy of stereotactic biopsy in the diagnosis of
primary glial neoplasms and cerebral metastases is well
documented.1"5 However, parenchymal involvement by
malignant lymphoma is unusual, and few studies have
addressed the effectiveness of stereotactic biopsy in the
diagnosis of these neoplasms. 6-9 We describe the pathologic findings in 15 cases of cerebral lymphoma in which
stereotactic biopsy was performed. Our results demon-
strate that this procedure is an accurate method for the
diagnosis of cerebral lymphoma, and that it is associated
infrequently with significant complications.
MATERIALS AND METHODS
Fifteen patients with cerebral involvement by malignant
non-Hodgkin's lymphoma who underwent CT-guided
stereotactic biopsy, were identified retrospectively by review of the cytopathology records of The Johns Hopkins
Hospital. A small-cleaved-cell lymphoma involving the
retroperitoneum had been diagnosed in one patient two
years before cerebral biopsy. The remaining patients presented with primary cerebral disease.
The biopsies were performed in a specially designed
CT scanning suite, using either the Leksell or BRW Frame
for three-dimensional localization, as previously described.10 Multiple specimens were obtained along the
trajectory of the needle tract, beginning 8 mm from the
From the Departments of Pathology, Neurosurgery, Neurology, and
Radiology, The Johns Hopkins Hospital and The Johns Hopkinstarget,
Uni- with subsequent sampling at 4-mm intervals. Minute tissue fragments obtained from each sample were
versity School of Medicine, Baltimore, Maryland.
crushed and smeared between two glass slides, stained
Received April 20, 1990; received revised manuscript and accepted
with
Diff-Quik®, and examined microscopically. The refor publication November 6, 1990.
maining
material was prepared as smears or passed
Supported in part by National Institutes of Health grant NS 26643,
contract AI 72634, and OP GCRC 5 MOl RR 00722.
through Millipore® filters, and stained with PapanicoAddress reprint requests to Dr. Erozan: Director of Cytopathology,
The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, Maryland laou's method. Tissue fragments were fixed in 50%
ethanol-formalin, processed as cell blocks, and stained
21205.
878
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Fifteen patients with cerebral involvement by malignant nonHodgkin's lymphoma were identified, among more than 200 patients who underwent stereotactic biopsy at The Johns Hopkins
Hospital. All but one of these cases were diagnosed accurately
by the stereotactic biopsy procedure. In 12 of 14 patients, the
material was adequate to classify the lymphoma according to
the Working Formulation. Because all but one of the lesions
were intermediate or high-grade neoplasms, a diagnosis of lymphoma was often possible by conventional light microscopic examination alone. Monotypic light chain expression was dem-
SHERMAN ET Al.
Stereotactic Brain Biopsy
with hematoxylin and eosin. In 11 cases, immunohistochemical studies were performed on air-dried cytospins
of material obtained by rinsing the biopsy needles. These
werefixedin acetone." In two cases, glutaraldehyde-fixed
tissue was processed for electron microscopic examination.
Sixteen biopsy specimens (from 15 patients) were reviewed microscopically, and the lymphomas were classified cytologically according to the guidelines of the International Working Formulation.12 Clinical records, tumor registry data, and available CT and magnetic
resonance imaging (MRI) scans were reviewed.
tients. Other clinical manifestations of disease included
headache, aphasia, nausea and vomiting, lethargy, and
cranial nerve palsies.
The most frequent clinical diagnoses in the nonimmunosuppressed patients were those of glioblastoma
multiforme and metastatic carcinoma. The syndrome of
inappropriate antidiuretic hormone secretion was present
in two patients, leading to a clinical diagnosis of metastatic
small cell undifferentiated carcinoma of the lung in one
instance. Lymphoma, toxoplasmosis, and abscess were
the most frequently considered differential diagnoses
among patients with acquired immune deficiency syndrome (AIDS). A diagnosis of cerebral infarct was entertained in a patient with a two-year history of small cleaved
cell lymphoma of the retroperitoneum.
Most patients presented with symptoms of several
weeks' duration. Two patients with visual symptoms were
evaluated by ophthalmologists for six months, and one
year before biopsy, respectively. One of them underwent
a partial vitrectomy, which revealed a "suspicious" lymphoid infiltrate. The diagnosis of malignant lymphoma
was confirmed by stereotactic biopsy in both cases.
One patient with multiple brain lesions that were demonstrated by CT was treated with palliative radiation
therapy at another hospital, for presumed metastatic carcinoma. A nondiagnostic open biopsy had been done at
that institution. A dramatic clinical response to steroids
and radiation therapy suggested a diagnosis of malignant
lymphoma, as confirmed subsequently by needle biopsy.
Another patient with Parinaud's ophthalmoplegia and a
hyperdense pineal mass was offered palliative treatment,
based on a presumptive diagnosis of glioma or germ cell
tumor. Examination of cerebrospinal fluid at our institution yielded a diagnosis of "malignant tumor, probably
TABLE 1. CLINICAL AND PATHOLOGIC FINDINGS IN 15 CASES OF CEREBRAL LYMPHOMA
Case
Age/Sex
HIV
Location
Diagnosis
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
35 M
32 M
33 M
27 M
64 F
62 M
11 M
53 F
65 F
27 M
57 M
59 M
61 F
83 M
64 F
+
+
+
+
+
-
Frontal lobe, basal ganglia
Basal ganglia
Parietal lobe, basal ganglia
Temporal lobe, basal ganglis , thalamus cerebellum
Thalamus, basal ganglia
Basal ganglia
Pineal
Occipital lobe
Frontal, parietal lobes
Brainstem, cerebellum
Frontal, parietal lobes
Basal ganglia
Parietal, frontal
Frontal, parietal, occipital lobes; basal ganglia; corpus callosum
Parietal lobe
IBS
SNC
LCL
LCL
IBS
IBS
LL
SNC
WDLL
LCL
LCL
SNC
ML
ML
?ML
IBS = immunoblastie sarcoma: SNC = small noncleaved cell lymphoma; LCL = large cell
lymphoma; LL = lymphoblastic lymphoma; WDLL = well-differentiated lymphocytic lymphoma;
Ancillary
Studies
Monoclonal B cell, X
Not available
Monoclonal B cell, A
Unsatisfactory, EM
Monoclonal B cell, K
Monoclonal B cell, K
LCA (+), Iter (-), EM
Monoclonal B cell, X
Monoclonal B cell, K
Not available
Not available
LCA(+), Leu-12(+), K e r ( - )
Unsatisfactory
Not available
Unsatisfactory
ML = malignant non-Hodgkin's lymphoma, unspecified; LCA = leukocyte common antigen;
Leu-12 = Pan-B-cell marker, Ker = keratin; EM = electron microscopy.
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RESULTS
The patients included ten men, four women, and one
child, whose ages ranged from 11 to 83 years. The median
age of five patients infected with the human immunodeficiency virus (HIV) was 32 years. The median age of
the nonimmunosuppressed adults was 62 years.
Initial CT scans of the brain revealed multiple lesions
in ten patients, and single lesions infive.Their anatomic
distribution is presented in Table 1. The basal ganglia
were the most frequent site of involvement, followed by
the frontal and parietal lobes. Radiologically, the lesions
were solid enhancing masses in 12 patients, and ring-enhancing defects in 3. A prominent mass effect, associated
with a midline shift, was observed rarely. One patient's
roentgenogram demonstrated evidence of subfalcine herniation.
Change in mental status, representing the most common presenting symptom, occurred in seven patients.
Hemiparesis or disturbance in gait were each the chief
complaint of three patients, and loss of visual acuity or
incontinence were the presenting symptoms of two pa-
879
880
ANATOMIC PATHOLOGY
' Article
lymphoma," and this interpretation was confirmed by
stereotactic biopsy.
The diagnosis of malignant lymphoma was supported
by the clinical course in 12 patients; it was established by
craniotomy and open biopsy in 1, and confirmed at autopsy in 2. Of the 14 patients for whom complete followup was available, all died. The median survival length
after diagnosis was two months for AIDS patients, and
six months for nonimmunosuppressed patients. All AIDS
patients were dead within three months of presentation,
whereas four of the remaining patients lived ten months
or longer.
PATHOLOGIC FINDINGS
Papanicolaou-stained cytologic preparations were
moderately to highly cellular. Geographic areas of coagulative necrosis or individually necrotic cells with pyknotic
nuclei were noted in more than three-fourths of the cases.
Necrosis was inconspicuous in two biopsy specimens.
Mitoses were prominent in two examples of small noncleaved cell lymphoma, one lymphoblastic lymphoma,
and one immunoblastic sarcoma. The background generally consisted of vacuolated cerebral white matter, con-
DISCUSSION
The clinical differential diagnosis of intracranial malignant lymphoma includes metastatic carcinoma, glioma,
abscess, and other neoplastic and nonneoplastic entities.
Because malignant lymphomas rarely shed diagnostic cells
into cerebrospinal fluid and frequently are inaccessible to
open biopsy, 1314 the pathologic diagnosis of these lesions
may pose a difficult challenge. Our experience suggests
that CT-guided stereotactic biopsy is an effective technique
that often yields a definitive diagnosis.
In this series, 14 of 15 patients with cerebral involvement by lymphoma received correct diagnoses by stereotactic biopsy. One case represented secondary involvement of the brain in a patient with known lymphoma,
whereas the remaining patients presented with primary
disease. Among those without known risk factors for cerebral lymphoma, the diagnosis often was unsuspected
clinically. Because the radiologic appearance of cerebral
A.J.C.P. • lune 1991
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Malignant lymphoma was observed in stereotactic biopsy specimens from 14 of 15 cases. The cytologic classification of the lymphomas (according to the Working
Formulation) is shown in Table 1. All except one of the
tumors were intermediate or high grade. Immunohistochemical stains performed on cytospins of needle-rinse
specimens provided evidence of a monoclonal B-cell neoplasm in six cases and confirmed the presence of a lymphoid lesion in two.
Diff-Quik-stained smears of crush preparations made
at the time of biopsy were available in 12 cases. Lymphoma was favored in eight cases, a "small cell malignant
tumor" was thought to be present in another, and results
from three biopsy specimens were reported as "adequate
cellularity." Hypercellular foci suggestive of a neoplasm
were present in three cases, in which necrosis or thick
smears prevented recognition of the lesion as lymphoid.
In eight cases, single atypical lymphocytes with round nuclei, prominent nucleoli, and a thin rim of dense blue
cytoplasm were evident. The tumor cells were frequently
identifiable at the periphery of thickly smeared areas in
difficult cases. In case 9, the presence of numerous mature
lymphocytes on a Diff-Quik-stained smear that was prepared at the time of biopsy suggested the unusual diagnosis
of well-differentiated lymphocytic lymphoma (Fig. 1).
Based on the preliminary diagnosis, material was obtained
for immunohistochemical studies, ultimately allowing for
the demonstration of a monotypic, kappa-positive, welldifferentiated lymphocytic lymphoma.
taining numerous thin-walled vessels (Fig. 2). The uninvolved brain tissue was normal, frankly necrotic, or gliotic.
Smears consisted primarily of individual cells and
stripped nuclei. Crush artifact was prominent in some
cases. Millipore filter preparations showed abnormal cells,
either singly, or in rounded groups with central necrosis.
Cytoplasmic preservation on filter preparations was superior to that of smears, especially in cases with extensive
necrosis. Cell blocks frequently showed single-cell invasion
of adjacent brain tissue (Fig. 3).
In nearly every case, diagnostic material was present
on all types of preparations. In five cases, the diagnosis
of lymphoma was based largely on cytologic preparations,
and in another five the cell block was of greater diagnostic
value. In the remaining cases, cytologic and histologic
preparations were equally useful. Nuclear detail was generally better in the cytologic material; hence, these preparations often were preferred for classification of the lymphomas. In biopsy specimens that contained lymphoma
cells admixed with inflammatory cells and necrosis, cell
blocks were useful in demonstrating the malignant, invasive features of the lesion.
One patient had a biopsy performed twice without a
definitive diagnosis. Both specimens contained rare,
atypical, mononuclear cells in a mixed inflammatory
background of necrotic debris, lymphocytes, plasma cells,
segmented leukocytes, and many foamy macrophages.
The cell block in one of these two cases showed rare vessels
cuffed by atypical cells, but the mixed inflammatory
background precluded a certain diagnosis. The diagnosis
of malignant non-Hodgkin's lymphoma was secured ultimately by craniotomy and open biopsy.
881
SHERMAN ET AL.
Stereotactic Brain Biopsy
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FIG. 1. A (upper, left). Smear prepared at time of biopsy revealing numerous lymphocytes suggestive of well-differentiated lymphocytic lymphoma.
Diff-Quik (X950). B (upper, right). Cell block revealing dense perivascular infiltrate of small lymphocytes. Hematoxylin and eosin (X210).
FIG. 2. A (lower, left). Smear demonstrating branching vessels surrounded by malignant lymphoid infiltrate. Papanicolaou (X420). B (lower, right).
Malignant lymphocytes with convoluted nuclei and prominent nucleoli. Papanicolaou (X 1,075).
lymphoma is variable,15 these neoplasms may be indistinguishable from metastatic carcinoma in immunocompetent patients, and from abscess in immunocompromised patients.
Fourteen of our cases were intermediate or high-grade
lymphomas; hence, nearly all of them could be diagnosed
by light microscopic examination alone. Twelve cases
contained sufficient material to permit their classification
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k
882
ANATOMIC PATHOLOGY
Original Article
FIG. 3. Malignant single-cell infiltrate surrounding blood vessel and invading adjacent
brain. Hematoxylin and eosin (X450).
well-circumscribed lesions. In contrast to small cell carcinomas, cerebral lymphomas generally demonstrate
prominent nucleoli and do not display nuclear molding.
In one of our cases, a mixed inflammatory background
precluded a diagnosis of lymphoma. Rare perivascular
cuffs of atypical mononuclear cells suggested the correct
interpretation in this case, but were insufficient for definitive diagnosis. Perivascular infiltration is a characteristic
feature of lymphoma that is often most apparent at the
periphery of the lesions. 6 " 91314 The atypia of the lymphocytes distinguishes lymphoma from vasculitis, infections,
and noninfectious inflammatory disorders.
Lymphoma often was suspected by cytologic evaluation
at the time of biopsy, and material was prepared for immunohistochemical studies in 11 cases. The lymphoid
nature of the lesion was confirmed by electron microscopic
examination in two cases, and by positive staining for
leukocyte common antigen (with negative keratin stains)
in an additional example. B-cell markers were positive in
one case, and monotypic light chain expression was demonstrated in six. In three patients, insufficient material
was obtained for immunohistochemical studies. We concur with previous investigators, however, that stereotactic
biopsies usually yield specimens that are suitable for immunohistochemical studies that may be used to support
a diagnosis of lymphoma.6"8
Malignant lymphoma accounts for less than 2% of primary cerebral neoplasms; however, the sharply increasing
incidence of these tumors has prompted several recent
reviews.1314 Most primary cerebral malignant lymphomas
are aggressive B-cell neoplasms. T-cell neoplasms also
A.J.C.P. -June 1991
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according to The Working Formulation. Some studies
suggest that categorization of cerebral lymphoma according to these guidelines may have prognostic value.14
Our experience suggests that the diagnostic accuracy of
cerebral stereotactic biopsy is enhanced by the use of several types of tissue preparation. Cell blocks often revealed
perivascular infiltrates or single-cell invasion of normal
brain, suggesting a diagnosis of lymphoma. Millipore-filter
preparations generally provided excellent individual cellular detail and were useful for classification. On-site evaluation of crush preparations at the time of biopsy was
helpful in selecting material for ancillary studies, even
when a definitive diagnosis was deferred initially.
Cytologically, lymphoma is distinguishable from glioma
by the absence of vascular proliferation and the presence
of individual cells that are round, and have scant cytoplasm, lobulated nuclei, and single-cell necrosis. Neoplastic astrocytes tend to be spindled and have more ample
cytoplasm than lymphoma cells do. Necrosis is present
only in high-grade glial tumors. Tissue adjacent to lymphomas may demonstrate striking reactive gliosis, resembling malignant glioma. Rarely, we have observed gemistocytic astrocytes among such reactive components. Review of the clinical and radiologic findings, the benign
appearance of the astrocytes, and the absence of endothelial proliferation generally allow for recognition of
gliosis and should prompt another biopsy procedure.
The presence of multiple lesions, a history of carcinoma,
and a lack of known risk factors for lymphoma favor a
diagnosis of metastatic carcinoma. Most of the latter consist of cohesive fragments of large tumor cells, forming
SHERMAN ET AL.
Stereotactic Brain Biopsy
Acknowledgments. The authors thank the house staff, the faculty and
staff of the AIDS Service, and the Tumor Registry of The Johns Hopkins
Hospital for assistance in performing this study.
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have been recognized. Multifocal involvement is seen in
as many as 50% of cases. Immunosuppressive therapy,
HIV infection, and many inherited and sporadically occurring immunodeficiency states are associated with an
increased risk for lymphoma. Although secondary meningeal spread develops in a significant percentage of patients with high-grade systemic lymphoma, parenchymal
involvement of the brain is rare.
Advances in the management of cerebral disease require
rapid and more exact pathologic diagnoses. Because many
brain lesions are treatable by radiation therapy, chemotherapy, antibiotics, and other nonoperative measures, the
least invasive diagnostic technique is often the most desirable. We conclude that cerebral stereotactic biopsy is
an accurate technique for the diagnosis of intracerebral
malignant lymphoma, and that it is associated infrequently with serious complications.
883