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Progressive cognitive decline in two patients with severe MRI brain changes – Answer

Published:March 08, 2021DOI:https://doi.org/10.1016/j.jocn.2021.01.034

      Highlights

      • Contrast enhancing/ non-enhancing ‘sentinel lesions’ described in PCNSL can recede spontaneously or following corticosteroids.
      • Histological finding can reveal lymphocyte-rich inflammation, often with demyelination and may delay diagnosis.
      • ‘Sentinel lesions’ of PCNSL should be considered in this spontaneously remitting clinicoradiological syndrome.

      1. Answer

      Sentinel lesions in Primary CNS lymphoma.

      2. Discussion

      These two cases are histologically-confirmed primary central nervous system, diffuse large B cell lymphoma presenting with ‘sentinel lesions’ on MRI. Both patients had multifocal T2 hyperintensities with patchy contrast enhancement on initial MRI, which regressed spontaneously (Fig. 1) or following corticosteroids (Fig. 2) on progress imaging 3 weeks later.
      Figure thumbnail gr1
      Fig. 1Multifocal hyperintensities on FLAIR (A1), with patchy contrast enhancement on T1-weighted sequences (A2, A3). Progress imaging after 3 weeks demonstrated regression of some lesions and reduction in enhancement (B1, B2, B3) (arrows). Progress MRI identified new lesions with contrast enhancement (C2, C3) (arrow heads).
      Figure thumbnail gr2
      Fig. 2Multifocal hyperintensities on FLAIR (A1), with patchy contrast enhancement on T1-weighted sequences (A2, A3). Progress imaging after 3 weeks demonstrated regression of some lesions and reduction in enhancement (B1, B2, B3) (arrows). Progress MRI identified new lesions with contrast enhancement (C2, C3) (arrow heads).
      Transient, contrast enhancing or non-enhancing ‘sentinel lesions’ have been described in PCNSL that recede spontaneously or following corticosteroids [
      • Alderson L.
      • Fetell M.R.
      • Sisti M.
      • Hochberg F.
      • Cohen M.
      • Louis D.N.
      Sentinel lesions of primary CNS lymphoma.
      ,
      • Javier R.
      • Shaikh N.
      • Lesniak M.S.
      • et al.
      B cell-rich non-neoplastic sentinel lesion preceding primary central nervous system lymphoma.
      ]. Histology reveals lymphocyte-rich inflammation, often with demyelination, and can result in delayed diagnosis [
      • Javier R.
      • Shaikh N.
      • Lesniak M.S.
      • et al.
      B cell-rich non-neoplastic sentinel lesion preceding primary central nervous system lymphoma.
      ]. ‘Sentinel lesions’ of PCNSL should be a differential diagnosis of this spontaneously remitting clinicoradiological syndrome.

      Author contributions

      Sophie Waller: study concept and design, first draft, literature review. Tien Lee Ong: study concept and design, first draft, literature review. Khairul Azmi Ibrahim: data acquisition, revising manuscript and critical review of manuscript. Zariah Abdul-Aziz: data acquisition, revising manuscript and critical review of manuscript. Neil Mahant: data acquisition, revising manuscript and critical review of manuscript. Victor SC Fung: study concept and design, critical review of manuscript for intellectual content, literature review.

      Study funding

      No targeted funding reported.

      Disclosure

      The authors report no disclosures relevant to the manuscript.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      References:

        • Alderson L.
        • Fetell M.R.
        • Sisti M.
        • Hochberg F.
        • Cohen M.
        • Louis D.N.
        Sentinel lesions of primary CNS lymphoma.
        J Neurol Neurosurg Psychiatry. 1996; 60: 102-105
        • Javier R.
        • Shaikh N.
        • Lesniak M.S.
        • et al.
        B cell-rich non-neoplastic sentinel lesion preceding primary central nervous system lymphoma.
        Diagn Pathol. 2018; 13: 37https://doi.org/10.1186/s13000-018-0717-9

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