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A 76-year-old woman presented with a 2 week history of left-sided hemiparesis thought to be caused by a stroke, and a progressively enlarging lump on the back of her head which was thought to be a haematoma. Subsequent scans showed the lesion to extend intracranially (fig 1), with involvement of the intervening bone (fig 2).
Her hemiparesis improved with steroids but her mobility did not. MRI showed the extent of intracranial invasion (figs 3–5). Biopsy of the extracranial portion revealed a soft yellow tumour of moderate vascularity, and histology showed it to be a diffuse large B cell lymphoma Further investigation revealed no evidence of disease in the rest of the body: bone marrow trephine was unremarkable and she was HIV negative.
Although transcalvarial lymphoma is a recognised phenomenon,1–5 this case is unique because of the size of the lesion. It is impossible to determine whether the lymphoma arose from the brain or from the calvarial bone—all previous reports describe primary bone disease spreading into the brain.
Primary cerebral lymphoma accounts for 1% of intracranial neoplasms and the incidence has increased in recent decades as a result of immunosuppression caused by AIDS and following organ transplantation. The vast majority of tumours are monoclonal B cell non-Hodgkin’s lymphomas with an exceptionally small proportion of true T cell lymphomas; primary Hodgkin’s lymphoma of the central nervous system is almost never seen.
She received radiotherapy but there was no response. Unfortunately, she developed a severe chest infection and died 2 weeks after starting radiotherapy. A post mortem was not performed.
This article has been adapted from Edward Graveson Uff Christopher, Louis Shieff Colin. Massive transcalvarial lymphoma Journal of Neurology, Neurosurgery and Psychiatry 2007;78:769
Competing interests: None.