An Unusual Presentation of a Low Grade Follicular Lymphoma Masquerading as a Meningioma

Case Report

Ann Hematol Oncol. 2018; 5(6): 1211.

An Unusual Presentation of a Low Grade Follicular Lymphoma Masquerading as a Meningioma

MacCann R*, Gleeson JP, Aird JJ, Beausang A, Breathnach O, Morris PG and Grogan W

Department of Medical Oncology, Beaumont Hospital, Dublin, Ireland

*Corresponding author: Rachel MacCann, Department of Medical Oncology, Beaumont Hospital, Dublin, Ireland

Received: June 28, 2018; Accepted: July 30, 2018; Published: August 06, 2018


The central nervous system (CNS) is an important area of involvement for both high-grade, aggressive primary and secondary lymphomas. Follicular lymphoma typically represents a low-grade histology. Here, we describe a case of higher-grade follicular lymphoma with CNS involvement, where the complicated and unsuspected diagnosis was prompted following a single seizure event.

Keywords: Indolent lymphoma; Follicular lymphoma; Diffuse large B-cell lymphoma; Secondary CNS involvement; Parenchymal CNS involvement


The CNS is often involved with both primary and secondary lymphomas, but different types of lymphoma manifest considerably different patterns of disease. The differential diagnosis of patients presenting with a CNS form of non-Hodgkin Lymphoma can thus be broad and variable. Typically, patients present with progressive encephalopathy or focal neurologic deficits accompanied by enhancing abnormalities on brain imaging. In light of this, we report a rare case of follicular lymphoma with diffuse lymphadenopathy following a single seizure episode.

Case Presentation

RM is a 41 year-old lady who presented to a peripheral hospital in September 2016 following a seizure episode. She had no history of previous seizures, no headaches, no neurological deficits and past medical history was non-contributory. She took no regular medications. She was an ex-smoker with a 30 pack-year history, had no history of illicit drug use and was a non-drinker. She worked parttime and lives with her partner and 13 year-old son. She had a strong neuro-oncological family history, with a maternal aunt and paternal uncle who had unspecified brain tumours and a paternal aunt had a meningioma. Her brother had acute myeloid leukaemia (AML). On examination, Glasgow Coma Scale (GCS) score was 15/15 with no focal neurological signs, no cerebellar signs, and no palpable lymphadenopathy. Cardiovascular and respiratory examinations were normal. A full blood count and metabolic profile was within the normal range except for mild anaemia. Lactate dehydrogenase (LDH) was normal.

A magnetic resonance imaging (MRI) scan, found a right parietal extra-axial mass which appeared to arise from the dural and so she was transferred to a tertiary neurosurgical centre, for further work up and surgery, with the initial working diagnosis of a seizure-inducing meningioma. RM underwent a parietoccipital craniotomy with resection of the right parietal lesion. She recovered well following surgery, with no complications or neurological deficits.

Formalin fixed paraffin embedded sections from the dural lesion demonstrated a cellular proliferation with follicular and diffuse architecture (Figure 1). The cells were small in size with irregular nuclei, condensed chromatin and scant cytoplasm. There were less than 15 centroblasts per high power field (hpf). Mitoses were not readily identified. The neoplastic cells were positive for CD20, CD10, BCL2, BCL6 and CD23 and negative for CD5, cyclin D1 and CD138. CD21 highlighted expanded and distorted follicular dendritic cell mesh works. CD3 and CD5 stained scattered background reactive T lymphocytes. MIB-1 proliferation index was approximately 40%. No evidence of a higher grade of lymphoma was identified. Fluorescent in-situ hybridisation analysis showed the presence of a t(14;18) (q32;q21) translocation. This was felt to be a somewhat inconclusive immunoprofile, however upon discussion at the Lymphoma Multidisciplinary Meeting (MDM), a diagnosis of follicular lymphoma was made. In the clinical context, these morphological, immunohistochemical and molecular features were diagnostic of a follicular lymphoma, grade 1-2, follicular and diffuse subtype. Surprisingly, further examination also showed indolent invasion of the cerebral cortex.