Primary Spinal Epidural Low-grade B-cell Lymphoma: Masquerading as a Case of Spinal Cord Compression

Abstract Lymphoma rarely arises within the central nervous system and occurs most commonly in association with disseminated systemic disease. Primary spinal epidural lymphoma (PSEL) is a subset of lymphomas, where there are no other recognizable sites of lymphomas at the time of diagnosis. Primary epidural lymphomas of the spine are infrequently encountered and are usually high-grade, diffuse large B-cell lymphomas. Low-grade lymphomas arising in the spine are rare. While treatment for systemic high-grade lymphomas is well defined, the treatment of low-grade lymphomas arising within the dura or within the epidural space is less defined. A 59-year-old female presented with complaints of back pain, progressive weakness (Grade 3 power), and numbness of bilateral lower limbs for 1 month duration. Magnetic resonance imaging (MRI) spine showed a homogenously contrast enhancing extra-axial lesion at D4-D8 levels. Contrast-enhanced computed tomography neck, abdomen, thorax, and MRI brain showed no other lesions elsewhere. She underwent D4-D8 laminectomy + excision of the epidural lesion. Her lower extremity strength continues to improve with rehabilitation. The biopsy came out to be B-cell lymphoproliferative neoplasm follicular lymphoma grade 1. Bone marrow biopsy done was negative for lymphoma. She was then referred for chemoradiation therapy. She underwent an interim positron emission tomography (PET) scan, which showed no evidence of lymphoma. After completing six cycles of treatment, the PET scan continued to show an ongoing response to treatment. PSEL is a rare pathological entity, which must be considered in middle-aged patients presenting with features of spinal cord compression. A favorable outcome can be expected in patients with PSEL, if diagnosed and treated early with surgery and multimodality treatment, unlike secondary spinal epidural lymphoma which has a poor outcome.