JMIR Publications

ABSTRACT

Impaired histological clarity resulting from various factors may hinder the diagnosis of primary central nervous system lymphoma (PCNSL). Corticosteroids are one such factor, as they can shrink lesions and obscure tumor morphology. Additionally, mechanical limitations during biopsy, such as tissue crush artifact, compression, or suboptimal sampling, can further diminish diagnostic accuracy. A 51-year-old white female presented with progressive bilateral lower back pain and left-sided sciatica. Magnetic resonance imaging (MRI) of the lumbar spine revealed an extensive epidural tumor from L4 downward involving the L5 and sacral bone. Presacral soft tissue mass needle core biopsy classified the mass as an atypical spindle cell tumor. Oncology requested an open biopsy to reach a more specific diagnosis. Meanwhile, the patient was prescribed a moderate dose of dexamethasone due to excruciating pain. The patient later had a laminotomy for an excisional biopsy to achieve a more specific diagnosis and to relieve radicular pain. Histological studies from this specimen were suggestive of a reactive process without definite evidence of neoplasm. The patient did not undergo chemotherapy or radiotherapy due to failure to obtain further classification. Persistent excruciating pain led to a laminectomy with an unsuccessful attempt at epidural mass resection. The histological study from this procedure provided a diagnosis of follicular lymphoma. The patient started systemic chemotherapy, and her symptoms significantly improved. This case highlights the challenges associated with diagnosing hematologic malignancies, as well as the importance of thorough histopathological analysis and repeated sampling when necessary. Additionally, this case emphasizes the need for interdisciplinary collaboration between pathologists, oncologists, radiation oncologists, neurosurgeons, and radiologists to navigate complex diagnostic pathways effectively.