LMD-11. Pure spinal cord invasion in recurrent classic Hodgkin’s Lymphoma - what is it?

We present the case of a 39-year-old male who initially presented in January 2017 with abdominal pain and weight loss. He was eventually diagnosed with stage IVB Classical Hodgkin’s Lymphoma. Brentuximab, Vinblastine, and Dacarbazine regimen was initiated with dose adjustments made due to cardiomyopathy and neuropathy. By cycle 5, good response was evident on systemic imaging. He was then lost to follow-up. He represented in December 2020 with near paraplegia, preceded by months of tingling, numbness in both legs, gait imbalance and low back pain. MRI spine in January 2021 demonstrated multifocal abnormal cord signal changes with scattered areas of intramedullary cord enhancement as well as extensive enhancement of the cauda equina ((Figures 1,2,3)). CNS angiitis as a paraneoplastic phenomenon, mimics a similar clinical and radiographic appearance. Unfortunately none of the cord lesions were amenable to biopsy. Full body PET CT showed florid disease concerning for recurrence. 2 lumbar punctures with limited CSF flow cytometry and cytology analyses were negative. Mediastinal lymph node biopsy revealed Classical Hodgkins Lymphoma. DHAP chemotherapy regimen was initiated, soon after. A 3rd time, high volume comprehensive CSF analysis performed later, was unremarkable. MRI spine, after 2 cycles demonstrated significant improvement((Figures 4,5,6))coinciding with systemic response and clinical improvement. This favored diagnosis of CNS Hodgkin lymphoma over secondary CNS angiitis. CNS Hodgkin’s Lymphoma is a rare occurrence1, let alone, pure spinal intramedullary and leptomeningeal metastases. Intramedullary metastases arise from direct hematogenous spread or by, centripetal growth of tumor along spinal nerve roots with secondary invasion of spinal cord(2). Systemic Hodgkin’s Lymphoma rarely affects the spine with a prevalence of 0.2% - 0.5%(3,4). In an analysis of a large cohort of Hodgkin’s patients comprising 14,868 individuals, a prevalence of less than 0.02%, indicating it had been overestimated in the past(5).