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Latest revision as of 04:16, 2 January 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Marjan Khan M.B.B.S.[2]

Overview

Primary CNS lymphoma is an intracranial tumor usually present in those with severe immunosuppression. It represents around 20% of all cases of lymphomas in HIV infection (other types being Burkitt's lymphoma and immunoblastic lymphoma). Primary central nervous system lymphoma may originate from a germinal center to an early postgerminal center in a secondary lymphoid organ, which may be capable of further maturation steps. EBV is almost always associated with primary CNS lymphoma in immunodeficient individuals, and latent EBV infection of B-cells leads to it's immortalization and to CNS tropism. In immunocompetent individuals, the B-cells infected with EBV are held in check by T-cells, and with the severity of immunosuppression, T cells gradually fall, leading to the B-cell proliferation and dissemination. . Primary central nervous system lymphoma constitutes approximately 3%-4% of all primary brain tumors and 1%-2% of all lymphomas. Primary central nervous system lymphoma has been diagnosed in at least 2% of individuals infected with human immunodeficiency virus, and in 9–14% of acquired immunodeficiency syndrome (AIDS)-autopsies. Primary CNS lymphoma is, after toxoplasmosis, the most common cause of focal brain lesions in AIDS patients. The overall incidence of primary central nervous system lymphoma is 0.4 per 100,000 individuals per year. The median age of occurrence of primary central nervous system lymphoma in immunocompetent and immunocompromised patients are 53-57 years and 31-35 years, respectively. The peak incidence is between 60 and 70 years old for immunocompetent patients. Significant increment of incidence rate over time is associated with increased incidence of AIDS and advanced age. Males are more commonly affected with primary central nervous system lymphoma than females.

Classification

Primary central nervous system lymphoma may be classified according to the site of involvement of the central nervous system into 3 groups:

Parenchymal
Intravascular lymphoma
Primary leptomeningeal lymphoma.

Primary CNS lymphomas are extranodal, malignant non-Hodgkin lymphomas of the diffuse large B-cell type that are confined to the brain, eyes, leptomeninges, or spinal cord, in the absence of systemic lymphoma. Primary CNS lymphomas are estimated to account for up to 1% of all lymphomas, 4–6% of all extranodal lymphomas, and about 3% of all CNS tumours. After a continuous rise in the incidence of primary CNS lymphoma during the 1980s and 1990s, epidemiological data in high-income countries show a decrease in incidence, particularly among young patients with AIDS.

Pathophysiology

Primary central nervous system lymphoma may originate from a germinal center to an early postgerminal center in a secondary lymphoid organ, which may be capable of further maturation steps.
EBV is almost always associated with primary CNS lymphoma in immunodeficient individuals, and latent EBV infection of B-cells leads to it's immortalization and to CNS tropism. In immunocompetent individuals, the B-cells infected with EBV are held in check by T-cells, and with the severity of immunosuppression, T cells gradually fall, leading to the B-cell proliferation and dissemination.
Genes involved in the pathogenesis of primary central nervous system lymphoma include IG, BCL6, CD95, PAX5, and PIM1.
Primary central nervous system lymphoma is highly associated with Epstein-Barr virus (EBV) infection (> 90%) in immunodeficient patients (such as those with AIDS and iatrogenically immunosuppressed).
Primary central nervous system lymphoma presents as a solitary or multiple, well circumscribed, greater than 2 cm in diameter, well-defined or infiltrating mass lesion/s that can arise in the cortex, white matter, or deep grey matter (more common in low-grade lesions). On gross pathology, the lesions could be brownish, gray-tan, or yellow, firm, homogenous, centrally necrotic with areas of hemorrhage.
On microscopic histopathological analysis, primary central nervous system lymphoma is characterized by accumulation of large atypical mononuclear cells around small calibre vascular channels with invasion of the walls of some vessels. The atypical cells have large round, oval and angulated hyperchromatic and vesicular nuclei, and a narrow rim of pale cytoplasm. An occasional mitotic figure is noted.
Primary central nervous system lymphoma is demonstrated by positivity to tumor markers, including B lymphocyte markers, such as CD19, CD20, CD79a, Ki-67, GFAP, BCL-2, and BCL-6.
Primary central nervous system lymphoma presents as a solitary or multiple, well circumscribed, greater than 2 cm in diameter, well-defined or infiltrating mass lesion/s that can arise in the cortex, white matter, or deep grey matter (more common in low-grade lesions).[5][2] On gross pathology, the lesions could be brownish, gray-tan, or yellow, firm, homogenous, centrally necrotic with areas of hemorrhage.[2] On microscopic histopathological analysis, primary central nervous system lymphoma is characterized by accumulation of large atypical mononuclear cells around small calibre vascular channels with invasion of the walls of some vessels.

Causes

There are no known direct causes for primary central nervous system lymphoma. To view a comprehensive list of risk factors that increase the risk of primary nervous system lymphoma, click here.

Differentiating Primary Central Nervous System Lymphoma from other Diseases

Primary central nervous system lymphoma must be differentiated from secondary CNS lymphoma, cerebral toxoplasmosis, glioblastoma multiforme, cerebral abscess, and tuberculoma.

Epidemiology and Demographics

Primary central nervous system lymphoma constitutes approximately 3%-4% of all primary brain tumors and 1%-2% of all lymphomas. Primary central nervous system lymphoma has been diagnosed in at least 2% of individuals infected with human immunodeficiency virus, and in 9–14% of acquired immunodeficiency syndrome (AIDS)-autopsies. Primary CNS lymphoma is, after toxoplasmosis, the most common cause of focal brain lesions in AIDS patients. The overall incidence of primary central nervous system lymphoma is 0.4 per 100,000 individuals per year. The median age of occurrence of primary central nervous system lymphoma in immunocompetent and immunocompromised patients are 53-57 years and 31-35 years, respectively. The peak incidence is between 60 and 70 years old for immunocompetent patients. Significant increment of incidence rate over time is associated with increased incidence of AIDS and advanced age. Males are more commonly affected with primary central nervous system lymphoma than females. The male to female ratio is approximately 1.2 to 1 in immunocompetent patients and approximately 7.38 to 1 in AIDS-associated primary central nervous system lymphoma.

Risk Factors

The most potent risk factor in the development of primary central nervous system lymphoma is a weakened or suppressed immune system in individuals who have acquired immunodeficiency syndrome (AIDS), received an organ transplant and are on immunosuppressants, inherited immunosuppressive disorders (IgA deficiency, Wiskott-Aldrich syndrome, ataxia telangiectasia), and autoimmune disorders (systemic lupus erythematosus, rheumatoid arthritis, myasthenia gravis).

Screening

There is insufficient evidence to recommend routine screening for primary central nervous system lymphoma.

Natural History, Complications and Prognosis

If left untreated, primary central nervous system lymphoma may progress to develop elevated intracranial pressure, ocular symptoms, focal neurological deficits, and neuropsychiatric problems. Common complications of primary central nervous system lymphoma include relapse, extracranial or subcutaneous metastasis, neuropsychiatric problems, and neurological toxicity. The prognosis of primary central nervous system lymphoma is generally poor.

Diagnosis

Staging

There is no established system for the staging of primary central nervous system lymphoma.

Symptoms

Symptoms of primary central nervous system lymphoma are identical to the other types of brain tumors and depend on the area of the brain that is affected. Primary central nervous system lymphoma is multifocal. Symptoms of primary nervous system lymphoma include headache, nausea, vomiting, difficulty swallowing, monocular vision loss, Muscle weakness or paralysis, memory loss, facial hypoesthesia, seizures, fever, night sweats, and weight loss.

Physical Examination

Common physical examination findings of primary central nervous system lymphoma include vision loss, papilledema, altered mental status, apathy, depression, aphasia, cranioneuropathies, ataxia, and hemiparesis.

Laboratory Findings

Laboratory tests performed in a case suspected of primary central nervous system lymphoma include complete blood count, complete metabolic panel, lactate dehydrogenase, serological testing for HIV, and CSF analysis. Laboratory findings consistent with the diagnosis of primary central nervous system lymphoma include elevated protein and decreased glucose on CSF analysis. Positive EBV DNA in CSF-PCR is helpful for diagnosis of primary central nervous system lymphoma, particularly in HIV/AIDS patients.

CT

Head CT scan may be helpful in the diagnosis of primary central nervous system lymphoma. Findings on CT scan suggestive of primary central nervous system lymphoma include supratentorial hyperattenuating, enhancing, hemorrhaging mass with subependymal extension crossing the corpus callosum. Chest, abdomen, and pelvic CT scans may be used to exclude any occult systemic disease from the spread of primary central nervous system lymphoma.

MRI

Contrast-enhanced MRI is the imaging modality of choice for primary central nervous system lymphoma. Findings on MRI suggestive of primary central nervous system lymphoma include solitary to multiple, 3-5 cm ring-enhancing lesions in almost any location, but usually deep in the white matter, which are typically hypointense on T1-weighted images and iso- to hypointense on T2-weighted images.

Other Imaging Findings

There are no other imaging findings associated with primary central nervous system lymphoma.

Other Diagnostic Studies

Other diagnostic studies for primary central nervous system lymphoma include magnetic resonance spectroscopy, magnetic resonance perfusion, scintigraphy, stereotactic biopsy, and polymerase chain reaction.

Treatment

Medical Therapy

The treatment of primary central nervous system lymphoma depends on the patient’s age, performance status, stage and location of the lymphoma, and whether or not the individual is immunosuppressed. Chemotherapy is the mainstay of treatment for primary central nervous system lymphoma. Corticosteroids are often used to destroy lymphoma cells and relieve cerebral edema. Radiation therapy may be given on its own or along with chemotherapy. The treatment of primary central nervous system lymphoma depends on the patient’s age, performance status, stage and location of the lymphoma, and whether or not the individual is immunosuppressed.

Surgery

Surgical intervention is not recommended for the management of primary central nervous system lymphoma, because the tumors are often deeply seated and spread throughout the brain.

Prevention

There are no primary or secondary preventive measures available for seminoma.

References

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 ==Overview==
-Primary CNS lymphoma is a [[brain tumor|primary intracranial tumor]] usually present in those with severe immunosuppression --- commonly in those with [[AIDS]] --- and represents around 20% of all cases of lymphomas in HIV infection (other types being [[Burkitt's lymphoma]] and immunoblastic lymphoma). Primary central nervous system lymphoma may originate from a germinal center to an early postgerminal center in a secondary lymphoid organ, which may be capable of further maturation steps.<ref name=pathogenesisprimarycentralnervousystemlymphoma1>PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMAS IN THE NEUROLOGICAL PRACTICE. file:///C:/Users/Owner/Downloads/psyneur_2014_1_2_8.pdf. Accessed on February 19, 2016</ref> [[EBV]] is almost always associated with primary CNS lymphoma in immunodeficient individuals, and latent EBV infection of B-cells leads to it's immortalization and to CNS tropism. In immunocompetent individuals, the B-cells infected with EBV are held in check by T-cells, and with the severity of immunosuppression, T cells gradually fall, leading to the B-cell proliferation and dissemination.<ref name="pmid18976024">{{cite journal| author=Bhagavathi S, Wilson JD| title=Primary central nervous system lymphoma. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 11 | pages= 1830-4 | pmid=18976024 | doi=10.1043/1543-2165-132.11.1830 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18976024  }} </ref> Genes involved in the pathogenesis of primary central nervous system lymphoma include ''IG'', ''BCL6'', ''CD95'', ''[[PAX5]]'', and ''[[PIM1]]''.<ref name="Ferreri2011">{{cite journal|last1=Ferreri|first1=A. J. M.|title=How I treat primary CNS lymphoma|journal=Blood|volume=118|issue=3|year=2011|pages=510–522|issn=0006-4971|doi=10.1182/blood-2011-03-321349}}</ref> Primary central nervous system lymphoma is highly associated with [[Epstein-Barr virus|Epstein-Barr virus (EBV) infection]] (> 90%) in immunodeficient patients (such as those with [[AIDS]] and iatrogenically immunosuppressed).<ref name=pcnslwikipediA1>Primary central nervous system lymphoma. Wikipedia 2016. https://en.wikipedia.org/wiki/Primary_central_nervous_system_lymphoma. Accessed on February 18, 2016</ref> On gross pathology, the lesions could be brownish, gray-tan, or yellow, firm, homogenous, [[necrosis|centrally necrotic]] with areas of [[hemorrhage]].<ref name="pmid18976024">{{cite journal| author=Bhagavathi S, Wilson JD| title=Primary central nervous system lymphoma. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 11 | pages= 1830-4 | pmid=18976024 | doi=10.1043/1543-2165-132.11.1830 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18976024  }} </ref> On microscopic histopathological analysis, primary central nervous system lymphoma is characterized by accumulation of large atypical mononuclear cells around small calibre vascular channels with invasion of the walls of some vessels. The atypical cells have large round, oval and angulated hyperchromatic and vesicular nuclei, and a narrow rim of pale cytoplasm. An occasional mitotic figure is noted.<ref name=pcnslwikipediA1>Primary central nervous system lymphoma. Wikipedia 2016. https://en.wikipedia.org/wiki/Primary_central_nervous_system_lymphoma. Accessed on February 18, 2016</ref><ref name=microscopicpathologyprimarycnslymphoma1>CNS lymphoma (primary). A.Prof Frank Gaillard. Radioapaedia 2016. http://radiopaedia.org/cases/cns-lymphoma-primary. Accessed on February 23, 2016</ref> There are no known direct causes for primary central nervous system lymphoma. To view a comprehensive list of risk factors that increase the risk of primary nervous system lymphoma, click [[Primary central nervous system lymphoma risk factors|'''here''']].<ref name=riskpcnsl1>Risks of primary central nervous lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref><ref name="ManentiDi Giuliano2013">{{cite journal|last1=Manenti|first1=G.|last2=Di Giuliano|first2=F.|last3=Bindi|first3=A.|last4=Liberto|first4=V.|last5=Funel|first5=V.|last6=Garaci|first6=F. G.|last7=Floris|first7=R.|last8=Simonetti|first8=G.|title=A Case of Primary T-Cell Central Nervous System Lymphoma: MR Imaging and MR Spectroscopy Assessment|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/916348}}</ref><ref name=epidemiologyprimarycnslymphoma1>Epidemiology of primary CNS lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 18, 2016</ref> Primary central nervous system lymphoma must be differentiated from secondary CNS lymphoma, [[toxoplasmosis|cerebral toxoplasmosis]], [[glioblastoma multiforme]], [[cerebral abscess]], and [[tuberculoma]].<ref name=ddxofprimarycnslymphoma1>Differential diagnosis of primary central nervous system lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 17, 2016</ref><ref name=Cerebralringenhancinglesions1>Cerebral ring enhancing lesions. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radioapaedia 2016. http://radiopaedia.org/articles/cerebral-ring-enhancing-lesions. Accessed on February 17, 2016</ref> Primary central nervous system lymphoma constitutes approximately 3%-4% of all primary brain tumors and 1%-2% of all [[lymphomas]].<ref name="ManentiDi Giuliano2013">{{cite journal|last1=Manenti|first1=G.|last2=Di Giuliano|first2=F.|last3=Bindi|first3=A.|last4=Liberto|first4=V.|last5=Funel|first5=V.|last6=Garaci|first6=F. G.|last7=Floris|first7=R.|last8=Simonetti|first8=G.|title=A Case of Primary T-Cell Central Nervous System Lymphoma: MR Imaging and MR Spectroscopy Assessment|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/916348}}</ref> Primary central nervous system lymphoma has been diagnosed in at least 2% of individuals infected with [[HIV|human immunodeficiency virus]], and in 9–14% of acquired immunodeficiency syndrome (AIDS)-autopsies.<ref name="HaldorsenKråkenes2008">{{cite journal|last1=Haldorsen|first1=Ingfrid S|last2=Kråkenes|first2=Jostein|last3=Goplen|first3=Anne K|last4=Dunlop|first4=Oona|last5=Mella|first5=Olav|last6=Espeland|first6=Ansgar|title=AIDS-related primary central nervous system lymphoma: a Norwegian national survey 1989–2003|journal=BMC Cancer|volume=8|issue=1|year=2008|pages=225|issn=1471-2407|doi=10.1186/1471-2407-8-225}}</ref> Primary CNS lymphoma is, after [[toxoplasmosis]], the most common cause of focal brain lesions in [[AIDS|AIDS patients]].<ref name="HaldorsenKråkenes2008">{{cite journal|last1=Haldorsen|first1=Ingfrid S|last2=Kråkenes|first2=Jostein|last3=Goplen|first3=Anne K|last4=Dunlop|first4=Oona|last5=Mella|first5=Olav|last6=Espeland|first6=Ansgar|title=AIDS-related primary central nervous system lymphoma: a Norwegian national survey 1989–2003|journal=BMC Cancer|volume=8|issue=1|year=2008|pages=225|issn=1471-2407|doi=10.1186/1471-2407-8-225}}</ref> The overall incidence of primary central nervous system lymphoma is 0.4 per 100,000 individuals per year.<ref name="ManentiDi Giuliano2013">{{cite journal|last1=Manenti|first1=G.|last2=Di Giuliano|first2=F.|last3=Bindi|first3=A.|last4=Liberto|first4=V.|last5=Funel|first5=V.|last6=Garaci|first6=F. G.|last7=Floris|first7=R.|last8=Simonetti|first8=G.|title=A Case of Primary T-Cell Central Nervous System Lymphoma: MR Imaging and MR Spectroscopy Assessment|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/916348}}</ref> The median age of occurrence of primary central nervous system lymphoma in immunocompetent and immunocompromised patients are 53-57 years and 31-35 years, respectively.<ref name="pmid18976024">{{cite journal| author=Bhagavathi S, Wilson JD| title=Primary central nervous system lymphoma. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 11 | pages= 1830-4 | pmid=18976024 | doi=10.1043/1543-2165-132.11.1830 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18976024  }} </ref> The peak incidence is between 60 and 70 years old for immunocompetent patients.<ref name="ManentiDi Giuliano2013">{{cite journal|last1=Manenti|first1=G.|last2=Di Giuliano|first2=F.|last3=Bindi|first3=A.|last4=Liberto|first4=V.|last5=Funel|first5=V.|last6=Garaci|first6=F. G.|last7=Floris|first7=R.|last8=Simonetti|first8=G.|title=A Case of Primary T-Cell Central Nervous System Lymphoma: MR Imaging and MR Spectroscopy Assessment|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/916348}}</ref> Significant increment of incidence rate over time is associated with increased incidence of [[AIDS]] and advanced age. Males are more commonly affected with primary central nervous system lymphoma than females.<ref name="ManentiDi Giuliano2013">{{cite journal|last1=Manenti|first1=G.|last2=Di Giuliano|first2=F.|last3=Bindi|first3=A.|last4=Liberto|first4=V.|last5=Funel|first5=V.|last6=Garaci|first6=F. G.|last7=Floris|first7=R.|last8=Simonetti|first8=G.|title=A Case of Primary T-Cell Central Nervous System Lymphoma: MR Imaging and MR Spectroscopy Assessment|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/916348}}</ref> The male to female ratio is approximately 1.2 to 1 in immunocompetent patients and approximately 7.38 to 1 in AIDS-associated primary central nervous system lymphoma.<ref name="pmid18976024">{{cite journal| author=Bhagavathi S, Wilson JD| title=Primary central nervous system lymphoma. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 11 | pages= 1830-4 | pmid=18976024 | doi=10.1043/1543-2165-132.11.1830 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18976024  }} </ref> If left untreated, primary central nervous system lymphoma may progress to develop [[elevated intracranial pressure]], ocular symptoms, focal neurological deficits, and neuropsychiatric problems.<ref name=SymptomsofprimaryCNSLymphoma1>Symptoms of primary CNS Lymphoma. Lymphomation 2016. http://www.lymphomation.org/type-cns.htm. Accessed on February 24, 2016</ref> Common complications of primary central nervous system lymphoma include [[relapse]], [[metastasis|extracranial or subcutaneous metastasis]], neuropsychiatric problems, and neurological toxicity.<ref name=SymptomsofprimaryCNSLymphoma1>Symptoms of primary CNS Lymphoma. Lymphomation 2016. http://www.lymphomation.org/type-cns.htm. Accessed on February 24, 2016</ref><ref name="AhmedRamanathan2014">{{cite journal|last1=Ahmed|first1=Zartaj|last2=Ramanathan|first2=Ramesh K.|last3=Ram|first3=Sunil|last4=Newell|first4=James|last5=Halepota|first5=Maqbool|title=Unusual Relapse of Primary Central Nervous System Lymphoma at Site of Lumbar Puncture|journal=Case Reports in Hematology|volume=2014|year=2014|pages=1–4|issn=2090-6560|doi=10.1155/2014/161952}}</ref><ref name="Yamanaka2013">{{cite journal|last1=Yamanaka|first1=Ryuya|title=Primary Central Nervous System Lymphoma − Recent Advance on Clinical Research|year=2013|doi=10.5772/52757}}</ref> The prognosis of primary central nervous system lymphoma is generally poor.<ref name="AhmedRamanathan2014">{{cite journal|last1=Ahmed|first1=Zartaj|last2=Ramanathan|first2=Ramesh K.|last3=Ram|first3=Sunil|last4=Newell|first4=James|last5=Halepota|first5=Maqbool|title=Unusual Relapse of Primary Central Nervous System Lymphoma at Site of Lumbar Puncture|journal=Case Reports in Hematology|volume=2014|year=2014|pages=1–4|issn=2090-6560|doi=10.1155/2014/161952}}</ref><ref name=prognosisofprimarycnslymphoma1>Prognosis of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref> Symptoms of primary central nervous system lymphoma are identical to the other types of brain tumors and depend on the area of the brain that is affected.<ref name=signsandsymptomsofprimarycnslymphoma1>Signs and symptoms of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref> Primary central nervous system lymphoma is multifocal.  Symptoms of primary nervous system lymphoma include [[headache]], [[nausea]], [[vomiting]], [[Dysphagia|difficulty swallowing]], [[vision loss|monocular vision loss]], [[Muscle weakness|Muscle weakness or paralysis]], [[memory loss]], [[hypoesthesia|facial hypoesthesia]], [[seizures]], [[fever]], [[night sweats]], and [[weight loss]].<ref name="Ferreri2011">{{cite journal|last1=Ferreri|first1=A. J. M.|title=How I treat primary CNS lymphoma|journal=Blood|volume=118|issue=3|year=2011|pages=510–522|issn=0006-4971|doi=10.1182/blood-2011-03-321349}}</ref><ref name=signsandsymptomsofprimarycnslymphoma1>Signs and symptoms of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref><ref name=signsandsymptomsprimarycnslymphomawiki1>Signs and symptoms of primary central nervous system lymphoma. Wikipedia 2016. https://en.wikipedia.org/wiki/Primary_central_nervous_system_lymphoma. Accessed on February 18, 2016</ref> Head CT scan may be helpful in the diagnosis of primary central nervous system lymphoma. Findings on CT scan suggestive of primary central nervous system lymphoma include [[Supratentorial|supratentorial]] hyperattenuating, enhancing, hemorrhaging mass with subependymal extension crossing the [[corpus callosum]].<ref name=radiographicfeaturesofprimarycnslymphoma1>Radiographic features of primary CNS lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 18, 2016</ref> Chest, abdomen, and pelvic CT scans may be used to exclude any occult systemic disease from the spread of primary central nervous system lymphoma.<ref name=diagnpstoicsprimarycnslymphoma1>Diagnostics of primary CNS lymphoma. National cancer institute 2016. http://www.cancer.gov/types/lymphoma/hp/primary-cns-lymphoma-treatment-pdq. Accessed on February 19, 2016</ref> Contrast-enhanced MRI is the imaging modality of choice for primary central nervous system lymphoma.<ref name="HaldorsenEspeland2010">{{cite journal|last1=Haldorsen|first1=I. S.|last2=Espeland|first2=A.|last3=Larsson|first3=E.- M.|title=Central Nervous System Lymphoma: Characteristic Findings on Traditional and Advanced Imaging|journal=American Journal of Neuroradiology|volume=32|issue=6|year=2010|pages=984–992|issn=0195-6108|doi=10.3174/ajnr.A2171}}</ref> Findings on MRI suggestive of primary central nervous system lymphoma include solitary to multiple, 3-5 cm ring-enhancing lesions in almost any location, but usually deep in the [[white matter]], which are typically hypointense on T1-weighted images and iso- to hypointense on T2-weighted images.<ref name=mrifeatiresprimarycnslymphoma1>Radiographic features of primary CNS lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 23, 2016</ref> Other diagnostic studies for primary central nervous system lymphoma include [[In vivo magnetic resonance spectroscopy|magnetic resonance spectroscopy]], [[Perfusion weighted imaging|magnetic resonance perfusion]], [[scintigraphy]], [[Stereotactic|stereotactic biopsy]], and [[PCR|polymerase chain reaction]].<ref name=radiographicfeaturesofprimarycnslymphoma1>Radiographic features of primary CNS lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 18, 2016</ref><ref name=diagnopsisofprimarycnslumphoma1>Diagnosis of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 18, 2016</ref><ref name=diagnpstoicsprimarycnslymphoma1>Diagnostics of primary CNS lymphoma. National cancer institute 2016. http://www.cancer.gov/types/lymphoma/hp/primary-cns-lymphoma-treatment-pdq. Accessed on February 19, 2016</ref><ref name="HaldorsenKråkenes2008">{{cite journal|last1=Haldorsen|first1=Ingfrid S|last2=Kråkenes|first2=Jostein|last3=Goplen|first3=Anne K|last4=Dunlop|first4=Oona|last5=Mella|first5=Olav|last6=Espeland|first6=Ansgar|title=AIDS-related primary central nervous system lymphoma: a Norwegian national survey 1989–2003|journal=BMC Cancer|volume=8|issue=1|year=2008|pages=225|issn=1471-2407|doi=10.1186/1471-2407-8-225}}</ref> The treatment of primary central nervous system lymphoma depends on the patient’s age, performance status, stage and location of the lymphoma, and whether or not the individual is immunosuppressed.<ref name=treatmentofprimarycentralnervoussystemlymphoma1>Treatment of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref><ref name=Certainfactorsaffectprognosischancofrecoveryandtreatmentoptions1>Certain factors affect prognosis (chance of recovery) and treatment options. National cancer institute 2016. http://www.cancer.gov/types/lymphoma/patient/primary-cns-lymphoma-treatment-pdq. Accessed on February 19, 2016</ref> [[Chemotherapy]] is the mainstay of treatment for primary central nervous system lymphoma.<ref name=treatmentofprimarycentralnervoussystemlymphoma1>Treatment of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref> Corticosteroids are often used to destroy lymphoma cells and relieve cerebral edema.<ref name=treatmentofprimarycentralnervoussystemlymphoma1>Treatment of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref> [[radiotherapy|Radiation therapy]] may be given on its own or along with chemotherapy.<ref name=treatmentofprimarycentralnervoussystemlymphoma1>Treatment of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref> [[surgery|Surgical intervention]] is not recommended for the management of primary central nervous system lymphoma, because the tumors are often deeply seated and spread throughout the brain.<ref name=treatmentofprimarycentralnervoussystemlymphoma1>Treatment of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 18, 2016</ref>
+Primary [[CNS]] [[lymphoma]] is an intracranial tumor usually present in those with severe [[immunosuppression]]. It represents around 20% of all cases of lymphomas in HIV infection (other types being Burkitt's lymphoma and immunoblastic lymphoma). Primary central nervous system lymphoma may originate from a germinal center to an early postgerminal center in a secondary lymphoid organ, which may be capable of further maturation steps. EBV is almost always associated with primary CNS lymphoma in immunodeficient individuals, and latent EBV infection of B-cells leads to it's immortalization and to CNS tropism. In immunocompetent individuals, the B-cells infected with EBV are held in check by T-cells, and with the severity of immunosuppression, T cells gradually fall, leading to the B-cell proliferation and dissemination. . Primary central nervous system lymphoma constitutes approximately 3%-4% of all primary brain tumors and 1%-2% of all lymphomas. Primary central nervous system lymphoma has been diagnosed in at least 2% of individuals infected with human immunodeficiency virus, and in 9–14% of acquired immunodeficiency syndrome (AIDS)-autopsies. Primary CNS lymphoma is, after toxoplasmosis, the most common cause of focal brain lesions in AIDS patients. The overall incidence of primary central nervous system lymphoma is 0.4 per 100,000 individuals per year. The median age of occurrence of primary central nervous system lymphoma in immunocompetent and immunocompromised patients are 53-57 years and 31-35 years, respectively. The peak incidence is between 60 and 70 years old for immunocompetent patients. Significant increment of incidence rate over time is associated with increased incidence of AIDS and advanced age. Males are more commonly affected with primary central nervous system lymphoma than females.
 ==Classification==
-Primary central nervous system lymphoma may be classified according to the site of involvement of the central nervous system into 3 groups: parenchymal, intravascular lymphoma, and primary leptomeningeal lymphoma.<ref name=classifdicationprimarycnslymphoma1>CNS lymphoma. Dr Henry Knipe and Dr Yuranga Weerakkody et al. Radiopaedia 2016. http://radiopaedia.org/articles/cns-lymphoma-1. Accessed on February 17, 2016</ref>
+Primary central nervous system lymphoma may be classified according to the site of involvement of the central nervous system into 3 groups:
+# Parenchymal
+# Intravascular lymphoma
+# Primary leptomeningeal lymphoma.
+Primary CNS lymphomas are extranodal, malignant non-Hodgkin lymphomas of the diffuse large B-cell type that are confined to the brain, eyes, leptomeninges, or spinal cord, in the absence of systemic lymphoma. Primary CNS lymphomas are estimated to account for up to 1% of all lymphomas, 4–6% of all extranodal lymphomas, and about 3% of all CNS tumours. After a continuous rise in the incidence of primary CNS lymphoma during the 1980s and 1990s, epidemiological data in high-income countries show a decrease in incidence, particularly among young patients with AIDS.
 ==Pathophysiology==
-Primary central nervous system lymphoma may originate from a germinal center to an early postgerminal center in a secondary lymphoid organ, which may be capable of further maturation steps.<ref name=pathogenesisprimarycentralnervousystemlymphoma1>PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMAS IN THE NEUROLOGICAL PRACTICE. file:///C:/Users/Owner/Downloads/psyneur_2014_1_2_8.pdf. Accessed on February 19, 2016</ref> [[EBV]] is almost always associated with primary CNS lymphoma in immunodeficient individuals, and latent EBV infection of B-cells leads to it's immortalization and to CNS tropism. In immunocompetent individuals, the B-cells infected with EBV are held in check by T-cells, and with the severity of immunosuppression, T cells gradually fall, leading to the B-cell proliferation and dissemination.<ref name="pmid18976024">{{cite journal| author=Bhagavathi S, Wilson JD| title=Primary central nervous system lymphoma. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 11 | pages= 1830-4 | pmid=18976024 | doi=10.1043/1543-2165-132.11.1830 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18976024  }} </ref> Genes involved in the pathogenesis of primary central nervous system lymphoma include ''IG'', ''BCL6'', ''CD95'', ''[[PAX5]]'', and ''[[PIM1]]''.<ref name="Ferreri2011">{{cite journal|last1=Ferreri|first1=A. J. M.|title=How I treat primary CNS lymphoma|journal=Blood|volume=118|issue=3|year=2011|pages=510–522|issn=0006-4971|doi=10.1182/blood-2011-03-321349}}</ref> Primary central nervous system lymphoma is highly associated with [[Epstein-Barr virus|Epstein-Barr virus (EBV) infection]] (> 90%) in immunodeficient patients (such as those with [[AIDS]] and iatrogenically immunosuppressed).<ref name=pcnslwikipediA1>Primary central nervous system lymphoma. Wikipedia 2016. https://en.wikipedia.org/wiki/Primary_central_nervous_system_lymphoma. Accessed on February 18, 2016</ref> Primary central nervous system lymphoma presents as a solitary or multiple, well circumscribed, greater than 2 cm in diameter, well-defined or infiltrating mass lesion/s that can arise in the [[cerebral cortex|cortex]], white matter, or deep grey matter (more common in low-grade lesions).<ref name=pathologyofprimarycentralknervouissystemlymphomaradiopeadk1>Pathology of primary central system lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 18, 2016</ref><ref name="pmid18976024">{{cite journal| author=Bhagavathi S, Wilson JD| title=Primary central nervous system lymphoma. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 11 | pages= 1830-4 | pmid=18976024 | doi=10.1043/1543-2165-132.11.1830 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18976024  }} </ref> On gross pathology, the lesions could be brownish, gray-tan, or yellow, firm, homogenous, [[necrosis|centrally necrotic]] with areas of [[hemorrhage]].<ref name="pmid18976024">{{cite journal| author=Bhagavathi S, Wilson JD| title=Primary central nervous system lymphoma. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 11 | pages= 1830-4 | pmid=18976024 | doi=10.1043/1543-2165-132.11.1830 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18976024  }} </ref> On microscopic histopathological analysis, primary central nervous system lymphoma is characterized by accumulation of large atypical mononuclear cells around small calibre vascular channels with invasion of the walls of some vessels. The atypical cells have large round, oval and angulated hyperchromatic and vesicular nuclei, and a narrow rim of pale cytoplasm. An occasional mitotic figure is noted.<ref name=pcnslwikipediA1>Primary central nervous system lymphoma. Wikipedia 2016. https://en.wikipedia.org/wiki/Primary_central_nervous_system_lymphoma. Accessed on February 18, 2016</ref><ref name=microscopicpathologyprimarycnslymphoma1>CNS lymphoma (primary). A.Prof Frank Gaillard. Radioapaedia 2016. http://radiopaedia.org/cases/cns-lymphoma-primary. Accessed on February 23, 2016</ref> Primary central nervous system lymphoma is demonstrated by positivity to tumor markers, including B lymphocyte markers, such as [[CD19]], [[CD20]], [[CD79a]], [[Ki-67 (Biology)|Ki-67]], [[GFAP]], [[BCL-2]], and BCL-6.<ref name="pmid18976024">{{cite journal| author=Bhagavathi S, Wilson JD| title=Primary central nervous system lymphoma. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 11 | pages= 1830-4 | pmid=18976024 | doi=10.1043/1543-2165-132.11.1830 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18976024  }} </ref><ref name=microscopicpathologyprimarycnslymphoma1>CNS lymphoma (primary). A.Prof Frank Gaillard. Radioapaedia 2016. http://radiopaedia.org/cases/cns-lymphoma-primary. Accessed on February 23, 2016</ref><ref name="HaldorsenKråkenes2008">{{cite journal|last1=Haldorsen|first1=Ingfrid S|last2=Kråkenes|first2=Jostein|last3=Goplen|first3=Anne K|last4=Dunlop|first4=Oona|last5=Mella|first5=Olav|last6=Espeland|first6=Ansgar|title=AIDS-related primary central nervous system lymphoma: a Norwegian national survey 1989–2003|journal=BMC Cancer|volume=8|issue=1|year=2008|pages=225|issn=1471-2407|doi=10.1186/1471-2407-8-225}}</ref><ref name="Yamanaka2013">{{cite journal|last1=Yamanaka|first1=Ryuya|title=Primary Central Nervous System Lymphoma − Recent Advance on Clinical Research|year=2013|doi=10.5772/52757}}</ref>
+* Primary central nervous system lymphoma may originate from a germinal center to an early postgerminal center in a secondary lymphoid organ, which may be capable of further maturation steps.
+* [[EBV]] is almost always associated with primary CNS lymphoma in immunodeficient individuals, and latent EBV infection of B-cells leads to it's immortalization and to CNS tropism. In immunocompetent individuals, the B-cells infected with EBV are held in check by T-cells, and with the severity of immunosuppression, T cells gradually fall, leading to the B-cell proliferation and dissemination.
+* Genes involved in the pathogenesis of primary central nervous system lymphoma include ''IG'', ''BCL6'', ''CD95'', ''[[PAX5]]'', and ''[[PIM1]]''.
+* Primary central nervous system lymphoma is highly associated with [[Epstein-Barr virus|Epstein-Barr virus (EBV) infection]] (> 90%) in immunodeficient patients (such as those with [[AIDS]] and iatrogenically immunosuppressed).
+* Primary central nervous system lymphoma presents as a solitary or multiple, well circumscribed, greater than 2 cm in diameter, well-defined or infiltrating mass lesion/s that can arise in the [[cerebral cortex|cortex]], white matter, or deep grey matter (more common in low-grade lesions). On gross pathology, the lesions could be brownish, gray-tan, or yellow, firm, homogenous, [[necrosis|centrally necrotic]] with areas of [[hemorrhage]].
+* On microscopic histopathological analysis, primary central nervous system lymphoma is characterized by accumulation of large atypical mononuclear cells around small calibre vascular channels with invasion of the walls of some vessels. The atypical cells have large round, oval and angulated hyperchromatic and vesicular nuclei, and a narrow rim of pale cytoplasm. An occasional mitotic figure is noted.
+* Primary central nervous system lymphoma is demonstrated by positivity to tumor markers, including B lymphocyte markers, such as [[CD19]], [[CD20]], [[CD79a]], [[Ki-67 (Biology)|Ki-67]], [[GFAP]], [[BCL-2]], and BCL-6.
+*Primary central nervous system lymphoma presents as a solitary or multiple, well circumscribed, greater than 2 cm in diameter, well-defined or infiltrating mass lesion/s that can arise in the cortex, white matter, or deep grey matter (more common in low-grade lesions).[5][2] On gross pathology, the lesions could be brownish, gray-tan, or yellow, firm, homogenous, centrally necrotic with areas of hemorrhage.[2] On microscopic histopathological analysis, primary central nervous system lymphoma is characterized by accumulation of large atypical mononuclear cells around small calibre vascular channels with invasion of the walls of some vessels.
 ==Causes==
-There are no known direct causes for primary central nervous system lymphoma. To view a comprehensive list of risk factors that increase the risk of primary nervous system lymphoma, click [[Primary central nervous system lymphoma risk factors|'''here''']].<ref name=riskpcnsl1>Risks of primary central nervous lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref><ref name="ManentiDi Giuliano2013">{{cite journal|last1=Manenti|first1=G.|last2=Di Giuliano|first2=F.|last3=Bindi|first3=A.|last4=Liberto|first4=V.|last5=Funel|first5=V.|last6=Garaci|first6=F. G.|last7=Floris|first7=R.|last8=Simonetti|first8=G.|title=A Case of Primary T-Cell Central Nervous System Lymphoma: MR Imaging and MR Spectroscopy Assessment|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/916348}}</ref><ref name=epidemiologyprimarycnslymphoma1>Epidemiology of primary CNS lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 18, 2016</ref>
+There are no known direct causes for primary central nervous system lymphoma. To view a comprehensive list of risk factors that increase the risk of primary nervous system lymphoma, click [[Primary central nervous system lymphoma risk factors|'''here''']].
 ==Differentiating Primary Central Nervous System Lymphoma from other Diseases==
-Primary central nervous system lymphoma must be differentiated from secondary CNS lymphoma, [[toxoplasmosis|cerebral toxoplasmosis]], [[glioblastoma multiforme]], [[cerebral abscess]], and [[tuberculoma]].<ref name=ddxofprimarycnslymphoma1>Differential diagnosis of primary central nervous system lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 17, 2016</ref><ref name=Cerebralringenhancinglesions1>Cerebral ring enhancing lesions. Dr Bruno Di Muzio and A.Prof Frank Gaillard et al. Radioapaedia 2016. http://radiopaedia.org/articles/cerebral-ring-enhancing-lesions. Accessed on February 17, 2016</ref>
+Primary central nervous system lymphoma must be differentiated from secondary CNS lymphoma, [[toxoplasmosis|cerebral toxoplasmosis]], [[glioblastoma multiforme]], [[cerebral abscess]], and [[tuberculoma]].
 ==Epidemiology and Demographics==
-Primary central nervous system lymphoma constitutes approximately 3%-4% of all primary brain tumors and 1%-2% of all [[lymphomas]].<ref name="ManentiDi Giuliano2013">{{cite journal|last1=Manenti|first1=G.|last2=Di Giuliano|first2=F.|last3=Bindi|first3=A.|last4=Liberto|first4=V.|last5=Funel|first5=V.|last6=Garaci|first6=F. G.|last7=Floris|first7=R.|last8=Simonetti|first8=G.|title=A Case of Primary T-Cell Central Nervous System Lymphoma: MR Imaging and MR Spectroscopy Assessment|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/916348}}</ref> Primary central nervous system lymphoma has been diagnosed in at least 2% of individuals infected with [[HIV|human immunodeficiency virus]], and in 9–14% of acquired immunodeficiency syndrome (AIDS)-autopsies.<ref name="HaldorsenKråkenes2008">{{cite journal|last1=Haldorsen|first1=Ingfrid S|last2=Kråkenes|first2=Jostein|last3=Goplen|first3=Anne K|last4=Dunlop|first4=Oona|last5=Mella|first5=Olav|last6=Espeland|first6=Ansgar|title=AIDS-related primary central nervous system lymphoma: a Norwegian national survey 1989–2003|journal=BMC Cancer|volume=8|issue=1|year=2008|pages=225|issn=1471-2407|doi=10.1186/1471-2407-8-225}}</ref> Primary CNS lymphoma is, after [[toxoplasmosis]], the most common cause of focal brain lesions in [[AIDS|AIDS patients]].<ref name="HaldorsenKråkenes2008">{{cite journal|last1=Haldorsen|first1=Ingfrid S|last2=Kråkenes|first2=Jostein|last3=Goplen|first3=Anne K|last4=Dunlop|first4=Oona|last5=Mella|first5=Olav|last6=Espeland|first6=Ansgar|title=AIDS-related primary central nervous system lymphoma: a Norwegian national survey 1989–2003|journal=BMC Cancer|volume=8|issue=1|year=2008|pages=225|issn=1471-2407|doi=10.1186/1471-2407-8-225}}</ref> The overall incidence of primary central nervous system lymphoma is 0.4 per 100,000 individuals per year.<ref name="ManentiDi Giuliano2013">{{cite journal|last1=Manenti|first1=G.|last2=Di Giuliano|first2=F.|last3=Bindi|first3=A.|last4=Liberto|first4=V.|last5=Funel|first5=V.|last6=Garaci|first6=F. G.|last7=Floris|first7=R.|last8=Simonetti|first8=G.|title=A Case of Primary T-Cell Central Nervous System Lymphoma: MR Imaging and MR Spectroscopy Assessment|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/916348}}</ref> The median age of occurrence of primary central nervous system lymphoma in immunocompetent and immunocompromised patients are 53-57 years and 31-35 years, respectively.<ref name="pmid18976024">{{cite journal| author=Bhagavathi S, Wilson JD| title=Primary central nervous system lymphoma. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 11 | pages= 1830-4 | pmid=18976024 | doi=10.1043/1543-2165-132.11.1830 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18976024  }} </ref> The peak incidence is between 60 and 70 years old for immunocompetent patients.<ref name="ManentiDi Giuliano2013">{{cite journal|last1=Manenti|first1=G.|last2=Di Giuliano|first2=F.|last3=Bindi|first3=A.|last4=Liberto|first4=V.|last5=Funel|first5=V.|last6=Garaci|first6=F. G.|last7=Floris|first7=R.|last8=Simonetti|first8=G.|title=A Case of Primary T-Cell Central Nervous System Lymphoma: MR Imaging and MR Spectroscopy Assessment|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/916348}}</ref> Significant increment of incidence rate over time is associated with increased incidence of [[AIDS]] and advanced age. Males are more commonly affected with primary central nervous system lymphoma than females.<ref name="ManentiDi Giuliano2013">{{cite journal|last1=Manenti|first1=G.|last2=Di Giuliano|first2=F.|last3=Bindi|first3=A.|last4=Liberto|first4=V.|last5=Funel|first5=V.|last6=Garaci|first6=F. G.|last7=Floris|first7=R.|last8=Simonetti|first8=G.|title=A Case of Primary T-Cell Central Nervous System Lymphoma: MR Imaging and MR Spectroscopy Assessment|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/916348}}</ref> The male to female ratio is approximately 1.2 to 1 in immunocompetent patients and approximately 7.38 to 1 in AIDS-associated primary central nervous system lymphoma.<ref name="pmid18976024">{{cite journal| author=Bhagavathi S, Wilson JD| title=Primary central nervous system lymphoma. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 11 | pages= 1830-4 | pmid=18976024 | doi=10.1043/1543-2165-132.11.1830 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18976024  }} </ref>
+Primary central nervous system lymphoma constitutes approximately 3%-4% of all primary brain tumors and 1%-2% of all [[lymphomas]]. Primary central nervous system lymphoma has been diagnosed in at least 2% of individuals infected with [[HIV|human immunodeficiency virus]], and in 9–14% of acquired immunodeficiency syndrome (AIDS)-autopsies. Primary CNS lymphoma is, after [[toxoplasmosis]], the most common cause of focal brain lesions in [[AIDS|AIDS patients]]. The overall incidence of primary central nervous system lymphoma is 0.4 per 100,000 individuals per year. The median age of occurrence of primary central nervous system lymphoma in immunocompetent and immunocompromised patients are 53-57 years and 31-35 years, respectively. The peak incidence is between 60 and 70 years old for immunocompetent patients. Significant increment of incidence rate over time is associated with increased incidence of [[AIDS]] and advanced age. Males are more commonly affected with primary central nervous system lymphoma than females. The male to female ratio is approximately 1.2 to 1 in immunocompetent patients and approximately 7.38 to 1 in AIDS-associated primary central nervous system lymphoma.
 ==Risk Factors==
-The most potent risk factor in the development of primary central nervous system lymphoma is a weakened or suppressed immune system in individuals who have [[Acquired immunodeficiency syndrome|acquired immunodeficiency syndrome (AIDS)]], received an organ transplant and are on [[immunosuppressants]], inherited immunosuppressive disorders ([[IgA deficiency]], [[Wiskott-Aldrich syndrome]], [[ataxia telangiectasia]]), and [[autoimmune disorders]] ([[systemic lupus erythematosus]], [[rheumatoid arthritis]], [[myasthenia gravis]]).<ref name=riskpcnsl1>Risks of primary central nervous lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref><ref name="ManentiDi Giuliano2013">{{cite journal|last1=Manenti|first1=G.|last2=Di Giuliano|first2=F.|last3=Bindi|first3=A.|last4=Liberto|first4=V.|last5=Funel|first5=V.|last6=Garaci|first6=F. G.|last7=Floris|first7=R.|last8=Simonetti|first8=G.|title=A Case of Primary T-Cell Central Nervous System Lymphoma: MR Imaging and MR Spectroscopy Assessment|journal=Case Reports in Radiology|volume=2013|year=2013|pages=1–5|issn=2090-6862|doi=10.1155/2013/916348}}</ref><ref name=epidemiologyprimarycnslymphoma1>Epidemiology of primary CNS lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 18, 2016</ref><ref name="pmid18976024">{{cite journal| author=Bhagavathi S, Wilson JD| title=Primary central nervous system lymphoma. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 11 | pages= 1830-4 | pmid=18976024 | doi=10.1043/1543-2165-132.11.1830 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18976024  }} </ref>
+The most potent risk factor in the development of primary central nervous system lymphoma is a weakened or suppressed immune system in individuals who have [[Acquired immunodeficiency syndrome|acquired immunodeficiency syndrome (AIDS)]], received an organ transplant and are on [[immunosuppressants]], inherited immunosuppressive disorders ([[IgA deficiency]], [[Wiskott-Aldrich syndrome]], [[ataxia telangiectasia]]), and [[autoimmune disorders]] ([[systemic lupus erythematosus]], [[rheumatoid arthritis]], [[myasthenia gravis]]).
 ==Screening==
-There is insufficient evidence to recommend routine screening for primary central nervous system lymphoma.<ref name=screeningofcentralnervoussystemlymphoma1>Screening of primary central nervous system lymphoma. U.S. preventive services task force 2016. http://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=PRIMARY+CENTRAL+NERVOUS+SYSTEM+LYMPHOMA. Accessed on February 24, 2016</ref>
+There is insufficient evidence to recommend routine screening for primary central nervous system lymphoma.
 ==Natural History, Complications and Prognosis==
-If left untreated, primary central nervous system lymphoma may progress to develop [[elevated intracranial pressure]], ocular symptoms, focal neurological deficits, and neuropsychiatric problems.<ref name=SymptomsofprimaryCNSLymphoma1>Symptoms of primary CNS Lymphoma. Lymphomation 2016. http://www.lymphomation.org/type-cns.htm. Accessed on February 24, 2016</ref> Common complications of primary central nervous system lymphoma include [[relapse]], [[metastasis|extracranial or subcutaneous metastasis]], neuropsychiatric problems, and neurological toxicity.<ref name=SymptomsofprimaryCNSLymphoma1>Symptoms of primary CNS Lymphoma. Lymphomation 2016. http://www.lymphomation.org/type-cns.htm. Accessed on February 24, 2016</ref><ref name="AhmedRamanathan2014">{{cite journal|last1=Ahmed|first1=Zartaj|last2=Ramanathan|first2=Ramesh K.|last3=Ram|first3=Sunil|last4=Newell|first4=James|last5=Halepota|first5=Maqbool|title=Unusual Relapse of Primary Central Nervous System Lymphoma at Site of Lumbar Puncture|journal=Case Reports in Hematology|volume=2014|year=2014|pages=1–4|issn=2090-6560|doi=10.1155/2014/161952}}</ref><ref name="Yamanaka2013">{{cite journal|last1=Yamanaka|first1=Ryuya|title=Primary Central Nervous System Lymphoma − Recent Advance on Clinical Research|year=2013|doi=10.5772/52757}}</ref> The prognosis of primary central nervous system lymphoma is generally poor.<ref name="AhmedRamanathan2014">{{cite journal|last1=Ahmed|first1=Zartaj|last2=Ramanathan|first2=Ramesh K.|last3=Ram|first3=Sunil|last4=Newell|first4=James|last5=Halepota|first5=Maqbool|title=Unusual Relapse of Primary Central Nervous System Lymphoma at Site of Lumbar Puncture|journal=Case Reports in Hematology|volume=2014|year=2014|pages=1–4|issn=2090-6560|doi=10.1155/2014/161952}}</ref><ref name=prognosisofprimarycnslymphoma1>Prognosis of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref>
+If left untreated, primary central nervous system lymphoma may progress to develop [[elevated intracranial pressure]], ocular symptoms, focal neurological deficits, and neuropsychiatric problems. Common complications of primary central nervous system lymphoma include [[relapse]], [[metastasis|extracranial or subcutaneous metastasis]], neuropsychiatric problems, and neurological toxicity. The prognosis of primary central nervous system lymphoma is generally poor.
 ==Diagnosis==
 ===Staging===
-There is no established system for the staging of primary central nervous system lymphoma.<ref name=StagingPrimaryCNSLymphoma1>Staging of Primary CNS Lymphoma. National Cancer Institute 2016. http://www.cancer.gov/types/lymphoma/patient/primary-cns-lymphoma-treatment-pdq#section/_18. Accessed on February 23, 2016</ref>
+There is no established system for the staging of primary central nervous system lymphoma.
 ===Symptoms===
-Symptoms of primary central nervous system lymphoma are identical to the other types of brain tumors and depend on the area of the brain that is affected.<ref name=signsandsymptomsofprimarycnslymphoma1>Signs and symptoms of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref> Primary central nervous system lymphoma is multifocal.  Symptoms of primary nervous system lymphoma include [[headache]], [[nausea]], [[vomiting]], [[Dysphagia|difficulty swallowing]], [[vision loss|monocular vision loss]], [[Muscle weakness|Muscle weakness or paralysis]], [[memory loss]], [[hypoesthesia|facial hypoesthesia]], [[seizures]], [[fever]], [[night sweats]], and [[weight loss]].<ref name="Ferreri2011">{{cite journal|last1=Ferreri|first1=A. J. M.|title=How I treat primary CNS lymphoma|journal=Blood|volume=118|issue=3|year=2011|pages=510–522|issn=0006-4971|doi=10.1182/blood-2011-03-321349}}</ref><ref name=signsandsymptomsofprimarycnslymphoma1>Signs and symptoms of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref><ref name=signsandsymptomsprimarycnslymphomawiki1>Signs and symptoms of primary central nervous system lymphoma. Wikipedia 2016. https://en.wikipedia.org/wiki/Primary_central_nervous_system_lymphoma. Accessed on February 18, 2016</ref>
+Symptoms of primary central nervous system lymphoma are identical to the other types of brain tumors and depend on the area of the brain that is affected. Primary central nervous system lymphoma is multifocal.  Symptoms of primary nervous system lymphoma include [[headache]], [[nausea]], [[vomiting]], [[Dysphagia|difficulty swallowing]], [[vision loss|monocular vision loss]], [[Muscle weakness|Muscle weakness or paralysis]], [[memory loss]], [[hypoesthesia|facial hypoesthesia]], [[seizures]], [[fever]], [[night sweats]], and [[weight loss]].
 ===Physical Examination===
-Common physical examination findings of primary central nervous system lymphoma include [[vision loss]], [[papilledema]], [[altered mental status]], [[apathy]], [[depression]], [[aphasia]], [[Nerve palsy|cranioneuropathies]], [[ataxia]], and [[hemiparesis]].<ref name=SymptomsofprimaryCNSLymphoma1>Symptoms of primary CNS Lymphoma. Lymphomation 2016. http://www.lymphomation.org/type-cns.htm. Accessed on February 24, 2016</ref><ref name=clinicaljournalprimarycnslumphoma1fdef>{{Citation |last=Moradi |first=A |last=Tajedini |first=A |last= Mehrabian |first=A |last= Sadeghi |first=S |last=Semnani |first=V |last= Khodabakhshi |first=R |last=Arefian |first=N |last=Afrakhteh |first=M |last=Keshvari |first=K|last=Yavari |first=P |last=Madani-Civi |first=M |year=2006 |title=Clinicopathological features of primary central nervous system lymphoma |publisher=Neurosciences |publication-place= |page= |url= |accessdate=02/19/2016 }}</ref>
+Common physical examination findings of primary central nervous system lymphoma include [[vision loss]], [[papilledema]], [[altered mental status]], [[apathy]], [[depression]], [[aphasia]], [[Nerve palsy|cranioneuropathies]], [[ataxia]], and [[hemiparesis]].
 ===Laboratory Findings===
-Laboratory tests performed in a case suspected of primary central nervous system lymphoma include [[complete blood count]], [[complete metabolic panel]], [[lactate dehydrogenase]], serological testing for HIV, and [[CSF analysis]]. Laboratory findings consistent with the diagnosis of primary central nervous system lymphoma include [[protein|elevated protein]] and [[glucose|decreased glucose]] on [[CSF analysis]].<ref name=pathologyofprimarycentralknervouissystemlymphomaradiopeadk1>Pathology of primary central system lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 18, 2016</ref> Positive [[EBV|EBV DNA]] in [[PCR|CSF-PCR]] is helpful for diagnosis of primary central nervous system lymphoma, particularly in [[HIV]]/[[AIDS]] patients.<ref name=pathologyofprimarycentralknervouissystemlymphomaradiopeadk1>Pathology of primary central system lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 18, 2016</ref>
+Laboratory tests performed in a case suspected of primary central nervous system lymphoma include [[complete blood count]], [[complete metabolic panel]], [[lactate dehydrogenase]], serological testing for HIV, and [[CSF analysis]]. Laboratory findings consistent with the diagnosis of primary central nervous system lymphoma include [[protein|elevated protein]] and [[glucose|decreased glucose]] on [[CSF analysis]]. Positive [[EBV|EBV DNA]] in [[PCR|CSF-PCR]] is helpful for diagnosis of primary central nervous system lymphoma, particularly in [[HIV]]/[[AIDS]] patients.
 ===CT===
-Head CT scan may be helpful in the diagnosis of primary central nervous system lymphoma. Findings on CT scan suggestive of primary central nervous system lymphoma include [[Supratentorial|supratentorial]] hyperattenuating, enhancing, hemorrhaging mass with subependymal extension crossing the [[corpus callosum]].<ref name=radiographicfeaturesofprimarycnslymphoma1>Radiographic features of primary CNS lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 18, 2016</ref> Chest, abdomen, and pelvic CT scans may be used to exclude any occult systemic disease from the spread of primary central nervous system lymphoma.<ref name=diagnpstoicsprimarycnslymphoma1>Diagnostics of primary CNS lymphoma. National cancer institute 2016. http://www.cancer.gov/types/lymphoma/hp/primary-cns-lymphoma-treatment-pdq. Accessed on February 19, 2016</ref>
+Head CT scan may be helpful in the diagnosis of primary central nervous system lymphoma. Findings on CT scan suggestive of primary central nervous system lymphoma include [[Supratentorial|supratentorial]] hyperattenuating, enhancing, hemorrhaging mass with subependymal extension crossing the [[corpus callosum]]. Chest, abdomen, and pelvic CT scans may be used to exclude any occult systemic disease from the spread of primary central nervous system lymphoma.
 ===MRI===
-Contrast-enhanced MRI is the imaging modality of choice for primary central nervous system lymphoma.<ref name="HaldorsenEspeland2010">{{cite journal|last1=Haldorsen|first1=I. S.|last2=Espeland|first2=A.|last3=Larsson|first3=E.- M.|title=Central Nervous System Lymphoma: Characteristic Findings on Traditional and Advanced Imaging|journal=American Journal of Neuroradiology|volume=32|issue=6|year=2010|pages=984–992|issn=0195-6108|doi=10.3174/ajnr.A2171}}</ref> Findings on MRI suggestive of primary central nervous system lymphoma include solitary to multiple, 3-5 cm ring-enhancing lesions in almost any location, but usually deep in the [[white matter]], which are typically hypointense on T1-weighted images and iso- to hypointense on T2-weighted images.<ref name=mrifeatiresprimarycnslymphoma1>Radiographic features of primary CNS lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 23, 2016</ref>
+Contrast-enhanced MRI is the imaging modality of choice for primary central nervous system lymphoma. Findings on MRI suggestive of primary central nervous system lymphoma include solitary to multiple, 3-5 cm ring-enhancing lesions in almost any location, but usually deep in the [[white matter]], which are typically hypointense on T1-weighted images and iso- to hypointense on T2-weighted images.
 ===Other Imaging Findings===
@@ Line 53: / Line 65: @@
 ===Other Diagnostic Studies===
-Other diagnostic studies for primary central nervous system lymphoma include [[In vivo magnetic resonance spectroscopy|magnetic resonance spectroscopy]], [[Perfusion weighted imaging|magnetic resonance perfusion]], [[scintigraphy]], [[Stereotactic|stereotactic biopsy]], and [[PCR|polymerase chain reaction]].<ref name=radiographicfeaturesofprimarycnslymphoma1>Radiographic features of primary CNS lymphoma. Dr Amir Rezaee and A.Prof Frank Gaillard et al. Radiopaedia 2016. http://radiopaedia.org/articles/primary-cns-lymphoma. Accessed on February 18, 2016</ref><ref name=diagnopsisofprimarycnslumphoma1>Diagnosis of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 18, 2016</ref><ref name=diagnpstoicsprimarycnslymphoma1>Diagnostics of primary CNS lymphoma. National cancer institute 2016. http://www.cancer.gov/types/lymphoma/hp/primary-cns-lymphoma-treatment-pdq. Accessed on February 19, 2016</ref><ref name="HaldorsenKråkenes2008">{{cite journal|last1=Haldorsen|first1=Ingfrid S|last2=Kråkenes|first2=Jostein|last3=Goplen|first3=Anne K|last4=Dunlop|first4=Oona|last5=Mella|first5=Olav|last6=Espeland|first6=Ansgar|title=AIDS-related primary central nervous system lymphoma: a Norwegian national survey 1989–2003|journal=BMC Cancer|volume=8|issue=1|year=2008|pages=225|issn=1471-2407|doi=10.1186/1471-2407-8-225}}</ref>
+Other diagnostic studies for primary central nervous system lymphoma include [[In vivo magnetic resonance spectroscopy|magnetic resonance spectroscopy]], [[Perfusion weighted imaging|magnetic resonance perfusion]], [[scintigraphy]], [[Stereotactic|stereotactic biopsy]], and [[PCR|polymerase chain reaction]].
 ==Treatment==
 ===Medical Therapy===
-The treatment of primary central nervous system lymphoma depends on the patient’s age, performance status, stage and location of the lymphoma, and whether or not the individual is immunosuppressed.<ref name=treatmentofprimarycentralnervoussystemlymphoma1>Treatment of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref><ref name=Certainfactorsaffectprognosischancofrecoveryandtreatmentoptions1>Certain factors affect prognosis (chance of recovery) and treatment options. National cancer institute 2016. http://www.cancer.gov/types/lymphoma/patient/primary-cns-lymphoma-treatment-pdq. Accessed on February 19, 2016</ref> [[Chemotherapy]] is the mainstay of treatment for primary central nervous system lymphoma.<ref name=treatmentofprimarycentralnervoussystemlymphoma1>Treatment of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref> Corticosteroids are often used to destroy lymphoma cells and relieve cerebral edema.<ref name=treatmentofprimarycentralnervoussystemlymphoma1>Treatment of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref> [[radiotherapy|Radiation therapy]] may be given on its own or along with chemotherapy.<ref name=treatmentofprimarycentralnervoussystemlymphoma1>Treatment of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 17, 2016</ref>
+The treatment of primary central nervous system lymphoma depends on the patient’s age, performance status, stage and location of the lymphoma, and whether or not the individual is immunosuppressed. [[Chemotherapy]] is the mainstay of treatment for primary central nervous system lymphoma. Corticosteroids are often used to destroy lymphoma cells and relieve cerebral edema. [[radiotherapy|Radiation therapy]] may be given on its own or along with chemotherapy. The treatment of primary central nervous system lymphoma depends on the patient’s age, performance status, stage and location of the lymphoma, and whether or not the individual is immunosuppressed.
 ===Surgery===
-[[surgery|Surgical intervention]] is not recommended for the management of primary central nervous system lymphoma, because the tumors are often deeply seated and spread throughout the brain.<ref name=treatmentofprimarycentralnervoussystemlymphoma1>Treatment of primary central nervous system lymphoma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-cns-lymphoma/?region=on. Accessed on February 18, 2016</ref>
+[[surgery|Surgical intervention]] is not recommended for the management of primary central nervous system lymphoma, because the tumors are often deeply seated and spread throughout the brain.
 ===Prevention===