Diagnosis of Primary Central Nervous System Lymphoma: Advanced Approaches and Clinical Insights

When patients present with neurological symptoms such as nausea, vomiting, or cognitive disturbances, imaging techniques like computed tomography (CT) may raise suspicion of a brain lesion. In cases where primary central nervous system lymphoma (PCNSL) is suspected, the most definitive diagnostic approach involves histopathological examination following tissue acquisition. Surgical biopsy remains the gold standard for confirming the diagnosis, providing not only confirmation of malignancy but also enabling accurate tumor grading and molecular subtyping.

Why Histopathology Is Essential

Histopathological analysis plays a critical role in distinguishing PCNSL from other intracranial neoplasms, including gliomas, metastatic tumors, and inflammatory conditions. The microscopic evaluation of tumor cells allows pathologists to identify characteristic features of lymphoma, such as dense perivascular infiltration of atypical lymphoid cells. Additionally, immunohistochemical staining helps determine the cell lineage—most commonly diffuse large B-cell lymphoma—which guides subsequent treatment strategies.

Alternatives When Surgery Is Not Feasible

In situations where open surgery poses significant risks due to tumor location or patient comorbidities, stereotactic needle biopsy offers a minimally invasive yet highly effective alternative. This technique uses advanced imaging guidance to precisely target the lesion and extract a small tissue sample for pathological evaluation. Despite its less invasive nature, stereotactic biopsy maintains high diagnostic accuracy when performed by experienced neurosurgeons using modern navigation systems.

Differentiating From Other CNS Tumors

Accurate tissue diagnosis is crucial not only for confirming PCNSL but also for ruling out mimicking conditions. For example, high-grade gliomas and cerebral metastases can appear similar on MRI scans, leading to potential misdiagnosis without histological confirmation. A definitive pathological assessment ensures appropriate management, avoiding ineffective treatments and enabling timely initiation of targeted therapies such as high-dose methotrexate-based regimens.

In summary, while radiological findings may suggest the presence of PCNSL, tissue biopsy—whether through surgical resection or stereotactic sampling—remains indispensable for a conclusive diagnosis. Early and accurate identification through pathological evaluation significantly improves clinical outcomes and supports personalized therapeutic planning in patients with primary central nervous system lymphoma.