1
|
Naydenov AV, Taylor LP. Leptomeningeal Carcinomatosis in Chronic Lymphocytic Leukemia: A Case Report and Review of the Literature. Oncologist 2019; 24:1237-1245. [PMID: 30842245 DOI: 10.1634/theoncologist.2018-0619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 01/25/2019] [Indexed: 11/17/2022] Open
Abstract
Leptomeningeal disease is a rare complication of chronic lymphocytic leukemia (CLL). We report a case of leptomeningeal disease in CLL with a complete clinical response and clearance of cerebral spinal fluid (CSF) after treatment with ibrutinib and intrathecal rituximab. In a comprehensive review of the published literature since 1976, we found 136 cases of CLL with leptomeningeal spread. We found that leptomeningeal disease in patients with CLL responds favorably to treatment in most cases and is associated with longer overall survival than is expected for other cancers. Clearance of CSF is associated with improved survival. Treatment with rituximab and ibrutinib is more frequently associated with complete response compared with older agents. IMPLICATIONS FOR PRACTICE: The incidence of leptomeningeal CLL is more common than previously described and can be recognized by attention to certain symptoms and signs. This case presentation and literature review reveals that, in many cases, leptomeningeal lymphomatosis is reversible with the use of rituximab and ibrutinib. The authors show a survival benefit associated with treating to cerebral spinal fluid (CSF) clearance by cytology and compare outcomes with various treatment strategies, focusing on novel agents. Now that there is effective therapy for leptomeningeal lymphoma in CLL, the importance for oncologists to recognize this neurologic complication has become clear.
Collapse
MESH Headings
- Adenine/analogs & derivatives
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/cerebrospinal fluid
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Male
- Meningeal Carcinomatosis/cerebrospinal fluid
- Meningeal Carcinomatosis/complications
- Meningeal Carcinomatosis/diagnosis
- Meningeal Carcinomatosis/drug therapy
- Middle Aged
- Piperidines
- Pyrazoles/administration & dosage
- Pyrimidines/administration & dosage
- Remission Induction
- Rituximab/administration & dosage
Collapse
Affiliation(s)
- Alipi V Naydenov
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Lynne P Taylor
- Department of Neurology, University of Washington, Seattle, Washington, USA
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
- Alvord Brain Tumor Center, University of Washington, Seattle, Washington, USA
- Seattle Cancer Care Alliance, Seattle, Washington, USA
| |
Collapse
|
2
|
de Souza SL, Santiago F, Ribeiro-Carvalho MDM, Arnóbio A, Soares AR, Ornellas MH. Leptomeningeal involvement in B-cell chronic lymphocytic leukemia: a case report and review of the literature. BMC Res Notes 2014; 7:645. [PMID: 25218117 PMCID: PMC4246480 DOI: 10.1186/1756-0500-7-645] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 09/08/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Central nervous system involvement is considered a rare complication of chronic lymphocytic leukemia, and so there is the risk of being overlooked. CASE PRESENTATION We report a case of central nervous system involvement in a 75-year-old mulatto woman with chronic lymphocytic leukemia after 5 years of follow-up and a literature review on the subject. The clinical course, treatment and outcome are described. A systematic, meticulous and comprehensive analysis of existing publications regarding chronic lymphocytic leukemia with central nervous system involvement was performed. CONCLUSION We concluded that central nervous system involvement of chronic lymphocytic leukemia is probably not associated with any evident risk factors. Diagnostic approach differs by institutions but often includes imaging, morphology and flow cytometry. Resolution of central nervous system symptoms can usually be accomplished with intrathecal chemotherapy or irradiation followed by systemic treatment. The recognition of this entity by clinicians could lead to early detection and treatment, resulting in better outcomes in this rare complication.
Collapse
Affiliation(s)
- Simone Lima de Souza
- />Departamento de Patologia, Faculdade de Ciências Medicas, Programa de Pós Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro, 444/4° andar, Vila Isabel, Rio de Janeiro Brazil
| | - Fábio Santiago
- />Departamento de Patologia, Faculdade de Ciências Medicas, Programa de Pós Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro, 444/4° andar, Vila Isabel, Rio de Janeiro Brazil
| | - Marilza de Moura Ribeiro-Carvalho
- />Departamento de Patologia, Faculdade de Ciências Medicas, Programa de Pós Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro, 444/4° andar, Vila Isabel, Rio de Janeiro Brazil
| | - Adriano Arnóbio
- />Departamento de Patologia, Faculdade de Ciências Medicas, Programa de Pós Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro, 444/4° andar, Vila Isabel, Rio de Janeiro Brazil
| | - Andréa Ribeiro Soares
- />Serviço de Hematologia, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Helena Ornellas
- />Departamento de Patologia, Faculdade de Ciências Medicas, Programa de Pós Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro, 444/4° andar, Vila Isabel, Rio de Janeiro Brazil
| |
Collapse
|
3
|
Spectrum of neurologic complications in chronic lymphocytic leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 12:164-79. [PMID: 22192500 DOI: 10.1016/j.clml.2011.10.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Revised: 10/19/2011] [Accepted: 10/27/2011] [Indexed: 12/21/2022]
Abstract
Neurologic disease is believed to be an unusual complication during the course of chronic lymphocytic leukemia. Nevertheless, it has already been proven in autopsy series that the incidence of occult nervous system infiltration is much higher than was previously expected. The advent of more potent drugs to treat this lymphoproliferative disorder has brought a new hope for a possible cure in the future. However, an appropriate systemic treatment for central nervous system infiltration of this disease is still lacking. Also, due to the potent immunosuppressive properties of the agents used in the up-front treatment, for example, the purine nucleoside analogues, we have witnessed an increase in the incidence of opportunistic infections, with progressive multifocal leukoencephalopathy being one of the most serious. The goal of this review is to summarize the spectrum of neurologic derangements linked to chronic lymphocytic leukemia and to raise clinicians' awareness to recognize the possibility of such associations.
Collapse
|
4
|
Tonino SH, Rijssenbeek AL, Oud ME, Pals ST, van Oers MH, Kater AP. Intracerebral Infiltration As the Unique Cause of the Clinical Presentation of Chronic Lymphocytic Leukemia/Small Lymphocytic Leukemia. J Clin Oncol 2011; 29:e837-9. [DOI: 10.1200/jco.2011.37.5055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
|
5
|
Moazzam AA, Drappatz J, Kim RY, Kesari S. Chronic lymphocytic leukemia with central nervous system involvement: report of two cases with a comprehensive literature review. J Neurooncol 2011; 106:185-200. [PMID: 21769650 DOI: 10.1007/s11060-011-0636-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 06/17/2011] [Indexed: 10/18/2022]
Abstract
Central nervous system (CNS) involvement is a rare complication of chronic lymphocytic leukemia (CLL) with varied outcomes. We contribute two additional cases of CLL with CNS involvement. The clinical course and response to treatment are described. All 78 previously reported cases of CLL with CNS involvement are presented in this comprehensive review of the literature. CNS involvement of CLL is a rare complication that does not seem to correlate with any evident risk factors. Resolution of CNS symptoms can often be accomplished with intrathecal chemotherapy or irradiation. Early detection and treatment may result in better outcomes in this rare complication.
Collapse
MESH Headings
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor
- Central Nervous System Neoplasms/drug therapy
- Central Nervous System Neoplasms/pathology
- Central Nervous System Neoplasms/radiotherapy
- Combined Modality Therapy
- Fatal Outcome
- Female
- Flow Cytometry
- Gait Disorders, Neurologic/etiology
- Humans
- Hypesthesia/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/radiotherapy
- Leukemic Infiltration
- Leukocyte Count
- Magnetic Resonance Imaging
- Middle Aged
- Tomography, X-Ray Computed
Collapse
Affiliation(s)
- Alan A Moazzam
- Department of Neurosciences, Moores UCSD Cancer Center, University of California at San Diego, 3855 Health Sciences Drive, La Jolla, CA 92093, USA
| | | | | | | |
Collapse
|
6
|
Guastafierro S, Falcone U, Celentano M, Carbone A, Ferrara MG, Cappabianca S, Sica A. Chronic lymphocytic leukemia presenting with symptomatic peritoneal infiltration. Leuk Res 2009; 34:e115-6. [PMID: 19939447 DOI: 10.1016/j.leukres.2009.10.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 10/23/2009] [Accepted: 10/24/2009] [Indexed: 11/30/2022]
|
7
|
Lange CPE, Brouwer RE, Brooimans R, Vecht CJ. Leptomeningeal disease in chronic lymphocytic leukemia. Clin Neurol Neurosurg 2007; 109:896-901. [PMID: 17850954 DOI: 10.1016/j.clineuro.2007.07.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Revised: 07/03/2007] [Accepted: 07/25/2007] [Indexed: 11/16/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is the most common lymphoproliferative disorder in the western hemisphere, with an annual incidence of 3:100000. Commonly patients are asymptomatic but not rarely disease progression occurs in the setting of lymphadenopathy and extensive leukemic burden. Leptomeningeal involvement in patients with CLL is infrequent, with presenting symptoms of headache (23%), acute or chronic changes in mental status (28%), cranial nerve abnormalities (54%) including optic neuropathy (28%), weakness of lower extremities (23%) and cerebellar signs (18%). In this report, we discuss a CLL patient with leptomeningeal involvement, who presented with neurological symptoms as the first clinical sign, and a diagnosis of leptomeningeal was made based on CSF cytology and flow cytometry. Treatment consisted of radiation therapy and intrathecal chemotherapy with arabinoside-cytosine and systemic chemotherapy. On the basis of this patient-report together with 37 other previously reported cases, the clinical characteristics together with treatment options and outcome of leptomeningeal involvement in CLL are reviewed. Our case together with data from the literature indicate that a timely diagnosis and intensive treatment of leptomeningeal disease of CLL may lead to longstanding and complete resolution of neurological symptoms.
Collapse
Affiliation(s)
- C P E Lange
- Neuro-oncology Unit, Department of Neurology, Medical Centre, The Hague, The Netherlands.
| | | | | | | |
Collapse
|
8
|
Schmidt-Hieber M, Thiel E, Keilholz U. Spinal paraparesis due to leukemic meningitis in early-stage chronic lymphocytic leukemia. Leuk Lymphoma 2005; 46:619-21. [PMID: 16019494 DOI: 10.1080/14767050400029681] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Leukemic meningitis is a rare manifestation of chronic lymphocytic leukemia (CLL) and typically occurs in advanced stages. We report the case of a 71-year-old male in whom Binet A, Rai 1 stage CLL was diagnosed in June 2002. The stage called for a "watch and wait" strategy. Six months later the patient presented with paraparesis. Magnetic resonance imaging of the lumbar spine revealed no abnormalities. Lumbar puncture disclosed xanthochromic cerebrospinal fluid (CSF) with 1003 cells/microl, 95% atypical lymphocytes. Flow cytometry confirmed typical features of CLL. Intrathecal injections of methotrexate, cytosine arabinoside and corticosteroids did not substantially reduce the CSF cell count and failed to improve the neurological symptoms. Two weeks later the patient developed a pulmonary embolism complicated by fatal secondary pneumonia. Leukemic meningitis is a rare manifestation of CLL, especially in early stages. Selective spinal paraparesis as the first symptom of meningitis in CLL is even rarer and has been reported only once.
Collapse
MESH Headings
- Aged
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Fatal Outcome
- Follow-Up Studies
- Humans
- Injections, Spinal
- Leukemia, Lymphocytic, Chronic, B-Cell/cerebrospinal fluid
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Male
- Meningitis/cerebrospinal fluid
- Meningitis/etiology
- Paraparesis/cerebrospinal fluid
- Paraparesis/etiology
- Treatment Failure
Collapse
Affiliation(s)
- Martin Schmidt-Hieber
- Medizinische Klinik III, Charité-Campus Benjamin Franklin, Hindenburgdamm 30, D-12200, Berlin, Germany
| | | | | |
Collapse
|
9
|
Remková A, Bezayová T, Vyskocil M. B cell chronic lymphocytic leukemia with meningeal infiltration by T lymphocytes. Eur J Intern Med 2003; 14:49-52. [PMID: 12554011 DOI: 10.1016/s0953-6205(02)00207-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is a generalized malignancy of the lymphoid tissue characterized by an accumulation of monoclonal lymphocytes, usually of the B cell type. Involvement of the central nervous system is a rare complication, usually seen in T cell leukemias. We report a case of a 78-year-old woman with B cell CLL and meningeal infiltration by both B and T lymphocytes, although predominantly T lymphocytes. Neurological symptoms were the first manifestation of this disease. Computed tomography of the brain was negative. The diagnosis of leukemic meningitis was made on the basis of the examination of the cerebrospinal fluid, and which included cytological and flow cytometry analysis. The patient was given systemic chemotherapy in the form of chlorambucil and intrathecal administration of methotrexate and dexamethasone. After recovery, she had regular follow-up. We assume that this rare case of CLL might have been biclonal, with both B and T cell types.
Collapse
Affiliation(s)
- Anna Remková
- 1st Department of Internal Medicine, Teaching Hospital and School of Medicine, Comenius University, Mickiewiczova 13, SK-813 69, Bratislava, Slovak Republic
| | | | | |
Collapse
|