Clinical and radiological features of brain neurotoxicity caused by antitumor and immunosuppressant treatments

Suicide attempt induced by drug-induced leukoencephalopathy: A case report

Background

Leukoencephalopathy is identified during the administration of anticancer drugs. Symptoms vary from neurological symptoms to psychiatric symptoms depending on the site of damage. There have been no previous reports of suicide attempts due to drug‐induced leukoencephalopathy.

Case Presentation

The patient was diagnosed with diffuse large B‐cell lymphoma (DLBCL) infiltrating the pharyngeal lesion. Rituximab + methotrexate + oncovin + procarbazine (R‐MPV) therapy, a methotrexate‐containing chemotherapy, was initiated. At the end of the fifth course, the patient attempted suicide by hanging with an appliance cord, which was associated with delusion. A head MRI scan showed no evidence of lymphoma recurrence, but white matter lesions around the ventricles showed progression.

Conclusion

We report the case of a patient in whom drug‐induced leukoencephalopathy related to methotrexate led to a suicide attempt. In addition to monitoring brain tumors, daily monitoring of psychiatric and neurological symptoms is important for patients with methotrexate‐induced encephalopathy.

MRI images revealed that the white matter lesions had progressed even after methotrexate administration was completed. The image taken after one dose of methotrexate also shows mild progression of white matter lesions.

Neurological imaging of brain damages after radiotherapy and/or chimiotherapy

Radiotherapy and chemotherapy may induce neurological toxicities with different appearances on CT and MRI scans. While optimized radiotherapy techniques have reduced some complications, new unwanted effects have occurred on account of therapeutic protocols involving the simultaneous use of radiotherapy and chemotherapy. Advances in radio-surgery, innovative anti-angiogenic therapies, as well as prolonged patient survival have led to the emergence of new deleterious side effects. In this report, we describe the early, semi-delayed, and late encephalic complications, while specifying how to identify the morphological lesions depending on the therapeutic protocol.

L-asparaginase fatal toxic encephalopathy during consolidation treatment in an adult with acute lymphoblastic leukemia

Patient: Male, 51

Final Diagnosis: Encephalopaty toxic

Symptoms: Confusion • disorientation • drowsiness • fever

Medication: L-asparaginase

Clinical Procedure: —

Specialty: Oncology

Postnatal toxic and acquired disorders

To develop and function optimally, the brain requires a balanced environment of electrolytes, amino acids, neurotransmitters, and metabolic substrates. As a consequence, organ dysfunction has the potential to induce brain disorders and toxic-metabolic encephalopathies, particularly when occurring during early stages of cerebral maturation. Induced toxicity of three different organ systems that are commonly associated with brain complications are discussed. First, thyroid hormone deficiency caused by intrinsic or extrinsic factors (e.g., environmental toxins) may induce severe adverse effects on child neurological development from reversible impairments to permanent mental retardation. Second, inadequate removal of wastes due to chronic renal failure leads to the accumulation of endogenous toxins that are harmful to brain function. In uremic pediatric patients, the brain becomes more vulnerable to exogenous substances such as aluminum, which can induce aluminum encephalopathy. Following surgical procedures, neurological troubles including focal defects and severe epileptic seizures may result from hypertensive encephalopathy combined with toxicity of immunomodulating substances, or from the delayed consequences of cardiovascular defect. Taken together, this illustrates that organ disorders clearly have an impact on child brain function in various ways.

[Central nervous system complications in patients undergoing cytotoxic chemotherapy and targeted therapies]

Anti-cancer treatments (cytotoxic chemotherapies, targeted therapies and hormonotherapies) are known to induce early and delayed neurological toxicities. Acute encephalopathies and posterior reversible encephalopathies are better known and described, physiopathological hypotheses are emerging. It is difficult to discriminate what drug is causing the symptoms in patients treated with multiple cytotoxic drugs. Methotrexate and ifosfamide are responsible for acute encephalopathies. L-asparaginase and methotrexate or targeted therapies may induce cerebrovascular complications. As life expectancy increases and more complex regimen including innovative targeted therapies are developed, new toxicity profiles can be expected. To be able to provide an early diagnosis, prevention, and treatment (when existing) of these pathologies remains a tremendous challenge that would allow a good quality of life with social and professional life after their cancer is cured.

Central nervous system chemotoxicity during treatment of pediatric acute lymphoblastic leukemia/lymphoma

In the last decades, increasing success rates are being obtained in the chemotherapy of pediatric leukemia and lymphoma. However, the cornerstone of this treatment is still formed by a reduced number of drugs with a highly toxic profile. In particular, central nervous system complications remain a challenging clinical problem, requiring rapid detection and prompt treatment to limit permanent damage. Furthermore, clinicians are often challenged to discriminate between CNS involvement by the disease, toxicity of drugs or infections. This clinically oriented review will help recognize and handle the main neurologic adverse effects induced by chemotherapy in pediatric patients with lymphoblastic leukemia/lymphoma. Different clinical entities and putative drugs involved are discussed in each chapter, with clinical cases illustrating the most relevant and challenging events. In addition, specific clinical-radiological patterns of some of these neurologic events are detailed. Finally, the role of pharmacogenetics, with special focus on those polymorphisms that could help explain the occurrence of neurotoxicity, is also discussed.

Clinical features of encephalopathy in children with cancer requiring cranial magnetic resonance imaging

We analyzed acute neurotoxic problems attributable to chemotherapy or immunosuppression in the context of childhood neoplastic diseases, based on clinical and neuroradiologic findings. This retrospective single-center study reviewed the acute neurologic complications of 62 children receiving conventional chemotherapy or hematopoietic stem cell transplantation from July 2005-July 2008. We excluded patients with central nervous system metastasis and various neurotoxic manifestations not usually requiring cranial magnetic resonance imaging. Of 62 patients, 12 (19.3%) developed acute neurologic complications. The most common complications included posterior reversible encephalopathy syndrome in six of 12 (50%) patients, and Wernicke's encephalopathy in three of 12 (25%) patients. Other complications included chemical arachnoiditis, grey matter injury induced by postchemotherapeutic angiopathy, and leukoencephalopathy. Posterior reversible encephalopathy syndrome was accompanied by hypertensive episodes in most patients (5/6), and Wernicke's encephalopathy was evident with altered mental status in malnourished children. These data indicate that posterior reversible encephalopathy syndrome and Wernicke's encephalopathy are the predominant complications in children undergoing chemotherapy or hematopoietic stem cell transplantation. Early radiologic and clinical evaluation and prompt treatment for these complications are necessary to prevent their progression to irreversible brain damage.

[Stroke in cancer patients. A paraneoplastic neurological syndrome?]

The coincidence of stroke and cancer is frequently encountered. From recent epidemiological data, the stroke risk in cancer patients seems to be equally distributed as compared to the non-cancer population. However, there are several clinical conditions in cancer patients which increase the risk for stroke: Trousseau's syndrome, non-bacterial thrombotic endocarditis and disseminated intravascular coagulation. Also some tumour-specific conditions such as coagulopathies, changes of viscosity and cellular mechanisms such as leukocytosis or thrombocytopathies must be considered. In several types of tumour treatment, such as various anticancer drugs, an increased occurrence of stroke has been reported. Presently there is no indication that stroke and cancer are related to the immune-mediated "classic" paraneoplastic syndromes. However, there are several cancer-specific types and causes of stroke which need to be considered in each patient, as they can be of significance in the treatment.