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Kaulen LD, Hielscher T, Doubrovinskaia S, Hoffmann DC, Kessler T, Traub BL, Baehring JM, Wick W. Clinical Presentation, Management, and Outcome in Neurolymphomatosis: A Systematic Review. Neurology 2024; 103:e209698. [PMID: 39102613 DOI: 10.1212/wnl.0000000000209698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Neurolymphomatosis (NL) refers to lymphomatous infiltration of the peripheral nervous system (PNS). NL diagnosis and treatment are challenging given the broad differential diagnosis of peripheral neuropathy, the lack of larger cohorts, and the subsequent unavailability of prognostic factors or consensus therapy. This study aimed to define characteristics and prognostic factors of NL. METHODS A systematic review of the literature (2004-2023) was performed using PubMed and Scopus databases and reported following PRISMA guidelines. Studies reporting individual patient data on cases with definitive NL diagnosis were included. Clinical, radiologic, pathologic, and outcome information were extracted. Univariable and multivariable survival analyses were performed using log-rank tests and Cox proportional hazard models. RESULTS A total of 459 NL cases from 264 studies were accumulated. NL was the first manifestation of malignancy (primary NL) in 197 patients. PNS relapse of known non-Hodgkin lymphoma (secondary NL) occurred in 262 cases after a median 12 months. NL predominantly presented with rapidly deteriorating, asymmetric painful polyneuropathy. Infiltrated structures included peripheral nerves (56%), nerve roots (52%), plexus (33%), and cranial nerves (32%). Diagnosis was established at a median of 3 months after symptom onset with substantial delays in primary NL. It mainly relied on PNS biopsy or FDG-PET, which carried high diagnostic yields (>90%). Postmortem diagnoses were rare (3%). Most cases were classified as B-cell (90%) lymphomas. Tumor-directed therapy was administered in 96% of patients and typically consisted of methotrexate or rituximab-based polychemotherapy. The median overall survival was 18 months. Primary NL without concurrent systemic disease outside the nervous system (hazard ratio [HR]: 0.44; 95% CI 0.25-0.78; p = 0.005), performance status (ECOG <2, HR: 0.30; 95% CI 0.18-0.52; p < 0.0001), and rituximab-based treatment (HR: 0.46; 95% CI 0.28-0.73; p = 0.001) were identified as favorable prognostic markers on multivariable analysis when adjusting for clinical and sociodemographic parameters. DISCUSSION Advances in neuroimaging modalities, particularly FDG-PET, facilitate NL diagnosis and offer a high diagnostic yield. Yet, diagnostic delays in primary NL remain common. Rituximab-based therapy improves NL outcome. Findings may assist clinicians in early recognition, prognostic stratification, and treatment of NL.
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Affiliation(s)
- Leon D Kaulen
- From the Department of Neurology (L.D.K., S.D., D.C.H., T.K., B.-L.T., W.W.), University Hospital Heidelberg, Heidelberg University; Clinical Cooperation Unit (CCU) Neuro-Oncology (L.D.K., D.C.H., T.K., W.W.), German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research, Heidelberg; Department of Biostatistics (T.H.), German Cancer Research Center (DKFZ), Heidelberg, Germany; and Departments of Neurology and Neurosurgery (J.M.B.), Yale School of Medicine, New Haven, CT
| | - Thomas Hielscher
- From the Department of Neurology (L.D.K., S.D., D.C.H., T.K., B.-L.T., W.W.), University Hospital Heidelberg, Heidelberg University; Clinical Cooperation Unit (CCU) Neuro-Oncology (L.D.K., D.C.H., T.K., W.W.), German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research, Heidelberg; Department of Biostatistics (T.H.), German Cancer Research Center (DKFZ), Heidelberg, Germany; and Departments of Neurology and Neurosurgery (J.M.B.), Yale School of Medicine, New Haven, CT
| | - Sofia Doubrovinskaia
- From the Department of Neurology (L.D.K., S.D., D.C.H., T.K., B.-L.T., W.W.), University Hospital Heidelberg, Heidelberg University; Clinical Cooperation Unit (CCU) Neuro-Oncology (L.D.K., D.C.H., T.K., W.W.), German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research, Heidelberg; Department of Biostatistics (T.H.), German Cancer Research Center (DKFZ), Heidelberg, Germany; and Departments of Neurology and Neurosurgery (J.M.B.), Yale School of Medicine, New Haven, CT
| | - Dirk C Hoffmann
- From the Department of Neurology (L.D.K., S.D., D.C.H., T.K., B.-L.T., W.W.), University Hospital Heidelberg, Heidelberg University; Clinical Cooperation Unit (CCU) Neuro-Oncology (L.D.K., D.C.H., T.K., W.W.), German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research, Heidelberg; Department of Biostatistics (T.H.), German Cancer Research Center (DKFZ), Heidelberg, Germany; and Departments of Neurology and Neurosurgery (J.M.B.), Yale School of Medicine, New Haven, CT
| | - Tobias Kessler
- From the Department of Neurology (L.D.K., S.D., D.C.H., T.K., B.-L.T., W.W.), University Hospital Heidelberg, Heidelberg University; Clinical Cooperation Unit (CCU) Neuro-Oncology (L.D.K., D.C.H., T.K., W.W.), German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research, Heidelberg; Department of Biostatistics (T.H.), German Cancer Research Center (DKFZ), Heidelberg, Germany; and Departments of Neurology and Neurosurgery (J.M.B.), Yale School of Medicine, New Haven, CT
| | - Benjamin-Leon Traub
- From the Department of Neurology (L.D.K., S.D., D.C.H., T.K., B.-L.T., W.W.), University Hospital Heidelberg, Heidelberg University; Clinical Cooperation Unit (CCU) Neuro-Oncology (L.D.K., D.C.H., T.K., W.W.), German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research, Heidelberg; Department of Biostatistics (T.H.), German Cancer Research Center (DKFZ), Heidelberg, Germany; and Departments of Neurology and Neurosurgery (J.M.B.), Yale School of Medicine, New Haven, CT
| | - Joachim M Baehring
- From the Department of Neurology (L.D.K., S.D., D.C.H., T.K., B.-L.T., W.W.), University Hospital Heidelberg, Heidelberg University; Clinical Cooperation Unit (CCU) Neuro-Oncology (L.D.K., D.C.H., T.K., W.W.), German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research, Heidelberg; Department of Biostatistics (T.H.), German Cancer Research Center (DKFZ), Heidelberg, Germany; and Departments of Neurology and Neurosurgery (J.M.B.), Yale School of Medicine, New Haven, CT
| | - Wolfgang Wick
- From the Department of Neurology (L.D.K., S.D., D.C.H., T.K., B.-L.T., W.W.), University Hospital Heidelberg, Heidelberg University; Clinical Cooperation Unit (CCU) Neuro-Oncology (L.D.K., D.C.H., T.K., W.W.), German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research, Heidelberg; Department of Biostatistics (T.H.), German Cancer Research Center (DKFZ), Heidelberg, Germany; and Departments of Neurology and Neurosurgery (J.M.B.), Yale School of Medicine, New Haven, CT
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Soleimani H, Khoroushi F, AtaeiAzimi S, Jafarian A, Salarzaei O, Aminzadeh B. Recurrence of diffuse large B-cell lymphoma in sciatic and tibial nerves: A case report. Radiol Case Rep 2024; 19:535-539. [PMID: 38044904 PMCID: PMC10686859 DOI: 10.1016/j.radcr.2023.10.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 12/05/2023] Open
Abstract
Infiltration of peripheral or cranial nerves with lymphatic cells is a rare condition that is known as neurolymphomatosis (NL). The involvement could be primary or secondary and mostly occurs in patients with a history of B-cell lymphoma. The most common peripheral nerve involved is the sciatic nerve. Patients may present with painful or painless mononeuropathy or polyneuropathy, and MRI is the perfect modality to evaluate the suspicious clinical findings that may demonstrate enlargement, thickening, and enhancement of the involved nerve or an enhancing mass lesion in the course of the nerve. Biopsy can be safely performed to confirm the diagnosis. Few articles have reported the cases of peripheral nerve involvement by lymphoma as well as MRI features of this diagnosis. In this article, we report a case of NL using MRI, ultrasound, and pathologic features and also present a brief review of relevant literature.
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Affiliation(s)
- Hourieh Soleimani
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farzaneh Khoroushi
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sajad AtaeiAzimi
- Department of Hematology-Oncology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - AmirHossein Jafarian
- Department of Pathology, Pathology Cancer Molecular Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Omid Salarzaei
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Behzad Aminzadeh
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Terao T, Tsushima T, Ikeda D, Fukumoto A, Kamura Y, Kuzume A, Tabata R, Miura D, Narita K, Takeuchi M, Matsue K. Limited efficacy of high-dose methotrexate to prevent the central nervous system relapse in patients with IVLBCL. Leuk Lymphoma 2022; 63:3394-3401. [PMID: 36111741 DOI: 10.1080/10428194.2022.2123239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
To evaluate the efficacy of high-dose methotrexate (HD-MTX, ≥1 g/m2) for the prevention of central nervous system (CNS) recurrence in patients with intravascular large B-cell lymphoma (IVLBCL), we reviewed 51 patients with pathologically diagnosed untreated IVLBCL. In total, there were five cases of CNS relapse (9.8%), and the 12-month CNS relapse rate was 9.2%. No statistical difference in CNS relapse rate (p = 0.86) was observed between patients with and without HD-MTX (n = 20 and 31, respectively). Furthermore, the composite endpoint defined as either CNS and/or neurolymphomatosis relapse was not significant in terms of the administration of HD-MTX (p = 0.25). No significant predictor of CNS relapse was found. In conclusion, patients with IVLBCL are at high risk of CNS recurrence; however, HD-MTX administration may not be effective for CNS recurrence prophylaxis. Key pointsThe administration of HD-MTX for patients with untreated IVLBCL may not be effective for preventing CNS relapse.
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Affiliation(s)
- Toshiki Terao
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Takafumi Tsushima
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Daisuke Ikeda
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Ami Fukumoto
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Yuya Kamura
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Ayumi Kuzume
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Rikako Tabata
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Daisuke Miura
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Kentaro Narita
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Masami Takeuchi
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Kosei Matsue
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
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Abstract
Though metastasis and malignant infiltration of the peripheral nervous system is relatively rare, physicians should have a familiarity with their presentations to allow for prompt diagnosis and initiation of treatment. This article will review the clinical presentations, diagnostic evaluation, and treatment of neoplastic involvement of the cranial nerves, nerve roots, peripheral nerves, and muscle. Due to the proximity of the neural structure traversing the skull base, metastasis to this region results in distinctive syndromes, most often associated with breast, lung, and prostate cancer. Metastatic involvement of the nerve roots is uncommon, apart from leptomeningeal carcinomatosis and bony metastasis with resultant nerve root damage, and is characterized by significant pain, weakness, and numbness of an extremity. Neoplasms may metastasize or infiltrate the brachial and lumbosacral plexuses resulting in progressive and painful sensory and motor deficits. Differentiating neoplastic involvement from radiation-induced injury is of paramount importance as it dictates treatment and prognosis. Neurolymphomatosis, due to malignant lymphocytic infiltration of the cranial nerves, nerve roots, plexuses, and peripheral nerves, deserves special attention given its myriad presentations, often mimicking acquired demyelinating neuropathies.
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Clinical manifestations of, diagnostic approach to, and treatment of neurolymphomatosis in the rituximab era. Blood Adv 2021; 5:1379-1387. [PMID: 33661298 DOI: 10.1182/bloodadvances.2020003666] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/19/2021] [Indexed: 12/31/2022] Open
Abstract
Neurolymphomatosis (NL) is a rare manifestation of lymphoma, with limited evidence for optimal management. The largest patient series, 50 cases of lymphoma and leukemia, was published in 2010 with limited rituximab exposure. This study aims to evaluate the clinical presentation, diagnostic testing, and outcomes of NL in the rituximab era. Forty biopsy-proven cases of NL, in association with non-Hodgkin lymphoma (NHL), at the Mayo Clinic were retrospectively evaluated. B-cell NHL was associated with 97% of NL cases, of which diffuse large B-cell lymphoma (DLBCL) was the most common (68%). Primary NL, defined as neural involvement present at the time of diagnosis of lymphoma, was noted in 52% cases. Seventy percent of patients presented with sensorimotor weakness and neuropathic pain. Magnetic resonance imaging (MRI) was positive in 100% patients. Overall survival (OS) was significantly better for primary NL and NL associated with indolent lymphomas. Relapses were seen in 60% (24/40) of patients; 75% involved the peripheral or central nervous system at relapse. The use of rituximab in the frontline setting significantly impacted progression-free survival (PFS). Transplant consolidation was noted to be associated with improved OS. This study adds to the available literature on NL in the rituximab era. The overall outcomes have improved in recent years. In our experience, MRI and positron emission tomography/computed tomography may be required for accurate assessment of the extent of disease involvement and identification of an optimal biopsy site. The use of rituximab was associated with improvement in PFS, and autologous stem cell transplant was associated with OS.
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Liu Y, Ma Y, Zhou H, Zhou X, Shao J. Analysis of clinicopathological features and prognostic factors of non-Hodgkin's intravascular large B-cell lymphoma. Oncol Lett 2020; 20:43. [PMID: 32802165 DOI: 10.3892/ol.2020.11908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 05/07/2020] [Indexed: 12/14/2022] Open
Abstract
Non-Hodgkin's intravascular large B-cell lymphoma is a highly invasive extranodal lymphoma. The proliferating tumor cells invade the small vessels and capillaries of different organs. The clinical symptoms are atypical, there is lack of specificity, and the molecular and biological behaviors are not clear, thus, the present study aimed to improve the current understanding of non-Hodgkin's intravascular large B-cell lymphoma (IVL) and provide an accurate basis for clinical treatment and prognosis, by retrospectively analyzing and summarizing the clinicopathological features, immunohistochemical findings and molecular characteristics of 17 patients with IVL. The Kaplan-Meier method and log rank test were implemented to determine survival outcomes. Fisher's exact test was used to determine the association between clinicopathological features and the expression levels of Ki-67, c-Myc, B-cell lymphoma 6 (Bcl-6) and B-cell lymphoma 2 (Bcl-2), while multivariate Cox regression analysis was performed to identify the independent risk factors that affect the survival rates of patients with IVL. P<0.05 was considered to indicate a statistically significant difference. Among the 17 patients with IVL, 13 cases (76.47%) occurred in the adrenal gland and four cases (23.53%) occurred on the skin demonstrated positive IgH gene rearrangement. FISH analysis indicated that cleavage of the c-Myc gene was closely associated with sex, hypertension status and tumor size, while cleavage of the Bcl-6 gene was closely associated with tumor size parameters. Overall, the results suggest that the Ki-67 proliferation index is an independent risk factor for the prognosis (survival time) of patients with IVL.
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Affiliation(s)
- Ying Liu
- Department of Oncology, Pathology and Dermatology, Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Yue Ma
- Department of Urology, Mianyang Central Hospital, Mianyang, Sichuan 621000, P.R. China
| | - Huihui Zhou
- Department of Oncology, Pathology and Dermatology, Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Xiuzhi Zhou
- School of Basic Medical Sciences, Binzhou Medical University, Yantai, Shandong 264003, P.R. China
| | - Juan Shao
- Department of Oncology, Pathology and Dermatology, Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
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