1
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Robak T, Puła A, Braun M, Robak E. Extramedullary and extranodal manifestations in chronic lymphocytic leukemia - an update. Ann Hematol 2024:10.1007/s00277-024-05854-1. [PMID: 39052034 DOI: 10.1007/s00277-024-05854-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/15/2024] [Indexed: 07/27/2024]
Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a common leukemia characterized by clonal expansion of mature CD5+/CD23 + B cells in the blood, bone marrow (BM) and lymphoid tissues. CLL can undergo extramedullary and extranodal infiltration, with one study noting an incidence of only 0.3 per 100,000 people, and in 17.6% of CLL patients in another report. The most common extranodal sites of leukemic involvement are the skin and central nervous system; however, other organs, including liver, lungs, kidney, gastrointestinal tract, bone, prostate and heart, are occasionally involved. The prognostic significance of extra-medullary CLL is still under debate, but the prognosis in such patients seems to be better in the era of novel targeted drugs. Following a diagnosis of extranodal CLL, survival appears to depend on the site of infiltration. This review presents an overview of CLL in patients with extramedullary and extranodal leukemic lesions, focusing on its epidemiology, pathogenesis, prognosis, clinical characteristics and treatment results.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Ciołkowskiego 2, Lodz, 93-510, Poland.
- Department of General Hematology, Copernicus Memorial Hospital, Lodz, Poland.
| | - Anna Puła
- Department of Hematology, Medical University of Lodz, Ciołkowskiego 2, Lodz, 93-510, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
| | - Marcin Braun
- Department of Pathology, Chair of Oncology, Medical University of Lodz, Lodz, Poland
| | - Ewa Robak
- Department of Dermatology, Medical University of Lodz, Lodz, Poland
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2
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Batayneh O, Lin A, Abu-Jaradeh O, Wu P, Villamar MF, Sharma P. Symptomatic leptomeningeal carcinomatosis: a rare presentation of chronic lymphocytic leukaemia relapse. BMJ Case Rep 2022; 15:e249940. [PMID: 35675961 PMCID: PMC9185480 DOI: 10.1136/bcr-2022-249940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2022] [Indexed: 11/03/2022] Open
Abstract
Central nervous system (CNS) involvement in patients with chronic lymphocytic leukaemia (CLL) is very rare and, when present, it is frequently asymptomatic. Rather, CNS involvement is more common in other haematological malignancies such as mantle cell lymphoma or diffuse large B cell lymphoma. The paucity of literature on CNS involvement in CLL underscores the importance of increasing awareness about its presentation, diagnosis and optimal management. We describe a case of symptomatic leptomeningeal leukaemic involvement as an atypical presentation of CLL relapse. A favourable clinical response was observed following systemic monotherapy with venetoclax.
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MESH Headings
- Adult
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Mantle-Cell
- Meningeal Carcinomatosis/diagnosis
- Neoplasm Recurrence, Local
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Affiliation(s)
- Osama Batayneh
- Department of Medicine, Kent Hospital/ The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Amy Lin
- OMS-III, University of New England College of Osteopathic Medicine, Warwick, RI, USA
| | - Omar Abu-Jaradeh
- Department of Medicine, Kent Hospital/ The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Peter Wu
- Department of Pathology, Kent Hospital, Warwick, RI, USA
| | - Mauricio F Villamar
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Medicine, Kent Hospital, Warwick, RI, USA
| | - Purva Sharma
- Department of Hematology and Oncology, Kent Hospital, Warwick, RI, USA
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3
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Nakanishi T, Ito T, Fujita S, Satake A, Konishi A, Hotta M, Yoshimura H, Nomura S. Refractory Chronic Lymphocytic Leukemia with Central Nervous System Involvement: A Case Report with Literature Review. J Blood Med 2020; 11:487-502. [PMID: 33380856 PMCID: PMC7767717 DOI: 10.2147/jbm.s271335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/16/2020] [Indexed: 12/17/2022] Open
Abstract
There have been few reports on central nervous system (CNS) involvement in chronic lymphocytic leukemia (CLL). This is an extremely rare disease with poor prognosis, owing to resistance to various treatments. We describe a 33-year-old man with intractable CLL with CNS involvement. He was diagnosed with CLL, with diplopia as the first manifestation. Magnetic resonance imaging revealed a contrast-enhancing tumor in the right temporal lobe, which was diagnosed as CNS involvement in CLL on brain biopsy. High-dose methotrexate therapy was ineffective for this lesion, which was also resistant to subsequent whole-brain irradiation, treatment with fludarabine–cyclophosphamide–rituximab chemoimmunotherapy, and ibrutinib administration. Because no standard protocol exists for CLL with CNS involvement, it is important to accumulate case data to verify the choice of new drugs for administration at an early stage. Therefore, we also conducted a literature review of 50 case reports of CNS lesions in the last 10 years to consider the pathophysiology, diagnosis, and treatment of CNS involvement in CLL. The possibility of new therapeutic agents, eg, ibrutinib and venetoclax, or a combination of these agents and methotrexate, can be envisioned as a treatment strategy for CLL with CNS involvement.
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Affiliation(s)
- Takahisa Nakanishi
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Shinya Fujita
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Atsushi Satake
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Akiko Konishi
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Masaaki Hotta
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Hideaki Yoshimura
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
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4
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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.
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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
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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
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5
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Treatment Sequencing in a Chronic Lymphocytic Leukemia Patient with Central Nervous System Involvement. Case Rep Hematol 2018; 2018:7817918. [PMID: 29977629 PMCID: PMC5994293 DOI: 10.1155/2018/7817918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/24/2018] [Accepted: 05/03/2018] [Indexed: 11/17/2022] Open
Abstract
Early-stage chronic lymphocytic leukemia (CLL) with neurologic involvement is a rare condition and should require a careful follow-up. Although no standard protocol exists for this condition, intrathecal chemotherapy, combined with systemic chemoimmunotherapy, has been used previously. This case describes the treatment of a patient with CLL and symptomatic compromise of the central nervous system. Our results suggest that a combination of chemotherapy, radiotherapy, and ibrutinib, administered sequentially over a 2-year period, led to a near-complete resolution of the cerebral spinal fluid neoplastic infiltration. Importantly, this response has been maintained with ibrutinib monotherapy for more than 12 months.
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6
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Christoforidou A, Kapsas G, Bezirgiannidou Z, Papamichos S, Kotsianidis Ι. Successful Treatment of Chronic Lymphocytic Leukemia Multifocal Central Nervous System Involvement with Ibrutinib. Turk J Haematol 2018; 35:147-149. [PMID: 29391330 PMCID: PMC5972345 DOI: 10.4274/tjh.2017.0313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Anna Christoforidou
- Democritus University of Thrace, Department of Hematology, Alexandroupolis, Greece
| | - Georgios Kapsas
- Democritus University of Thrace, Department of Radiology, Alexandroupolis, Greece
| | - Zoe Bezirgiannidou
- Democritus University of Thrace, Department of Hematology, Alexandroupolis, Greece
| | - Spyros Papamichos
- Democritus University of Thrace, Department of Hematology, Alexandroupolis, Greece
| | - Ιoannis Kotsianidis
- Democritus University of Thrace, Department of Hematology, Alexandroupolis, Greece
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7
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Sethi TK, Reddy NM. Treatment of newly diagnosed primary central nervous system lymphoma: current and emerging therapies. Leuk Lymphoma 2018; 60:6-18. [DOI: 10.1080/10428194.2018.1466296] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Tarsheen K. Sethi
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nishitha M. Reddy
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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8
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Mihaljevic B, Smiljanic M, Antic D, Kurtovic NK, Balint MT. Chronic Lymphocytic Leukemia Involvement of Central Nervous System: Clinical Diversity, Diagnostic Algorithm and Therapeutic Challenges. Ann Indian Acad Neurol 2018; 21:85-87. [PMID: 29720808 PMCID: PMC5909156 DOI: 10.4103/aian.aian_442_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Biljana Mihaljevic
- Clinic of Haematology, Clinical Centre of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Darko Antic
- Clinic of Haematology, Clinical Centre of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Milena Todorovic Balint
- Clinic of Haematology, Clinical Centre of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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9
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Cervilla Muñoz E, Demelo Rodríguez P, García García A, Menarguez Palanca J, Del Toro Cervera J. Brain biopsy in the diagnosis of leptomeningeal involvement in stage I chronic lymphocytic leukemia. Clin Case Rep 2017; 5:1919-1922. [PMID: 29225825 PMCID: PMC5715602 DOI: 10.1002/ccr3.1106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 05/09/2017] [Accepted: 05/27/2017] [Indexed: 11/08/2022] Open
Abstract
Leptomeningeal involvement of CLL is usually underdiagnosed as neurological symptoms are unspecific. It is important to carefully evaluate neurological status in these patients and consider this entity between the differential diagnosis of a neurological deterioration as adequate treatment improves the prognosis. Imaging techniques, analyses of cerebrospinal fluid, and brain biopsy are useful to establish a definitive diagnosis.
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Affiliation(s)
- Eva Cervilla Muñoz
- Department of Internal Medicine Hospital General Universitario Gregorio Marañón Madrid Spain
| | - Pablo Demelo Rodríguez
- Department of Internal Medicine Hospital General Universitario Gregorio Marañón Madrid Spain
| | - Alejandra García García
- Department of Internal Medicine Hospital General Universitario Gregorio Marañón Madrid Spain
| | | | - Jorge Del Toro Cervera
- Department of Internal Medicine Hospital General Universitario Gregorio Marañón Madrid Spain
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10
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Szczepanek D, Wąsik-Szczepanek E, Szymczyk A, Wach M, Cioch M, Podhorecka M, Grywalska E, Hus M. Central nervous involvement by chronic lymphocytic leukaemia. Neurol Neurochir Pol 2017; 52:228-234. [PMID: 29146406 DOI: 10.1016/j.pjnns.2017.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/19/2017] [Accepted: 10/20/2017] [Indexed: 11/25/2022]
Abstract
Inclusion of the central nervous system (CNS) in the course of chronic lymphocytic leukaemia (CLL) is rare. At the moment no risk factors or proven treatment methods are known. The disease is described both in its early phase and during its acceleration period, thus it has been suggested that there might be independent mechanisms influencing the development of this condition. As there are no unified diagnostic procedure algorithms each patient needs to be assessed individually. CLL can manifest mostly in elderly people, for whom a possibility of development of neurological disorders with their aetiology different from leukaemia, should also be taken into consideration. The thesis presents a group of seven patients with CLL with CNS infiltration. Patients with prolymphocytic leukaemia, Richter's transformation and the original location of leukemic infiltration within the eye socket constitute an especially interesting case.
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Affiliation(s)
- Dariusz Szczepanek
- Department of Neurosurgery and Paediatric Neurosurgery, Medical University of Lublin, Poland
| | - Ewa Wąsik-Szczepanek
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Poland
| | - Agnieszka Szymczyk
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Poland; Independent Clinical Transplantology Unit, Medical University of Lublin, Poland.
| | - Małgorzata Wach
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Poland
| | - Maria Cioch
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Poland
| | - Monika Podhorecka
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Poland
| | - Ewelina Grywalska
- Department of Clinical Immunology, Medical University of Lublin, Poland
| | - Marek Hus
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Poland
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11
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Amira M, Bouzidi N, Damak M, Mhiri C. [Neuro-myelitis optica secondary to chronic lymphocytic leukemia]. J Fr Ophtalmol 2017; 40:e219-e221. [PMID: 28583695 DOI: 10.1016/j.jfo.2016.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/05/2016] [Accepted: 05/30/2016] [Indexed: 11/28/2022]
Affiliation(s)
- M Amira
- Service de neurologie, CHU Habib Bourguiba, 7, rue El-Ferdaous, 3029 Sfax, Tunisie.
| | - N Bouzidi
- Service de neurologie, CHU Habib Bourguiba, 7, rue El-Ferdaous, 3029 Sfax, Tunisie
| | - M Damak
- Service de neurologie, CHU Habib Bourguiba, 7, rue El-Ferdaous, 3029 Sfax, Tunisie
| | - C Mhiri
- Service de neurologie, CHU Habib Bourguiba, 7, rue El-Ferdaous, 3029 Sfax, Tunisie
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12
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Ibrutinib responsive central nervous system involvement in chronic lymphocytic leukemia. Blood 2016; 127:2356-8. [PMID: 26994148 DOI: 10.1182/blood-2016-02-697193] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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13
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Heidari N, Saki N, De Filippis L, Shahjahani M, Teimouri A, Ahmadzadeh A. Central nervous system niche involvement in the leukemia. Clin Transl Oncol 2015; 18:240-50. [DOI: 10.1007/s12094-015-1370-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 07/20/2015] [Indexed: 12/25/2022]
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14
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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.
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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
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15
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Tatarczuch M, Blombery P, Seymour JF. De novoB-cell prolymphocytic leukemia with central nervous system involvement. Leuk Lymphoma 2014; 55:1665-7. [DOI: 10.3109/10428194.2013.842991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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