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Loser V, Segot A, de Leval L, Bisig B, Brouland JP, Hewer E, Barcena C, Hottinger AF, Pot C. Primary diffuse large B-cell lymphoma of the central nervous system identified with CSF biomarkers. BMC Neurol 2024; 24:250. [PMID: 39039441 PMCID: PMC11265112 DOI: 10.1186/s12883-024-03761-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/15/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Diagnosis of primary diffuse large B-cell lymphoma of the central nervous system (PCNSL) is challenging and often delayed. MRI imaging, CSF cytology and flow cytometry have a low sensitivity and even brain biopsies can be misleading. We report three cases of PCNSL with various clinical presentation and radiological findings where the diagnosis was suggested by novel CSF biomarkers and subsequently confirmed by brain biopsy or autopsy. CASE PRESENTATIONS The first case is a 79-year-old man with severe neurocognitive dysfunction and static ataxia evolving over 5 months. Brain MRI revealed a nodular ventriculitis. An open brain biopsy was inconclusive. The second case is a 60-year-old woman with progressive sensory symptoms in all four limbs, evolving over 1 year. Brain and spinal MRI revealed asymmetric T2 hyperintensities of the corpus callosum, corona radiata and corticospinal tracts. The third case is a 72-year-old man recently diagnosed with primary vitreoretinal lymphoma of the right eye. A follow-up brain MRI performed 4 months after symptom onset revealed a T2 hyperintense fronto-sagittal lesion, with gadolinium uptake and perilesional edema. In all three cases, CSF flow cytometry and cytology were negative. Mutation analysis on the CSF (either by digital PCR or by next generation sequencing) identified the MYD88 L265P hotspot mutation in all three cases. A B-cell clonality study, performed in case 1 and 2, identified a monoclonal rearrangement of the immunoglobulin light chain lambda (IGL) and kappa (IGK) gene. CSF CXCL-13 and IL-10 levels were high in all three cases, and IL-10/IL-6 ratio was high in two. Diagnosis of PCNSL was later confirmed by autopsy in case 1, and by brain biopsy in case 2 and 3. CONCLUSIONS Taken together, 5 CSF biomarkers (IL-10, IL-10/IL-6 ratio, CXCL13, MYD88 mutation and monoclonal IG gene rearrangements) were strongly indicative of a PCNSL. Using innovative CSF biomarkers can be sensitive and complementary to traditional CSF analysis and brain biopsy in the diagnosis of PCNSL, potentially allowing for earlier diagnosis and treatment.
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Affiliation(s)
- Valentin Loser
- Department of Clinical Neurosciences, Service of Neurology, Lausanne University Hospital (CHUV)and, University of Lausanne , CHUV-BH07, Lausanne, Switzerland.
| | - Amandine Segot
- Department of Oncology, Service and Central Laboratory of Hematology, Lausanne University Hospital (CHUV)and, University of Lausanne , Lausanne, Switzerland
| | - Laurence de Leval
- Institute of Pathology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV)and, University of Lausanne , Lausanne, Switzerland
| | - Bettina Bisig
- Institute of Pathology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV)and, University of Lausanne , Lausanne, Switzerland
| | - Jean-Philippe Brouland
- Institute of Pathology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV)and, University of Lausanne , Lausanne, Switzerland
| | - Ekkehard Hewer
- Institute of Pathology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV)and, University of Lausanne , Lausanne, Switzerland
| | - Carmen Barcena
- Institute of Pathology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV)and, University of Lausanne , Lausanne, Switzerland
| | - Andreas F Hottinger
- Department of Clinical Neurosciences, Service of Neurology, Lausanne University Hospital (CHUV)and, University of Lausanne , CHUV-BH07, Lausanne, Switzerland
- Lundin Family Brain Tumor Research Centre, Departments of Oncology & Clinical Neurosciences, Lausanne University Hospital (CHUV)and, University of Lausanne , Lausanne, Switzerland
| | - Caroline Pot
- Department of Clinical Neurosciences, Service of Neurology, Lausanne University Hospital (CHUV)and, University of Lausanne , CHUV-BH07, Lausanne, Switzerland.
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Work E, Gupta D, Slayton WB, Rees J, Coppola JA, Seifert R, Bleiweis MS, Jacobs JP, Peek G, Philip J, Brock A, Rivera JH, Sullivan K, Narasimhulu SS. Epstein Barr virus-directed T-cell therapy for refractory EBV-PTLD in a toddler post Orthotopic heart transplantation. Pediatr Transplant 2024; 28:e14707. [PMID: 38419558 DOI: 10.1111/petr.14707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/08/2024] [Accepted: 01/23/2024] [Indexed: 03/02/2024]
Abstract
Epstein-Barr Virus (EBV) is a ubiquitous herpes type virus that is associated with post-transplant lymphoproliferative disorder (PTLD). Usual management includes reduction or cessation of immunosuppression and in some cases chemotherapy including rituximab. However, limited therapies are available if PTLD is refractory to rituximab. Several clinical trials have investigated the use of EBV-directed T cells in rituximab-refractory patients; however, data regarding response is scarce and inconclusive. Herein, we describe a patient with EBV-PTLD refractory to rituximab after orthotopic heart transplantation (OHT) requiring EBV-directed T-cell therapy. This article aims to highlight the unique and aggressive clinical presentation and progression of PTLD with utilization of EBV-directed T-cell therapy for management and associated pitfalls.
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Affiliation(s)
- Emily Work
- University of Florida, Gainesville, Florida, USA
| | - Dipankar Gupta
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - William B Slayton
- Division of Hematology and Oncology, University of Florida, Gainesville, Florida, USA
| | - John Rees
- Department of Radiology, University of Florida, Gainesville, Florida, USA
| | | | - Robert Seifert
- Department of Pathology, University of Florida, Gainesville, Florida, USA
| | - Mark S Bleiweis
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Jeffrey P Jacobs
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Giles Peek
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Joseph Philip
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Alan Brock
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | | | - Kevin Sullivan
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
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Hahn C, Budhram A, Alikhani K, AlOhaly N, Beecher G, Blevins G, Brooks J, Carruthers R, Comtois J, Cowan J, de Robles P, Hébert J, Kapadia RK, Lapointe S, Mackie A, Mason W, McLane B, Muccilli A, Poliakov I, Smyth P, Williams KG, Uy C, McCombe JA. Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults. Can J Neurol Sci 2024:1-21. [PMID: 38312020 DOI: 10.1017/cjn.2024.16] [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: 02/06/2024]
Abstract
Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.
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Affiliation(s)
- Christopher Hahn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Adrian Budhram
- Clinical Neurological Sciences, London Health Sciences Centre, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Katayoun Alikhani
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nasser AlOhaly
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Grayson Beecher
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Gregg Blevins
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - John Brooks
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jacynthe Comtois
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine Ottawa Hospital, Ottawa, ON, Canada
| | - Paula de Robles
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sarah Lapointe
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Warren Mason
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Brienne McLane
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | | | - Ilia Poliakov
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | - Penelope Smyth
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | - Christopher Uy
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
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Momen N, Tario J, Fu K, Qian YW. Initial and follow-up evaluations on cerebrospinal fluid involvement by hematologic malignancy. J Hematop 2023; 16:131-140. [PMID: 38175400 DOI: 10.1007/s12308-023-00550-x] [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] [Received: 02/10/2023] [Accepted: 06/07/2023] [Indexed: 01/05/2024] Open
Abstract
Central nervous system (CNS) involvement is a serious complication in hematologic malignancy, and early detection and management of CNS involvement in these cases significantly impact the prognosis. Currently, there is no consensus on the use of multiparametric flow cytometry (MFC) and conventional cytology (CC) testing for initial and follow-up cerebrospinal fluid (CSF) specimens to diagnose CNS involvement by hematologic malignancy. In our institution, after initial MFC and CC, two subsequent negative MFCs are required before discontinuing MFC. The aim of this study is to evaluate the outcome of this approach. CSF cytology and MFC reports were retrieved from Laboratory Information System, and data was reviewed. Between January 2020 and December 2021, 1789 CSF samples from 280 patients were submitted for CSF analysis. For those 517 CSF samples tested by both MFC and CC, 97 cases tested positive by both MFC and CC with 95% concordance. Eighteen cases were MFC + /CC - and 7 were MFC - /CC + . Thirty-six cases had initially positive MFCs followed by more than one MFC evaluation. Among those 36 cases, 22 cases (61.1%) converted to negative after the second follow-up sample, 9 cases (25%) were continuously positive for at least three samples, and 5 cases (13.9%) exhibited negative to positive conversion. Compared to negative CSF cases, positive CSFs had higher total nucleated cell count and higher total protein levels while red blood cells, glucose, and lactate dehydrogenase levels remained at comparable levels. The concordance between MFC and CC was excellent. The high incidence of positive MFCs on two or more follow-up samples and the high frequency of negative MFC to positive conversion indicate the necessity of repeated negative MFCs before discontinuing MFC. The fact that more than half of the positive cases converted to negative after the second CSF specimen and most follow-up positive cases can be detected by CC alone suggests it is adequate to use CC alone for follow-up CSF study after two consecutive negative MFCs.
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Affiliation(s)
- Nouran Momen
- Department of Pathology and Laboratory Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
- Clinical & Chemical Pathology Department, Cairo University, Cario, Egypt
| | - Joseph Tario
- Department of Pathology and Laboratory Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Kai Fu
- Department of Pathology and Laboratory Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - You-Wen Qian
- Department of Pathology and Laboratory Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA.
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Saad T, Tuck A, Golestani F, Smith P, McCulloch R. Primary central nervous system lymphoma: a practical guide for neurologists. Pract Neurol 2023:pn-2022-003656. [PMID: 36823116 DOI: 10.1136/pn-2022-003656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 02/25/2023]
Abstract
Primary central nervous system lymphoma is rare, comprising 4% of intracranial neoplasms. Although haematologists or oncologists subsequently manage the condition, it is often neurologists who first make, or at least suspect, the diagnosis. This article reviews the disease, its clinical and radiological features and details the work-up needed to achieve a diagnosis (namely histological or cytological confirmation) and to prepare the patient for treatment. We note the importance of brain biopsy, the role of corticosteroids and the varied treatment options.
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Affiliation(s)
- Toni Saad
- Department of Neurology, Gloucestershire Royal Hospital, Gloucester, UK
| | | | - Farhad Golestani
- Department of Neurology, Gloucestershire Royal Hospital, Gloucester, UK
| | - Paul Smith
- Department of Neurology, Gloucestershire Royal Hospital, Gloucester, UK.,Neuroradiology, North Bristol NHS Trust, Bristol, UK
| | - Rory McCulloch
- Haematology, Gloucestershire Royal Hospital, Gloucester, UK
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Cell-Free DNA in Cerebrospinal Fluid Complements the Monitoring Value of Interleukin-10 in Newly Diagnosed Primary Central Nervous System Lymphoma. JOURNAL OF ONCOLOGY 2023; 2023:5808731. [PMID: 36644235 PMCID: PMC9836788 DOI: 10.1155/2023/5808731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/11/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023]
Abstract
Objectives Primary central nervous system lymphoma (PCNSL) usually has a poor prognosis. Cerebrospinal fluid (CSF) interleukin (IL)-10 has shown diagnostic, prognostic, and monitoring value in our previous studies. Cell-free circulating tumor DNA can be detected in the CSF of refractory/relapse cases and has also shown monitoring value. However, information about its monitoring value in newly diagnosed PCNSL patients and comparisons of CSF IL-10 and CSF cell-free DNA (cfDNA) are scarce. Methods We performed next-generation sequencing on paraffin-embedded tissue and the serial CSF cfDNA of 10 newly diagnosed PCNSL patients and on the baseline CSF cfDNA of 11 other central nervous system lymphoma patients. We also monitored the CSF IL-10 levels of the 10 newly diagnosed PCNSL patients. Results In seven newly diagnosed PCNSL patients with sufficient baseline CSF cfDNA, six had ≥1 mutated genes in their CSF cfDNA. The most common were MYD88(4/7), PIM1(3/7), MLL2(3/7), and ETV6(2/7). We also identified multiple somatic mutations, most commonly in PIM1. MYD88L265P can be detected in both tumor tissue and CSF cfDNA. The genomic profiles of CFS cfDNA were similar in PCNSL and PIOL patients. Newly diagnosed PCNSL patients with persistently positive cfDNA and negative IL-10 progressed quickly, while those with negative cfDNA and negative IL-10 were in maintenance therapy for more than 18 months. Two patients without cfDNA had increased CSF IL-10 concentrations before disease relapse. These results indicate that negative CSF cfDNA predicts better results, and persistently positive CSF cfDNA predicts disease progression earlier than conventional magnetic resonance imaging. Conclusion In conclusion, CSF cfDNA is a potential predictor of relapse and progression, which complements the monitoring value of CSF IL-10 in newly diagnosed PCNSL patients.
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Mokhtari M, Alizadeh A, Monabati A, Safaei A. Comparison of flowcytometry and conventional cytology for diagnosis of CNS involvement in hematologic malignancies. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2022. [DOI: 10.1016/j.phoj.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Murthy NK, Amrami KK, Broski SM, Johnston PB, Spinner RJ. Perineural spread of peripheral neurolymphomatosis to the cauda equina. J Neurosurg Spine 2021:1-6. [PMID: 34598154 DOI: 10.3171/2021.4.spine21344] [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: 03/03/2021] [Accepted: 04/28/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neurolymphomatosis (NL) is a rare manifestation of lymphoma confined to the peripheral nervous system that is poorly understood. It can be found in the cauda equina, but extraspinal disease can be underappreciated. The authors describe how extraspinal NL progresses to the cauda equina by perineural spread and the implications of this on timely and safe diagnostic options. METHODS The authors used the Mayo Clinic medical records database to find cases of cauda equina NL with sufficient imaging to characterize the lumbosacral plexus diagnosed from tissue biopsy. Demographics (sex, age), clinical data (initial symptoms, cerebrospinal fluid, evidence of CNS involvement, biopsy location, primary or secondary disease), and imaging findings were reviewed. RESULTS Ten patients met inclusion and exclusion criteria, and only 2 of 10 patients presented with cauda equina symptoms at the time of biopsy, with 1 patient undergoing a cauda equina biopsy. Eight patients were diagnosed with diffuse large B-cell lymphoma, 1 with low-grade B-cell lymphoma, and 1 with mantle cell lymphoma. Isolated spinal nerve involvement was identified in 5 of 10 cases, providing compelling evidence regarding the pathophysiology of NL. The conus medullaris was not radiologically involved in any case. Lumbosacral plexus MRI was able to identify extraspinal disease and offered diagnostically useful biopsy targets. FDG PET/CT was relatively insensitive for detecting disease in the cauda equina but was helpful in identifying extraspinal NL. CONCLUSIONS The authors propose that perineural spread of extraspinal NL to infiltrate the cauda equina occurs in two phases. 1) There is proximal and distal spread along a peripheral nerve, with eventual spread to anatomically connected nerves via junction and branch points. 2) The tumor cells enter the spinal canal through corresponding neural foramina and propagate along the spinal nerves composing the cauda equina. To diffusely infiltrate the cauda equina, a third phase occurs in which tumor cells can spread circumdurally to the opposite side of the spinal canal and enter contralateral nerve roots extending proximally and distally. This spread of disease can lead to diffuse bilateral spinal nerve disease without diffuse leptomeningeal spread. Recognition of this phasic mechanism can lead to identification of safer extraspinal biopsy targets that could allow for greater functional recovery after appropriate treatment.
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Affiliation(s)
| | | | | | - Patrick B Johnston
- 3Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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