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Intrathecal therapy for the management of leptomeningeal metastatic disease: a scoping review of the current literature and ongoing clinical trials. J Neurooncol 2022; 160:79-100. [PMID: 35999434 DOI: 10.1007/s11060-022-04118-0] [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: 07/29/2022] [Accepted: 08/16/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE Leptomeningeal metastatic disease (LMD) from advanced malignancies has poor prognoses and limited treatments. Intrathecal therapy (ITT) protocols are available, showing variable outcomes. We reviewed the therapeutic and toxicity profiles of ITT in LMD. METHODS PubMed, EMBASE, Web-of-Science, and Scopus were searched following the PRISMA-ScR guidelines to include studies reporting ITT for LMD. CLINICALTRIAL gov and Cochrane were searched to identify ongoing clinical trials. RESULTS We included 27 published studies encompassing 2161 patients and 4 ongoing trials. LMD originated from brain metastases (85.5%), lymphomas (5.4%), high-grade gliomas (4.6%), medulloblastomas (2.3%), and leukemias (2.1%). LMD was mostly diagnosed with the co-presence of neurological-related symptoms and positive imaging and/or cerebrospinal fluid cytology (60.8%). The most common ITT agents were methotrexate (35.9%), cytarabine (21.9%), and thiotepa (8.2%), standalone or combined. Patients received a median of 6.5 ITT cycles (range, 1.0-71.0) via intraventricular (58.8%) or lumbar intrathecal (41.2%) routes. The Ommaya reservoir was implanted in 38.5% cases. Concurrent systemic chemotherapy (45.2%) and/or radiotherapy (30.6%) were used. After 1-3 cycles, 44.7% patients had improved clinical status and 29.9% converted into negative cerebrospinal fluid cytology. The most common ITT-related severe adverse events were neutropenia (6.5%), meningitis (5.2%) and encephalopathy (4.5%). Median freedom from progression was 2.4 months (range, 0.1-59.5) and median overall survival 5.5 months (range, 0.1-148.0). CONCLUSION Current ITT protocols are variable but effective and well-tolerated in LMD. Ongoing trials are investigating dose-limiting toxicity profiles and long-term overall survival. Future studies should analyze the therapeutic and safety profiles of ITT compared to newer systemic therapies.
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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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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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Lad D, Malhotra P, Varma N, Sachdeva MS, Das A, Srinivasan R, Bal A, Khadwal A, Prakash G, Suri V, Kumari S, Jain S, Varma S. CLL: Common Leukemia; Uncommon Presentations. Indian J Hematol Blood Transfus 2014; 32:268-75. [PMID: 27429518 DOI: 10.1007/s12288-014-0488-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 12/03/2014] [Indexed: 12/25/2022] Open
Abstract
We report here a series of ten patients with uncommon presentations and associations of chronic lymphocytic leukemia (CLL) not reported hitherto or occasionally reported in literature. The first two cases describe unusual causes of abdominal distension in CLL and unusual sites infiltration by CLL. The next two cases illustrate occurrence of CLL in association with other hematological malignancies. Cases five and six describe unusual infections and their impact on CLL. Cases seven and eight depict associations of rare non-hematological autoimmune conditions with CLL. The last two cases describe transformation at unusual sites. This series of ten cases illustrates how a common leukemia like CLL can present in different forms and how despite so much progress in understanding of this leukemia so little is known of such presentations.
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Affiliation(s)
- Deepesh Lad
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Pankaj Malhotra
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Neelam Varma
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manupdesh Singh Sachdeva
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashim Das
- Department of Pathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Radhika Srinivasan
- Department of Cytology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjit Bal
- Department of Pathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Khadwal
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Gaurav Prakash
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Vikas Suri
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Savita Kumari
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Sanjay Jain
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Subhash Varma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
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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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Rossi C, Brisou G, Baseggio L, Roch J, Safar V, Karlin L, Sesques P, Bouafia-Sauvy F, Lebras L, Coiffier B, Salles G, Michallet AS. Central nervous system involvement in chronic lymphocytic leukemia: uncommon manifestation with undefined therapeutic management. Leuk Lymphoma 2014; 55:1939-41. [PMID: 24237449 DOI: 10.3109/10428194.2013.858152] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Cédric Rossi
- Department of Hematology, Centre Hospitalier Lyon Sud , Pierre Bénite , France
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Jain P, Benjamini O, Pei L, Caraway NP, Landon G, Kim S, Shivaprasad S, Woodman K, O'Brien S, Ferrajoli A, Kadia T, Estrov Z. Central nervous system Richter's transformation and parvovirus B19 infection. Leuk Lymphoma 2013; 54:2070-2. [PMID: 23320889 DOI: 10.3109/10428194.2013.765565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
MESH Headings
- Aged
- Bone Marrow/pathology
- Central Nervous System/pathology
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphocytes/metabolism
- Lymphocytes/pathology
- Male
- Optic Disk/pathology
- Parvoviridae Infections/complications
- Parvoviridae Infections/diagnosis
- Parvovirus B19, Human
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Benjamini O, Jain P, Schlette E, Sciffman JS, Estrov Z, Keating M. Chronic lymphocytic leukemia with central nervous system involvement: a high-risk disease? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 13:338-41. [PMID: 23332395 DOI: 10.1016/j.clml.2012.12.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 12/06/2012] [Accepted: 12/08/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Ohad Benjamini
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
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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.
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