Non-Hodgkin's lymphoma involving the central nervous system

Central nervous involvement by chronic lymphocytic leukaemia

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.

Isolated recurrence of secondary CNS lymphoma: case report and literature review

Isolated secondary central nervous system lymphoma (SCNSL) relapse is a rare disease. Consequently, standardized treatment regimens have yet to be developed. We present an interesting case of isolated SCNSL presenting with altered mental status and panhypopituitarism in a patient at low risk of developing the disease. We also review the related literature and discuss newer, more aggressive treatments for primary CNS lymphoma and SCNSL.

Primary lymphoblastic B-cell lymphoma of the cranial dura mater: a case report and review of the literature

Primary lymphomas of the cranial dura mater are rare. Mucosa-associated lymphoid tissue extranodal marginal zone lymphomas are the most common subtype of non-Hodgkin's lymphomas that present as primary cranial dura tumors. A 33 year-old male presented with a 3-month history of a growing lump in the right frontal area. Neuroimaging studies demonstrated an extra-axial, broad-based mass with a dural tail in the right frontal bone convexity. Biopsy led to the diagnosis of localized dural precursor B-cell lymphoblastic lymphoma. The patient was treated with a combination of chemotherapy and radiotherapy, achieving durable disease-free survival. This is the first report of precursor B-cell lymphoblastic lymphoma of dura mater. A review of the literature on primary lymphomas of cranial dura mater is presented. Primary lymphomas of the cranial dura mater are rare. Mucosa-associated lymphoid tissue extranodal marginal zone lymphomas are the most common subtype of non-Hodgkin's lymphomas that present as primary cranial dura tumors. A 33 year-old male presented with a 3-month history of a growing lump in the right frontal area. Neuroimaging studies demonstrated an extra-axial, broad-based mass with a dural tail in the right frontal bone convexity. Biopsy led to the diagnosis of localized dural precursor B-cell lymphoblastic lymphoma. The patient was treated with a combination of chemotherapy and radiotherapy, achieving durable disease-free survival. This is the first report of precursor B-cell lymphoblastic lymphoma of dura mater. A review of the literature on primary lymphomas of cranial dura mater is presented.

Central nervous system-directed preventative therapy in adults with lymphoma

All adult patients with Burkitt lymphoma or lymphoblastic lymphoma should receive central nervous system (CNS)-directed therapy with both intrathecal and high-dose systemic chemotherapy. There is no evidence to support the routine use of prophylactic CNS-directed therapy in any specific subgroup of adult patients with 'low grade' lymphomas. There are some anatomical sites where involvement by lymphoma is associated with a higher risk of CNS relapse. These probably include testis, breast, paranasal sinuses and the epidural space. Multivariate analyses strongly support a raised serum lactate dehydrogenase level and the involvement of more than one extranodal site as the strongest predictors of subsequent CNS relapse. A high International Prognostic Index score may replace the use of the above two factors in combination. There is evidence of good efficacy when intrathecal chemotherapy and high-dose systemic chemotherapy are used in combination. It is not clear how the best balance between the 'sensitivity' and 'specificity' of the choice of patients to receive CNS-directed therapy can be achieved.

Central nervous system involvement in indolent lymphomas

BACKGROUND

Central nervous system (CNS) involvement, a well-recognized complication of aggressive non-Hodgkin's lymphomas (NHL), has rarely been reported in indolent lymphomas. Large series have reported this complication in 3% of indolent NHLs, generally following histological transformation.

PATIENTS AND METHODS

We retrospectively reviewed the disease characteristics and clinical course in seven patients (six females, one male) with indolent B-cell lymphomas who developed CNS involvement during various stages of their illness.

RESULTS

The median ages at diagnosis of systemic and CNS lymphoma were 60 and 63 years, respectively. Histologies were: small lymphocytic lymphoma (two), follicular lymphoma grade I (two), follicular lymphoma grade II (two) and unclear low-grade histology (one). There were diverse neurological symptoms. Two patients had parenchymal involvement, three had leptomeningial involvement and two had both. Systemic lymphoma was found in all patients, all but one having bone marrow involvement. Four patients had a transformation to high-grade histology. Six patients were treated with systemic and intra-cerebrospinal fluid chemotherapy, and two received radiotherapy as well. Five patients achieved CNS response. Survival was 1-9 years for treated patients (median 2 years). Three patients died of CNS disease.

CONCLUSIONS

CNS involvement is a rare and unexpected complication of indolent NHL, which should be considered in the differential diagnosis of patients presenting with new neurological signs. This condition is treatable and some patients have a long clinical course.

Neurologic complications of hematologic neoplasms

The new WHO classification of hematopoietic and lymphatic neoplasms was devised to offer pathologists, oncologists, and geneticists a system of classification based on histopathologic, clinical, and genetic features. From the neurologic standpoint, it offers an opportunity to consolidate the complications produced by leukemias, lymphomas, and plasma cell dyscrasias. This article summarizes such complications that occur as a result of direct infiltration or compression of nervous tissue by tumor or as a result of indirect effects such as infection, vascular disorders, iatrogenesis, and paraneoplasia.

Central nervous system involvement following diagnosis of non-Hodgkin's lymphoma: a risk model

BACKGROUND

To determine the incidence and risk factors for central nervous system (CNS) relapse in patients with non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

Patient records were registered prospectively in successive patients with NHL admitted to the Norwegian Radium Hospital from 1980 to 1996. A total of 2514 patients had no CNS involvement at diagnosis and were treated according to standard protocols. The incidence and risk factors for CNS progression or relapse were examined retrospectively.

RESULTS

In low-grade (L)-NHL, the risk of CNS involvement was low (2.8%). In high-grade (H)-NHL, lymphoblastic and Burkitt's NHL patients had a high risk of CNS recurrence (24.4%) at 5 years, and prophylaxis seemed to reduce this risk. For the other patients with H-NHL, the proportion with CNS involvement at 5 years was 5.2%. Multivariate analysis identified five independent risk factors, each present in >5% of patients: elevated serum lactate dehydrogenase, serum albumin <35 g/l, <60 years of age, retroperitoneal lymph node involvement and involvement of more than one extranodal site. If four or five of these risk factors were present, the risk of CNS recurrence was in excess of 25% at 5 years.

CONCLUSIONS

The risk of CNS involvement in this study is comparable with the results from other large series. CNS prophylaxis is not recommended in any subgroup of L-NHL. The risk of CNS involvement among patients with either Burkitt's or lymphoblastic lymphomas is considerable and these patients should therefore receive intensive chemotherapy including systemic and intrathecal methotrexate. Patients with other types of H-NHL should receive adequate CNS prophylaxis if at least four of the five risk factors identified are present.

Central nervous system relapse of systemic non-Hodgkin's lymphoma: results of treatment based on high-dose methotrexate combination chemotherapy

The objective of this study was to evaluate the feasibility and possible response to pre-radiation chemotherapy given to patients with central nervous system (CNS) relapse of systemic non-Hodgkin's lymphoma (NHL). Twenty-three consecutive adult patients with systenic NHL and first CNS relapse were evaluated by CSF cytology and neuroaxis MRI. Treatment was based on weekly high-dose methotrexate (HD-MTX) 3.5 g/m2 and weekly intra-CSF cytarabine (ARA-C). Oral procarbazine 100 mg/m2 days 2-15 was added to patients whose bone marrow reserve could tolerate this drug. Radiation therapy (RT) to the CNS was deferred in responding/stable CNS disease. All patients with leptomeningeal seeding, but without parenchymal involvement responded to treatment prior to RT with 33% achieving a complete response (CR). Concomitant response of systemic disease was noted in 36% of the cases with 9% CR. Addition of RT to the CNS did not significantly change the overall rate of CR. Progression free survival for CNS disease was 5 months and for systemic disease 2 months. All patients with parenchymal involvement responded to therapy prior to RT with only 9% achieving CR, and the addition of RT in these cases increased the rate of CR to 24%. In this group, three of four patients who had active systemic disease responded systemically. Progression free survival was 3 months for both CNS and systemic disease. The median survival of the whole group was 6 months; 1-year survival 32% and 2-year survival 15%. In conclusion, systemic HD-MTX-based combination chemotherapy yields an initial response rate of 100% in the CNS and a 47% concomitant systemic response. A complete CNS response can be obtained prior to RT but this adds little to the overall CR rate. Durable responses are rare. Since both CNS and systemic relapses appear in tandem, future trials should evaluate alternative modalities in order to enhance drug delivery into the CNS.

Clinical, immunologic, and pathologic correlates of bone marrow involvement in 291 patients with acquired immunodeficiency syndrome-related lymphoma

Bone marrow involvement is reported in approximately 25% of patients with newly diagnosed acquired immunodeficiency syndrome-related lymphoma (ARL). Studied were 291 patients with ARL, diagnosed and treated at one medical center between 1984 and 1998. Clinical, immunologic, and pathologic characteristics of patients with bone marrow involvement were compared with those of patients without marrow involvement. Bone marrow involvement was present in 55 patients (19%). Small noncleaved lymphoma was diagnosed in 38% of the entire group and was the most common pathologic subtype in patients with bone marrow involvement (55% versus 34%; P =.008). Analysis of complete blood counts revealed a median hemoglobin level of 10.6 g/dL in both marrow-positive and marrow-negative groups. In contrast, a platelet count lower than 100 000/microL was more common in patients with bone marrow involvement (27% versus 11%; P =.02). Patients with marrow involvement were more likely to have leptomeningeal (cerebrospinal fluid [CSF]) lymphoma than patients whose marrows were uninvolved (24% versus 7%; P <.001) and were also more likely to have high lactate dehydrogenase (LDH) (P =.002), bone involvement (P <.001), and/or systemic B symptoms including fever, night sweats, and/or weight loss (P =.05). Median survival did not differ between marrow-positive and marrow-negative groups. On multivariate analysis, factors associated with decreased survival of marrow-positive patients included greater than 50% involvement (P =.002), systemic B symptoms (P =.008), and high-grade histologic type (P =.035). Marrow involvement in ARL correlates with small noncleaved pathology, thrombocytopenia lower than 100 000 mm(3), high LDH, and lymphomatous involvement of the CSF. Survival is statistically shorter in patients with greater than 50% marrow involvement, high-grade pathology, and/or systemic B symptoms.

CNS involvement in primary mediastinal large B-cell lymphoma

PURPOSE

The risk of CNS involvement by non-Hodgkin's Lymphoma (NHL) has been associated with bone marrow and/or testicular involvement; however, it was recently reported that the number of extranodal sites is a more reliable predictor of CNS disease. Because primary mediastinal thymic large B-cell lymphoma (PMLCL) has a high propensity for involving extranodal sites, we investigated the frequency and pattern of CNS involvement in PMLCL.

PATIENTS AND METHODS

The medical records of 219 patients with aggressive NHL, consecutively entered onto protocols at the National Cancer Institute between 1987 and 1998, were retrospectively reviewed.

RESULTS

Twenty-three patients (11%) had clinical and pathologic features of PMLCL. These patients were young (median age, 29 years), female (61%), and presented with massive mediastinal adenopathy (70%). Extranodal disease occurred at presentation in 70% and at relapse in 93% of patients and involved contiguous intrathoracic structures and/or distant sites, including the lungs, kidneys, liver, adrenals, ovaries, pancreas, and bone. Six patients (26%) developed CNS involvement, two (9%) at presentation and four (27%) at relapse. All had extranodal disease, but only one had bone marrow involvement. Parenchymal and leptomeningeal CNS disease occurred in four and three patients, respectively.

CONCLUSION

CNS involvement in PMLCL is associated with extranodal involvement other than bone marrow and may reflect the unique biology of this disease. The propensity to involve the CNS parenchyma raises the concern that intrathecal prophylaxis may not be effective and suggests that CNS imaging should be considered in patients with extranodal disease.

Lymphoma at uncommon sites

Lymphoma can often present in unusual situations. This article provides a comprehensive review of the literature in which both non-Hodgkin's lymphoma and Hodgkin's disease are discussed.

Risk factors for central nervous system involvement in non-Hodgkins-lymphoma--a multivariate analysis

A consecutive cohort of patients with NHL was examined to identify the factors predictive of CNS-involvement with Cox's proportional hazards model in a multivariate analysis. Twenty-seven cases of CNS-involvement were found among 498 patients with NHL. Only 3 of 96 patients with low-grade lymphomas had CNS involvement, all occurring after transformation into high-grade lymphoma. In univariate analysis of 402 patients with intermediate or high-grade lymphoma, lymphoblastic histology (including Burkitt's lymphoma), age <35 years, B-symptoms, stage IV disease, testis involvement and bone marrow involvement were found to be statistically significant risk factors. Lymphoblastic histology was found to be strongly correlated to age younger than 35 years. In the multivariate analysis only lymphoblastic histology, stage IV disease and B-symptoms were found to be significantly associated with CNS involvement. It is concluded that CNS prophylaxis should be considered in all patients with lymphoblastic histology and in patients with stage IV B lymphomas other than those of low-grade types.