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Lambe G, Doran S, Clifford R, Nasoodi A. Isolated CNS relapse of medullary aggressive high-grade B-cell lymphoma on 18F-FDG-PET/CT. Eur J Hybrid Imaging 2022; 6:9. [PMID: 35501493 PMCID: PMC9061919 DOI: 10.1186/s41824-022-00130-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/06/2022] [Indexed: 11/10/2022] Open
Abstract
This is a case of high-risk, aggressive, high-grade medullary B-cell lymphoma presenting with new onset of neurological dysfunction following initial complete response to the standard chemoimmunotherapy. A whole-body re-staging PET using fluorodeoxyglucose (18F-FDG) integrated with computed tomography (18FDG-PET/CT) performed with clinical suspicion of arachnoiditis, eloquently demonstrated unequivocal multifocal FDG uptake by the spinal cord without evidence of systemic recurrence, leading to a clinical diagnosis of secondary CNS lymphoma, which is a rare complication of DLBCL with ominous prognosis. Four cycles of Modified-MATRIX protocol resulted in a halt in fulminant course of the disease and the patient experienced slight reversal of the neurological deficits, although not deemed clinically fit for a repeat 18FDG-PET/CT due to his poor general well-being. Repeat MRI was suggestive of partial recovery, however. The clinical stability was proven short-lived, and the patient experienced progressive lower limb weakness only 3 weeks after discharge following his last cycle of treatment. Isolated CNS relapse of lymphoma is a rare occurrence in the literature. The CNS recurrence is more often leptomeningeal or confined to the brain parenchyma rather than the spinal cord. The role of 18FDG-PET/CT in the diagnostic algorithm of secondary CNS lymphoma is unclear and its significance in risk stratification and assessing the response to treatment has not been evaluated. This case report illustrates the imaging findings of a more unusual form of the disease with multifocal intramedullary involvement of the spinal cord, and highlights imaging features of this rare condition with 18FDG-PET/CT and MRI to support decision making in good clinical practice.
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Affiliation(s)
- Gerard Lambe
- Radiology Department, Mater Misericordiae University Hospital, Eccles Street,, Dublin 7, Ireland
| | - Simon Doran
- Radiology Department, St. James's Hospital, James's Street, Dublin 8, Ireland
| | - Ruth Clifford
- Haematology Department, University Hospital Limerick, St Nessan's Road, Dooradoyle, County Limerick, Ireland
| | - Afshin Nasoodi
- Radiology Department, Mater Misericordiae University Hospital, Eccles Street,, Dublin 7, Ireland.
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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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Conway EA, Waugh EM, Knottenbelt C. A case of T-cell chronic lymphocytic leukemia progressing to Richter syndrome with central nervous system involvement in a dog. Vet Clin Pathol 2020; 49:147-152. [PMID: 32215932 DOI: 10.1111/vcp.12839] [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: 08/09/2019] [Accepted: 09/19/2019] [Indexed: 11/28/2022]
Abstract
An 8-year-old neutered Beagle dog was presented with polyuria and polydipsia. Routine clinicopathologic testing showed a significant lymphocytosis and proteinuria. Lymphocytes were of small to intermediate in size with a mature morphology. Infectious disease screening was negative. PCR for antigen receptor gene rearrangements showed a clonal T-cell receptor (TCR) rearrangement consistent with T-cell chronic lymphocytic leukemia (CLL). Bone marrow cytology showed <30% lymphocytes, while the proportion in splenic fine-needle aspirate cytology was considered increased. The dog was initially monitored but started on prednisolone and chlorambucil therapy 2 months later due to worsening clinical signs and progressive lymphocytosis. After an additional 2 weeks, the dog developed multifocal spinal pain and single-node lymphadenomegaly. Cytology of the lymph node showed a monomorphic population of large lymphoblasts consistent with lymphoma. Cytology of a cerebrospinal fluid sample also showed large lymphoblasts. PCR for antigen receptor gene rearrangement at both sites showed a clonal TCR rearrangement of the same molecular size as in the initial leukemic cells. The dog was diagnosed with a transformation of the CLL to Richter syndrome (RS) with involvement of the central nervous system (CNS). Therapy was started with L-asparaginase and an increased dose of prednisolone; however, the dog was euthanized due to progressive clinical signs. To our knowledge, this is the first report of canine RS with direct involvement of the CNS.
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Affiliation(s)
- Elizabeth A Conway
- School of Veterinary Medicine, Small Animal Hospital, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK
| | - Elspeth M Waugh
- Veterinary Diagnostic Services, School of Veterinary Medicine, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK
| | - Clare Knottenbelt
- School of Veterinary Medicine, Small Animal Hospital, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK
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Xu L, Song JC, Sun XH, Gao ZF, Lv L, Zhu J. Richter's syndrome of the central nervous system diagnosed concurrently with chronic lymphocytic leukaemia: A case report and literature review. Medicine (Baltimore) 2018; 97:e12701. [PMID: 30313065 PMCID: PMC6203471 DOI: 10.1097/md.0000000000012701] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 09/11/2018] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Central nervous system (CNS) infiltration of Richter's syndrome (RS) is rare and only a few cases were discussed. Of these published cases, either they were accompanied with lymph node involvement or with a history of chronic lymphocytic leukemia (CLL). To our knowledge, this is the first published case of RS of the brain and meninges diagnosed concurrently with CLL in the absence of any evidence of lymphoma outside of the CNS. PATIENT CONCERNS A 67-year-old female presented with slurred speech, headache, and left-sided hemiparesis. Magnetic resonance imaging of the brain revealed an irregular lesion 30 mm in diameter in the right parietal lobe. The mass was totally removed and pathology revealed diffuse large B-cell lymphoma (DLBCL) of non-germinal center type by Hans' classification. The patient's leukocyte count was 12.1 × 109/L (76.9% lymphocytes), and fluorescence-activated cell sorting (FACS) analysis of blood revealed a clonal B-cell population (36.75% leukocytes) corresponding to the immunological CLL profile (Matutes score of 5/5). Bone marrow (BM) aspiration and biopsy also indicated CLL. The analysis of immunoglobulin heavy chain gene (IGH) and kappa chain gene (IGK) in the patient's BM and CNS tissue indicated that the DLBCL of the brain was derived from the CLL clone. DIAGNOSES RS of the CNS diagnosed concurrently with CLL. INTERVENTIONS The patient received intravenous chemotherapy (6.0 g methotrexate) and intrathecal chemotherapy (10 mg methotrexate, 50 mg cytarabine, 5 mg dexamethasone). OUTCOMES The patient returned to our department with left-sided hemiparesis and headache 2 weeks after the chemotherapy. Repeat MRI showed progression of the brain lesion. Her general condition deteriorated significantly with confusion and high fever, and she died within a few days at only 10 weeks after the onset of symptoms. LESSONS The survival of CNS-RS patients is very poor and and is always complicated with multiple and different genetic alterations. Because of chemotherapy insensitivity, a multidisciplinary treatment including surgery and radiotherapy together with novel agents may be an option to improving patient outcomes.
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MESH Headings
- Aged
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Central Nervous System/pathology
- Female
- Flow Cytometry
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukocyte Count
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
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Affiliation(s)
- Liye Xu
- Myeloma and Lymphoma Research Center
| | | | - Xiu Hua Sun
- Myeloma and Lymphoma Research Center, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province
| | - Zi Fen Gao
- Department of Pathology, Peking University, Third Hospital, Beijing
| | | | - Jie Zhu
- Flow Cytometry Center, Second Affiliated Hospital of Dalian Medical University, Dalian, China
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Isolated Richter's syndrome of the brain: diagnosis in the eye of the beholder. Ann Hematol 2018; 97:1509-1511. [PMID: 29627880 DOI: 10.1007/s00277-018-3322-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 03/30/2018] [Indexed: 10/17/2022]
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DeRosa P, Cappuzzo JM, Sherman JH. Isolated recurrence of secondary CNS lymphoma: case report and literature review. J Neurol Surg Rep 2014; 75:e154-9. [PMID: 25083377 PMCID: PMC4110153 DOI: 10.1055/s-0034-1378152] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 04/04/2014] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Peter DeRosa
- Department of Neurological Surgery, The George Washington University, Washington, District of Columbia, United States
| | - Justin M Cappuzzo
- School of Medical and Health Sciences, The George Washington University, Washington, District of Columbia, United States
| | - Jonathan H Sherman
- Department of Neurological Surgery, The George Washington University, Washington, District of Columbia, United States
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Di Pauli F, Berger T, Walder A, Maier H, Rhomberg P, Uprimny C, Steurer M, Stockhammer G. Progressive multifocal leukoencephalopathy complicating untreated chronic lymphatic leukemia: case report and review of the literature. J Clin Virol 2014; 60:424-7. [PMID: 24929753 DOI: 10.1016/j.jcv.2014.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 04/28/2014] [Accepted: 05/10/2014] [Indexed: 11/27/2022]
Abstract
A 58-year old female with a four-year history of previously untreated CLL at Binet stage A complained about word finding problems, impaired vision, and gait unsteadiness. Concerning her CLL she was asymptomatic and had never required any specific treatment. Her neurological examination disclosed cognitive alterations, homonyme hemianopia to the right, aphasia, and mild right-sided hemiparesis. Cerebral MRI showed a hyperintense lesion on T2 weighted images without contrast enhancement. CSF examination revealed normal findings, including CSF protein, cell count, cytology and PCR-analysis was negative for the presence of JC virus DNA. On follow-up MRI, performed 2 weeks later, the T2 lesion was further enlarging. Subsequent stereotactic brain biopsy was diagnostic for PML revealing abnormal oligodendrocytes staining positive against antibodies specific for simian vacuolating virus 40. In addition, repeated CSF analyses for JC-Virus DNA in the course of the disease became positive. After confirmation of diagnosis treatment with mirtazapine (30 mg/d) and mefloquine (250 mg/d) was initiated. Rapid clinical progression correlated to further worsening on MRI. Therefore this treatment was terminated after 16 days and the regime was changed to a five-day courses of cytarabine (2 mg/kg/d) combined with intrathecal administration of liposomal cytarabine (50 mg). Due to further clinical progression with global aphasia, blindness and severe right-sided hemiparesia, medication was stopped. The Patient died three and a half months after onset of symptoms.
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Affiliation(s)
- Franziska Di Pauli
- Clinical Department of Neurology, Innsbruck Medical University, Anichstr. 35, 6020 Innsbruck, Austria.
| | - Thomas Berger
- Clinical Department of Neurology, Innsbruck Medical University, Anichstr. 35, 6020 Innsbruck, Austria
| | - Alois Walder
- Division of Haematology & Oncology, Regional Hospital Lienz, Emanuel-von-Hibler-Str 5, 9900 Lienz, Austria
| | - Hans Maier
- Institute of Pathology, Innsbruck Medical University, Anichstr. 35, 6020 Innsbruck, Austria
| | - Paul Rhomberg
- Department of Radiology, Innsbruck Medical University, Anichstr. 35, 6020 Innsbruck, Austria
| | - Christian Uprimny
- Department of Nuclear Medicine, Innsbruck Medical University, Anichstr. 35, 6020 Innsbruck, Austria
| | - Michael Steurer
- Division of Haematology & Oncology, Innsbruck Medical University, Anichstr. 35, 6020 Innsbruck, Austria
| | - Guenther Stockhammer
- Clinical Department of Neurology, Innsbruck Medical University, Anichstr. 35, 6020 Innsbruck, Austria
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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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