Acute sciatica: an unusual presentation of extramedullary relapse of acute lymphoblastic leukemia

Painless progressive mononeuritis multiplex secondary to AML associated neuroleukemiosis

Neuroleukemiosis describes peripheral nerve involvement secondary to leukemic infiltration, a rare complication of leukemia with various clinical presentations, leading to diagnostic challenges for hematologists and neurologists. We present two cases of painless progressive mononeuritis multiplex secondary to neuroleukemiosis. A literature review of previously reported cases of neuroleukemiosis was undertaken. Neuroleukemiosis may present as a progressive mononeuritis multiplex. The diagnosis of neuroleukemiosis requires a high index of suspicion and be aided by repeated CSF analysis.

Neoplastic nerve lesions

Though metastasis and malignant infiltration of the peripheral nervous system is relatively rare, physicians should have a familiarity with their presentations to allow for prompt diagnosis and initiation of treatment. This article will review the clinical presentations, diagnostic evaluation, and treatment of neoplastic involvement of the cranial nerves, nerve roots, peripheral nerves, and muscle. Due to the proximity of the neural structure traversing the skull base, metastasis to this region results in distinctive syndromes, most often associated with breast, lung, and prostate cancer. Metastatic involvement of the nerve roots is uncommon, apart from leptomeningeal carcinomatosis and bony metastasis with resultant nerve root damage, and is characterized by significant pain, weakness, and numbness of an extremity. Neoplasms may metastasize or infiltrate the brachial and lumbosacral plexuses resulting in progressive and painful sensory and motor deficits. Differentiating neoplastic involvement from radiation-induced injury is of paramount importance as it dictates treatment and prognosis. Neurolymphomatosis, due to malignant lymphocytic infiltration of the cranial nerves, nerve roots, plexuses, and peripheral nerves, deserves special attention given its myriad presentations, often mimicking acquired demyelinating neuropathies.

Cardiac Relapse of Acute Lymphoblastic Leukemia Following Hematopoietic Stem Cell Transplantation: A Case Report and Review of Literature

Isolated extramedullary relapse of acute lymphoblastic leukemia (ALL) occurs in soft tissues and various organs outside the testis and central nervous system. Treatments such as hematopoietic stem cell transplantation and more novel modalities such as immunotherapy have eradicated ALL at extramedullary sites. In some instances, survival times for relapsed ALL at these sites are longer than those for relapsed disease involving only the bone marrow. Isolated relapse of ALL in the myocardium is rare, especially in children, making diagnosis and treatment of it difficult. More recent treatment options such as chimeric antigen receptor T-cell therapy carry a high risk of cytokine release syndrome and associated risk of worsening cardiac function. Herein we present the case of an 11-year-old boy who presented with relapsed symptomatic B-cell ALL in the myocardium following allogeneic hematopoietic stem cell transplantation. This is an unusual presentation of relapsed ALL and this case demonstrates the associated challenges in its diagnosis and treatment. The case report is followed by a literature review of the advances in treatment of pediatric leukemia and their application to extramedullary relapse of this disease in particular.

Brachial plexus chloroma as a presenting feature of relapse in a child with KMT2A-rearranged acute lymphoblastic leukemia, a case report

Approximately 30–40% of relapses in pediatric acute lymphoblastic leukemia (ALL) are extra-medullary. KMT2A gene rearrangements are common in patients with infantile ALL. Chloromas are rare tumors composed of collections of acute leukemic cells that typically involve the bone or skin. Exceptionally uncommon, chloromas invade the peripheral nervous system, a phenomenon termed “neuroleukemiosis.” We describe A 6-year-old girl with a history of pre-B ALL with CNS involvement and KMT2A rearrangement diagnosed initially at 4 months of age. During continuation therapy she developed a scalp mass that was confirmed to be a leukemic relapse. She underwent re-induction chemotherapy followed by blinatumomab with subsequent remission and proceeded to allogeneic hematopoietic cell transplant (HCT). Three years following HCT, she presented with brachial plexus palsy and was found to have a lymphoblastic chloroma invading the brachial plexus. Review of existing literature shows relapse in pediatric ALL patients presenting as brachial plexus chloroma has only been documented once before. It has long been suggested that KMT2A gene rearrangements play a role in development of chloromas in patients with AML, however it is still unclear what role KMT2A has in ALL. Here we report a rare case of ALL relapse that presented as a left arm palsy secondary to a leukemic chloroma invading the brachial plexus and aim to explore the potential role of KMT2A in the formation of ALL chloromas.

Clinical usefulness of ultrasound as an early diagnostic tool for neuroleukemiosis -a case report

Background

Neuroleukemiosis is a rare complication of leukemia. The diagnosis may be delayed owing to non-specific symptoms and the need for special diagnostic modalities.

Case

A 70-year-old man in his sixth year of remission from acute myeloid leukemia was referred to the pain clinic for shooting and radiating pain in the left posterior leg. A lumbar spine magnetic resonance imaging showed mild disc bulging of the L2-3, which was insufficient to explain the patient’s symptoms. With insufficient pain response to lumbar epidural block and piriformis injection, we examined both sciatic nerves using an ultrasound and identified an enlarged hypoechoic mass on the left sciatic nerve at mid-thigh level. After that, we biopsied the mass under general anesthesia, and histology confirmed it to be neuroleukemiosis.

Conclusions

Ultrasound is an inexpensive, non-invasive, simple, and quick diagnostic modality that can be used as a screening tool in the diagnosis of neuroleukemiosis.

Neuroleukemiosis: Diagnosis and management

An exceedingly rare manifestation of leukemia, termed neuroleukemiosis, involves peripheral nerve infiltration by leukemic cells. Patients with neuroleukemiosis typically present with a peripheral neuropathy and/or chloromatous masses. The diagnosis is supported by, and established with, electrophysiologic testing, imaging, histopathology, and immunophenotyping. We present the case of 21 year old male with multiply relapsed M4 type of acute myelogenous leukemia (AML) who presented with extremity pain and was subsequently found to have multiple cervical, thoracic, and lumbosacral nerve root masses. A diagnosis of neuroleukemiosis was established via CT-guided biopsy and immunophenotyping. The patient's neuroleukemiosis responded well to chemotherapy, donor lymphocyte infusions, and spinal irradiation. The literature is reviewed regarding this interesting and rare clinical condition.

Plexus and peripheral nerve metastasis

Cancer in the form of solid tumors, leukemia, and lymphoma can infiltrate and metastasize to the peripheral nervous system, including the cranial nerves, nerve roots, cervical, brachial and lumbosacral plexuses, and, rarely, the peripheral nerves. This review discusses the presentation, diagnostic evaluation, and treatment options for metastatic lesions to these components of the peripheral nervous system and is organized based on the anatomic distribution. As skull base metastases (also discussed in Chapter 14) result in cranial neuropathies, these will be covered in detail, as well as cancers that directly infiltrate the cranial nerves. Particular emphasis is placed on the clinical, imaging, and electrodiagnostic features that differentiate neoplastic plexopathies from radiation-induced plexopathies. Neurolymphomatosis, in which malignant lymphocytes invade the cranial nerves, nerve roots, brachial and lumbosacral plexuses, and peripheral nerves, is a rare manifestation of lymphoma and leukemia. Diagnoses of neurolymphomatosis are often missed or delayed given its varied presentations, resulting in poorer outcomes. Thus this disease will also be discussed in depth.

Neuromuscular complications in cancer

Cancer is becoming a treatable and even often curable disease. The neuromuscular system can be affected by direct tumor invasion or metastasis, neuroendocrine, metabolic, dysimmune/inflammatory, infections and toxic as well as paraneoplastic conditions. Due to the nature of cancer treatment, which frequently is based on a DNA damaging mechanism, treatment related toxic side effects are frequent and the correct identification of the causative mechanism is necessary to initiate the proper treatment. The peripheral nervous system is conventionally divided into nerve roots, the proximal nerves and plexus, the peripheral nerves (mono- and polyneuropathies), the site of neuromuscular transmission and muscle. This review is based on the anatomic distribution of the peripheral nervous system, divided into cranial nerves (CN), motor neuron (MND), nerve roots, plexus, peripheral nerve, the neuromuscular junction and muscle. The various etiologies of neuromuscular complications - neoplastic, surgical and mechanic, toxic, metabolic, endocrine, and paraneoplastic/immune - are discussed separately for each part of the peripheral nervous system.

Isolated Recurrence of Diffuse Large B-Cell Lymphoma in Sciatic Nerve

Sciatica is a common clinical presentation with a number of etiological factors. Many of them are innocuous like prolapsed intervertebral disc or peripheral compression in the sciatic nerve. Occasionally the cause could be of a more serious nature like a nerve sheath tumor or more infrequently, lymphomatosis. We describe recurrent lymphoma in a patient who had been in remission presented with sciatica as result of the involvement of the nerve with metastatic tumor.

Imaging findings in recurrent extramedullary leukaemias

Acute leukaemias are relatively common malignancies. Treatment has advanced significantly in the recent past and there has been improved patient survival. This improved initial response is leading to an increasing number of cases of relapse. Extramedullary relapse occurs in a wide variety of locations with varying presentations, imaging findings and differentials. The pathophysiology and clinical course of recurrent extramedullary myeloid and lymphocytic leukaemias are reviewed in this article. The wide variety of imaging findings associated with many important sites of recurrence and the associated differential diagnosis are discussed and illustrated.

Malignant cell infiltration in the peripheral nervous system

The peripheral nervous system can be affected by malignancies involving different mechanisms. Neoplastic nerve lesion by compression, invasion, and infiltration is rare and occurs in particular in leukemia (neuroleukemiosis) and lymphoma (neurolymphomatosis). Its occurrence is much rarer in cancer, and even less so in sarcoma. The neoplastic infiltration of peripheral nerves by solid tumors is characterized by specific topographical sites such as the base of the skull, the ear, nose and throat region, and the cervico-brachial plexus as well as the lumbar and sacral plexus. Rarely malignant invasion affects the cranial nerves of the face where it can spread centripetally. Autonomic nerves and ganglia can also be affected. The retrograde spread of cancer in nerves is a bad prognostic sign. The clinical diagnosis is determined by tumor type, the pattern of involvement, and often pain.

Pediatric sciatic neuropathy associated with neoplasms

Seven children with sciatic neuropathy associated with an underlying neoplasm are reported. Clinical presentation, electrophysiological data, imaging, pathology, and/or autopsy results are described. Pain and weakness, primarily foot drop, were the most common presenting symptoms. The mechanism of sciatic neuropathy was varied and included: nerve infiltration by the adjacent neoplasm (neuroblastoma, rhabdomyosarcoma, and leukemic or lymphomatous infiltration); an expanding, intrinsic neurogenic tumor (perineurioma); or intraoperative stretch injury (osteosarcoma resection). The prognosis for sciatic nerve recovery was good among children who survived their associated cancer. Three children died from the cancer or complications of treatment. One child with perineurioma remained clinically stable, and two children improved after treatment of their neoplasm.

Recurrent neurotropic chloroma: report of a case and review of the literature

We are reporting a case of a young woman with acute myelogenous leukemia status postallogeneic transplantation who developed multiply recurrent chloromas occurring along peripheral nerves in the absence of bone marrow relapse, all treated with radiation therapy. The patient is currently free of disease nearly four years after her first posttransplant chloroma. The case presented is unique for its isolated peripheral nervous system involvement, rare posttransplant occurrence, and indolent course without marrow relapse despite multiple extramedullary recurrences.

Neuroleukemiosis: case report of leukemic nerve infiltration in acute lymphoblastic leukemia

We describe a patient in remission from acute lymphoblastic leukemia who developed a painless common peroneal neuropathy. Magnetic resonance imaging (MRI) revealed nerve thickening and enhancement, while a positron emission tomography (PET) scan demonstrated increased fluorodeoxyglucose uptake in a large segment of the neurovascular bundle, suggesting peripheral nerve infiltration. Both findings resolved following treatment with chemotherapy that crossed the blood-nerve barrier. In selected patients presenting with peripheral neuropathy, MRI and PET scan can be helpful in the diagnosis of peripheral nerve infiltration.