Prevalence and characteristics of central nervous system involvement by chronic lymphocytic leukemia

Hematologic malignancies and hematopoietic stem cell transplantation

Paraneoplastic neurologic syndromes are rarely associated with hematologic malignancies. In their rarity, lymphomas are the diseases with more frequent paraneoplastic neurologic syndrome. High-risk antibodies are absent in most lymphoma-associated paraneoplastic neurologic syndromes, with the exception of antibodies to Tr/DNER in paraneoplastic cerebellar degeneration, mGluR5 in limbic encephalitis, and mGluR1 in some cerebellar ataxias. Peripheral nervous system paraneoplastic neurologic syndromes are rare and heterogeneous, with a prevalence of demyelinating polyradiculoneuropathy in non-Hodgkin lymphoma. Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes (POEMS) is a rare, paraneoplastic syndrome due to an underlying plasma cell disorder. The diagnosis is based on defined criteria, and vascular endothelial growth factor (VEGF), not an antibody, is considered a reliable diagnostic marker that also mirrors therapy response. As with the paraneoplastic neurologic syndromes in solid tumors, therapies rely on cancer treatment associated with immunomodulatory treatment with better response in PNS with antibodies to surface antigens. The best outcome is generally present in Ophelia syndrome/limbic encephalitis with anti-mGluR5 antibodies, with frequent complete recovery. Besides patients with isolated osteosclerotic lesions (where radiotherapy is indicated), hematopoietic stem-cell transplantation is the therapy of choice in patients with POEMS syndrome. In the paraneoplastic neurologic syndromes secondary to immune checkpoint inhibitors, discontinuation of the drug together with immunomodulatory treatment is recommended.

Treatment strategy in chronic lymphocytic leukemia with symptomatic central nervous system involvement: A case report

Key Clinical Message

This case report offers support for treatment approaches in a historically rare and very difficult to treat CLL patient population with no established guidelines.

Abstract

Central nervous system involvement of chronic lymphocytic leukemia is a rare condition. Its diagnosis is often challenging, and treatment can be difficult with a lack of established guidelines. We describe a case of a 76-year-old male Caucasian with known chronic lymphocytic leukemia for more than 25 years, initially treated with chlorambucil. Upon first clinical relapse, cytogenetic analysis and fluorescence in situ hybridization combined showed three different abnormalities (complex karyotype), suggesting a poor prognosis. He was started on ibrutinib but developed an out-of-hospital cardiac arrest due to ventricular fibrillation 2 months later. Ibrutinib treatment was consequently discontinued. Due to the seriousness of the adverse event and the lack of apparent treatment indication after rapid improvement on ibrutinib, a watch-and-wait approach was maintained. Four years later, he developed progressive cognitive impairment, a balance disorder, and a peripheral facial nerve palsy. Anamnesis further revealed significant progressive weight loss. Routine blood tests did not show any abnormalities, but brain magnetic resonance imaging showed focal staining of cranial nerves and leptomeningeal staining. Cerebrospinal fluid analysis revealed the same monoclonal B-cell lymphocytosis as that was already known to be present in the peripheral blood. Further analysis ruled out sample contamination or other conditions. PET-CT scan revealed an increased uptake in the liver, and biopsy confirmed infiltration of chronic lymphocytic leukemia at the site. The patient was first started on treatment with intrathecal administration of dexamethasone, cytarabine, and methotrexate. This did not result in complete clearance in the cerebrospinal fluid. Next, oral venetoclax was initiated, resulting in rapid clearance and clinical resolution. Venetoclax, administered orally, was able to achieve clearance of the monoclonal B-cell lymphocytosis from the cerebrospinal fluid as well as clinical response of neurological symptoms. Response was durable with persistent remission at 1 year of treatment.

Real-world evidence on venetoclax in chronic lymphocytic leukemia: The Italian experience

Chronic lymphocytic leukemia (CLL) is the most common form of adult leukemia in the western world. In Italy, venetoclax was approved for use in patients with CLL as monotherapy in 2017 and in combinations in 2019. As a result of this delayed approval, there are relatively few real-world studies from Italian clinical practice and much of the data are in heavily pretreated patients. We have collected the available studies in Italian routine practice. Three studies confirm the effectiveness and tolerability of this agent in patients with relapsed/refractory CLL and high-risk disease characteristics, many of whom had received prior B-cell receptor signaling treatment. Addition of rituximab to venetoclax produced more complete responses in patients with relapsed/refractory CLL, while higher disease burden and progression while receiving a prior Bruton's tyrosine kinase inhibitor were both associated with poorer outcomes in patients treated with venetoclax. Venetoclax was well-tolerated with low discontinuation rates. No studies of venetoclax plus obinutuzumab for the first-line treatment of patients with CLL were available due to the short time since approval in Italy. Several cohorts addressed the impact of COVID-19 on patient management and outcomes, suggesting that treated patients and those in clinical observation had similar rates of COVID-19-related hospital admission, intensive care unit admission, and mortality. Overall, the responses and tolerance to venetoclax observed in the Italian real-world setting confirm the tolerability and effectiveness of venetoclax regimens in high-risk patients.

Diagnosis and management of adult central nervous system leukemia

Central nervous system leukemia (CNSL) is a prominent infiltration reason for therapy failing in acute leukemia. Recurrence rates and the prognosis have alleviated with current prophylactic regimens. However, the accurate stratification of relapse risk and treatment regimens for relapsed or refractory patients remain clinical challenges yet to be solved. Recently, with hematopoietic stem cell transplantation (HSCT) and chimeric antigen receptor-T (CAR-T) cellular therapy showing encouraging effects in some CNSL patients, advances in treating CNSL have already been reported. The development of molecular targeted agents as well as antibody-based drugs will provide patients with more personalized treatment. This article summarized recent research developments about risk factors, diagnosis, prevention, and treatment in adults with CNSL.

Unusual complications in the management of chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is a common, indolent disease that typically presents with a proliferation of mature, immunologically dysfunctional CD5+ B-cells which preferentially occupy the bone marrow, peripheral blood and lymphoid organs. Immune dysfunction leads to an increase in autoimmune diseases which occur in approximately 10% of patients with CLL. Autoimmune cytopenias are the most common, but other organs may be affected as well. The treatment of these conditions typically depends on the extent of CLL and severity of symptoms, but generally consists of CLL-directed therapies, immunosuppression or both. CLL may also infiltrate extranodal sites in the body. Symptomatic extranodal CLL or extranodal disease which threatens normal organ function is an indication for initiation of CLL-directed therapy. The following review summarizes autoimmune and extranodal complications that can occur in patients with CLL and our suggested approach to their treatment.

Symptomatic leptomeningeal carcinomatosis: a rare presentation of chronic lymphocytic leukaemia relapse

Central nervous system (CNS) involvement in patients with chronic lymphocytic leukaemia (CLL) is very rare and, when present, it is frequently asymptomatic. Rather, CNS involvement is more common in other haematological malignancies such as mantle cell lymphoma or diffuse large B cell lymphoma. The paucity of literature on CNS involvement in CLL underscores the importance of increasing awareness about its presentation, diagnosis and optimal management. We describe a case of symptomatic leptomeningeal leukaemic involvement as an atypical presentation of CLL relapse. A favourable clinical response was observed following systemic monotherapy with venetoclax.

Progressive Multifocal Leukoencephalopathy Among Ibrutinib Treatment In Chronic Lymphocytic Leukemia

INTRODUCTION

Both chronic lymphocytic leukemia (CLL) itself and the drugs used for its treatment, pose a risk for progressive multifocal leukoencephalopathy (PML). Although the relationship between Rituximab and PML is well known, case reports that have been recently published, suggest that ibrutinib; which is used in the treatment of CLL, may increase the risk of PML.

CASE REPORT

Here, we report a case of 64 year-old female patient with CLL who was previously treated with rituximab, fludarabine and bendamustin but developed PML after receiving monotherapy with ibrutinib. According to Naranjo's algorithm, the causality relationship with the drug is possible with a score of 3. The patient initially exhibited neurological symptoms. Magnetic resonance of the brain revealed a bilateral asymmetric hyperintensity in the white matter involving the parietal and occipital lobules, and there was no mass effect, edema, hemorrhagic or iscemic lesions. No enhancement of contrast media was observed. The findings were consistent with demyelination and suggestive of PML.

MANAGEMENT AND OUTCOME

Mirtazapine treatment was initiated. However, neurological sympthoms continuously progressed over the following weeks and the patient, aged 64, died six weeks after diagnosis of PML.

DISCUSSION

PML is a rare and often fatal demyelinating disease of the central nervous system (CNS) that is exclusively seen in immunocompromised patients and there is no specific agent to treat PML. The case discussed here, highlights that the use of ibrutinib in chronic lymphocytic leukemia (CLL) therapy may result in PML.

Chronic Lymphocytic Leukaemia: Rare Involvement of the Central Nervous System

Involvement of the central nervous system, although uncommon, is one of the most frequent extramedullary manifestations of chronic lymphocytic leukaemia (CLL). Various conditions can lead to neurological symptoms in CLL patients and distinguishing between clinically significant CLL involvement of the CNS and other aetiologies can be challenging.

The authors report the case of a 90-year-old woman with a previous diagnosis of low-risk CLL who presented to the emergency room with altered mental status. After the most frequent causes were ruled out and considering the underlying disease, CNS infiltration by clonal B-cells was hypothesised and later confirmed. Treatment was initiated, but the patient died soon afterwards.

Chronic lymphocytic leukaemia and Richter's transformation: multimodal review and new imaging paradigms

Chronic lymphocytic leukaemia (CLL) is the most common leukaemia in adults. It is a malignancy of CD5 B-cells characterised by small, mature-appearing lymphocytes accumulating in the blood, bone marrow, and lymphoid tissues. Richer transformation (RT) is an important adverse complication. Detection of RT is critical to allow initiation of appropriate therapy. CLL staging and response evaluation is complicated and nuanced. From our extensive tertiary centre experience of several hundred CLL cases over the last decade, we detail key computed tomography (CT) and positron-emission tomography (PET) imaging features of the natural history of CLL. The authors present an original imaging-based patient-management paradigm for the investigation of potential RT, which will inform global practice. Potential applications of whole-body diffusion weighted imaging, novel PET radiotracers, minimal residual disease, and ct-DNA are addressed.

Isolated Richter's transformation in central nervous system in a patient with refractory chronic lymphocytic leukemia

A 67-year-old woman was diagnosed with Chronic Lymphocytic Leukemia (CLL) and chemotherapy was started. Due to epileptic seizure and left hemiplegia that developed on the twenty first day of the treatment, cranial magnetic resonance imaging was performed and a markedly increased mass of a diameter of 5 cm in the right frontal lobe was seen. Diffuse large B-cell non-Hodgkin lymphoma was concluded at diagnostic brain biopsy. Repeated bone marrow biopsy implemented simultaneously, was reported as CLL. Based on the diagnosis of isolated Richter transformation in the CNS secondary to CLL, R-IDARAM (Rituximab, idarubicin, dexamethasone,cytrabine, methotrexate) treatment was initiated. The patient died on the eighteenth day of treatment due to neutropenic fever and septicemia caused by pulmonary infection.

Anti-Tumour Activity of Glycodendrimer Nanoparticles in a Subcutaneous MEC-1 Xenograft Model of Human Chronic Lymphocytic Leukemia

BACKGROUND

Chronic Lymphocytic Leukaemia (CLL) is an indolent disorder, which mainly affects older adults. Since the advent of chemoimmunotherapy, great progress has been made in its treatment. However, some patients develop a more aggressive form of the disease and are included in the group of high-risk CLL patients with a dismal prognosis and a need for new therapies.

OBJECTIVE

Maltotriose-modified poly(propylene imine) dendrimers were presented as potential agents in targeted therapy for CLL in the murine xenograft model.

METHODS

Tumour, brain and internal organs resected from NOD scid gamma mice were subjected to gross and histopathological evaluation.

RESULTS

The results of ex vivo tissue examination indicated that open-shell glycodendrimers prevented/inhibited the spread of CLL into the brain and internal organs and its transformation into a more aggressive form.

CONCLUSION

The results of the study have a potentially important impact on the design of future personalized therapies as well as clinical trials.

Demyelinating brain lesions developing in a patient with chronic lymphocytic leukemia shortly after treatment with a fludarabine containing regimen

Autoimmune manifestations are known to occur in patients with chronic lymphocytic leukemia (CLL) and of these hemolytic anemia and immune thrombocytopenia are the most well recognized. Autoimmunity may also be triggered by some of the therapeutic agents used like purine analoges and these events may sometimes be severe and even fatal. Non-hematological autoimmune stigmata occur far less frequently and are rarely encountered. Here we report a 59 year-old-woman, with CLL, who complained of recurrent headache starting 1 month after completing 6 cycles of fludarabine, cyclophosphamide, and rituximab combination therapy. Computed tomography scan of the brain showed a contrast enhancing lesion of 1 cm in diameter, with surrounding edema in the right frontal lobe. Brain MRI revealed ring enhancing lesions in the right frontal lobe and some additional small lesions in the left parietal lobe. Brain biopsy showed an inflammatory demyelinating lesion, not associated with JC virus. The patient subsequently improved after steroid therapy. Currently, after 2 years of follow-up, she remains in complete hematologic remission, has no neurological deficits, and is carefully followed by a team of neurologists and hematologists. Treating physicians should be aware of this rare autoimmune inflammatory demyelinating lesion which can occur in patients with CLL during the course of treatment and that may be linked to treatment with purine analogues like fludarabine.

A Needle in the Haystack: A Rare Case of Spontaneous Tumor Lysis in Newly Diagnosed Chronic Lymphocytic Leukemia Unmasked by Acute Renal Failure

Tumor lysis syndrome (TLS) is the phenomenon of metabolic derangements that typically follows the initiation of cytotoxic chemotherapy. Metabolic disturbances include hyperphosphatemia, hyperkalemia, hyperuricemia and hypocalcemia. Hematological malignancies are associated with spontaneous TLS (STLS), which is cell lysis in the absence of chemotherapy. STLS is extremely rare in chronic lymphocytic leukemia (CLL). This has been documented only once in the medical literature, making this an extraordinarily uncommon case. We present here a 68-year-old male with a history of benign prostatic hyperplasia (BPH) who is admitted for a two-week history of abdominal pain and three days of anuria, despite adequate fluid intake. Laboratory values yielded a greatly elevated leukocyte count with a lymphocytic predominance and smudge cells. Potassium, phosphorus, and uric acid were also significantly increased. EKG revealed peaked T-waves. Flow cytometry confirmed the presence of an abnormal B-cell population consistent with B-cell chronic lymphocytic leukemia, with the following markers: CD19+, CD20+, CD23+, CD5+, CD10-. He was diagnosed with CLL and treated with aggressive fluid resuscitation, allopurinol and rasburicase. The patient had another similar episode within one month. His CLL fluorescence in-situ hybridization (FISH) showed complex cytogenetics with unmutated IgVH and he was subsequently started on ibrutinib.

Chronic lymphocytic leukemia, a rare cause of pituitary stalk thickening

This case highlights a rare presentation of chronic lymphocytic leukemia (CLL). CNS involvement by CLL is rare, and only 5 cases with pituitary or hypothalamic involvement have previously been reported. Unfamiliarity with this disease complication may lead to a delay in diagnosis and treatment.This case highlights a rare presentation of chronic lymphocytic leukemia (CLL). CNS involvement by CLL is rare, and only 5 cases with pituitary or hypothalamic involvement have previously been reported. Unfamiliarity with this disease complication may lead to a delay in diagnosis and treatment.

Ophthalmic involvement of chronic lymphocytic leukemia: A systematic review of 123 cases

To identify clinical presentations, main causes, and prognosis of ophthalmic involvement in chronic lymphocytic leukemia (CLL), we performed a systematic review of articles describing CLL ophthalmic involvement in January 2019, using the PubMed database. We found 86 articles describing 123 cases of patients with ophthalmic involvement associated with CLL. Ophthalmic symptoms were CLL's first manifestation in 25.6% of patients and revealed Richter transformation in 11.0%. There were three main causes of ophthalmic features: CLL-infiltration (52.0%), lymphoma (26.0%), and infection (15.4%), with specific clinical and radiological characteristics. CLL-infiltration was mostly bilateral, whereas lymphoma was usually unilateral (P = 0.02). Optic neuropathy was always secondary to CLL-infiltration, and in those cases, cerebrospinal fluid immunophenotyping was a potential alternative to invasive biopsy as it confirmed the diagnosis in 4 patients (36.4%). On the contrary, lymphoma usually presented as adnexal involvement (P = 0.04), particularly as an orbital mass (P = 0.004). Infections concerned mostly patients previously treated for CLL (P < 0.0001), and main presentations included posterior uveitis (P = 0.0002) and retinal infiltrates (P < 0.0001). Overall, the prognosis was poor, as 29.3% of the patients died within 36 months of follow-up, and 26.1% had a partial or total visual loss. Eye infections were associated with the poorest prognosis as 47% of patients died, with a 6-month-median survival.

A case of T-cell chronic lymphocytic leukemia progressing to Richter syndrome with central nervous system involvement in a dog

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.

Unilateral Blurred Vision as the Sole Presenting Symptom of Chronic Lymphocytic Leukemia

Purpose

To describe a case of infiltrative optic neuropathy caused by chronic lymphocytic leukemia.

Case Report

A 41-year-old white male presented with painless, blurry vision in the left eye. Examination revealed unilateral optic nerve swelling confirmed by optical coherence tomography (OCT). Initial workup revealed mild leukocytosis, eventually diagnosed as chronic lymphocytic leukemia (CLL). No other cause of optic neuropathy was identified despite extensive investigation. The patient developed rapidly progressive retinal ganglion cell nerve fiber layer (NFL) atrophy and relative afferent pupillary defect (RAPD) of the left eye despite steroid treatment but stabilized after four cycles of CLL-targeted chemotherapy. Although infiltrative optic neuropathy is well-known in leukemia, presentation with only subtle vision loss is rare. Vision loss usually presents late in leukemic infiltrative optic neuropathy and therefore must be considered in patients with optic disc swelling and leukocytosis.

Conclusion

When treating CLL, progressive visual decline with coexistent optic neuropathy may warrant chemotherapy.

Stage IV Small Lymphocytic Lymphoma Presenting with Unilateral Vision Loss

Small lymphocytic lymphoma (SLL) is a manifestation of chronic lymphocytic leukemia (CLL) in which malignant B-cell lymphocytes accumulate in the lymph nodes or bone marrow. In this report, we describe the medical course of a patient diagnosed with stage IV small cell lymphocytic lymphoma, who presented to the emergency room with acute neurologic manifestations of SLL.

Venetoclax with high-dose methotrexate and rituximab seem effective and well-tolerated in the treatment of central nervous system involvement of chronic lymphocytic leukemia: A case report

Venetoclax with high-dose methotrexate and rituximab seem effective and safe to treat central nervous system involvement of chronic lymphocytic leukemia.

Central Nervous System Involvement by Small Lymphocytic Lymphoma after a Myxoma-Related Embolic Event

Involvement of the central nervous system by chronic lymphocytic leukemia/small lymphocytic lymphoma is exceedingly rare, and currently no risk factors have been described. We report the case of a patient with concomitant chronic lymphocytic leukemia/small lymphocytic lymphoma and an embolic cerebrovascular accident related to a cardiac myxoma, who developed parenchymal central nervous system involvement of lymphoma on the ischemic bed. The patient was successfully treated with a high-dose fludarabine-based chemotherapy regimen, achieving a sustained remission. We propose that embolic breakage of the blood-brain barrier may be a major risk factor in producing central nervous system involvement. We also propose that a high-dose fludarabine-based chemotherapy regimen may be adequate to achieve a better CNS penetration and improved outcomes.

An uncommon neurological manifestation of chronic lymphocytic leukemia: Longitudinally extensive transverse myelitis

We describe a 50-year-old male patient who was admitted to the emergency department with complaints of fever and fatigue that had suddenly started two weeks ago. In the laboratory evaluation, a white blood cell count of 131.000/mm³ was detected. The patient was hospitalized and developed fecal incontinence on the first day of hospitalization. Detailed neurological examination revealed the patient had tetraparesis. Long segment high signal intensity was observed on spinal MRI. Flow cytometry examination of the CSF and biopsy findings of the bone marrow were compatible with Chronic Lymphocytic Leukemia (CLL). The patient's MRI appearances resolved after treatment. The tetraparesis resolved partially. There was no motor deficit in upper extremities and the patient was able to walk without aid or rest for 100 m. Clinical manifestation of central nervous system (CNS) involvement in CLL is heterogeneous and therefore may be difficult to pinpoint. We have described an uncommon occurrence of CNS involvement in CLL.

How we manage Bing-Neel syndrome

Bing-Neel syndrome (BNS) is an uncommon presentation of Waldenström macroglobulinaemia (WM), seen during the course of the disease in about 1% of patients. BNS occurs when WM cells gain access to the central nervous system (CNS) causing neurological deficits. The diagnosis of BNS is suggested by the presence of radiological abnormalities, such as leptomeningeal enhancement on magnetic resonance imaging and confirmed by the presence of clonal lymphoplasmacytic cells and MYD88 L265P in the cerebrospinal fluid. The treatment of BNS requires agents with good penetration into the CNS, such as fludarabine, methotrexate and cytarabine. The novel Bruton Tyrosine Kinase inhibitor ibrutinib has shown CNS-penetrating properties, and recent data suggest a therapeutic role in BNS. In this review, we will discuss the clinical and pathological features, diagnostic criteria, treatment options and outcomes of patients with BNS.

Chronic Lymphocytic Leukemia Resulting in Hemorrhagic Brain Masses After Sepsis

Chronic lymphocytic leukemia (CLL) rarely results in central nervous system (CNS) involvement. When CLL does affect the CNS, it typically manifests as leptomeningeal involvement, not commonly causing parenchymal involvement unless having undergone a higher grade transformation. We report a case of a patient with untreated CLL who presented with a large right frontal hemorrhagic mass along with additional bilateral masses after being found unresponsive. He had recently been hospitalized with Staphylococcus aureus sepsis. His neurological examination improved after resection of the largest mass however deteriorated again with accumulation of blood in the resection cavity requiring evacuation of the blood products and placement of an external ventricular drain. Pathology from the initial resection revealed sheets of CD20 consistent with untransformed CLL. Additionally, there were areas of necrosis and gram-positive organisms. Given the unusual presentation with large hemorrhagic brain masses, we suspect that the antecedent bacteremia may have resulted in blood-brain barrier breakdown and seeding of the CNS parenchyma with CLL cells.

Leptomeningeal Carcinomatosis in Chronic Lymphocytic Leukemia: A Case Report and Review of the Literature

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.

Multimodality imaging of indolent B cell lymphoma from diagnosis to transformation: what every radiologist should know

Indolent B cell lymphomas are a group of lymphoid malignancies characterized by their potential to undergo histologic transformation to aggressive lymphomas. While different subtypes of indolent B cell lymphomas demonstrate specific clinical and imaging features, histologic transformation can be suspected on cross-sectional imaging when disproportionate lymph node enlargement or new focal lesions in extranodal organs are seen. On PET/CT, transformed indolent lymphoma may show new or increased nodal FDG avidity or new FDG-avid lesions in different organs. In this article, we will (1) review the imaging features of different subtypes of indolent B cell lymphomas, (2) discuss the imaging features of histologic transformation, and (3) propose a diagnostic algorithm for transformed indolent lymphoma. The purpose of this review is to familiarize radiologists with the spectrum of clinical and imaging features of indolent B cell lymphomas and to define the role of imaging in raising concern for transformation and in guiding biopsy for confirmation.

Central Nervous System Lymphoma in a Patient with Chronic Lymphocytic Leukemia: A Case Report and Literature Review

Chronic lymphocytic leukemia (CLL) is the most common type of leukemia that affects older adults in the Western world. Symptomatic nervous system invasion in undiagnosed CLL is rare, poorly understood, challenging to treat, and associated with decreased survival. The average survival of CLL patients with central nervous system (CNS) involvement is 3.79 years as compared to six years in CLL patients without CNS involvement. Autopsy studies demonstrated a high incidence of undiagnosed CLL with CNS involvement, suggesting that CNS involvement is either underdiagnosed or subclinical. Although the most common site of CNS involvement is the leptomeninges, our case demonstrates an extremely rare form of CNS diffuse large B-cell parenchymal involvement in a patient with a concurrent diagnosis of systemic CLL.

West Nile Encephalitis, an Unusual Infection in a Chronic Lymphocytic Leukemia Patient

CNS involvement by CLL is a rare occurrence, usually happening in the context of a transformation to a more aggressive lymphoma in what is known as Richter's transformation. We report a patient with active CLL who developed confusion and was found to have West Nile encephalitis that initially mimicked CNS involvement by CLL. The patient recovered with supportive treatment and later restarted ibrutinib therapy. This case illustrates the importance of maintaining a broad differential among cancer patients with new onset confusion as well as that of questioning malignant infiltration of CNS when there is concomitant active CNS infection.

Amebic Encephalitis in a Patient with Chronic Lymphocytic Leukemia on Ibrutinib Therapy

Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in Western countries. A common first-line therapy offered to qualifying patients includes ibrutinib, an oral covalent inhibitor of Bruton's tyrosine kinase. Treatment of CLL with ibrutinib therapy is generally well tolerated; however, serious opportunistic infections are being reported in patients treated with ibrutinib. In this report, we present a patient with CLL on ibrutinib therapy who developed rapidly declining neurological status concerning for the central nervous system (CNS) process related to his immunocompromised status. Despite multiple testing modalities, no evidence was found to explain the acute changes the patient was experiencing, and he had no improvement with common antimicrobial coverage. The patient ultimately expired, and autopsy of the brain revealed granulomatous amebic encephalitis due to opportunistic infection by Acanthamoeba species. As evidenced by this case, ibrutinib therapy, despite being generally well tolerated, has the potential to predispose patients to opportunistic infections like amebic encephalitis. Amebic encephalitis is a highly lethal CNS infection, and it is important for clinicians to recognize early on the potential for infection in patients on ibrutinib therapy presenting with CNS symptoms.

Treatment Sequencing in a Chronic Lymphocytic Leukemia Patient with Central Nervous System Involvement

Early-stage chronic lymphocytic leukemia (CLL) with neurologic involvement is a rare condition and should require a careful follow-up. Although no standard protocol exists for this condition, intrathecal chemotherapy, combined with systemic chemoimmunotherapy, has been used previously. This case describes the treatment of a patient with CLL and symptomatic compromise of the central nervous system. Our results suggest that a combination of chemotherapy, radiotherapy, and ibrutinib, administered sequentially over a 2-year period, led to a near-complete resolution of the cerebral spinal fluid neoplastic infiltration. Importantly, this response has been maintained with ibrutinib monotherapy for more than 12 months.

Neurologic Complications of Lymphoma, Leukemia, and Paraproteinemias

PURPOSE OF REVIEW

This article reviews the spectrum of neurologic complications associated with lymphoma, leukemia, and paraproteinemic disorders. While leptomeningeal metastasis is the most common complication of lymphoma and leukemia and peripheral neuropathy is the most common complication of paraproteinemic disorders, clinicians need to be familiar with the diverse neurologic complications of these disorders.

RECENT FINDINGS

Lymphomatous nervous system involvement can be difficult to diagnose, especially when it is the presenting symptom. CSF cytology and flow cytometry, as well as the imaging pattern, assist in diagnosis. Neurologic complications are less common in Hodgkin lymphoma; however, some unique paraneoplastic syndromes are associated with Hodgkin lymphoma, including primary central nervous system angiitis, limbic encephalitis, and cerebellar degeneration. Recent reports suggest that anti-metabotropic glutamate receptor 5 (mGluR5) antibodies are associated with limbic encephalitis and that anti-Tr antibodies are associated with cerebellar degeneration in Hodgkin lymphoma. Polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes (POEMS) syndrome is often misdiagnosed as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). A lambda protein, thrombocytosis, and elevated vascular endothelial growth factor (VEGF) can all be helpful clues in diagnosis. Early recognition is important, as the neuropathy responds to radiation therapy or chemotherapy.

SUMMARY

Neurologic involvement can occur throughout the disease course in lymphoma and leukemia, including at presentation, with systemic progression, and at relapse. In paraproteinemias, the peripheral neuropathy phenotype, monoclonal protein type, and associated autonomic and systemic features aid in identification of an underlying plasma cell disorder.

Chronic Lymphocytic Leukemia: Diagnosis and Treatment

The complexity of the treatment of patients with chronic lymphocytic leukemia has increased substantially over the past several years as a consequence of the advent of novel biological agents such as ibrutinib, idelalisib, and venetoclax, as well as increasingly potent anti-CD20 monoclonal antibodies. In addition, the identification of molecular predictive markers and the introduction of more sensitive and sophisticated techniques to assess minimal residual disease have allowed optimization of the use of chemoimmunotherapy and targeted therapies and may become standard of care in the future. This review summarizes the diagnosis, prognostication, and treatment of patients with chronic lymphocytic leukemia with emphasis on new prognostic and predictive factors and novel treatment strategies.

Central nervous system localisation of chronic lymphocytic leukaemia, description of two very distinct cases and a review of the literature

Central nervous system (CNS) localisation of chronic lymphocytic leukaemia (CLL) can induce various neurological symptoms. Unfamiliarity with this manifestation causes diagnostic delay. We present two cases of leptomeningeal CLL. These cases and our literature review emphasise that CNS localisation of CLL should be considered in patients with any neurological symptom, irrespectively of the stage and systemic activity of CLL.

Review of targeted therapy in chronic lymphocytic leukemia: what a radiologist needs to know about CT interpretation

The last 5 years have been marked by profound innovation in the targeted treatment of chronic lymphocytic leukemia (CLL) and indolent lymphomas. Using CLL as a case study, we present a timeline and overview of the current treatment landscape for the radiologist, including an overview of clinical and radiological features of CLL, discussion of the targeted agents themselves, and the role of imaging in response and toxicity assessment. The goal is to familiarize the radiologist with multiple Food and Drug Administration (FDA)-approved targeted agents used in this setting and associated adverse events which are commonly observed in this patient population.

Unusual Relapse of Chronic Lymphocytic Leukemia After Remission

Chronic lymphocytic leukemia (CLL) is the most prevalent leukemia with over 20,000 estimated cases in 2017. Leukemic involvement of the nervous system from CLL causing neurologic symptoms is reported in only about one percent of patients. Unfortunately, there is no current standard therapy for the treatment of CLL leptomeningeal disease. In this case, we discuss an unusual presentation of CLL leptomeningeal disease misdiagnosed as chronic rebound headache.

A 61-year-old female was diagnosed with Rai stage I CLL in 2002. She presented at that time with peripheral blood lymphocytosis and subsequent flow cytometry revealed a mature B cell population consistent with CLL. She was monitored clinically as there were no indications for therapy. In 2006, she developed B symptoms along with hemolytic anemia refractory to steroids and was initiated on chemotherapy with fludarabine, cyclophosphamide, and rituximab (FCR). She had a complete response after six cycles.

The patient was in her usual state of health until 2016, when she complained of chronic headaches. She took acetaminophen and ibuprofen regularly and was diagnosed with rebound headaches by neurology. These symptoms progressed and the patient developed encephalopathy requiring inpatient admission. Magnetic resonance imaging (MRI) revealed abnormal enhancement in the cerebellar peduncles and dentate nuclei symmetrically; a lumbar puncture performed revealed evidence of CLL consistent with leptomeningeal disease. Therapy was started with oral ibrutinib at 560 mg daily for better central nervous system (CNS) penetration. After three months of therapy, she had complete resolution of symptoms and MRI abnormalities.

Leptomeningeal disease is a rare complication of CLL that clinicians should be aware of and ibrutinib can be an effective, tolerable therapy for this debilitating disease.

Brain biopsy in the diagnosis of leptomeningeal involvement in stage I chronic lymphocytic leukemia

Leptomeningeal involvement of CLL is usually underdiagnosed as neurological symptoms are unspecific. It is important to carefully evaluate neurological status in these patients and consider this entity between the differential diagnosis of a neurological deterioration as adequate treatment improves the prognosis. Imaging techniques, analyses of cerebrospinal fluid, and brain biopsy are useful to establish a definitive diagnosis.

Chronic lymphocytic leukemia with clinical debut as neurological involvement: a rare phenomenon and the need for better predictive markers

Background

Chronic lymphocytic leukemia (CLL) is the most common leukemia in Western countries. The frequency of symptomatic central nervous system (CNS) involvement is unknown but thought to be a rare phenomenon. Currently there are no known risk factors for CNS involvement.

Case presentation

We describe a clinically staged low-risk CLL case that presented with symptomatic CNS involvement and progressed rapidly to death. Evaluation of the surface adhesion molecules identified a markedly altered expression pattern of the integrin, CD49d, and the tetraspanin, CD82, in the index case when compared to similar low-risk CLL cases. We found that the early Rai clinical stage CLL patients showed linear correlation for the co-expression of CD82 and CD49d. In contrast, this unique index case with CNS involvement, which has the same Rai clinical stage, had a significantly lower expression of CD82 and higher expression of CD49d.

Conclusions

These data suggest that the expression profile of CD49d and CD82 may represent potential biomarkers for patients with increased propensity of CNS involvement. Moreover, this study illustrates the critical need for a better mechanistic understanding of how specific adhesion proteins regulate the interactions between CLL cells and various tissue sites.

Major infections, secondary cancers and autoimmune diseases occur in different clinical subsets of chronic lymphocytic leukaemia patients

BACKGROUND

Major infections (MIs), secondary cancers (SCs) and autoimmune diseases (ADs) are the most common and relevant complications in patients with chronic lymphocytic leukaemia.

METHODS

We performed a single-centre retrospective study to investigate the prevalence of the above quoted complications, the association with most important prognostic markers and their impact on survival (n = 795).

RESULTS

Almost one out of three patients experienced at least one complication and only 0.9% of the cohort developed all three complications. One hundred and twenty (20%) subjects developed SC, 98 MI (12%) and 80 AD (10%); these complications seem to occur in a mutually exclusive manner. By Kaplan-Meier analysis we estimated that after 20 years from the diagnosis SC, MI and AD occurred in 48%, 42% and 29% of patients, respectively. Furthermore, we showed that some clinical and biological markers are skewed among patients with different complications and that subjects with MI and SC had a worse prognosis than those with AD and all other patients (p < 0.0001).

CONCLUSIONS

This study reveals the existence of different clinical subsets of chronic lymphocytic leukaemia patients characterised by an increased and different risk for developing specifically MI, SC and AD.