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Naydenov AV, Taylor LP. Leptomeningeal Carcinomatosis in Chronic Lymphocytic Leukemia: A Case Report and Review of the Literature. Oncologist 2019; 24:1237-1245. [PMID: 30842245 DOI: 10.1634/theoncologist.2018-0619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 01/25/2019] [Indexed: 11/17/2022] Open
Abstract
Leptomeningeal disease is a rare complication of chronic lymphocytic leukemia (CLL). We report a case of leptomeningeal disease in CLL with a complete clinical response and clearance of cerebral spinal fluid (CSF) after treatment with ibrutinib and intrathecal rituximab. In a comprehensive review of the published literature since 1976, we found 136 cases of CLL with leptomeningeal spread. We found that leptomeningeal disease in patients with CLL responds favorably to treatment in most cases and is associated with longer overall survival than is expected for other cancers. Clearance of CSF is associated with improved survival. Treatment with rituximab and ibrutinib is more frequently associated with complete response compared with older agents. IMPLICATIONS FOR PRACTICE: The incidence of leptomeningeal CLL is more common than previously described and can be recognized by attention to certain symptoms and signs. This case presentation and literature review reveals that, in many cases, leptomeningeal lymphomatosis is reversible with the use of rituximab and ibrutinib. The authors show a survival benefit associated with treating to cerebral spinal fluid (CSF) clearance by cytology and compare outcomes with various treatment strategies, focusing on novel agents. Now that there is effective therapy for leptomeningeal lymphoma in CLL, the importance for oncologists to recognize this neurologic complication has become clear.
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MESH Headings
- Adenine/analogs & derivatives
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/cerebrospinal fluid
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Male
- Meningeal Carcinomatosis/cerebrospinal fluid
- Meningeal Carcinomatosis/complications
- Meningeal Carcinomatosis/diagnosis
- Meningeal Carcinomatosis/drug therapy
- Middle Aged
- Piperidines
- Pyrazoles/administration & dosage
- Pyrimidines/administration & dosage
- Remission Induction
- Rituximab/administration & dosage
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Affiliation(s)
- Alipi V Naydenov
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Lynne P Taylor
- Department of Neurology, University of Washington, Seattle, Washington, USA
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
- Alvord Brain Tumor Center, University of Washington, Seattle, Washington, USA
- Seattle Cancer Care Alliance, Seattle, Washington, USA
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2
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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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3
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Morscio J, Bittoun E, Volders N, Lurquin E, Wlodarska I, Gheysens O, Vandenberghe P, Verhoef G, Demaerel P, Dierickx D, Sagaert X, Janssens A, Tousseyn T. Secondary B-cell lymphoma associated with the Epstein-Barr virus in chronic lymphocytic leukemia patients. J Hematop 2016; 9:113-120. [PMID: 29861791 PMCID: PMC5962620 DOI: 10.1007/s12308-016-0273-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 05/02/2016] [Indexed: 01/07/2023] Open
Abstract
Up to 10 % of chronic lymphocytic leukemia (CLL) patients present with aggressive secondary B-cell lymphoma (most frequently diffuse large B-cell lymphoma, DLBCL) which may be clonally related to the CLL (i.e., Richter transformation, RT, 80 % of the cases) or de novo (20 % of the cases). Several genetic lesions associated with RT have already been identified, but the potential role of the Epstein-Barr virus (EBV) has been largely overlooked. In this study, we describe six CLL patients who developed a secondary EBV-positive (EBV+) B-cell lymphoma (five DLBCL, one Hodgkin lymphoma) and compare their clinicopathological characteristics to ten CLL patients with EBV-negative (EBV-) secondary B-cell lymphomas (all DLBCL). All 16 patients had a history of iatrogenic immunosuppression or chemotherapy. Eighty percent had received fludarabine as part of the CLL treatment. Most secondary lymphomas were clonally related to the previous CLL (3/4 EBV+, 7/7 EBV- cases tested). Notably EBV+ RT was associated with a trend for older age at onset (median 72 vs. 63 years, p value >0.05), longer interval between CLL and RT diagnosis (median 4.2 vs. 2.9 years, p value >0.05), and shorter overall survival (median 4 vs. 10 months, p value >0.05). These differences were not significant, probably due to small sample size. Immunohistochemical profiling suggested more frequent overexpression of TP53 and MYC in EBV- compared to EBV+ secondary lymphoma. Based on this small retrospective single center series, we hypothesize that EBV+ RT may constitute a separate subgroup of RT. Larger series are required to validate this suggestion.
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Affiliation(s)
- Julie Morscio
- Department of Imaging and Pathology, Lab for Translational Cell and Tissue Research, KU Leuven, Leuven, Belgium
| | - Emilie Bittoun
- Department of Imaging and Pathology, Lab for Translational Cell and Tissue Research, KU Leuven, Leuven, Belgium
| | - Nathalie Volders
- Department of Imaging and Pathology, Lab for Translational Cell and Tissue Research, KU Leuven, Leuven, Belgium
| | - Eveline Lurquin
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Iwona Wlodarska
- Center of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Gheysens
- Department of Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Gregor Verhoef
- Hematology Department, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Demaerel
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Daan Dierickx
- Hematology Department, University Hospitals Leuven, Leuven, Belgium
| | - Xavier Sagaert
- Department of Imaging and Pathology, Lab for Translational Cell and Tissue Research, KU Leuven, Leuven, Belgium
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Ann Janssens
- Hematology Department, University Hospitals Leuven, Leuven, Belgium
| | - Thomas Tousseyn
- Department of Imaging and Pathology, Lab for Translational Cell and Tissue Research, KU Leuven, Leuven, Belgium
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
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4
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Jamroziak K, Tadmor T, Robak T, Polliack A. Richter syndrome in chronic lymphocytic leukemia: updates on biology, clinical features and therapy. Leuk Lymphoma 2015; 56:1949-58. [PMID: 25356923 DOI: 10.3109/10428194.2014.979411] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Richter syndrome (RS) or Richter transformation is the development of secondary aggressive lymphoma in the setting of underlying chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Most frequently CLL transforms into diffuse large B-cell lymphoma (DLBCL) (90%) and rarely (10%) into Hodgkin lymphoma, termed Hodgkin variant of Richter syndrome (HvRS). RS is generally characterized by an aggressive clinical course and poor prognosis. In recent years, major advances have been made in understanding genetic events which relate to the progression of CLL or transformation into RS. Better understanding of the molecular pathways has revealed that RS is not a single homogeneous entity. The majority of cases are clonally related to the original CLL clone, while a minority develop from an unrelated clone. This review summarizes new data relating to the molecular biology and the genetic/epigenetic changes occurring during Richter transformation, and also considers the clinical features and therapy for both DLBCL-RS and Hodgkin variant-RS.
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Affiliation(s)
- Krzysztof Jamroziak
- Department of Hematology, Institute of Hematology and Transfusion Medicine , Warsaw , Poland
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5
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Ratterman M, Kruczek K, Sulo S, Shanafelt TD, Kay NE, Nabhan C. Extramedullary chronic lymphocytic leukemia: systematic analysis of cases reported between 1975 and 2012. Leuk Res 2013; 38:299-303. [PMID: 24064196 DOI: 10.1016/j.leukres.2013.08.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 08/16/2013] [Accepted: 08/17/2013] [Indexed: 11/26/2022]
Abstract
The prognostic significance of extra-medullary chronic lymphocytic leukemia (EM-CLL) is unknown. We conducted a Medline database systematic search analyzing English language articles published between 1975 and 2012 identifying 192 cases. Patients with EM-CLL were more commonly treated than not (p < .001). Skin and central nervous system (CNS) were the most commonly reported sites of organ involvement. Survival after diagnosis of EM-CLL appeared to depend on the site of EM involvement. Prospective evaluation and further studies of EM-CLL are warranted.
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Affiliation(s)
- Megan Ratterman
- Department of Medicine, Advocate Lutheran General Hospital, Park Ridge, IL, United States
| | - Kimberly Kruczek
- Department of Medicine, Advocate Lutheran General Hospital, Park Ridge, IL, United States
| | - Suela Sulo
- James R. & Helen D. Russell Institute for Research & Innovation, Advocate Lutheran General Hospital, Park Ridge, IL, United States
| | - Tait D Shanafelt
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Neil E Kay
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Chadi Nabhan
- Department of Medicine, Section of Hematology and Oncology, The University of Chicago, Chicago, IL, United States.
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6
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Robak T. Second Malignancies and Richter's Syndrome in Patients with Chronic Lymphocytic Leukemia. Hematology 2013; 9:387-400. [PMID: 15763979 DOI: 10.1080/10245330400018599] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Second malignancies are frequent complications in patients with chronic lymphocytic leukemia (CLL). Patients with this leukemia may develop large cell lymphoma (LCL) known as Richter's syndrome (RS). RS occurs in CLL patients of about 3% and may develop in a single lymph node or more often in a group of nodes. However, in some patients extranodal localization of aggressive lymphoma in RS has been observed. Besides LCL, Hodgkin's disease, prolymphocytoid leukemia, multiple myeloma and acute lymphoblastic leukemia may also occur as RS variants. The origin of lymphoid cells in RS remains tentative. However, CLL and RS originate from the same clone for some patients, whereas, in other patients cells of aggressive lymphoma do not have the features of the same clone as the CLL cells. The prognosis of RS is poor. Survival in different studies will be usually 2-5 months. The secondary development or coexistence of myeloproliferative disorders or myelodysplastic syndrome and solid tumors have also been rarely documented in CLL patients. It is of great concern that therapy may further increase the risk of a second neoplasm. However, until now, there are no clear evidence that alkylating agents or purine nucleoside analogs may be associated with an increased incidence of second malignancies in patients with CLL. In this review, epidemiology, biology, clinical characteristic and treatment approaches in RS and other secondary neoplasms in patients with CLL are discussed.
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MESH Headings
- Cell Lineage
- Disease-Free Survival
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphoma, Large B-Cell, Diffuse/etiology
- Lymphoma, Large B-Cell, Diffuse/mortality
- Lymphoma, Large B-Cell, Diffuse/therapy
- Neoplasms, Second Primary/etiology
- Neoplasms, Second Primary/mortality
- Neoplasms, Second Primary/therapy
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Lodz and Copernicus Memorial Hospital, Lodz, Pabianicka, Poland.
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7
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Spectrum of neurologic complications in chronic lymphocytic leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 12:164-79. [PMID: 22192500 DOI: 10.1016/j.clml.2011.10.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Revised: 10/19/2011] [Accepted: 10/27/2011] [Indexed: 12/21/2022]
Abstract
Neurologic disease is believed to be an unusual complication during the course of chronic lymphocytic leukemia. Nevertheless, it has already been proven in autopsy series that the incidence of occult nervous system infiltration is much higher than was previously expected. The advent of more potent drugs to treat this lymphoproliferative disorder has brought a new hope for a possible cure in the future. However, an appropriate systemic treatment for central nervous system infiltration of this disease is still lacking. Also, due to the potent immunosuppressive properties of the agents used in the up-front treatment, for example, the purine nucleoside analogues, we have witnessed an increase in the incidence of opportunistic infections, with progressive multifocal leukoencephalopathy being one of the most serious. The goal of this review is to summarize the spectrum of neurologic derangements linked to chronic lymphocytic leukemia and to raise clinicians' awareness to recognize the possibility of such associations.
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8
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Moazzam AA, Drappatz J, Kim RY, Kesari S. Chronic lymphocytic leukemia with central nervous system involvement: report of two cases with a comprehensive literature review. J Neurooncol 2011; 106:185-200. [PMID: 21769650 DOI: 10.1007/s11060-011-0636-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 06/17/2011] [Indexed: 10/18/2022]
Abstract
Central nervous system (CNS) involvement is a rare complication of chronic lymphocytic leukemia (CLL) with varied outcomes. We contribute two additional cases of CLL with CNS involvement. The clinical course and response to treatment are described. All 78 previously reported cases of CLL with CNS involvement are presented in this comprehensive review of the literature. CNS involvement of CLL is a rare complication that does not seem to correlate with any evident risk factors. Resolution of CNS symptoms can often be accomplished with intrathecal chemotherapy or irradiation. Early detection and treatment may result in better outcomes in this rare complication.
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MESH Headings
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor
- Central Nervous System Neoplasms/drug therapy
- Central Nervous System Neoplasms/pathology
- Central Nervous System Neoplasms/radiotherapy
- Combined Modality Therapy
- Fatal Outcome
- Female
- Flow Cytometry
- Gait Disorders, Neurologic/etiology
- Humans
- Hypesthesia/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/radiotherapy
- Leukemic Infiltration
- Leukocyte Count
- Magnetic Resonance Imaging
- Middle Aged
- Tomography, X-Ray Computed
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Affiliation(s)
- Alan A Moazzam
- Department of Neurosciences, Moores UCSD Cancer Center, University of California at San Diego, 3855 Health Sciences Drive, La Jolla, CA 92093, USA
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Fløisand Y, Delabie J, Fosså A, Helseth E, Jacobsen EA, Rolke J, Tjønnfjord GE. Richter syndrome presenting as a solitary cerebellar tumor during first-line treatment for chronic lymphocytic leukemia. Leuk Lymphoma 2011; 52:2007-9. [PMID: 21663503 DOI: 10.3109/10428194.2011.580480] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
MESH Headings
- Antineoplastic Agents/therapeutic use
- Cerebellar Neoplasms/etiology
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Magnetic Resonance Imaging
- Male
- Middle Aged
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Omoti CE, Omoti AE. Richter syndrome: a review of clinical, ocular, neurological and other manifestations. Br J Haematol 2008; 142:709-16. [DOI: 10.1111/j.1365-2141.2008.07248.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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