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Robak T, Puła A, Braun M, Robak E. Extramedullary and extranodal manifestations in chronic lymphocytic leukemia - an update. Ann Hematol 2024; 103:3369-3383. [PMID: 39052034 PMCID: PMC11358350 DOI: 10.1007/s00277-024-05854-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/15/2024] [Indexed: 07/27/2024]
Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a common leukemia characterized by clonal expansion of mature CD5+/CD23 + B cells in the blood, bone marrow (BM) and lymphoid tissues. CLL can undergo extramedullary and extranodal infiltration, with one study noting an incidence of only 0.3 per 100,000 people, and in 17.6% of CLL patients in another report. The most common extranodal sites of leukemic involvement are the skin and central nervous system; however, other organs, including liver, lungs, kidney, gastrointestinal tract, bone, prostate and heart, are occasionally involved. The prognostic significance of extra-medullary CLL is still under debate, but the prognosis in such patients seems to be better in the era of novel targeted drugs. Following a diagnosis of extranodal CLL, survival appears to depend on the site of infiltration. This review presents an overview of CLL in patients with extramedullary and extranodal leukemic lesions, focusing on its epidemiology, pathogenesis, prognosis, clinical characteristics and treatment results.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Ciołkowskiego 2, Lodz, 93-510, Poland.
- Department of General Hematology, Copernicus Memorial Hospital, Lodz, Poland.
| | - Anna Puła
- Department of Hematology, Medical University of Lodz, Ciołkowskiego 2, Lodz, 93-510, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
| | - Marcin Braun
- Department of Pathology, Chair of Oncology, Medical University of Lodz, Lodz, Poland
| | - Ewa Robak
- Department of Dermatology, Medical University of Lodz, Lodz, Poland
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2
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Qin LY, Geng Y, Mu JF, Wang WJ, Zhang CX, Gao YN, He JX. Central nervous system involvement in chronic lymphocytic leukemia: a case report and review of literature. J Med Case Rep 2024; 18:315. [PMID: 38982482 PMCID: PMC11234772 DOI: 10.1186/s13256-024-04639-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 06/19/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Central nervous system involvement in chronic lymphocytic leukemia rarely occurs, and there is no standard therapy for central nervous system involvement in chronic lymphocytic leukemia. This article aims to analyze the diagnosis and treatment of central nervous system involvement in chronic lymphocytic leukemia. CASE PRESENTATION It reports two cases of central nervous system involvement in chronic lymphocytic leukemia describing the clinical course, therapy, and prognosis. Case 1 is a 67-year-old Asian male patient, he experienced complications with central nervous system involvement after developing resistance to ibrutinib, bendamustine, and rituximab (BR) chemotherapies. The central nervous system lesion was controlled with high-dose methotrexate combined with pomalidomide, but Richter transformation occurred several months later. Case 2 is a 62-year-old Asian female patient, she had central nervous system involvement at initial diagnosis, and bone marrow and central nervous system lesions were controlled by ibrutinib therapy. CONCLUSION Central nervous system involvement in chronic lymphocytic leukemia is rare and can be diagnosed on the basis of clinical features, cerebrospinal fluid testing, and radiographic evaluation. Ibrutinib, pomalidomide, and other drugs that can cross the blood-brain barrier may be effective for treating central nervous system involvement in chronic lymphocytic leukemia.
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Affiliation(s)
- Li-Yuan Qin
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030012, China
| | - Ye Geng
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030012, China
| | - Jian-Feng Mu
- Department of Medicine, Shanxi Vocational College of Tourism, Taiyuan, 030091, China
| | - Wen-Jun Wang
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030012, China
| | - Cai-Xia Zhang
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030012, China
| | - Yi-Nan Gao
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030012, China
| | - Jian-Xia He
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030012, China.
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3
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Stumpf J, Al-Sawaf O. Chronic Lymphocytic Leukemia: Time-Limited Therapy in the First-Line Setting and Role of Minimal Residual Disease. Curr Oncol Rep 2024; 26:136-146. [PMID: 38175465 PMCID: PMC10891251 DOI: 10.1007/s11912-023-01482-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW In this review, we provide an overview of different time-limited combination therapies of chronic lymphocytic leukemia (CLL) and summarize the data of pivotal clinical studies. Furthermore, we discuss the relevance of MRD in clinical trials and summarize the challenges that arise in routine clinical care. Finally, we provide an outlook on studies and datasets needed to optimize the use of time-limited treatment strategies and MRD assessments in modern CLL management. RECENT FINDINGS In recent years, first-line treatment of CLL has undergone a considerable transformation, with targeted substances having largely replaced chemoimmunotherapy (CIT) as a time-limited strategy in the frontline setting. BTK inhibitors were the first class of targeted agents introduced in CLL, which achieved longer progression-free survival (PFS) and in some cases also overall survival (OS) than CIT. However, this required an indefinite drug intake until disease progression, while CIT is generally administered over the course of few months. In contrast to BTK inhibitors, BCL2 inhibitors, another class of targeted agents, can achieve high rates of undetectable minimal residual disease (uMRD) levels and induce deep molecular remissions with the potential to stop treatment while maintaining remissions. Combinations of BCL2 inhibitors with CD20 antibodies or with BTK inhibitors have been explored to establish time-limited treatment strategies with targeted agents. In this context, one of the strongest predictors of long-term outcomes is MRD status at the end of treatment, which has been shown to correlate closely with PFS and OS in most cases.
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Affiliation(s)
- Janina Stumpf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany.
| | - Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
- Cancer Institute, University College London, London, UK
- Francis Crick Institute, London, UK
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4
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Habringer S, Demel UM, Fietz AK, Lammer F, Schroers R, Hofer S, Bairey O, Braess J, Meier-Stiegen AS, Stuhlmann R, Schmidt-Hieber M, Hoffmann J, Zinngrebe B, Kaiser U, Reimer P, Möhle R, Fix P, Höffkes HG, Langenkamp U, Büschenfelde CMZ, Hopfer O, Stoltefuß A, La Rosée P, Blasberg H, Jordan K, Kaun S, Meurer A, Unteroberdörster M, von Brünneck AC, Capper D, Heppner FL, Chapuy B, Janz M, Schwartz S, Konietschke F, Vajkoczy P, Korfel A, Keller U. A prospective observational study of real-world treatment and outcome in secondary CNS lymphoma. Eur J Cancer 2024; 196:113436. [PMID: 38008033 DOI: 10.1016/j.ejca.2023.113436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/31/2023] [Accepted: 11/05/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Secondary central nervous system lymphoma (SCNSL) confers a dismal prognosis and treatment advances are constrained by the lack of prospective studies and real-world treatment evidence. METHODS Patients with SCNSL of all entities were included at first diagnosis and patient characteristics, treatment data, and outcomes were prospectively collected in the Secondary CNS Lymphoma Registry (SCNSL-R) (NCT05114330). FINDINGS 279 patients from 47 institutions were enrolled from 2011 to 2022 and 243 patients (median age: 66 years; range: 23-86) were available for analysis. Of those, 49 (20 %) patients presented with synchronous (cohort I) and 194 (80 %) with metachronous SCNSL (cohort II). The predominant histology was diffuse large B-cell lymphoma (DLBCL, 68 %). Median overall survival (OS) from diagnosis of CNS involvement was 17·2 months (95 % CI 12-27·5), with longer OS in cohort I (60·6 months, 95 % CI 45·5-not estimable (NE)) than cohort II (11·4 months, 95 % CI 7·8-17·7, log-rank test p < 0.0001). Predominant induction regimens included R-CHOP/high-dose MTX (cohort I) and high-dose MTX/cytarabine (cohort II). Rituximab was used in 166 (68 %) of B-cell lymphoma. Undergoing consolidating high-dose therapy and autologous hematopoietic stem cell transplantation (HDT-ASCT) in partial response (PR) or better was associated with longer OS (HR adjusted 0·47 (95 % CI 0·25-0·89), p = 0·0197). INTERPRETATION This study is the largest prospective cohort of SCNSL patients providing a comprehensive overview of an international real-world treatment landscape and outcomes. Prognosis was better in patients with SCNSL involvement at initial diagnosis (cohort I) and consolidating HDT-ASCT was associated with favorable outcome in patients with PR or better.
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Affiliation(s)
- Stefan Habringer
- Department of Hematology, Oncology and Cancer Immunology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health at Charité (BIH), Berlin, Germany; German Cancer Consortium (DKTK), Berlin, Germany
| | - Uta M Demel
- Department of Hematology, Oncology and Cancer Immunology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health at Charité (BIH), Berlin, Germany
| | - Anne-Katrin Fietz
- Institute of Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin, Berlin, Germany
| | - Felicitas Lammer
- Department of Hematology, Oncology and Cancer Immunology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Roland Schroers
- Department of Medicine, Hematology and Oncology, Ruhr University Bochum, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Bochum, Germany
| | - Silvia Hofer
- Division Medical Oncology Cantonal Hospital Luzern, Luzern, Switzerland; Department of Neurology, University Hospital Zürich, Zürich, Switzerland
| | - Osnat Bairey
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Tel Aviv University, Tel Aviv, Israel
| | - Jan Braess
- Department of Oncology and Hematology, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Anna Sofia Meier-Stiegen
- Department of Hematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Reingard Stuhlmann
- Department of Hematology, Oncology and Stem Cell Transplantation, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Martin Schmidt-Hieber
- Department of Hematology and Oncology, Carl-Thiem-Klinikum Cottbus, Cottbus, Germany
| | - Johannes Hoffmann
- Pius-Hospital, University Medicine Oldenburg, Department of Hematology and Oncology, University Department Internal Medicine-Oncology, Oldenburg, Germany
| | - Bettina Zinngrebe
- Department of Hematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Ulrich Kaiser
- Medizinische Klinik II, St Bernward Krankenhaus, Hildesheim, Germany
| | - Peter Reimer
- Department of Hematology, Medical Oncology and Stem Cell Transplantation, Kliniken Essen-Mitte, Essen, Germany
| | - Robert Möhle
- Department of Internal Medicine II, Medical University Hospital, Tübingen, Germany
| | - Peter Fix
- Onkologische Praxis Dr. med. Peter Fix, Jena, Germany
| | | | - Ulrich Langenkamp
- Department of Internal Medicine, Medical Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, University of Rostock, 18057 Rostock, Germany
| | | | - Olaf Hopfer
- Department of Medicine I, Hospital Frankfurt (Oder), Frankfurt (Oder), Germany
| | - Andrea Stoltefuß
- Department of Hematology, Oncology and Palliative Care, Evangelisches Krankenhaus Hamm, Hamm, Germany
| | - Paul La Rosée
- Abteilung Hämatologie und Internistische Onkologie, Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany; Klinik für Innere Medizin II, Schwarzwald-Baar-Klinikum, Villingen-Schwenningen, Germany
| | - Henning Blasberg
- Hospital of Internal Medicine II, Hematology and Oncology, St. Georg Hospital Leipzig, Leipzig, Germany
| | - Karin Jordan
- Department of Hematology, Oncology and Palliative Medicine, Ernst von Bergmann Hospital, Potsdam, Germany
| | - Stephan Kaun
- Hematology/Oncology, Klinikum Bremen-Mitte, Bremen, Germany
| | - Anna Meurer
- Department of Hematology, Oncology and Cancer Immunology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Meike Unteroberdörster
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ann-Christin von Brünneck
- Institute of Pathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - David Capper
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Cluster of Excellence, NeuroCure, Berlin, Germany
| | - Frank L Heppner
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany; Cluster of Excellence, NeuroCure, Berlin, Germany
| | - Björn Chapuy
- Department of Hematology, Oncology and Cancer Immunology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Janz
- Department of Hematology, Oncology and Cancer Immunology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stefan Schwartz
- Department of Hematology, Oncology and Cancer Immunology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Cancer Consortium (DKTK), Berlin, Germany
| | - Frank Konietschke
- Institute of Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Agnieszka Korfel
- Department of Hematology, Oncology and Cancer Immunology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ulrich Keller
- Department of Hematology, Oncology and Cancer Immunology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Cancer Consortium (DKTK), Berlin, Germany.
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Caballero CA, Cebrian FY, Parra Salinas IM. [Infiltration of the central nervous system in patients with chronic lymphatic leukemia]. Med Clin (Barc) 2023; 161:361-362. [PMID: 37419846 DOI: 10.1016/j.medcli.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 07/09/2023]
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6
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Liu L, Hadyah S, Park A, Akhtari M, Scott J, Ran-Castillo D, Chong E, Koh H, Oregel K, Khandelwal K, Demisse R. Leukemic infiltration of the optic nerve in chronic lymphocytic leukemia: A case report and review of literature. Leuk Res Rep 2023; 20:100391. [PMID: 37711672 PMCID: PMC10498303 DOI: 10.1016/j.lrr.2023.100391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 06/21/2023] [Accepted: 08/27/2023] [Indexed: 09/16/2023] Open
Abstract
Ophthalmic and neurologic involvement are rare complications of CLL, with few cases reported in the literature. We report a case of CLL with leukemic infiltration of the optic nerve and review of literature focusing on management and outcomes. A patient with heavily pretreated CLL presented to our hospital with progressive eye pain and was found to have infiltrative optic neuritis. CSF analysis confirmed involvement with CLL. After systemic treatment with R-CHOP and high-dose methotrexate, along with intrathecal cytarabine and hydrocortisone, she experienced significant improvement and was discharged home. Given the rarity of ophthalmic involvement in CLL, we reviewed all 15 previously reported cases of CLL with optic neuropathy as the first manifestation of CNS involvement and discussed the range of treatment options used and their respective outcomes.
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Affiliation(s)
- Louisa Liu
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, United States of America
| | - Sana Hadyah
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, United States of America
| | - Annie Park
- Department of Medical Oncology/Hematology, Loma Linda University Medical Center, Loma Linda, California, United States of America
| | - Mojtaba Akhtari
- Department of Medical Oncology/Hematology, Loma Linda University Medical Center, Loma Linda, California, United States of America
| | - Jonathan Scott
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, United States of America
| | - Dani Ran-Castillo
- Department of Medical Oncology/Hematology, Loma Linda University Medical Center, Loma Linda, California, United States of America
| | - Esther Chong
- Department of Medical Oncology/Hematology, Loma Linda University Medical Center, Loma Linda, California, United States of America
| | - Han Koh
- Department of Medical Oncology/Hematology, Loma Linda University Medical Center, Loma Linda, California, United States of America
| | - Karlos Oregel
- Department of Medical Oncology/Hematology, Loma Linda University Medical Center, Loma Linda, California, United States of America
| | - Keerti Khandelwal
- Department of Medical Oncology/Hematology, Loma Linda University Medical Center, Loma Linda, California, United States of America
| | - Rahel Demisse
- Department of Medical Oncology/Hematology, Loma Linda University Medical Center, Loma Linda, California, United States of America
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Babici D, Sharma P, DeGregorio J, Snelling B, Hanafy K. Acute subdural hematoma due to acute myeloid leukemia and B-cell lymphoma. eNeurologicalSci 2022; 29:100425. [PMID: 36164337 PMCID: PMC9508343 DOI: 10.1016/j.ensci.2022.100425] [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: 07/21/2022] [Accepted: 09/10/2022] [Indexed: 11/26/2022] Open
Abstract
Chloroma, is an rare malignant tumor characterized by the extramedullary blast proliferation of myeloid lineages that subsequently change the normal architecture of surrounding tissues. Because this is very rare disease, primary central nervous system myeloid sarcoma has not been widely reported. Myeloid sarcoma, as a group of heterogenetic diseases, presents with differential clinical and histological pictures depending upon the primary affected site. We are presenting a 77-year-old gentleman, with past medical history of chronic lymphoblastic leukemia that was not on any treatment and who presented with complaints of lethargy, disorientation, and weakness. CT scan of the head showed left-sided subdural hematoma with significant mass effect with left-to-right shift. Craniotomy and hematoma evacuation was performed and hematoma and subdural lesion was sent for pathological evaluation. Histologic examination of the hematoma revealed solid sheets of small-medium sized atypical hematopoietic cells that was imbedded in an acute and chronic hematoma. To confirm the final diagnosis, flow cytometry was performed and showed two neoplastic clones, consistent with acute myeloid leukemia with monocytic differentiation and a separate mature B-cell lymphoma. To our knowledge we are presenting the first case in the literature of the Intracranial acute myeloid leukemia/myeloid sarcoma and B-cell lymphoma that was found in the same brain lesion.
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Affiliation(s)
- Denis Babici
- Department of Neurology, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, United States of America
| | - Pamraj Sharma
- Department of Neurology, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, United States of America
| | - Jason DeGregorio
- Department of Pathology, Boca Raton Regional Hospital, United States of America
| | - Brian Snelling
- Department of Neurosurgery, Marcus Neuroscience Institute, Boca Raton, FL, United States of America
| | - Khalid Hanafy
- Department of Neurocritical care, Marcus Neuroscience Institute, Boca Raton, FL, United States of America
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Gordon MJ, Ferrajoli A. Unusual complications in the management of chronic lymphocytic leukemia. Am J Hematol 2022; 97 Suppl 2:S26-S34. [PMID: 35491515 DOI: 10.1002/ajh.26585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Max J Gordon
- MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
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Simard J, Roschewski M. SOHO State of the Art Updates and Next Questions: Prophylaxis and Management of Secondary CNS Lymphoma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:709-717. [PMID: 35787364 PMCID: PMC9529879 DOI: 10.1016/j.clml.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/01/2022] [Accepted: 06/04/2022] [Indexed: 06/15/2023]
Abstract
Secondary CNS lymphoma (SCNSL) is a rare but frequently fatal complication of systemic lymphoma. There is no standard treatment for SCNSL, and patients who develop SCNSL at diagnosis or after frontline therapy often receive highly intensive chemotherapy regimens that are inactive against primary chemorefractory disease and too toxic for older, frail patients to tolerate. Because the prognosis of SCNSL is so poor, management has historically emphasized prevention, but the current methods of CNS prophylaxis are not universally effective. To improve both the prevention and management of SCNSL, better characterization of the molecular determinants of CNS invasion is needed. Novel treatments that are currently being studied in SCNSL include targeted pathway inhibitors and cellular therapy, but SCNSL patients are often excluded from clinical trials of promising new therapies.
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Affiliation(s)
- Jillian Simard
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Mark Roschewski
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD.
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10
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Batayneh O, Lin A, Abu-Jaradeh O, Wu P, Villamar MF, Sharma P. Symptomatic leptomeningeal carcinomatosis: a rare presentation of chronic lymphocytic leukaemia relapse. BMJ Case Rep 2022; 15:e249940. [PMID: 35675961 PMCID: PMC9185480 DOI: 10.1136/bcr-2022-249940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2022] [Indexed: 11/03/2022] Open
Abstract
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.
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MESH Headings
- Adult
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Mantle-Cell
- Meningeal Carcinomatosis/diagnosis
- Neoplasm Recurrence, Local
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Affiliation(s)
- Osama Batayneh
- Department of Medicine, Kent Hospital/ The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Amy Lin
- OMS-III, University of New England College of Osteopathic Medicine, Warwick, RI, USA
| | - Omar Abu-Jaradeh
- Department of Medicine, Kent Hospital/ The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Peter Wu
- Department of Pathology, Kent Hospital, Warwick, RI, USA
| | - Mauricio F Villamar
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Medicine, Kent Hospital, Warwick, RI, USA
| | - Purva Sharma
- Department of Hematology and Oncology, Kent Hospital, Warwick, RI, USA
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Optic nerve and spinal involvement associated with chronic lymphocytic leukemia. Rev Neurol (Paris) 2022; 178:742-744. [PMID: 35568517 DOI: 10.1016/j.neurol.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 11/23/2022]
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12
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Evans MG, Shestakova A, Haghighi N, Zhao X, Nardi V, Pinter-Brown LC, Rezk SA. Rare case of leptomeningeal small lymphocytic lymphoma with TP53 mutation detected by deep next-generation sequencing. Leuk Lymphoma 2022; 63:2479-2483. [DOI: 10.1080/10428194.2022.2070911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mark G. Evans
- Department of Hematopathology, Division of Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anna Shestakova
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nahideh Haghighi
- Department of Pathology, City of Hope National Medical Center, Duarte, CA, USA
| | - Xiaohui Zhao
- Department of Pathology and Laboratory Medicine, University of California Irvine (UCI) Medical Center, Orange, CA, USA
| | - Valentina Nardi
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren C. Pinter-Brown
- Department of Medicine, Hematology/Oncology Division, University of California Irvine (UCI) Medical Center, Orange, CA, USA
| | - Sherif A. Rezk
- Department of Pathology and Laboratory Medicine, University of California Irvine (UCI) Medical Center, Orange, CA, USA
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13
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Amado C, Duarte V, Silva Leal M, Cruz M, Ferreira G. Chronic Lymphocytic Leukaemia: Rare Involvement of the Central Nervous System. Eur J Case Rep Intern Med 2021; 8:002847. [PMID: 34912734 PMCID: PMC8667997 DOI: 10.12890/2021_002847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/05/2021] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Carolina Amado
- Internal Medicine Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Valter Duarte
- Internal Medicine Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Mariana Silva Leal
- Internal Medicine Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Margarida Cruz
- Internal Medicine Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Gisela Ferreira
- Haematology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
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14
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Demircioğlu S, Oltulu P, Emlik GD, Tekinalp A, Çeneli Ö. Bing-Neel syndrome: A case reports. J Oncol Pharm Pract 2020; 27:1758-1761. [PMID: 33356992 DOI: 10.1177/1078155220983426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Bing-Neel syndrome (BNS) is a rare complication of of Waldenström macroglobulinemia (WM) identified by involvement of central nervous system (CNS) lymphoplasmacytic cells. CASE REPORT We present a patient who was diagnosed with Bing-Neel syndrome four years after the diagnosis of Waldenström macroglobulinemia. MANAGEMENT & OUTCOME The patient was admitted with neurological symptoms. There were lesions associated with WM involvement on brain imaging. The diagnosis was made by brain biopsy. High dose methotrexate treatment was given. DISCUSSION CNS infiltrating agents such as fludarabine, methotrexate and cytarabine are often used in BNS treatment. Ibrutinib, which is a new bruton tyrosine kinase inhibitor, has recently started to be used in BNS treatment, as it has been shown to be effective and penetrate the CNS.
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Affiliation(s)
- Sinan Demircioğlu
- Department of Hematology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Pembe Oltulu
- Department of Pathology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Ganime D Emlik
- Department of Radiology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Atakan Tekinalp
- Department of Hematology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Özcan Çeneli
- Department of Hematology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
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15
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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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16
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Maleita D, Serras Pereira R, Hipolito-Fernandes D, Moura-Coelho N, Cunha JP, Tavares Ferreira J. Optic neuropathy due to chronic lymphocytic leukemia: The first manifestation of the disease. Am J Ophthalmol Case Rep 2020; 18:100603. [PMID: 32467860 PMCID: PMC7244917 DOI: 10.1016/j.ajoc.2020.100603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 12/20/2019] [Accepted: 01/05/2020] [Indexed: 11/26/2022] Open
Abstract
Purpose Chronic lymphocytic leukemia (CLL) is the most common lymphoproliferative disorder in the western world. The involvement of the central nervous system (CNS) or the optic nerve in CLL, however, is rare. We report a case of a previously untreated patient with CLL whose first manifestation of the disease was a progressive visual loss caused by optic neuropathy. Observations Clinical manifestations, optical coherence tomography (OCT), and automated visual fields pointed to the diagnosis of neuropathy. Leukemic involvement of the CNS was confirmed after cells suggestive of CLL were found by cerebrospinal fluid analysis. Optic nerve infiltration is thought to be the cause of this optic neuropathy, and the clinical course and treatment are described herein. Conclusions When readily diagnosed, optic nerve infiltration is a rare, yet manageable complication of CLL.
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Affiliation(s)
- Diogo Maleita
- Ophthalmology Department, Centro Hospitalar Universitário de Lisboa Central, Alameda Santo António dos Capuchos, 1169-050, Lisboa, Portugal
| | - Rita Serras Pereira
- Ophthalmology Department, Centro Hospitalar Universitário de Lisboa Central, Alameda Santo António dos Capuchos, 1169-050, Lisboa, Portugal
| | - Diogo Hipolito-Fernandes
- Ophthalmology Department, Centro Hospitalar Universitário de Lisboa Central, Alameda Santo António dos Capuchos, 1169-050, Lisboa, Portugal
| | - Nuno Moura-Coelho
- Ophthalmology Department, Centro Hospitalar Universitário de Lisboa Central, Alameda Santo António dos Capuchos, 1169-050, Lisboa, Portugal.,Nova Medical School, Faculdade de Ciências Médicas, Campo Mártires da Pátria 130, 1169-056, Lisboa, Portugal
| | - João Paulo Cunha
- Ophthalmology Department, Centro Hospitalar Universitário de Lisboa Central, Alameda Santo António dos Capuchos, 1169-050, Lisboa, Portugal.,Nova Medical School, Faculdade de Ciências Médicas, Campo Mártires da Pátria 130, 1169-056, Lisboa, Portugal
| | - Joana Tavares Ferreira
- Ophthalmology Department, Centro Hospitalar Universitário de Lisboa Central, Alameda Santo António dos Capuchos, 1169-050, Lisboa, Portugal.,Nova Medical School, Faculdade de Ciências Médicas, Campo Mártires da Pátria 130, 1169-056, Lisboa, Portugal
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17
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Chauhan AF, Viruni N, Alvin Liu T, Arevalo JF, Cheson BD. Successful Treatment of Ocular Chronic Lymphocytic Leukemia with Ibrutinib: Case Report and Review of the Literature. Leuk Res Rep 2020; 14:100200. [PMID: 32509518 PMCID: PMC7265052 DOI: 10.1016/j.lrr.2020.100200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/03/2020] [Accepted: 04/11/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Ayushi F Chauhan
- Department of Hematology and Oncology, MedStar Georgetown University Hospital, Washington, DC
| | - Narine Viruni
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland
| | - T.Y. Alvin Liu
- Department of Ophthalmology, Retina Division, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland
| | - J Fernando Arevalo
- Department of Ophthalmology, Retina Division, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland
| | - Bruce D Cheson
- Department of Hematology and Oncology, MedStar Georgetown University Hospital, Washington, DC
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18
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Beziat G, Gauthier M, Protin C, Oberic L, Lerebours F, Carlier J, Ysebaert L. 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. Clin Case Rep 2020; 8:269-273. [PMID: 32128171 PMCID: PMC7044374 DOI: 10.1002/ccr3.2580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/25/2019] [Accepted: 10/26/2019] [Indexed: 12/14/2022] Open
Abstract
Venetoclax with high-dose methotrexate and rituximab seem effective and safe to treat central nervous system involvement of chronic lymphocytic leukemia.
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Affiliation(s)
- Guillaume Beziat
- Department of HematologyInstitut Universitaire du Cancer de Toulouse‐OncopoleToulouseFrance
| | - Martin Gauthier
- Department of HematologyInstitut Universitaire du Cancer de Toulouse‐OncopoleToulouseFrance
| | - Caroline Protin
- Department of HematologyInstitut Universitaire du Cancer de Toulouse‐OncopoleToulouseFrance
| | - Lucie Oberic
- Department of HematologyInstitut Universitaire du Cancer de Toulouse‐OncopoleToulouseFrance
| | | | | | - Loïc Ysebaert
- Department of HematologyInstitut Universitaire du Cancer de Toulouse‐OncopoleToulouseFrance
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19
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Central Nervous System Involvement by Small Lymphocytic Lymphoma after a Myxoma-Related Embolic Event. Case Rep Hematol 2019; 2019:1825491. [PMID: 31827948 PMCID: PMC6881765 DOI: 10.1155/2019/1825491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/05/2019] [Accepted: 10/23/2019] [Indexed: 12/22/2022] Open
Abstract
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.
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20
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Fürstenau M, De Silva N, Eichhorst B, Hallek M. Minimal Residual Disease Assessment in CLL: Ready for Use in Clinical Routine? Hemasphere 2019; 3:e287. [PMID: 31942542 PMCID: PMC6919470 DOI: 10.1097/hs9.0000000000000287] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/15/2019] [Indexed: 11/26/2022] Open
Abstract
The introduction of chemoimmunotherapy and more recently the implementation of novel agents into first-line and relapse treatment have substantially improved treatment outcomes in patients with chronic lymphocytic leukaemia (CLL). With longer progression-free survival and more frequently observed deep remissions there is an emerging need for sensitive methods quantitating residual disease after therapy. Over the last decade, assessment of minimal residual disease (MRD) has increasingly been implemented in CLL trials. The predictive value of MRD status on survival outcomes has repeatedly been proven in the context of chemoimmunotherapy and cellular therapies. Recent data suggests a similar correlation for Bcl-2 inhibitor-based therapy. While the relevance of MRD assessment as a surrogate endpoint in clinical trials is largely undisputed, its role in routine clinical practice has not yet been well defined. This review outlines current methods of MRD detection in CLL and summarizes MRD data from relevant trials. The significance of MRD testing in clinical studies and in routine patient care is assessed and new MRD-guided treatment strategies are discussed.
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Affiliation(s)
- Moritz Fürstenau
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Nisha De Silva
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf, German CLL Study Group, University Hospital Cologne, Cologne, Germany
- Cologne Cluster of Excellence in Cellular Stress Responses in Aging-associated Disease (CECAD), University of Cologne, Cologne, Germany
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21
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Abstract
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.
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Affiliation(s)
- Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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22
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Chronic lymphocytic leukemia with central nervous system infiltration versus CLL-associated auto-immune disease with neurological involvement: A tricky differential diagnosis. Rev Neurol (Paris) 2019; 176:120-123. [PMID: 31253361 DOI: 10.1016/j.neurol.2019.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 02/22/2019] [Accepted: 02/24/2019] [Indexed: 11/21/2022]
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23
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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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24
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Ibrutinib for the treatment of Bing-Neel syndrome: a multicenter study. Blood 2019; 133:299-305. [DOI: 10.1182/blood-2018-10-879593] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 11/29/2018] [Indexed: 11/20/2022] Open
Abstract
Abstract
The treatment of patients with Bing-Neel syndrome (BNS) is not standardized. We included patients with Waldenström macroglobulinemia (WM) and a radiologic and/or cytologic diagnosis of BNS treated with ibrutinib monotherapy. Response assessment was based on criteria for BNS from the 8th International Workshop for WM. Survival from BNS diagnosis (BNS survival), survival from ibrutinib initiation to last follow-up or death (ibrutinib survival), and time from ibrutinib initiation to ibrutinib discontinuation for toxicity, progression, or death (event-free survival [EFS]) were estimated. Twenty-eight patients were included in our study. The median age at BNS diagnosis was 65 years. Ibrutinib was the first line of treatment for BNS in 39% of patients. Ibrutinib was administered orally at a dose of 560 and 420 mg once daily in 46% and 54% of patients, respectively; symptomatic and radiologic improvements were seen in 85% and 60% of patients within 3 months of therapy. At best response, 85% of patients had improvement or resolution of BNS symptoms, 83% had improvement or resolution of radiologic abnormalities, and 47% had cleared the disease in the cerebrospinal fluid. The 2-year EFS rate with ibrutinib was 80% (95% confidence interval [CI], 58%-91%), the 2-year ibrutinib survival rate was 81% (95% CI, 49%-94%), and the 5-year BNS survival rate was 86% (95% CI, 63%-95%). Ibrutinib therapy is effective in patients with BNS and should be considered as a treatment option in these patients.
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25
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Espinoza-Gutarra MR, Cervantez SL, Nooruddin Z. West Nile Encephalitis, an Unusual Infection in a Chronic Lymphocytic Leukemia Patient. Case Rep Hematol 2018; 2018:3270348. [PMID: 30405921 PMCID: PMC6204171 DOI: 10.1155/2018/3270348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/18/2018] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Manuel R. Espinoza-Gutarra
- Department of Internal Medicine, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Sherri L. Cervantez
- Department of Hematology-Oncology, Mays Cancer Center, UT Health San Antonio, 7979 Wurzbach Rd., San Antonio, TX 78229, USA
| | - Zohra Nooruddin
- Department of Hematology-Oncology, South Texas VA, 7400 Merton Minter, San Antonio, TX 78229, USA
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26
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A Case of Bing-Neel Syndrome Successfully Treated with Ibrutinib. Case Rep Hematol 2018; 2018:8573105. [PMID: 30228918 PMCID: PMC6136466 DOI: 10.1155/2018/8573105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/23/2018] [Accepted: 08/01/2018] [Indexed: 11/17/2022] Open
Abstract
Bing–Neel syndrome is a rare manifestation of Waldenström macroglobulinemia characterized by lymphoplasmacytic cells' infiltration into the central nervous system. We present a case of a 74-year-old patient with a known diagnosis of Waldenström macroglobulinemia and newly depressed consciousness. Flow cytology of his cerebral spinal fluid demonstrated a lambda light chain-restricted population of B-cells consistent with a CD5+ CD10+ B-cell lymphoma. Magnetic resonance imaging suggested involvement of the left optic nerve sheath and the bilateral orbital and parietal parenchyma and leptomeninges. He was diagnosed with Bing–Neel syndrome and treated with intrathecal liposomal cytarabine, intravenous high-dose methotrexate, and rituximab without improvement. Subsequently, he started treatment with ibrutinib 560 mg daily and concurrent rituximab. Within three months, he showed clinical and radiologic improvement. The patient has continued on ibrutinib and has now been stable for over 36 months. This represents the longest reported period of successful treatment of Bing–Neel syndrome with ibrutinib.
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27
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Christoforidou A, Kapsas G, Bezirgiannidou Z, Papamichos S, Kotsianidis Ι. Successful Treatment of Chronic Lymphocytic Leukemia Multifocal Central Nervous System Involvement with Ibrutinib. Turk J Haematol 2018; 35:147-149. [PMID: 29391330 PMCID: PMC5972345 DOI: 10.4274/tjh.2017.0313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Anna Christoforidou
- Democritus University of Thrace, Department of Hematology, Alexandroupolis, Greece
| | - Georgios Kapsas
- Democritus University of Thrace, Department of Radiology, Alexandroupolis, Greece
| | - Zoe Bezirgiannidou
- Democritus University of Thrace, Department of Hematology, Alexandroupolis, Greece
| | - Spyros Papamichos
- Democritus University of Thrace, Department of Hematology, Alexandroupolis, Greece
| | - Ιoannis Kotsianidis
- Democritus University of Thrace, Department of Hematology, Alexandroupolis, Greece
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28
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Mihaljevic B, Smiljanic M, Antic D, Kurtovic NK, Balint MT. Chronic Lymphocytic Leukemia Involvement of Central Nervous System: Clinical Diversity, Diagnostic Algorithm and Therapeutic Challenges. Ann Indian Acad Neurol 2018; 21:85-87. [PMID: 29720808 PMCID: PMC5909156 DOI: 10.4103/aian.aian_442_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Biljana Mihaljevic
- Clinic of Haematology, Clinical Centre of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Darko Antic
- Clinic of Haematology, Clinical Centre of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Milena Todorovic Balint
- Clinic of Haematology, Clinical Centre of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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29
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Central nervous system localisation of chronic lymphocytic leukaemia, description of two very distinct cases and a review of the literature. Ann Hematol 2018; 97:1627-1632. [PMID: 29707738 PMCID: PMC6097746 DOI: 10.1007/s00277-018-3329-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 04/04/2018] [Indexed: 11/01/2022]
Abstract
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.
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30
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Hampel PJ, Chaffee KG, King RL, Simonetto D, Larson MC, Achenbach S, Call TG, Ding W, Kenderian SS, Leis JF, Chanan-Khan AA, Bowen DA, Conte MJ, Schwager SM, Hanson CA, Slager SL, Kay NE, Shanafelt TD, Parikh SA. Liver dysfunction in chronic lymphocytic leukemia: Prevalence, outcomes, and pathological findings. Am J Hematol 2017; 92:1362-1369. [PMID: 28940587 PMCID: PMC7219181 DOI: 10.1002/ajh.24915] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 09/15/2017] [Accepted: 09/19/2017] [Indexed: 01/03/2023]
Abstract
The prevalence of liver dysfunction and its association with outcomes in patients with previously untreated chronic lymphocytic leukemia (CLL) is unknown. Newly diagnosed (<12 months) previously untreated CLL patients seen at Mayo Clinic, Rochester, MN between 9/1993 and 4/2016 who had baseline assessment of at least one liver function test (LFT) were included in this analysis. The prevalence of liver dysfunction at baseline, proportion of patients who acquired LFT abnormalities, time to first therapy (TTFT) and overall survival (OS) were assessed. An abnormal LFT was present in 82/2336 (3.5%) patients at diagnosis and was associated with advanced Rai stage (Rai III-IV) (21% vs. 6%; P < .001), lower hemoglobin (13.1 g/dL vs. 13.9 g/dL; P < .001), and lower platelet count (187 × 109/L vs. 200 × 109/L; P = .03). Additionally, 236 patients with normal LFTs at diagnosis developed acquired liver dysfunction during follow-up. Patients with abnormal LFTs at diagnosis had a shorter OS compared to those with normal LFTs (HR 1.80 95% CI 1.13-2.87; P = .014, adjusted for age, sex, Rai stage, and treatment), although TTFT was not different. Of 52 patients who underwent a liver biopsy, CLL was present in liver tissue in 39/52 (73%) patients, with the portal tracts the most common region involved. Histopathology findings of liver involvement by CLL had limited correlation with choice of CLL therapy. In conclusion, approximately 1 of 25 newly diagnosed CLL patients has abnormal LFTs at diagnosis. Although the TTFT was not different among patients with abnormal LFTs, these patients have a shorter OS compared to those with normal LFTs.
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Affiliation(s)
- Paul J. Hampel
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kari G. Chaffee
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Rebecca L. King
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Douglas Simonetto
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Melissa C. Larson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Sara Achenbach
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Timothy G. Call
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Wei Ding
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Saad S. Kenderian
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jose F. Leis
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Deborah A. Bowen
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael J. Conte
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan M. Schwager
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Curtis A. Hanson
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Susan L. Slager
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Neil E. Kay
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Tait D. Shanafelt
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sameer A. Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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