Flow cytometry shows added value in diagnosing lymphoma in brain biopsies

Background

To assess the sensitivity, specificity and turnaround time of flow cytometric analysis on brain biopsies compared to histology plus immunohistochemistry analysis in tumors with clinical suspicion of lymphoma.

Methods

All brain biopsies performed between 2010 and 2015 at our institution and analyzed by both immunohistochemistry and flow cytometry were included in this retrospective study. Immunohistochemistry was considered the gold standard.

Results

In a total of 77 biopsies from 71 patients, 49 lymphomas were diagnosed by immunohistochemistry, flow cytometry results were concordant in 71 biopsies (92.2%). We found a specificity and sensitivity of flow cytometry of 100% and 87.8%, respectively. The time between the biopsy and reporting the result (turnaround time) was significantly shorter for flow cytometry, compared to immunohistochemistry (median: 1 vs. 5 days).

Conclusions

Flow cytometry has a high specificity and can confirm the diagnosis of a lymphoma significantly faster than immunohistochemistry. This allows for rapid initiation of treatment in this highly aggressive tumor. However, since its sensitivity is less than 100%, we recommend to perform histology plus immunohistochemistry in parallel to flow cytometry. © 2018 The Authors. Cytometry Part B: Clinical Cytometry published by Wiley Periodicals, Inc. on behalf of International Clinical Cytometry Society

Human chorionic gonadotropin treatment of anti-Hu-associated paraneoplastic neurological syndromes

OBJECTIVE

Paraneoplastic neurological syndromes associated with anti-Hu antibodies (Hu-PNS) are mediated by a T-cell immune response that is directed against the Hu antigens. In pregnancy, many Th1-mediated autoimmune diseases such as rheumatoid arthritis and multiple sclerosis regress. We hypothesised that this decreased disease activity during pregnancy may be related to high human chorionic gonadotropin (hCG) levels.

METHODS

15 Hu-PNS patients were treated in a prospective, uncontrolled and unblinded trial with 10,000 IU daily of hCG administered by intramuscular injection during 12 weeks. Primary outcome measures were functional improvement defined as a decrease of one or more points on the modified Rankin Scale (mRS) or stabilisation in patients with mRS score ≤3 and improvement of neurological impairment assessed with the Edinburgh Functional Impairment Tests (EFIT). Secondary end points included the change in activities of daily living as evaluated using the Barthel Index.

RESULTS

Seven of 15 patients (47%) improved on the mRS or stabilised at mRS score ≤3. Four patients (27%) showed significant improvement of neurological impairment as indicated by an overall Edinburgh Functional Impairment Tests score of ≥1 point. Five patients improved on the Barthel Index (33%).

CONCLUSION

Comparison with previous studies suggests that hCG may have immunomodulatory activity and may modify the course of Hu-PNS, although well-established confounding factors may have contributed in this uncontrolled trial.

IDH1 mutations in low-grade astrocytomas predict survival but not response to temozolomide

BACKGROUND

Mutations in isocitrate dehydrogenase 1 and 2 (IDH1 and IDH2) have been implicated in tumorigenesis of gliomas. Patients with high-grade astrocytomas with IDH1 or IDH2 mutations were reported to have a better survival, but it is unknown if this improved survival also holds for low-grade astrocytoma and whether these mutations predict outcome to specific treatment.

METHODS

We retrospectively investigated the correlation of IDH1 and IDH2 mutations with overall survival and response to temozolomide in a cohort of patients with dedifferentiated low-grade astrocytomas treated with temozolomide at the time of progression after radiotherapy.

RESULTS

IDH1 mutations were present in 86% of the 49 progressive astrocytomas. No mutations in IDH2 were found. Presence of IDH1 mutations were early events and significantly improved overall survival (median survival 48 vs 98 months), but did not affect outcome of temozolomide treatment.

CONCLUSION

These results indicate that IDH1 mutations identify a subgroup of gliomas with an improved survival, but are unrelated to the temozolomide response.

[Three patients with a paraneoplastic neurological syndrome: the significance of paraneoplastic antibodies]

Establishing the presence of paraneoplastic antibodies is important in identifying an often severe neurological syndrome as paraneoplastic and hence directing the search for an underlying neoplasm. A paraneoplastic neurological syndrome was diagnosed in 3 patients. The first was a 64-year-old woman in whom paraneoplastic encephalomyelitis was diagnosed. The diagnosis was strongly supported by a high titre of serum anti-Hu antibodies, despite three negative biopsies from a mediastinal mass. The patient died of a non-convulsive status epilepticus; autopsy revealed not only paraneoplastic encephalomyelitis but also small-cell lung cancer. The second patient was a 55-year-old woman with metastatic breast cancer. After a three-year period of progressive neurological deterioration, a high titre of anti-CV2/CRMP5 antibodies was detected, on the basis of which the clinical syndrome was diagnosed as paraneoplastic. She received immunotherapy and her condition stabilised. The third patient, a 41-year-old man, presented with severe limbic encephalitis. Biopsy from a paraaortic mass was positive for undifferentiated carcinoma. The patient had a high titre ofanti-Ma2 antibodies and was subsequently tested positive for serum alpha-foetoprotein (AFP) and beta-human-chorionic gonadotrophin (bta-HCG). During chemotherapy for a non seminoma testicular cancer, the limbic encephalitis improved both clinically and radiologically, but the patient died as a result of the toxicity of the treatment.

[Clinical reasoning and decision making in practice. A man with unilateral attacks of muscular rigidity following neck surgery for a malignant tumor]

A 54-year-old man with a history of generalised tonic clonic seizures presented with complaints of daily unilateral stiffening of the limbs, preceded by paraesthesia. Two years before he had been treated with surgery and radiotherapy for a laryngo-pharyngeal carcinoma. Therefore, epilepsy due to intracerebral metastasis was suggested. However, neither CT nor MRI of the brain (with intravenous contrast) showed any abnormalities and the EEG showed no epileptiform discharges. Laboratory tests revealed elevated levels of thyroid-stimulating hormone in the blood, hypocalcaemia, hyperphosphataemia and hypomagnesaemia. In combination with the medical history, tetany was found to be the correct diagnosis. In this patient, tetany was caused by hypoparathyroidism secondary to surgery and radiotherapy in the neck region. He was treated with levothyroxine, magnesium, calcium, and vitamin D and recovered in a few weeks' time. Hypothyroidism and hypoparathyroidism are common complications after treatment (surgery, radiotherapy and/or chemotherapy) for laryngo-pharyngeal carcinoma and other malignancies in the neck region.

White matter lesions and encephalopathy in patients treated for primary central nervous system lymphoma

A retrospective analysis of the clinical presentations and neuroimaging characteristics of 33 patients with a primary central nervous system lymphoma (PCNL) who received cranial radiotherapy was performed to assess incidence of and risk factors for radiation-induced encephalopathy. CT and MRI scans were revised by a neurologist and a radiologist in conference. White matter abnormalities before and after radiotherapy on the last scan before recurrence were quantified according to a semi-quantitative scale. All available medical records were retrieved and reviewed with respect to demographic and tumor-related variables, treatment modalities, disease-free and overall survival and clinical symptoms and signs of encephalopathy. CT and MRI scans showed severe white matter lesions in 75% of 20 patients and in 86% of patients aged more than 60 years. Forty percent of patients presented with new clinical signs of cognitive impairment a median of 14.5 months after initial diagnosis (8.5 months after radiotherapy). The risk of white matter lesions appeared greater in patients aged >60 (RR 1.2, 95% CI = 0.8-2.0), in patients with prior white matter lesions (RR 1.3, 95% CI = 0.8-2.1) and in patients with multifocal cerebral lymphoma (RR 1.5, 95% CI = 1.0-2.1). In conclusion, the risk of white matter lesions and clinical symptoms and signs of encephalopathy is high in patients treated by radiotherapy for PCNL. The risk appears to be greatest in older patients, patients with multifocal tumor and in those with prior white matter lesions on CT or MRI.

Recurrent subdural haematoma as the primary and sole manifestation of chronic lymphocytic leukaemia

An 81-year-old man with a recurrent subdural haematoma as the first and only manifestation of chronic lymphocytic leukaemia (CLL) is described. Microscopic examination of the encapsulated haematoma showed leukaemic infiltration and the diagnosis was confirmed by bone marrow aspiration and by pathological examination of the brain at autopsy.

[Neurological presentation of non-Hodgkin lymphoma: a diagnostic problem]

In two patients, men aged 69 and 38 years, neurological signs were the first presenting symptoms of systemic non-Hodgkin's lymphoma (NHL). This presentation is uncommon. The patients had focal neurological deficit and elevated serum lactate dehydrogenase (LDH) activity. Neurological manifestations of NHL may be caused by extradural lymphoma or by diffuse leptomeningeal metastasis (meningitis lymphomatosa). A third patient, a woman of 48, had a third form of nervous system involvement, primary cerebral NHL, which is not a metastatic sequel to systemic NHL. Primary neurological presentation of NHL may be difficult to diagnose, particularly in case of prior treatment with corticosteroids.

Family history of subarachnoid haemorrhage: supplemental value of scrutinizing all relatives

OBJECTIVE AND METHODS

To assess the validity of the family history obtained at the bedside of patients with recent subarachnoid haemorrhage by subsequently contacting all first and second degree relatives, with verification from medical record data.

RESULTS

In a prospectively collected series of 163 patients with recent subarachnoid haemorrhage the history or cause of death could be ascertained in 1259 (98%) of the first degree relatives and in 3038 (85%) of the second degree relatives. For first degree relatives only, the sensitivity of the family history at the bedside was 0.75 (95% confidence interval (95% CI) 0.35-0.97) and the positive predictive value was 0.55 (95% CI 0.23-0.83); for first and second degree relatives together the sensitivity was 0.58 (95% CI 0.28-0.85) and the positive predictive value was 0.64 (95% CI 0.31-0.89).

CONCLUSION

The accuracy of the family history taken at the bedside is modest; a more thorough collection of data is crucial if the decision is taken to screen relatives based on the family history.

Validation of family history in subarachnoid hemorrhage

BACKGROUND AND PURPOSE

In 6% to 9% of patients with subarachnoid hemorrhage (SAH), familial aggregation occurs; truly familial cases carry a worse prognosis than sporadic cases and raise the question of screening. If relatives have died from SAH, the family history is often the only available clue to the diagnosis, but the sensitivity and predictive value of such a history for SAH are unknown.

METHODS

We contacted a next of kin for a consecutive series of patients who had died in the hospital of subarachnoid hemorrhage (n=20), intracerebral hemorrhage (n=22), or ischemic stroke (n=23) between 3 and 5 years previously, and we compared the diagnosis based on the history from this next of kin with the medical diagnosis confirmed by a CT scan.

RESULTS

The positive predictive value of the diagnosis of "probable SAH" from the history in our study sample was 0.7; when adjusted for incidence rates in the general population it was 0.6 (95% confidence interval, 0.3 to 0.8). The sensitivity of the diagnosis based on the history was 0.5 (95% confidence interval. 0.3 to 0.7); 10 of the 20 cases of SAH were not identified.

CONCLUSIONS

The family history of SAH, without confirmation from medical documents, is an insufficiently accurate tool to prove or disprove the diagnosis of familial SAH.

Hypertension, stroke, and coronary heart disease in relatives of patients with subarachnoid hemorrhage

BACKGROUND AND PURPOSE

First-degree relatives of patients with subarachnoid hemorrhage (SAH) have a three to seven times greater risk of SAH than second-degree relatives and than the general population. If hypertension, which is in part genetically determined, contributes to this increased risk, the frequency of hypertension and its sequelae would be expected to be higher in first- than in second-degree relatives of patients with SAH.

METHODS

We compared the reported frequency of hypertension, stroke, and coronary heart disease between 1290 first- and 3588 second-degree relatives of a prospective series of patients with SAH.

RESULTS

The relative risk adjusted for age and survival status in first-degree relatives was 2.3 (95% confidence interval [CI], 1.9 to 2.9) for hypertension, 1.8 (95% CI, 1.3 to 2.4) for stroke, and 1.9 (95% CI, 1.5 to 2.3) for coronary heart disease.

CONCLUSIONS

Hypertension is a familial factor contributing to the risk of SAH. Hypertension should be sought and treated in first-degree relatives of patients with SAH to reduce the increased risk of cerebrovascular and cardiovascular diseases.

Familial subarachnoid hemorrhage: distinctive features and patterns of inheritance

To delineate the distinctive features of familial subarachnoid hemorrhage, we compared gender and age at the time of subarachnoid hemorrhage, as well as site and number of aneurysms, in patients with familial subarachnoid hemorrhage (at least 1 first-degree relative with subarachnoid hemorrhage) and patients with sporadic subarachnoid hemorrhage (no subarachnoid hemorrhage in first- or second-degree relatives), in a prospective, hospital-based series of patients. In addition we studied the pattern of inheritance in 17 families with familial subarachnoid hemorrhage. Mean age at the time of hemorrhage in patients with the familial form was 6.8 years lower than that in those with the sporadic form, and middle cerebral artery aneurysms occurred more often in patients with familial disease. Sex distribution and number of aneurysms were similar in the two groups. Inheritance was compatible with autosomal dominant transmission in some families, and with autosomal recessive or multifactorial transmission in others. In our 5 families as well as in all 18 previously reported families with two affected generations, the age at the time of subarachnoid hemorrhage was invariably lower in later generations, which is suggestive of anticipation. We conclude that familial subarachnoid hemorrhage is a separate entity with occurrence at a young age, predilection for aneurysms of the middle cerebral artery, and variable modes of inheritance, including autosomal dominant inheritance with possible anticipation.

Outcome in familial subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The outcome of subarachnoid hemorrhage in patients with familial occurrence of subarachnoid hemorrhage (familial SAH) is an important but neglected factor in balancing the risks of screening for asymptomatic aneurysms and repairing these in unaffected members of such families.

METHODS

We studied the outcome of familial SAH in a prospective, hospital-based series of patients with at least one first-degree relative with SAH and compared it with the outcome in a prospectively collected hospital series of patients selected for the absence of SAH in first- and second-degree relatives. Outcome was graded in three categories: independence, dependence, or death. Poor outcome was defined as death or dependence.

RESULTS

Of 29 patients with familial SAH, 52% had a poor outcome, whereas only 37% of 125 patients with sporadic SAH had a poor outcome. The crude relative risk for poor outcome in familial SAH was 1.4 (95% confidence interval [CI], 0.9 to 2.1; P = .14); the odds ratio adjusted for age and sex was 2.5 (95% CI, 1.0 to 6.0; P = .04). This risk is probably an underestimation due to our strict patient selection criteria.

CONCLUSIONS

Patients with familial SAH have a greater risk of poor outcome than patients with sporadic SAH. This adds to the factors in favor of screening unaffected first-degree relatives of patients with familial SAH.

Definition of initial grading, specific events, and overall outcome in patients with aneurysmal subarachnoid hemorrhage. A survey

BACKGROUND AND PURPOSE

Scientific communication in medicine can be effective only if reports are based on unequivocal criteria for clinical conditions or specific diagnoses.

METHODS

We reviewed all articles about subarachnoid hemorrhage published in nine neurosurgical or neurological journals from 1985 through 1992 and assessed the presence and the precision of definitions used for reporting the initial grade, the specific complications of rebleeding, delayed cerebral ischemia, and hydrocephalus, and the overall outcome. We identified 184 articles reporting direct observations in at least 10 patients on one or more of these conditions.

RESULTS

Of 161 articles reporting the initial condition, only 19% used an unequivocal grading system (World Federation of Neurological Surgeons Scale or Glasgow Coma Scale); this proportion did not increase after 1988, when the World Federation of Neurological Surgeons Scale was introduced. The specific outcome events of rebleeding, ischemia, and hydrocephalus (283 instances) were sufficiently defined in only 31% of instances, incompletely in 22%, and not at all in 47%. The proportions were similar when the results were analyzed according to the type of complication, the year of publication, or per study. The four exclusively neurosurgical journals featured suitable definitions for any of the three outcome events in 20% of 209 instances, whereas the five mainly neurological journals published fewer articles about subarachnoid hemorrhage (74 instances of outcome events) but more often with precise criteria (65%). Overall outcome was adequately reported in 63% of all articles, with an increase over the years (54% in 1985 through 1988, 71% in 1989 through 1992).

CONCLUSIONS

Reports about subarachnoid hemorrhage require closer scrutiny before publication to ascertain whether the conclusions about specific outcome events are based on unequivocal criteria.