case discussion burkitt ’ s lymphoma with central nervous system relapse 指導醫師 : vs...
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Case DiscussionCase DiscussionBurkitt’s Lymphoma with Burkitt’s Lymphoma with Central Nervous System Relapse Central Nervous System Relapse
指導醫師 : VS 蘇裕傑醫師實習醫師 : Intern 傅斯誠醫師
2005/11/05
Patient Data
盧 先生19 year-old male
ID: I100150062
Admission date: 2005/10/12
Chief Complaint:
Patient Data
盧 先生19 year-old male
ID: I100150062
Admission date: 2005/10/12
Chief Complaint:Bilateral leg weakness and numbnessBilateral leg weakness and numbness
For 1 dayFor 1 day
Past History
2005/01 Burkitt’s lymphoma
Completed 10 courses of chemotherapy
Present Illness
2005/01Abdominal fullness and poor appetite
Hospitalized at 台南市立醫院Gastric ulcer and ascites
Present Illness
2005/01Abdominal fullness and poor appetite
Hospitalized at 台南市立醫院Gastric ulcer and ascites
Transferred to 嘉義基督教醫院Abdominal Imaging revealed masses
Suspect intra-abdominal lymphoma
Transferred to 台北恩主公醫院CT-guide biopsy for diagnosis
Burkitt’s lymphoma
Liver metastasis
Transferred to 台北恩主公醫院CT-guide biopsy for diagnosis
Burkitt’s lymphoma
Liver metastasis
Transferred to 台大醫院Port-A insertion and Chemotherapy
Transferred to 台北恩主公醫院CT-guide biopsy for diagnosis
Burkitt’s lymphoma
Liver metastasis
Transferred to 台大醫院Port-A insertion and Chemotherapy
Transferred to 大林慈濟醫院Completed 10 courses of chemotherapy
(2005/01/14 ~ 2005/09/23)
2005/01/14 Abdominal CT
2005/01/17
Bone scanNo bony lesions
2005/01/18
Gallium scan
DiagnosisIntra-abdominal origin
Burkitt’s lymphoma
Liver metastases
DiagnosisIntra-abdominal origin
Burkitt’s lymphoma
Liver metastases
Chemotherapy regimen:EPOCH (x2)
High dose MTX + LV + Ara-C
Endoxan + Mesna + Oncovin + Epirubicin (x4)
+ IT Methotrexate and Ara-C
DiagnosisIntra-abdominal origin
Burkitt’s lymphoma
Liver metastases
Chemotherapy regimen:EPOCH (x2)
High dose MTX + LV + Ara-C
Endoxan + Mesna + Oncovin + Epirubicin (x4)
+ IT Methotrexate and Ara-C
Completed on 2005/09/23Completed on 2005/09/23
2005/10/11 15:00
Came to our Emergency Dept.
Chief complaint:General weaknessGeneral weakness
DizzinessDizziness
DyspneaDyspnea
At our ER…
Lab data revealed hypokalemia (K+2.hypokalemia (K+2.8)8)
Given K+ supplement
Allowed discharge
2005/10/12 08:00
Returned to our Emergency Dept.Bilateral lower leg weakness, numbnessBilateral lower leg weakness, numbness
Drooped right faceDrooped right face
DiplopiaDiplopia
Stool IncontinenceStool Incontinence
Social History
No smoking, betel nut, or alcohol use
Lives at home with family
Family HistoryNo family member with tumor history.
No known allergies
Allergy
Physical Examination
Weight: 58kg Height: 178cmVital signs:
TPR: 37.3°C / 98bpm / 20TPR: 37.3°C / 98bpm / 20BP: 127/85 mmHg.BP: 127/85 mmHg.
Skin: normal skin turgor
Head & Skull:Bold, no OP scars
Eyes:Pupils 3.0 / 3.0 Light reflex sluggishConjunctiva pink
Physical Examination
ENT & Mouth:Hearing normal, oral mucosa intact
Neck:No jugular vein engorgement, no carotid bruits
Neck movement normal, no palpable lymph nodes
Thyroid gland impalpable
Chest & Lungs:Breathing sounds regular, bilateral expansion symmetric
Heart: Heart sounds regular, no murmurs.
Physical Examination
Abdomen:Flat, soft, no tenderness
Liver and spleen impalpable.
Extremities:Movement of upper extremities normal
Movement of lower extremities ok, but weakMovement of lower extremities ok, but weak
Back & Spine:No kocking pain over C-V angles
Neurological Examination
Level of consciousness : clear, alert Mental status normal
JudgementOrientationMemoryAbstract thinkingCalculation
SpeechContent logical, comprehensibleArticulation slightly unclearArticulation slightly unclear
Neurological Examination
Cranial nerves :CN I: no loss of smellCN II:
Pupils isocoric 3.0 / 3.0, light reflex sluggish Visual field normalVisual acuity well
CN III, IV, VI: Left eye lateral movement impairedLeft eye lateral movement impaired
CN V: Normal muscle power of masseterNo numbness over faceCorneal reflex normal
Neurological Examination
CN VII: Right facial expression impairedRight facial expression impaired
Peripheral type Bell’s facial palsyPeripheral type Bell’s facial palsy
CN VIII: hearing normal
CN IX, X: Phonation normal
Swallowing normal
No deviation of uvula
CN XI: Normal muscle power of S.C.M & trapezious m.
CN XII: Leftward deviation of tongueLeftward deviation of tongue
Neurological Examination
Motor system:Bilateral lower extremity weaknessBilateral lower extremity weaknessStool Incontinence (+)Stool Incontinence (+)
Neurological Examination
Motor system:Bilateral lower extremity weaknessBilateral lower extremity weaknessStool Incontinence (+)Stool Incontinence (+)
Sensory system :Decreased sensation over right lateral thighDecreased sensation over right lateral thigh
Neurological Examination
Motor system:Bilateral lower extremity weaknessBilateral lower extremity weaknessStool Incontinence (+)Stool Incontinence (+)
Sensory system :Decreased sensation over right lateral thighDecreased sensation over right lateral thigh
Cerebellar function:F-to-N : intactRAM : intactTruncal ataxia : nil
Neurological Examination
Motor system:Bilateral lower extremity weaknessBilateral lower extremity weaknessStool Incontinence (+)Stool Incontinence (+)
Sensory system :Decreased sensation over right lateral thighDecreased sensation over right lateral thigh
Cerebellar function:F-to-N : intactRAM : intactTruncal ataxia : nil
Deep tendon reflexDiffuse decrease of DTR
Summary ofNeurological Findings1) Left eye deviation
2) Right Bell’s palsy
3) Tongue deviation
4) Right thigh numbness
5) Bil. lower extremity weakness
6) Stool incontinence
7) Diffuse decrease of DTR
Summary ofNeurological Findings1) Left eye deviation (CNIII, VI)
2) Right Bell’s palsy (CNVII peripheral)
3) Tongue deviation (CN XII)
4) Right thigh numbness (L1)
5) Bil. lower extremity weakness (PT)
6) Stool incontinence (Spine)
7) Diffuse decrease of DTR (K+)
Lab Data
Upon Admission…
<CBC>
<CBC>
2005/10/11
PA CXR
Problem List
Burkitt’s lymphoma with CNS replapse
Hypokalemia, Hyponatremia
Treatment Plan
Burkitt’s lymphoma with CNS replapse Bone marrow aspirationBone marrow aspiration
CSF studyCSF study
Intra-thecal chemotherapyIntra-thecal chemotherapy
CNS RadiotherapyCNS Radiotherapy
Hypokalemia, HyponatremiaK+, Na+ supplementK+, Na+ supplement
Bone Marrow Aspiration 10/12
Large lymphocytes
>Blue cytoplasm
>Vacuoles
Bone Marrow Aspiration 10/12
Large lymphocytes
>Blue cytoplasm
>Vacuoles
RELAPSE!RELAPSE!
2005/10/12 Lumbar puncture
2005/10/12 Lumbar puncture
Cytology:Burkitt’s lymphoma with CNS involvementMassive tumor cells with large nucleus, scanty cytoplasm
Intrathecal methotrexate
2005/10/12 Lumbar puncture
2005/10/12 Lumbar puncture
Cytology:Burkitt’s lymphoma with CNS involvementMassive tumor cellsSome cell necrosis
Intrathecal methotrexate
2005/10/17 Lumbar puncture
2005/10/17 Lumbar puncture
Cytology:Burkitt’s lymphoma with CNS involvementSome tumor cellsCell necrosis
Follow-up Conditions
10/16Spontaneous stool passageAble to stand, walk slowly
Follow-up Conditions
10/16Spontaneous stool passageAble to stand, walk slowly
10/17Left eye lateral movement (+)Walking improvedSwallowing improvedDTR (+)
Questions?Questions?
DiscussionBurkitt’s Lymphoma with Burkitt’s Lymphoma with
Central Nervous System RelapseCentral Nervous System Relapse
DiscussionBurkitt’s Lymphoma with Burkitt’s Lymphoma with
Central Nervous System RelapseCentral Nervous System Relapse
IT HAPPENS!IT HAPPENS!
Natural Course
Burkitt's Lymphoma CNS involvement: 20~30%
Presentation?Risk factors?Benefit?Prognosis?CNS prophylaxis regimen?
Presentation
The commonest featuresHeadache
Cranial nerve palsies
Spinal cord compression
Altered mental state and affect
Central Nervous System LymphomaAndrew Lister, Lauren E. Abrey, and John T. Sandlund, Hematology 2002
Risk Factors
Risk Factors
1980~1996Norwegian Radium Hospital 2514 Non-Hodgkin Lymphoma patientsWithout CNS presentationRetrospective analysis
Risk Factors
Non-Hodgkin’s Lymphoma
Age > 60 years old
LDH > 450 U/L
Albumin < 35 g/L
Retroperitoneal gland involvement
Extranodal sites >1
Burkitt’s type is a risk factor! (24%)
Useful for High-grade NHL
Benefit of Prophylaxis
CNS involvement in Burkitt’s (at 5 years)Overall 24%Without prophylaxis 78%With prophylaxis 19%
Central Nervous System involvement following diagnosis of non-Hodgkin’s Central Nervous System involvement following diagnosis of non-Hodgkin’s lymphoma: a risk model lymphoma: a risk model A. Hollender et alA. Hollender et al. Annals of Oncology 2002. Annals of Oncology 2002
Prognosis
CNS involvement to deathMedian survival
Primary progression 2.4 Months
Relapse 2.2 Months
Regimen
Regimen
2004 Feb.~Apr. (159 UK Medical Centers)293 questionnaires
158 Received65 Followed by telephone7 0 Did not care for NHL patients
96%96%
Back to our patient…
Presentation
Risk Factors
Regimen
Prognosis
Back to our patient…
PresentationTypical relapse
Risk FactorsBurkitt’s type high risk
RegimenMTX based (+Ara-C)
PrognosisPoor
Back to our patient…
PresentationTypical relapse
Risk FactorsBurkitt’s type high risk
RegimenMTX based (+Ara-C)
PrognosisPoor
Comments?
Discussion comments
1) If patient turned out to have normal CSF study, what is our next step?
Cancinomatosis of meninges can also be diagnosed through MRI image studies.
2) The journals involved in this discussion did not help with patient’s future management. What are some other topics of consideration in the benefit of our patient?
The discussion included here focused mainly on statistical analysis of the course of Burkitt’s lymphoma. Of course, newer studies on autologous stem cell transplant for cure are also being carried out. This topic should also be included here.