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[Discrimination of leukoencephalopathy from leukemic cell invasion by MR spectroscopy in a patient with acute
T Sumikuma1, T Kikuta, H Hirai
1Second Department of Medicine, Kyoto Prefectural University of Medicine.
Insights
Proton magnetic resonance spectroscopy (1H-MRS) helped differentiate leukoencephalopathy from leukemic cell invasion in a patient with acute lymphoblastic leukemia. This imaging technique is crucial for diagnosing neurological complications post-stem cell transplant.
Area of Science:
- Neurology
- Oncology
- Medical Imaging
Background:
- A 58-year-old male diagnosed with acute lymphoblastic leukemia (ALL) achieved complete remission after initial treatment.
- The patient underwent consolidation therapy, including intrathecal (IT) chemotherapy, high-dose Ara-C, VP-16, and peripheral blood stem cell collection supported by recombinant human G-CSF.
Observation:
- The patient relapsed with leukemic cells in the cerebrospinal fluid (CSF), necessitating further IT injections.
- Following a successful peripheral blood stem cell transplant (PBSCT), the patient developed neurological symptoms including mental aberrations and loss of consciousness.
Findings:
- Proton magnetic resonance spectroscopy (1H-MRS) revealed severe frontal lobe necrosis consistent with leukoencephalopathy and leukemic cell infiltration around the lateral ventricles.
- The patient's neurological decline was attributed to severe necrosis, precluding further treatment for these symptoms.
Implications:
- 1H-MRS is a valuable tool for distinguishing between leukoencephalopathy and direct leukemic cell invasion in the central nervous system.
- Accurate diagnosis through 1H-MRS is critical for managing neurological complications in leukemia patients, particularly after stem cell transplantation.
- Understanding the specific cause of neurological symptoms is essential for appropriate patient management and therapeutic decision-making in complex oncological cases.
Abstract:
A 58-year-old man was admitted to our hospital in November 1992 because of fever and arthralgia. He was given a diagnosis of acute lymphoblastic leukemia and treated with an Ad-VP regimen, which resulted in complete remission. After two courses of consolidation therapy and intrathecal (IT) injections of methotrexate, Ara-C, and prednisolone the patient received high-dose Ara-C plus VP-16 followed by recombinant human G-CSF for the collection of peripheral blood stem cells. However, he relapsed with the appearance of leukemic cells in cerebrospinal fluid (CSF), and was accordingly given IT injections 8 more times. After the disappearance of leukemic cells from CSF, the patient received a peripheral blood stem cell transplant (PBSCT) and achieved rapid hematopoietic recovery. However, he suffered mental aberrations and loss of consciousness 9 days after PBSCT. Proton magnetic resonance spectroscopy (1H-MRS) disclosed severe necrosis due to leukoencephalopathy in the frontal lobe and invasion of leukemic cells around the lateral ventricles. The patient did not receive any therapy for neurological symptoms because of severe necrosis in the frontal lobe, and died of bone marrow relapse in April 1995. MRS is useful for the discrimination of leukoencephalopathy from leukemic cell invasion.
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