CSF analysis of IgH gene rearrangement in CNS lymphoma: relationship to the disease course

PURPOSE: To assess whether clonal IgH genes in CSF of patients with CNS lymphoma correlates with the disease course. BACKGROUND: It has been shown that the PCR technique, which offers a sensitive test for diagnosis of systemic lymphoproliferative malignancies, can be applied to the CSF. METHODS: Seventy-three CSF specimens from 32 patients (27 with primary CNS lymphoma and 5 with an isolated parenchymal CNS relapse of systemic lymphoma) were examined. The results were evaluated retrospectively and compared to conventional cytology, clinical and imaging data, and course of the disease. CNS disease was defined as active when leptomeningeal and/or parenchymal brain involvement was evident on neuroimaging. Patients were considered to have a complete response when imaging confirmed absence of a tumor mass or leptomeningeal seeding. RESULTS: Sixty-three of 73 samples had adequate genetic material for testing. Of the 63, 15 (24%) were positive for clonal IgH rearrangement. In nine (60%) of the 15 patients with active disease, PCR results were positive, while negative results were observed in 19 (95%) of the 20 patients showing clear response to treatment. The sensitivity and specificity of the PCR evaluation were 54% and 97%, respectively. The predictive values of positive and negative tests were 93% and 74%, respectively. CONCLUSIONS: The integrated results of both PCR and cytology evaluations increase the sensitivity of CSF analysis. The PCR study has high specificity and positive results are indicative for the presence of active disease, even when the tumor seems confined to the brain parenchyma.     

CSF evaluation in primary CNS lymphoma patients by PCR of the CDR III IgH genes

BACKGROUND: Cytologic evaluation of CSF does not consistently detect malignant cells in patients with primary CNS lymphoma (PCNSL). The potentially more sensitive molecular assessment of monoclonality has not been shown in CSF samples. METHODS: The authors studied nested PCR of the complementary determining region III (CDR III) on 76 CSF specimens of patients with PCNSL. Patients with systemic disseminated B-cell non-Hodgkin's lymphoma (n = 17) and 17 patients with no history of lymphoma were compared. PCR products were evaluated by automated fluorescent fragment analysis (ALF). RESULTS: In 68 patients with PCNSL, the authors analyzed the first obtained CSF sample. Nevertheless, 60 patients were taking corticosteroids. In 16 PCNSL samples, amplifiable DNA was not yielded. Taking into account that at least two independent assays have to be performed, CDR III PCR consistently revealed monoclonal products in eight PCNSL and polyclonal results in 52 PCNSL specimens. CDR III PCR detected no monoclonal PCR products in patients without history of lymphoma. In 10 patients with PCNSL, the PCR result and the CSF cytology were discordant. Concerning therapeutic impact, leptomeningeal tumor spread did not predict tumor response in this group of patients with PCNSL. CONCLUSIONS: This study performed CDR III PCR as a routine diagnostic technique applicable even on CSF samples with low cell counts. These data present low incidence of leptomeningeal involvement in this subset of pretreated PCNSL patients. Because the CSF evaluation did not predict outcome in our patients, further analysis in patients with PCNSL should focus on CSF samples that are obtained very early after diagnosis.     

Babinski and the diagnosis of amyotrophic lateral sclerosis

Cytological evaluation of cerebrospinal fluid (CSF) is an important means of following response to intracavitary chemotherapy for leptomeningeal malignancy. We studied the feasibility of quantitative cytological evaluation by retrospective analysis of serial CSF specimens from 7 patients receiving phase I intracavitary chemotherapy for leptomeningeal malignancy who had persistent malignant cytology. Three to 34 CSF specimens per patient obtained over a 3- to 48-week period were reviewed. Significant (five- to 10-fold or greater) reductions in numbers of malignant cells in CSF during treatment could be identified in specimens otherwise diagnosed as positive. Quantitative CSF cytological evaluation is neither overly time consuming nor tedious to perform and may provide useful clinical information.     

脑膜淋巴瘤的临床脑脊液细胞学研究

目的探讨脑脊液细胞学、免疫细胞化学和流式细胞分析在脑膜淋巴瘤诊断中的灵敏性和特异性。方法13例诊断为脑膜淋巴瘤的患者，其中原发性中枢神经系统淋巴瘤5例，均为非霍奇金淋巴瘤B细胞型（NHL-B）；继发性8例，包括NHL-B6例，非霍奇金淋巴瘤T细胞型（NHL-T）1例，mantle型1例。神经系统表现为头痛、视乳头水肿、脑脊膜刺激征、脊髓腰骶神经根受累和多脑神经麻痹等。腰穿脑脊液压力升高，细胞计数、蛋白均升高，糖减低。所有患者均采用沉淀池法，免疫细胞化学单克隆抗体CD19、CD20、CD79a、CD34和免疫球蛋白轻链等；其中3例脑脊液进行淋巴细胞亚群流式细胞分析。以4例病毒性脑炎和5例炎性脱髓鞘病患者的脑脊液为对照。结果脑脊液细胞学发现每例患者均有淋巴瘤细胞或异型淋巴细胞。免疫细胞化学发现5例患者多数细胞B细胞标记物阳性；例6多数细胞CD34阳性；例8CD20阳性细胞比例升高；例7CD19、CD20阴性。除例8外，其余脑脊液中细胞呈CD4和CD8阴性或极少数阳性。对照组CD4阳性细胞为主，伴有少量CD8阳性细胞，CD19和CD20阴性或极少数阳性。脑脊液流式细胞分析发现例9和例11的B淋巴细胞占85．9％～97．4％，提示异常的B细胞克隆。对照组以CD4、CD8阳性细胞为主，CD19阳性细胞低于4．0％。结论脑脊液细胞学和免疫细胞化学是诊断脑膜淋巴瘤的重要方法，脑脊液淋巴细胞亚群的流式分析能够对诊断脑膜淋巴瘤有所帮助。     

Leptomeningeal carcinomatosis as primary manifestation of pancreatic cancer

Leptomeningeal carcinomatosis (LMC) is a rare complication of cancer that often presents at an advanced stage after obvious metastasis of a primary cancer or locally advanced disease. We present an uncommon case of LMC secondary to pancreatic carcinoma presenting with headache, unilateral VII nerve palsy, and lower extremity weakness. Initial cerebrospinal fluid (CSF) studies were concerning for chronic aseptic meningitis but negative for malignant cells; the diagnosis of tuberculous meningitis was erroneously evoked. Three lumbar punctures were required to capture malignant cells. The diagnosis of LMC was based on CSF examination with cytology/immunohistochemistry and leptomeningeal enhancement on MRI. Post mortem autopsy revealed advanced and diffusely metastatic pancreatic adenocarcinoma. This patient demonstrates that solid tumors can present with leptomeningeal spread that often confuses the treating physician. Fungal or tuberculous meningitis can mimic LMC in the absence of neoplastic signs and negative CSF cytology. This event is exceedingly rare in pancreatic cancer. If the index of suspicion is high, repeat CSF sampling can increase the sensitivity of detection of malignant cells and thus result in the correct diagnosis.     

Primary leptomeningeal sarcomatosis

6 autopsy cases of primary leptomeningeal sarcomatosis are presented as a distinct nosological entity with a variable clinical picture and morphology in 5 males and 1 female. The clinical course from onset of symptoms till death ran for only a few weeks in most cases. 2 infants showed brain tumor symptoms and signs. 2 patients of advanced age presented a polyradiculoneuritic syndrome and 2 young adults had spinal cord compression symptoms and a mixed clinical form. In almost all cases, clinical symptoms and signs were for most of the course confined to one part of the neuraxis. The CSF was distinctly abnormal in all cases, showing elevated protein, depressed glucose and pleocytosis of variable extent. CSF sediment was investigated in 3 cases in all of which malignant tumor cells were found so a diagnosis of malignant meningeal tumor was made during life. Electron microscopy of CSF cells in 1 case confirmed the primitive character of the tumor cells. Complete autopsies revealed absence of any neoplasm outside of the CNS. Gross meningeal involvement was visible in all cases. Histologically, 3 tumor types were distinguished: polymorphic cell sarcoma, an undifferentiated form, and fibrosarcomatosis. Clinical data are analyzed in order to distinguish the condition from other neoplasms or infectious, especially tuberculous meningeal infiltrations. CSF cytology studies are considered the most useful step in clinical diagnosis. Neuropathological features are reviewed with stress on differentiation from malignant lymphomas of the CNS, diffusely spreading medulloblastoma, meningeal melanoblastosis and gliomatosis. The origin of meningeal sarcomatosis cells is briefly discussed. The use of the term "meningeal meningiomatosis" for this condition is deprecated.     

Glucosephosphate isomerase as a CSF marker for leptomeningeal metastasis

Glucosephosphate isomerase (GPI), also known as phosphohexoisomerase, is a glycolytic enzyme whose activity is elevated in serum and CSF of patients with primary and metastatic CNS tumors. To improve the diagnostic accuracy of leptomeningeal metastasis (LM), we measured GPI levels in CSF of 66 patients with CNS or systemic malignancies with suspected LM. We determined GPI kinetically using a coupled enzyme reaction assay. There were 31 males and 35 females, aged 1 to seventy-six. Thirty-one had primary brain tumors, and 35 had systemic cancer with suspected CNS metastasis. We analyzed 95 samples; GPI values ranged from 0.85 to 329.0 U/l (normal, less than 20 U/l). Compared with positive CSF cytology and myelography, GPI sensitivity was 53.5% and specificity 92.1% for the group as a whole. There was a highly significant association between elevated CSF GPI (greater than 20 U/l) and LM. The results were similar for both primary CNS and systemic malignancies. Although not very sensitive, an elevated CSF GPI strongly suggests LM and may aid in early diagnosis of this serious complication of cancer.     

脑膜癌病的脑脊液细胞学与临床观察

目的研究脑膜癌病(LC)的脑脊液(CSF、)细胞学、临床及神经影像学特点。方法回顾分析16例LC。结果16例LC患者中，男6例、女10例，年龄29～69岁。亚急性起病，头痛14例，伴恶心、呕吐、眼底视乳头水肿；出现脑膜刺激征12例；双下肢无力5例，排尿困难3例；意识丧失、抽搐7例；视力减退5例，眼肌麻痹4例，听力下降1例，吞咽困难2例，偏瘫1例，多饮多尿1例。消瘦10例，低热5例。7例有癌症病史。CSF压力升高13例，CSF、常规计数白细胞升高10例，蛋白均升高，糖减低9例。CSF细胞学均见癌细胞，4例行免疫组化检查示，肿瘤细胞上皮膜抗原和细胞角蛋白阳性。临床及病理学确定来源肺癌6例、乳腺癌3例、胃癌2例、卵巢癌1例，来源未明4例。结论LC可作为首发症状和主要症状而缺少肿瘤原发灶表现。表现为亚急性脑膜炎，进行性颅内压升高，常合并多脑神经和脊髓神经根损害。CSF细胞学是确诊LC主要方法，结合免疫细胞化学方法对确诊有重要帮助。     

Presenting features and value of diagnostic procedures in leptomeningeal metastases.

OBJECTIVE: To study the presenting features and value of routine diagnostic procedures in patients with leptomeningeal metastases (LMM) related to the primary malignancy to improve diagnostic assessment. METHODS: The authors studied the presenting features and value of routine diagnostic procedures in relation to the histology of primary malignant disease in 45 patients with LMM of solid (n = 30) or hematologic (n = 15) malignancies. RESULTS: Patients with solid LMM present mostly with spinal or radicular symptoms (53%), whereas patients with hematologic LMM more often show cranial nerve dysfunction at presentation (53%). Multifocal neurologic symptoms were seen in 67% of patients. The first CSF cytology demonstrated malignant cells more frequently in solid LMM compared with hematologic LMM (73% versus 53%). Extralumbar punctures increased the sensitivity of cytology to a greater extent in hematologic LMM than in solid LMM (34% versus 10%). Abnormal neuroimaging findings were found more often in solid LMM than in hematologic LMM (67% versus 40%). Increased total CSF protein in combination with either multifocal neurologic symptoms or abnormal neuroimaging findings was found in 73% of patients with a negative first CSF cytology. CONCLUSIONS: Patients with LMM presented differently depending on the histology of the primary tumor. In patients with a negative first CSF cytologic examination, multiple lumbar punctures increased the diagnostic accuracy, especially in hematologic LMM. LMM could also be diagnosed in patients with known cancer if total CSF protein was increased in combination with either multifocal neurologic symptoms or abnormal neuroimaging findings, preferably MRI.     

Meningeal gliomatosis: a review of 12 cases

Diffuse or multifocal invasion of the leptomeninges by malignant glioma (meningeal gliomatosis) is believed to be rare. From 1971 through 1977, 11 of 52 patients with intracranial malignant gliomas examined at autopsy were found to have meningeal gliomatosis, and 1 additional patient was diagnosed clinically without autopsy (12 cases total). Eight of the 12 patients were diagnosed antemortem with positive cerebrospinal fluid (CSF) cytology, while the other 4 patients were diagnosed at autopsy only. All 11 autopsied patients had multifocal or diffuse meningeal tumor distant from the primary site; 8 patients had spinal subarachnoid seeding with tumor encroachment of cauda equina and spinal nerve roots, and 9 patients had tumor invasion into the lateral ventricles. Three patients had symptomatic spinal cord compression at the thoracic or lumbar level, and 10 patients had hydrocephalus. These 12 patients with meningeal gliomatosis were compared with the other 41 autopsied malignant glioma patients without the complication (controls); the patients with meningeal gliomatosis were significantly younger (mean age, 40 versus 57 years; p less than 0.005). Patients with meningeal gliomatosis lived somewhat longer (median, 49 weeks) compared to controls (35 weeks), but the difference was not statistically significant. With the advance of chemotherapy, patients with malignant glioma are living longer and the incidence of meningeal gliomatosis may rise. The diagnosis of meningeal gliomatosis can be suspected, especially if hydrocephalus is present, and can often be confirmed by CSF cytology.     

Neuroimaging and cerebrospinal fluid cytology in the diagnosis of leptomeningeal metastasis

The diagnosis of leptomeningeal metastasis is often difficult and usually requires the demonstration of malignant cells in the cerebrospinal fluid. Neuroimaging, however, may establish or support the diagnosis in some patients. Radiographic abnormalities consistent with or suggestive of leptomeningeal metastasis include leptomeningeal, subependymal, dural, or cranial nerve enhancement; superficial cerebral lesions; and communicating hydrocephalus. We evaluated 137 cancer patients with clinical symptoms suspicious for leptomeningeal metastasis with neuroimaging or cerebrospinal fluid cytology or both. Neuroimaging findings were abnormal in 70 of 128 tested patients; cytology was performed in 58 of these 70 and the results were positive in 37. Conversely, cytological findings were positive in 53 of 115 tested patients; neuroimaging was performed in 49 of these 53 and the findings were abnormal in 37 (26/29 solid tumors and 11/20 hematological tumors). Of the total series of 137 patients, leptomeningeal metastasis was diagnosed in 77; in 24 (31%) the diagnosis was made on the basis of clinical picture and abnormal neuroimaging alone. Neuroimaging is a valuable tool in the investigation of leptomeningeal metastasis in the cancer population, and the presence of typical clinical features together with appropriate neuroimaging abnormalities is adequate to make the diagnosis of leptomeningeal metastasis even if cerebrospinal fluid cytological results are negative.     

Leptomeningeal melanoma of unknown primary site: two cases with an atypical presentation of acute meningitis

Primary melanoma of the central nervous system accounts for only 1% of the cases of melanoma, having a relatively rare frequency of being reported in the literature. We report two cases of leptomeningeal melanoma of unknown primary site diagnosed after post mortem examination. In the first case, the patient presented with resisting epilepsy, whereas in the second with persisting fever and mental slowness. Cranial CT in the first patient showed postgadolinium enhancement of the ependyma and the infundibulum, while in the second there was diffuse enhancement of the leptomeninges. Analyses of the CSF in both cases did not establish the presence of malignant cells but revealed altered CSF glucose and increased CSF protein levels. There were no extracranial abnormalities. Both patients were treated for infectious meningitis and died a few days afterwards. At autopsy, all body cavities including oral cavity and the entire integument were examined. In both cases the leptomeninges were diffusely covered with brownish material. Histological examination of the brain specimens revealed the presence of a malignant neoplasm of low differentiation. Diagnosis was established with the results of immunohistochemistry, tumor cells were positive for HMB-45 and S-100 whereas they were negative for cytokeratins, CD45 and GFAP. In conclusion, both patients, although presenting with symptoms and signs highly suggestive of meningitis, suffered from leptomeningeal melanomas of unknown primary site. Clinical, radiological and histological findings are discussed with a review of the literature.     

CSF cytology versus immunocytochemistry in meningeal carcinomatosis.

CSF immunocytochemistry with monoclonal antibodies was compared with conventional cytology to determine its sensitivity in detecting malignant cells in patients with meningeal carcinomatosis. One hundred and eighteen samples were investigated. Cytology was tumour positive in 83 samples and immunocytochemistry in 85. Dissimilar results between the two diagnostic methods were noted in 12 specimens, invariably occurring in samples with a low cell count and obtained from treated patients. Combined use of the two methods led to a 9% increase of sensitivity in detecting malignant cells compared with cytology alone. It is concluded that immunocytochemistry is of minor help in the problem of false-negative cytology in meningeal carcinomatosis.     

Cerebrospinal fluid carcinoembryonic antigen and alphafetoprotein in patients with central nervous system neoplasia

A solid phase immunoassay was used to evaluate the levels of serum and cerebrospinal fluid of alphafetoprotein and carcinoembryonic antigen in 33 individuals treated for backache and headache with no evidence of organic neurological disease, 19 patients with primary CNS tumor (benign or malignant) and 22 with CNS metastasis from a solid tumor. AFP serum and CSF levels were found in trace amounts or slightly elevated not exceeding normal limits in all groups. Patients with CNS metastasis were found to have statistically significant higher CEA levels (both in serum and CSF) than the control group, and the patients with primary brain tumors. Patients with leptomeningeal dissemination had statistically significantly higher CEA CSF levels than did patients with primary tumors, and patients with parenchymal metastasis.     

Cerebrospinal fluid tumour markers in patients treated for meningeal malignancy.

The results of cerebrospinal fluid (CSF) biochemical markers were compared with conventional CSF cytology in patients treated for leptomeningeal metastases from extra cranial malignancies. For lumbar CSF, before treatment, no statistically significant difference of the probabilities of being positive was found between CSF cytology and a classification by linear discriminant analysis, based on patient's age, of beta-glucuronidase and beta 2-microglobulin. During treatment, classification by linear discriminant analysis was found more often positive than cytology. Possible mechanisms for this difference are discussed. For ventricular CSF a correlation was found between CSF cytology and beta-glucuronidase for solid tumours, and between CSF cytology and beta 2-microglobulin for haematological malignancies. Reference values for ventricular protein, CEA beta-glucuronidase and beta 2-microglobulin were obtained for cytological negative samples.     

The Clinical Features of Spinal Leptomeningeal Dissemination from Malignant Gliomas

Objective

The incidence of leptomeningeal dissemination from malignant glioma is rare, so the clinical features of this are not well documented yet. We attempted to determine the clinical features of leptomeningeal dissemination from malignant gliomas.

Methods

We retrospectively analyzed 11 cases of leptomeningeal dissemination of malignant glioma, who were treated at our institution between 2006 and 2009. We investigated the clinical features of these patients by considering the following factors : tumor locations, the events of ventricular opening during surgery and the cerebrospinal fluid (CSF) profiles, including the cytology.

Results

The group was composed of 9 males and 2 females. The histological diagnosis of their initial intracranial tumors were 4 primary glioblastoma, 3 anaplastic astrocytoma, 1 anaplastic oligoastrocytoma, 2 ganglioglioma and 1 pleomorphic xanthoastrocyotma with anaplastic features. The mean age of the patients at the time of the initial presentation was 42.8±10.3 years. The mean time between surgery and the diagnosis of spinal dissemination was 12.3±7.9 (3-28) months. The mean overall survival after dissemination was 2.7±1.3 months. All our patients revealed a history of surgical opening of the ventricles. Elevated protein in the CSF was reported for eight patients who had their CSF profiles checked.

Conclusion

We propose that in the malignant gliomas, the surgical opening of ventricles can cause the spinal leptomeningeal dissemination and the elevated protein content of CSF may be a candidate marker of leptomeningeal dissemination.     

Cerebrospinal fluid cytology in meningeal invasion of leukemia and malignant lymphoma. Reliable diagnosis by immunocytochemistry]

Cerebrospinal fluid cytology was performed in 64 patients who were suspected of having a meningeal infiltration of malignant lymphoma or leukemia. Conventional staining with May Grünwald Giemsa revealed a positive result in 51 cases, and a negative result in one case. In 4 cases diagnosis was hampered by blood contamination or a lack of CSF cells. In the remaining 8 cases with doubtful cytologic specimens, additional immunocytochemic staining allowed definite diagnosis. In 5 of these cases malignancy was confirmed, while in the remaining 3 an inflammatory cell pattern was found and later confirmed by follow-up. In summary, immunocytochemistry was essential for definite diagnosis in 12% of CSF cell specimens suspected of leukemia or malignant lymphoma. It may be concluded that immunocytochemistry in CSF cytology is a valuable tool for enhancement of diagnostic reliability.     

CSF protein profiling using Multiplex Immuno-assay

Objective The diagnosis of leptomeningeal metastases (LM) is based on clinical symptoms, magnetic resonance imaging (MRI) of brain and spine and cytological analysis of cerebrospinal fluid (CSF). The clinical picture of LM is highly variable and both cytological CSF analysis and contrast-enhanced MRI are limited in sensitivity. More sensitive tools are needed to diagnose LM. We measured a profile of proteins involved in adhesion and inflammation in the CSF of LM and control patients and determined their potential diagnostic value for LM. Patients and methods Using Multiplex Immuno-Assay (MIA), the CSF concentrations of nine soluble adhesion molecules, cyto- and chemokines were measured in patients with cytologically proven LM (n=57) and control patients with a systemic malignancy (n=20), aseptic/viral meningitis (n=11) or other (non-)neurological diseases (n=19). Results We found high CSF levels of soluble Vascular Cell Adhesion Molecule-1 (sVCAM-1), soluble Intercellular Adhesion Molecule-1 (sICAM-1), Interleukin-8 (IL-8), Pulmonary and Activation Regulated Chemokine (PARC), Interleukin-18 (IL-18) and Interferon-γ inducible protein (IP-10) in patients with LM. The CSF protein profile in LM patients differed significantly from the profile found in control patients. Multivariate logistic regression and ROC analysis showed that the MIA-measured CSF protein profile has an additive discriminating value for LM above standard CSF parameters. A combination of total protein, glucose, IL-8, PARC and IP-10 CSF levels proved to be most discriminative between LM and non-LM patients. Conclusion Our results warrant a prospective study to determine whether a CSF protein profile, including IL-8, PARC and IP-10 has diagnostic value compared with CSF cytology, the golden standard for LM. Received in revised form: 2 November 2005     

Accumulation of macrophages in the CSF of schizophrenic patients during acute psychotic episodes.

OBJECTIVE: There have been numerous reports of organic or structural abnormalities in the central nervous system (CNS) of patients with schizophrenia. Given that pathological conditions in the CNS are frequently reflected in the cell profiles of CSF, the authors compared the cytology of CSF from schizophrenic patients with that from a reference population in order to find out trails of elementary pathogenetic events in this serious psychiatric disease. METHOD: CSF samples from 35 patients with acute schizophrenia and 46 comparison subjects were prepared by Millipore filtration. The total and differential counts of CSF mononuclear cells were performed by light microscopy. RESULTS: At the beginning of treatment, the proportion of mononuclear phagocytes/macrophages in the patients' CSF was significantly higher than that in the comparison subjects. During treatment with conventional neuroleptic medication, the cytology returned to normal in several patients. CONCLUSIONS: The high proportion of macrophages in schizophrenia without a significantly higher total cell count may reflect neurodevelopmental disorder, a neurodegenerative process, or subtle CNS immunoactivation with mobilization of microglia.     

黑色素瘤软脑膜转移诊断及疾病监测的更新

黑色素瘤软脑膜转移(LM)是黑色素瘤患者罕见的晚期严重并发症,预后极差,且近几年的发病率呈上升趋势.LM的诊断和监测具有挑战性,目前是基于神经症状,影像学和CSF检查进行的.CSF细胞学仍是目前诊断的"金标准".同时,不断发展的CSF"液体活检"也显著促进了细胞学和基因分型分析的进展.CSF是与软脑膜接触的直接介质,对...