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Case Discussion Burkitt ’ s Lymphoma with 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.

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Presentation on theme: "Case Discussion Burkitt ’ s Lymphoma with 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."— Presentation transcript:

1 Case Discussion Burkitt ’ s Lymphoma with 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

2 Patient Data 盧 先生 19 year-old male ID: I Admission date: 2005/10/12 Chief Complaint:

3 Patient Data 盧 先生 19 year-old male ID: I Admission date: 2005/10/12 Chief Complaint: Bilateral leg weakness and numbness For 1 day

4 Past History 2005/01 Burkitt ’ s lymphoma Completed 10 courses of chemotherapy

5 Present Illness 2005/01 Abdominal fullness and poor appetite Hospitalized at 台南市立醫院 Gastric ulcer and ascites

6 Present Illness 2005/01 Abdominal 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

7 Transferred to 台北恩主公醫院 CT-guide biopsy for diagnosis Burkitt ’ s lymphoma Liver metastasis

8 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

9 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)

10 2005/01/14 Abdominal CT

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12 2005/01/17 Bone scan No bony lesions

13 2005/01/18 Gallium scan

14 Diagnosis Intra-abdominal origin Burkitt’s lymphoma Liver metastases

15 Diagnosis Intra-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

16 Diagnosis Intra-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 2005/09/23

17 2005/10/11 15:00 Came to our Emergency Dept. Chief complaint: General weakness DizzinessDyspnea

18 At our ER … hypokalemia (K+2.8) Lab data revealed hypokalemia (K+2.8) Given K+ supplement Allowed discharge

19 2005/10/12 08:00 Returned to our Emergency Dept. Bilateral lower leg weakness, numbness Drooped right face Diplopia Stool Incontinence

20 Social History No smoking, betel nut, or alcohol use Lives at home with family

21 Family History No family member with tumor history. No known allergies Allergy

22 Physical Examination Weight: 58kg Height: 178cm Vital signs: TPR: 37.3°C / 98bpm / 20 BP: 127/85 mmHg. Skin: normal skin turgor Head & Skull: Bold, no OP scars Eyes: Pupils 3.0 / 3.0 Light reflex sluggish Conjunctiva pink

23 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.

24 Physical Examination Abdomen: Flat, soft, no tenderness Liver and spleen impalpable. Extremities: Movement of upper extremities normal Movement of lower extremities ok, but weak Back & Spine: No kocking pain over C-V angles

25 Neurological Examination Level of consciousness : clear, alert Mental status normal Judgement Orientation Memory Abstract thinking Calculation Speech Content logical, comprehensible Articulation slightly unclear

26 Neurological Examination Cranial nerves : CN I: no loss of smell CN II: Pupils isocoric 3.0 / 3.0, light reflex sluggish Visual field normal Visual acuity well CN III, IV, VI: Left eye lateral movement impaired CN V: Normal muscle power of masseter No numbness over face Corneal reflex normal

27 Neurological Examination CN VII: Right facial expression impaired Peripheral 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. Leftward deviation of tongue CN XII: Leftward deviation of tongue

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31 Neurological Examination Motor system: Bilateral lower extremity weakness Stool Incontinence (+)

32 Neurological Examination Motor system: Bilateral lower extremity weakness Stool Incontinence (+) Sensory system : Decreased sensation over right lateral thigh

33 Neurological Examination Motor system: Bilateral lower extremity weakness Stool Incontinence (+) Sensory system : Decreased sensation over right lateral thigh Cerebellar function: F-to-N : intact RAM : intact Truncal ataxia : nil

34 Neurological Examination Motor system: Bilateral lower extremity weakness Stool Incontinence (+) Sensory system : Decreased sensation over right lateral thigh Cerebellar function: F-to-N : intact RAM : intact Truncal ataxia : nil Deep tendon reflex Diffuse decrease of DTR

35 Summary of Neurological Findings 1) 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

36 Summary of Neurological Findings 1) 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+)

37 Lab Data Upon Admission…

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40 2005/10/11 PA CXR

41 Problem List Burkitt ’ s lymphoma with CNS replapse Hypokalemia, Hyponatremia

42 Treatment Plan Burkitt ’ s lymphoma with CNS replapse Bone marrow aspiration CSF study CSF study Intra-thecal chemotherapy Intra-thecal chemotherapy CNS Radiotherapy CNS Radiotherapy Hypokalemia, Hyponatremia K+, Na+ supplement

43 Bone Marrow Aspiration 10/12 Large lymphocytes >Blue cytoplasm >Vacuoles

44 Bone Marrow Aspiration 10/12 Large lymphocytes >Blue cytoplasm >VacuolesRELAPSE!

45 2005/10/12 Lumbar puncture

46 Cytology: Burkitt’s lymphoma with CNS involvement Massive tumor cells with large nucleus, scanty cytoplasm Intrathecal methotrexate

47 2005/10/12 Lumbar puncture

48 Cytology: Burkitt’s lymphoma with CNS involvement Massive tumor cells Some cell necrosis Intrathecal methotrexate

49 2005/10/17 Lumbar puncture

50 Cytology: Burkitt’s lymphoma with CNS involvement Some tumor cells Cell necrosis

51 Follow-up Conditions 10/16 Spontaneous stool passage Able to stand, walk slowly

52 Follow-up Conditions 10/16 Spontaneous stool passage Able to stand, walk slowly 10/17 Left eye lateral movement (+) Walking improved Swallowing improved DTR (+) Questions?

53 Discussion Burkitt ’ s Lymphoma with Central Nervous System Relapse

54 Discussion Burkitt ’ s Lymphoma with Central Nervous System Relapse IT HAPPENS!

55 Natural Course Burkitt's Lymphoma CNS involvement: 20~30% Presentation? Risk factors? Benefit? Prognosis? CNS prophylaxis regimen?

56 Presentation The commonest features Headache Cranial nerve palsies Spinal cord compression Altered mental state and affect Central Nervous System Lymphoma Andrew Lister, Lauren E. Abrey, and John T. Sandlund, Hematology 2002

57 Risk Factors

58 1980~1996 Norwegian Radium Hospital 2514 Non-Hodgkin Lymphoma patients Without CNS presentation Retrospective analysis

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62 Risk Factors Non-Hodgkin’s Lymphoma Age > 60 years old LDH > 450 U/L Albumin < 35 g/L Retroperitoneal gland involvement Extranodal sites >1

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64 Burkitt’s type is a risk factor! (24%) Useful for High-grade NHL

65 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 lymphoma: a risk model A. Hollender et al. Annals of Oncology 2002

66 Prognosis CNS involvement to death Median survival Primary progression  2.4 Months Relapse  2.2 Months

67 Regimen

68 2004 Feb.~Apr. (159 UK Medical Centers) 293 questionnaires 158 Received 65 Followed by telephone 70 Did not care for NHL patients

69 96%

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71 Back to our patient… Presentation Risk Factors Regimen Prognosis

72 Back to our patient… Presentation Typical relapse Risk Factors Burkitt’s type high risk Regimen MTX based (+Ara-C) Prognosis Poor

73 Back to our patient… Presentation Typical relapse Risk Factors Burkitt’s type high risk Regimen MTX based (+Ara-C) Prognosis Poor Comments?

74 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.


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