Cerebrospinal Fluid Flow Cytometry in Acute Lymphoblastic Leukemia/Lymphoma: Is It Beneficial?.

Abstract 2576 Cerebrospinal fluid (CSF) involvement by leukemic blasts occurs in fewer than 10 % of adult patients with newly diagnosed acute lymphoblastic leukemia/lymphoma (ALL). Leukemic meningitis is diagnosed by microscopic detection of blasts in the CSF. Flow cytometry is a highly sensitive tool for detection of aberrant cells. We sought to analyze the additional benefit flow cytometry might provide for the diagnosis of leukemic meningitis. Between 11/2007 and 8/2011, 80 patients were diagnosed with ALL and treated at Emory University. 800 CSF samples were available for analysis 80 of which were collected from a diagnostic lumbar puncture (LP), 689 from follow-up LPs and 31 from LPs obtained at the time of relapse. As shown in the table, flow cytometry confirmed the presence of leukemic blasts in one, four and five samples diagnosed with leukemic meningitis by cytology at diagnosis, different stages of treatment and relapse, respectively. One and three samples were positive for leukemic blasts by cytology but negative by flow cytometry during different treatment stages and relapse respectively. We conclude that flow cytometry provided no additional benefit to cytology in the diagnosis of leukemic meningitis. Table: CSF Cytology and Flow Cytometry in 80 Adult ALL patients: CSF samples New Diagnosis N=80 Induction/Consolidation/Intensification/Maintenance/Remission/Post-transplant N = 689 Systemic relapse N = 31 N Cytology N = 80 Flow cytometry N = 66 Cytology N = 689 Flow cytometry N = 188 Cytology N = 31 Flow cytometry N = 13 Negative 79/80 65/66 684/689 184/188 23/31 8/13 Positive 1/80 1/66∼ 5/689 4/188∼* 8/31 5/13∼** ∼ CSF samples positive by flow cytometry were also positive by cytology * One CSF sample was positive by cytology but negative by flow cytometry ** CSF flow cytometry was not done in 3/8 positive CSF samples by cytology Disclosures: No relevant conflicts of interest to declare.

“Lymphomatous and Leukemic Meningitis – Patterns of Cytomorphology and Value of MRI and Protein Analysis”.

Abstract 5011 Introduction Lymphomatous and leukemic meningitis (LM), although a well known and relatively frequent complication of aggressive lymphoma and leukemia, are still difficult to detect. With cytomorphology, neoplastic lyphocytes are difficult to distinguish from inflammatory lymphocytes. We evaluated here if specific morphological criteria can improve this differentiation. Moreover, we assessed the sensitivity of MRI and protein analysis for the detection of LM in comparison with CSF-cytology. Patients and Methods To establish cytomorphological criteria, 42 cytospin preparations of CSF from patients with confirmed CSF involvement by aggressive lymphoma or acute leukemia were compared with 26 samples of inflammatory diseases. CSF cytology was analyzed morphologically for pre-selected parameters of cell, cytoplasm and nucleic appearance and the presence of mitoses or apoptoses. For the comparison of cytology and MRI, 38 patients with leukemic or lymphomatous meningitis were evaluated retrospectively for MRI-signs of neoplastic meningitis and for CSF-protein abnormalities (total protein, oligoclonal bands, lactate, ferritine). Results as expected, none of the cytomorphological parameters sharply discerns neoplastic and inflammatory transformation. However, neoplastic cells were significantly larger than inflammatory lymphocytes with a mean of 3.0 as opposed to 1.8 times the size of normal small lymphocytes (p=0.0001). Moreover, irregular shape, pointed borders of the cytoplasm, and deep notches in the nucleus were significantly more often found with neoplastic than with inflammatory lymphocytes. The total cell count was elevated in 68% of cases of lymphomatous meningitis. While cytomorphology could achieve approx. 90% sensitivity for the detection of LM, spinal and/or cranial MRI only detected 71% of cases with normal and 52% with elevated cell counts. Total protein was elevated in 77% of cases, lactate in 55% and ferritine in 48%. Oligoclonal IgG was found in 11% isolated in the CSF and in 18% in CSF and serum identically. Only 3/38 patients (8%) had completely normal CSF cell count and proteins. Conclusions CSF cytology is more sensitive than MRI for the detection of LM, but application of both methods clearly enhances the sensitivity by approx. 10%. No single cytomorphological parameter is sufficient to detect neoplastic lymphocytes. Considering a combination of cell size and irregular shape of cell and nucleus may improve the diagnostic accuracy of CSF dissemination by aggressive hematological malignancies. Disclosures Strik: Mundipharma : Consultancy, Honoraria, Research Funding, Speakers Bureau; Essex/Shering-Plough/Merck: Consultancy, Honoraria, Speakers Bureau; Medac: Research Funding.

Efficacy and Tolerability of Liposomial Cytosine Arabinoside (DepoCyte®) for the Treatment of Lymphomatous and Leukemic Meningitis.

Meningeal blastic involvement is a severe complication of aggressive non-Hodgkin lymphoma (NHL) and acute leukemia (AL). DepoCyte® is an unique liposomal formulation for IT administration, that provides a lower toxicity profile and a more convenient dosing regimen compared with other treatments, such as radiotherapy, high-dose (HD) or intrathecal (IT) chemotherapy (CT). Twentyseven patients (pts) with meningeal involvment from aggressive NHL or AL treated with DepoCyte® at the standard dose of 50 mg every 2 weeks were evaluated for cytological negativization of the cerebro-spinal fluid (CSF) from neoplastic cells and improvement of neurologic symptoms. Seventeen had a diagnosis of aggressive NHL and 10 of AL; only 1 pt affected by DLBCL was HIV positive. Median age was 50,3 years. (range 23–81). Five pts showed meningites at the diagnosis associated with systemic disease, 3 pts had isolated meningeal recurrence and the remaining systemic recurrence associated with meningeal involvement; these data are not available for PCNSL pts. All patients received standard therapies for their systemic disease, except 3 elderly DLBCL pts not receiving any systemic treatment; 9 pts received CNS prophylaxis. Four pts had received previous HD- or IT CT for meningeal localization. A total of 93.cycles were administred (median cycles/pt: 3,6; range 1–8). Overall responses (OR) of both NHL and AL pts are 16/27. Four pts with DLBCL recorded a complete response (RC) or a partial response (PR), both neurological and cytological, 3 had a progressive disease (PD) and 1 pt was not evaluable because he is still in treatment and has received only 1 administration of DepoCyte®. Two Burkitt-like lymphoma pts recorded a neurological and cytological CR, but 1 HIV+ pt showed a PD. One Burkitt’s lymphoma showed a PR; 1 mantle cell lymphoma had a CR, while a second mantle cell lymphoma pt recorded a cytological PR and no neurological improvement. Among ALL pts, 5 had a neurological and cytological CR, whereas 1 recorded a PD. All 3 AML pts had a response (1 PR and 2 CR). PTS with PCNSL, lymphoblastic lymphoma and CML in blastic phase pts had a neurological and cytological PD. No dose reduction was required for toxicity. In 1 DLBCL pt receiving concomitant hyperCVAD, G4 neutropenia was recorded, together with G2 anemia and G1 PLTpenia,. A mantle cell lymphoma pt showed G3 neutropenia and mental confusion. Depocyte® appears to be a feasible and active therapeutic option for lymphomatous and leukemic meningitis. Tolerability has been confirmed largely in previous studies. Randomized phase II trials are needed to settle up the efficacy in meningitis of lymphoblastic and myeloid leukemias. Nr of pts NHL AL 27 Burkitt-like (3), Burkitt’s (1), Mantle cell (2), DLBCL (8), Lymphoblastic (1), PCNSL (2) Lymphoblastic (6), Myeloid (3), CML in blastic phase (1) Median age (range) 58 (28–81) 42 (23–71) Profylaxis 5 4 Nr of OR 8 8

Dramatic and Sustained Hematologic Complete Remission with Denileukin Diftitox (ONTAK®) in a Patient with Refractory Adult T-Cell Leukemia (ATL).

Background: Acute ATL is an aggressive hematologic malignacy with a median survival of 9 months. It is a malignant disease of mature activated T-cells caused by human T-cell lymphotropic virus (HTLV-I). Chemotherapy is disappointing for ATL, particulary for acute ATL. Antiretroviral therapy with combination interferon/zivodudine increases responses and improves survival. However, the disease is characterized by repeated relapses with few novel therapeutic options available for patients. Allogeneic stem cell transplant is the only known cure for ATL. We present a case report of refractory acute ATL and relapsed leukemic meningitis with marked clinical response and hematologic remission to single-agent denileukin diftitox. Method: The patient (pt) is a 55 year-old black man (from Mississippi) who presented Janurary 2004 with mild fatigue, lymphocytosis and was found to be in chronic-phase ATL. Peripheral blood (PB) flow cytometry showed a 72% clonal T-cell population: CD3+, CD7−, CD5+, CD2+, CD4+, and CD25+. Serology was + for HTLV-1 and T-cell genes were rearranged. Results: The pt was initially observed without therapy. Within 6 months, he developed profound fagtigue, weight loss, severe headaches, eye pain, tinnitus and myalgias. White blood count (WBC) increased and acute ATL and leukemic meningitis was diagnosed. The pt began daily zidovudine/α interferon (1 gram and 9 million units, respectively) and intrathecal (IT) methotrexate. Cerebral spinal fluid (CSF) cleared with slight decrease in WBC, and improvement in symptoms. He relapsed 5 months later with reccurrence of constitutional and CNS symptoms. Repeated ommaya catheter CSF analysis at that time was negative, however, a lumbar puncture was floridly positive. The pt subsequently began daily aresenic trioxide and weekly pegylated interferon therapy. There was a transient decline in symtoms and WBC with clearing of the CSF, although the patient quickly relapsed with massive PB and CSF infiltration of ATL cells (PB absolute lymphocyte count 89.3 cc3/mm3) and severe constitutional symtpoms including 20 pound weight loss. Acute T-cell Leukemia Treatment Time Line Acute T-cell Leukemia Treatment Time Line At this relapse, the pts CSF T-cells were 87% CD25-positive. Denileukin diftitox was started at 18 μg/kg/day IV(days 1–5) every 21 days with concurrent IT cytarabine. The only other concomitant medications were diflucan and gabapentin (no steroids given at any time). The pt had rapid resolution of all symptoms and normalization of the WBC following his 1st cycle. The pt has tolerated 8 denileukin diftitox cycles well. PB flow cytometry now shows 1% CD25 T-cell positivity. The pt is currently asymptomatic and proceeding to 6/6 matched sibling allogeneic transplant. Conclusion: This case demonstrates a marked and sustained response to single-agent denilekin difitox. There is 1 published case of ATL treated with denileukin diftitox. However, that pt was also treated with hyper-CVAD chemotherapy. Despite the anecdotal nature of this case, we believe it is important to report this information, especially in a disease with often few therapeutic options.