Central nervous system imaging in childhood leukaemia
Introduction
Leukaemia is the commonest form of childhood cancer and accounts for approximately one-third of new `tumours'. One reason for improved survival and cure rates in children with leukaemia is the successful management of central nervous system (CNS) manifestations. However, successful control of CNS disease is inevitably accompanied by complications of treatment and, sometimes, treatment failure. Histologically, effects of the disease may involve the leptomeninges, brain parenchyma or intracranial vessels [1]. The commonest early manifestations of CNS leukaemia are symptoms of increasing intracranial pressure. Periodic examination of the cerebrospinal fluid (CSF) is used in the management of children once they are diagnosed with leukaemia. Accordingly, CNS involvement is often detected before clinical signs appear [1].
Radiologically, treatment-related CNS complications include white matter lesions, small-vessel calcifications, cerebrovascular disorders, treatment-induced tumours, infections and enlargement of ventricles and/or widening of sulci – a sign of cortical atrophy [1]. Both `early' and `late' CNS complications can be related to the neurotoxicity of the chemotherapy regimens, and radiation therapy, including bone marrow transplantation, or to immunosuppression caused by the disease itself or its treatment. Children and adolescents who survive leukaemia may develop endocrinopathies and/or neurocognitive deficits caused by the `late effects' of their treatment.
The purpose of this retrospective study was to answer the following questions: (1) How often do children with leukaemia have imaging-detectable CNS abnormalities? (2) Of those abnormalities, how many are cerebral or spinal complications? (3) What are the commonest underlying disease processes? (4) Are there differences between patients with acute lymphoblastic leukaemia (ALL) and those with acute myeloid leukaemia (AML)? (5) Are there differences between patients with early complications and those with late complications? and (6) Do children more often have CNS abnormalities due to complications of leukaemia itself, or to its treatment?
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Subjects
From January 1996 to December 2000, 135 consecutive patients underwent treatment for leukaemia (98 with ALL, 25 with AML, 7 with ALL relapse, 2 with B-ALL and 3 with chronic myeloid leukaemia (CML) at our Institute.
At diagnosis, all patients underwent Magnetic Resonance Imaging (MRI) of the CNS, as is `standard practice' in our Department to rule out CNS involvement in children with leukaemia. Additional MR images were obtained if the patient developed new neurological abnormalities. Of the 135
Results
Twenty two (16%) showed CNS abnormalities on MR images and/or CT scans, with or without neurological symptoms. Patients with cortical atrophy as an isolated finding were not included. Proportionately, CNS abnormalities were more often found in patients with AML (28%) than in patients with ALL (14%). Among the 22 patients with abnormalities, 9 had two or more different CNS abnormalities identified on CT scans or MR images. From these retrospectively determined CNS abnormalities, 18 were
Discussion
Contemporary risk-directed therapy now cures at least 70–75% of children with ALL. However, the use of increasingly more intensive therapy has led to the emergence of new adverse sequelae, especially in high-risk cases. Currently, many of the CNS complications seen in connection with ALL are related to the neurotoxicities of various chemotherapeutic regimens, such as the acute and delayed effects of CNS radiation [2], [3], coagulopathy caused by the disease or by asparaginase [4], and breakdown
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