Leptomeningeal involvement in B-cell chronic lymphocytic leukemia: a case report and review of the literature

BMC Research Notes

Maria Helena Ornellas¹  Andréa Ribeiro Soares²  Adriano Arnóbio¹  Marilza de Moura Ribeiro-Carvalho¹  Fábio Santiago¹  Simone Lima de Souza¹ 

[1] Departamento de Patologia, Faculdade de Ciências Medicas, Programa de Pós Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro, 444/4° andar, Vila Isabel, Rio de Janeiro, Brazil;Serviço de Hematologia, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil

关键词: Central nervous system involvement;    Flow cytometry;    Chronic lymphocytic leukemia;   

Others  :  1129495
DOI  :  10.1186/1756-0500-7-645

 received in 2014-03-27, accepted in 2014-09-08,  发布年份 2014

【 摘 要 】

Background

Central nervous system involvement is considered a rare complication of chronic lymphocytic leukemia, and so there is the risk of being overlooked.

Case presentation

We report a case of central nervous system involvement in a 75-year-old mulatto woman with chronic lymphocytic leukemia after 5 years of follow-up and a literature review on the subject. The clinical course, treatment and outcome are described. A systematic, meticulous and comprehensive analysis of existing publications regarding chronic lymphocytic leukemia with central nervous system involvement was performed.

Conclusion

We concluded that central nervous system involvement of chronic lymphocytic leukemia is probably not associated with any evident risk factors. Diagnostic approach differs by institutions but often includes imaging, morphology and flow cytometry. Resolution of central nervous system symptoms can usually be accomplished with intrathecal chemotherapy or irradiation followed by systemic treatment. The recognition of this entity by clinicians could lead to early detection and treatment, resulting in better outcomes in this rare complication.

【 授权许可】

   
2014 de Souza et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Matutes E, Attygalle A, Wotherspoon A, Catovsky D: Diagnostic issues in chronic lymphocytic leukaemia (CLL). Best Pract Res Clin Haematol 2010, 23:3-20.
• [2]Moazzam AA, Drappatz J, Kim RY, Kesari S: Chronic lymphocytic leukemia with central nervous system involvement: report of two cases with a comprehensive literature review. J Neurooncol 2012, 106:185-200.
• [3]Bojsen-Moller M, Nielsen JL: CNS involvement in leukaemia. An autopsy study of 100 consecutive patients. Acta Pathol Microbiol Immunol Scand A 1983, 91:209-216.
• [4]Barcos M, Lane W, Gomez GA, Han T, Freeman A, Preisler H, Henderson E: An autopsy study of 1206 acute and chronic leukemias (1958 to 1982). Cancer 1987, 60:827-837.
• [5]Cramer SC, Glaspy JA, Efird JT, Louis DN: Chronic lymphocytic leukemia and the central nervous system: a clinical and pathological study. Neurology 1996, 46:19-25.
• [6]Reske-Nielsen E, Petersen JH, Sogaard H, Jensen KB: Leukaemia of the central nervous system. Lancet 1974, 1:211-212.
• [7]Akintola-Ogunremi O, Whitney C, Mathur SC, Finch CN: Chronic lymphocytic leukemia presenting with symptomatic central nervous system involvement. Ann Hematol 2002, 81:402-404.
• [8]Imitola J, Pitt K, Peoples JL, Krynska B, Sheikh H, Kesari S, Azizi SA: Multifocal CNS infiltration of chronic lymphocytic leukemia in the form of small-cell solid metastatic lesions. J Neurooncol 2012, 109:213-215.
• [9]Cohen JB, Cavaliere R, Byrd JC, Andritsos LA: Hearing loss due to infiltration of the tympanic membrane by chronic lymphocytic leukemia. Case Rep Hematol 2012, 2012:589718.
• [10]Benjamini O, Jain P, Schlette E, Sciffman JS, Estrov Z, Keating M: Chronic lymphocytic leukemia with central nervous system involvement: a high-risk disease? Clin Lymphoma Myeloma Leuk 2013, 13:338-341.
• [11]Nowakowski GS, Call TG, Morice WG, Kurtin PJ, Cook RJ, Zent CS: Clinical significance of monoclonal B cells in cerebrospinal fluid. Cytometry B Clin Cytom 2005, 63:23-27.
• [12]Bommer M, Nagy A, Schöpflin C, Pauls S, Ringhoffer M, Schmid M: Cerebrospinal fluid pleocytosis: pitfalls and benefits of combined analysis using cytomorphology and flow cytometry. Cancer Cytopathol 2011, 119:20-26.
• [13]Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009, 339:332-336.
• [14]Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Mike C, Devereaux PJ, Kleijnen J, Moher D: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. BMJ 2009, 339:b2700.
• [15]Kelly K, Lynch K, Farrell M, Rawluk D, Kaliaperumal C, Murphy P: Intracranial small lymphocytic lymphoma. Br J Haematol 2008, 141:411.
• [16]Nimubona S, Bernard M, Morice P, Brassier G, Caulet-Maugendre S, Carsin B, Meunier C, Lamy T: Complications of malignancy: case 3. Chronic lymphocytic leukemia presenting with panhypopituitarism. J Clin Oncol 2004, 22:374-376.
• [17]Kiewe P, Dallenbach FE, Fischer L, Hoecht S, Kombos T, Thiel E, Korfel A: Isolated B-cell lymphoproliferative disorder at the dura mater with B-cell chronic lymphocytic leukemia immunophenotype. Clin Lymphoma Myeloma 2007, 7:594-596.
• [18]Denier C, Tertian G, Ribrag V, Lozeron P, Bilhou-Nabera C, Lazure T, Abbed K, Lacroix C, Adams D: Multifocal deficits due to leukemic meningoradiculitis in chronic lymphocytic leukemia. J Neurol Sci 2009, 277:130-132.
• [19]Kakimoto T, Nakazato T, Hayashi R, Hayashi H, Hayashi N, Ishiyama T, Asada H, Ishida A: Bilateral occipital lobe invasion in chronic lymphocytic leukemia. J Clin Oncol 2010, 28:e30-e32.
• [20]Amiel JL, Droz JP: Letter: spinal lymphocytosis during chronic lymphocytic leukemia. Nouv Presse Med 1976, 5:94-95.
• [21]Boogerd W, Vroom TM: Meningeal involvement as the initial symptom of B cell chronic lymphocytic leukemia. Eur Neurol 1986, 25:461-464.
• [22]Brick WG, Majmundar M, Hendricks LK, Kallab AM, Burgess RE, Jillella AP: Leukemic leptomeningeal involvement in Stage 0 and Stage 1 chronic lymphocytic leukemia. Leukemia Lymphoma 2002, 43:199-201.
• [23]Calvo-Villas JM, Fernández JA, de la Fuente I, Godoy AC, Mateos MC, Poderós C: Intrathecal liposomal cytarabine for treatment of leptomeningeal involvement in transformed (Richter’s syndrome) and non-transformed B-cell chronic lymphocytic leukaemia in Spain: a report of seven cases. Br J Haematol 2010, 150:618-620.
• [24]Cash J, Fehir KM, Pollack MS: Meningeal involvement in early stage chronic lymphocytic leukemia. Cancer 1987, 59:798-800.
• [25]Conesa V, Mompel A, Ruiz J, Gómez A, Fernandez P, Lucas J, Aranda I: Fulminant brain lymphoid infiltration in a patient with chronic lymphocytic leukemia. Am J Hematol 1999, 60:167-168.
• [26]Currie JN, Lessell S, Lessell IM, Weiss JS, Albert DM, Benson EM: Optic neuropathy in chronic lymphocytic leukemia. Arch Ophthalmol 1988, 106:654-660.
• [27]Diwan RV, Diwan VG, Bellon EM: Brain involvement in chronic lymphocytic leukemia. J Comput Assist Tomogr 1982, 6(4):812-814.
• [28]Elliott MA, Letendre L, Li CY, Hoyer JD, Hammack JE: Chronic lymphocytic leukaemia with symptomatic diffuse central nervous system infiltration responding to therapy with systemic fludarabine. Br J Haematol 1999, 104:689-694.
• [29]Estevez M, Chu C, Pless M: Small B-cell lymphoma presenting as diffuse dural thickening with cranial neuropathies. J Neurooncol 2002, 59:243-247.
• [30]Fain JS, Naeim F, Becker DP, Van Herle A, Yan-Go F, Petrus L, Vinters HV: Chronic lymphocytic leukemia presenting as a pituitary mass lesion. Can J Neurol Sci 1992, 19:239-242.
• [31]Fernández P, Ordónez FS, Dominguez AR, Rodriguez AS: Infiltration of the central nervous system as a presentation form of early stage chronic lymphocyte leukemia. Am J Hematol 1998, 58:339-342.
• [32]Garicochea B, Cliquet MG, Melo N, del Giglio A, Dorlhiac-Llacer PE, Chamone DA: Leptomeningeal involvement in chronic lymphocytic leukemia identified by polymerase chain reaction in stored slides: a case presentation. Mod Pathol 1997, 10:500-503.
• [33]Garofalo M Jr, Murali R, Halperin I, Magardician K, Moussouris HF, Masdeu JC: Chronic lymphocytic leukemia with hypothalamic invasion. Cancer 1989, 64:1714-1716.
• [34]Getaz EP, Miller GJ: Spinal cord involvement in chronic lymphocytic leukemia. Cancer 1979, 43:1858-1861.
• [35]Giordano A, Perrone T, Guarini A, Ciappetta P, Rubini G, Ricco R, Palma M, Specchia G, Liso V: Primary intracranial dural B cell small lymphocytic lymphoma. Leuk Lymphoma 2007, 48:1437-1443.
• [36]Gobbi M, Tazzari PL, Raspadori D, Cavo M, Pileri S, Tura S: Meningeal leukemia complicating prolymphocytoid transformation of B-chronic lymphocytic leukemia. Acta Haematol 1985, 74(4):205-207.
• [37]Grisold W, Jellinger K, Lutz D: Human neurolymphomatosis in a patient with chronic lymphocytic leukemia. Clin Neuropathol 1990, 9:224-230.
• [38]Hagberg H, Lannemyr O, Acosta S, Birgegård G, Hagberg H: Successful treatment of syndrome of inappropriate antidiuretic secretion (SIADH) in 2 patients with CNS involvement of chronic lymphocytic leukaemia. Eur J Haematol 1997, 58:207-208.
• [39]Hanse MC, Van't Veer MB, van Lom K, van den Bent MJ: Incidence of central nervous system involvement in chronic lymphocytic leukemia and outcome to treatment. J Neurol 2008, 255:828-830.
• [40]Hoffman MA, Valderrama E, Fuchs A, Friedman M, Rai K: Leukemic meningitis in B-cell prolymphocytic leukemia. A clinical, pathologic, and ultrastructural case study and a review of the literature. Cancer 1995, 75:1100-1103.
• [41]Kaiser U: Cerebral involvement as the initial manifestation of chronic lymphocytic leukaemia. Acta Haematol 2003, 109:193-195.
• [42]Kalac M, Suvic-Krizanic V, Ostojic S, Kardum-Skelin I, Barsic B, Jaksica B: Central nervous system involvement of previously undiagnosed chronic lymphocytic leukemia in a patient with neuroborreliosis. Int J Hematol 2007, 85:323-325.
• [43]Knop S, Herrlinger U, Ernemann U, Kanz L, Hebart H: Fludarabine may induce durable remission in patients with leptomeningeal involvement of chronic lymphocytic leukemia. Leuk Lymphoma 2005, 46:1593-1598.
• [44]Korsager S, Laursen B, Munck Mortensen T: Dementia and central nervous system involvement in chronic lymphocytic leukaemia. Scand J Haematol 1982, 29:283-286.
• [45]Kuwabara H, Kanamori H, Takasaki H, Takabayashi M, Yamaji S, Tomita N, Fujimaki K, Fujisawa S, Ishigatsubo Y: Involvement of central nervous system in prolymphocytoid transformation of chronic lymphocytic leukemia. Leuk Lymphoma 2003, 44:1235-1237.
• [46]Lange CP, Brouwer RE, Brooimans R, Vecht CJ: Leptomeningeal disease in chronic lymphocytic leukemia. Clin Neurol Neurosurg 2007, 109:896-901.
• [47]Liepman MK, Votaw ML: Meningeal leukemia complicating chronic lymphocytic leukemia. Cancer 1981, 47:2482-2484.
• [48]López Guillermo A, Cervantes F, Bladé J, Matutes E, Urbano A, Montserrat E, Rozman C: Central nervous system involvement demonstrated by immunological study in prolymphocytic variant of chronic lymphocytic leukemia. Acta Haematol 1989, 81:109-111.
• [49]Lustman F, Flament-Durant J, Colle H, Lambert M, Sztern B: Paraplegia due to epidural infiltration in a case of chronic lymphocytic leukemia. J Neurooncol 1988, 6:259-260.
• [50]Majumdar G: Chronic lymphocytic leukaemia with cerebral infiltration. Leuk Lymphoma 1998, 28:603-605.
• [51]Marmont AM: Leukemic meningitis in B-cell chronic lymphocytic leukemia: resolution following intrathecal methotrexate. Blood 2000, 96:776-777.
• [52]Michalevicz R, Burstein A, Razon N, Reider I, Ilie B: Spinal epidural compression in chronic lymphocytic leukemia. Cancer 1989, 64:1961-1964.
• [53]Michallet M, Socié G, Mohty M, Sobh M, Bay JO, Morisset S, Labussière-Wallet H, Tabrizi R, Milpied N, Bordigoni P, El-Cheikh J, Blaise D: Rituximab, fludarabine, and total body irradiation as conditioning regimen before allogeneic hematopoietic stem cell transplantation for advanced chronic lymphocytic leukemia: long-term prospective multicenter study. Exp Hematol 2013, 41:127-133.
• [54]Miller K, Budke H, Orazi A: Leukemic meningitis complicating early stage chronic lymphocytic leukemia. Arch Pathol Lab Med 1997, 121:524-547.
• [55]Morrison C, Shah S, Flinn IW: Leptomeningeal involvement in chronic lymphocytic leukemia. Cancer Pract 1998, 6:223-228.
• [56]Mowatt L, Matthews T, Anderson I: Sustained visual recovery after treatment with intrathecal methotrexate in a case of optic neuropathy caused by chronic lymphocytic leukemia. J Neuroophthalmol 2005, 25:113-115.
• [57]Nemoto K, Ohnishi Y, Tsukada T: Chronic lymphocytic leukemia showing pituitary tumor with massive leukemic cell infiltration, and special reference to clinicopathological findings of CLL. Acta Pathol Jpn 1978, 28:797-805.
• [58]Pastor E, Grau E, Real E: Leukemic meningitis in a patient with B-cell prolymphocytic leukemia. Haematologica 1997, 82:511-512.
• [59]Patton WN, Carey MP, Fletcher MR, Rolfe EB, Spooner D, Richardson PR, Franklin IM: Diffuse intracerebral involvement in B-cell chronic lymphocytic leukaemia: a case presentation. Clin Lab Haematol 1992, 14:149-154.
• [60]Pohar S, de Metz C, Poppema S, Hugh J: Chronic lymphocytic leukemia with CNS involvement. J Neurooncol 1993, 16:35-37.
• [61]Poplawska-Szczyglowska L, Walewski J, Pienkowska-Grela B, Rymkiewicz G, Mioduszewska O: Chronic lymphocytic leukaemia presenting with central nervous system involvement. Med Oncol 1999, 16:65-68.
• [62]Remkova A, Bezayova T, Vyskocil M: B cell chronic lymphocytic leukemia with meningeal infiltration by T lymphocytes. Eur J Int Med 2003, 14:49-52.
• [63]Rubin P, Harris NL: Case records of the Massachusetts General Hospital: case 4. A 73-year-old man with severe facial pain, visual loss, decreased ocular motility, and an orbital mass. N Engl J Med 1993, 328:266-275.
• [64]Ruiz P, Moezzi M, Chamizo W, Ganjei P, Whitcomb CC, Rey LC: Central nervous system expression of a monoclonal paraprotein in a chronic lymphocytic leukemia patient. Acta Haematol 1992, 88:37-40.
• [65]Russwurm G, Heinsch M, Radkowski R, Erlemann R, Aul C, Haase S, Giagounidis A: Dasatinib induces complete remission in a patient with primary cerebral involvement of B-cell chronic lymphocytic leukemia failing chemotherapy. Blood 2010, 116:2617-2618.
• [66]Rye AD, Stitson RN, Dyer MJ: Pituitary infiltration in B-cell chronic lymphocytic leukaemia. Br J Haematol 2001, 115:718.
• [67]Sáenz-Francés F, Calvo-González C, Reche-Frutos J, Donate-López J, Huelga-Zapico E, García-Sánchez J, García-Feijoó J: Bilateral papilledema secondary to chronic lymphocytic leukaemia. Arch Soc Esp Oftalmol 2007, 82:303-306.
• [68]Schmidt-Hieber M, Thiel E, Keilholz U: Spinal paraparesis due to leukemic meningitis in early-stage chronic lymphocytic leukemia. Leuk Lymphoma 2005, 46:619-621.
• [69]Singh AK, Thompson RP: Leukaemic meningitis in chronic lymphocytic leukaemia. Acta Haematol 1986, 75:113-115.
• [70]Solal-Celigny P, Schuller E, Courouble Y, Gislon J, Elghozi D, Boivin P: Cerebromeningeal location of chronic lymphoid leukemia. Rapid immunochemical diagnosis and complete remission by intrathecal chemotherapy. Presse Med 1983, 12:2323-2325.
• [71]Spectre G, Gural A, Amir G, Lossos A, Siegal T, Paltiel O: Central nervous system involvement in indolent lymphomas. Ann Oncol 2005, 16:450-454.
• [72]Stagg MP, Gumbart CH: Chronic lymphocytic leukemic meningitis as a cause of the syndrome of inappropriate secretion of antidiuretic hormone. Cancer 1987, 60:191-192.
• [73]Steinberg JP, Pecora M, Lokey JL: Leukemic meningitis in B-cell chronic lymphocytic leukemia. Cancer Treat Rep 1985, 69:687-688.
• [74]Thiruvengadam R, Bernstein ZP: Central nervous system involvement in prolymphocytic transformation of chronic lymphocytic leukemia. Acta Haematol 1992, 87:163-164.
• [75]Tonino SH, Rijssenbeek AL, Oud ME, Pals ST, van Oers MH, Kater AP: Intracerebral infiltration as the unique cause of the clinical presentation of chronic lymphocytic leukemia/small lymphocytic leukemia. J Clin Oncol 2011, 29:e837-e839.
• [76]Treppendahl MB, Andersen N, Jurlander J, Geisler C: A case of chronic lymphocytic leukemia with deletion 17p and bilateral retinal leukemic infiltrates. Eur J Haematol 2009, 82:79-80.
• [77]Vogt-Schaden M, Wildemann B, Stelljes M, Haas J, Storch-Hagenlocher B, Grond-Ginsbach C: Leptomeningeal dissemination of chronic lymphatic leukemia. Molecular genetic detection in cerebrospinal fluid. Nervenarzt 1999, 70:363-367.
• [78]Wang ML, Shih LY, Dunn P, Kuo MC: Meningeal involvement in B-cell chronic lymphocytic leukemia: report of two cases. J Formos Med Assoc 2000, 99:775-778.
• [79]Watanabe N, Takahashi T, Sugimoto N, Tanaka Y, Kurata M, Matsushita A, Maeda A, Nagai K, Nasu K: Excellent response of chemotherapy- resistant B-cell-type chronic lymphocytic leukemia with meningeal involvement to rituximab. Int J Clin Oncol 2005, 10:357-361.
• [80]Lopes da Silva R: Spectrum of neurologic complications in chronic lymphocytic leukemia. Clin Lymphoma Myeloma Leuk 2012, 12:164-179.
• [81]Ratterman M, Kruczek K, Sulo S, Shanafelt TD, Kay NE, Nabhan C: Extramedullary chronic lymphocytic leukemia: systematic analysis of cases reported between 1975 and 2012. Leuk Res 2014, 38:299-303.
• [82]Rai KR, Sawitsky A, Cronkite EP, Chanana AD, Levy RN, Pasternack BS: Clinical staging of chronic lymphocytic leukemia. Blood 1975, 46:219-234.
• [83]Binet JL, Auquier A, Dighiero G, Chastang C, Piguet H, Goasguen J, Vaugier G, Potron G, Colona P, Oberling F, Thomas M, Tchernia G, Jacquillat C, Boivin P, Lesty C, Duault MT, Monconduit M, Belabbes S, Gremy F: A new prognostic classification of chronic lymphocytic leukemia derived from a multivariate survival analysis. Cancer 1981, 48:198-206.
• [84]Robak E, Robak T: Skin lesions in chronic lymphocytic leukemia. Leuk Lymphoma 2007, 48:855-865.
• [85]Moore W, Baram D, Hu Y: Pulmonary infiltration from chronic lymphocytic leukemia. J Thorac Imaging 2006, 21:172-175.
• [86]D'Arena G, Guariglia R, Villani O, Martorelli MC, Pietrantuono G, Mansueto G, Patitucci G, Imbriani E, Masciandaro T, Borgia L, Vita G, D'Auria F, Statuto T, Musto P: An urologic face of chronic lymphocytic leukemia: sequential prostatic and penis localization. Mediterr J Hematol Infect Dis 2013, 5:e2013008.
• [87]Uprety D, Peterson A, Shah BK: Renal failure secondary to leukemic infiltration of kidneys in CLL–a case presentation and review of literature. Ann Hematol 2013, 92:271-273.
• [88]Malhotra P, Singh M, Kochhar R, Nada R, Wig JD, Varma N, Varma S: Leukemia infiltration of bowel in chronic lymphocytic leukemia. Gastrointest Endosc 2005, 62:614-615.
• [89]Bower JH, Hammack JE, McDonnell SK, Tefferi A: The neurologic complications of B-cell chronic lymphocytic leukemia. Neurology 1997, 48:407-412.
• [90]Lee SH, Hur J, Kim YJ, Lee HJ, Hong YJ, Choi BW: Additional value of dual-energy CT to differentiate between benign and malignant mediastinal tumors: an initial experience. Eur J Radiol 2013, 82:2043-2049.
• [91]Glantz MJ, Cole BF, Glantz LK, Cobb J, Mills P, Lekos A, Walters BC, Recht LD: Cerebrospinal fluid cytology in patients with cancer: minimizing false-negative results. Cancer 1998, 82:733-739.
• [92]Gold DR, Nadel RE, Vangelakos CG, Davis MJ, Livingston MY, Heath JE, Reich SG, Gojo I, Morales RE, Weiner WJ: Pearls and oy-sters: the utility of cytology and flow cytometry in the diagnosis of leptomeningeal leukemia. Neurology 2013, 80:e156-e159.
• [93]Hegde U, Filie A, Little RF, Janik JE, Grant N, Steinberg SM, Dunleavy K, Jaffe ES, Abati A, Stetler-Stevenson M, Wilson WH: High incidence of occult leptomeningeal disease detected by flow cytometry in newly diagnosed aggressive B-cell lymphomas at risk for central nervous system involvement: the role of flow cytometry versus cytology. Blood 2005, 105:496-502.
• [94]Bromberg JE, Breems DA, Kraan J, Bikker G, van der Holt B, Smitt PS, van den Bent MJ, van't Veer M, Gratama JW: CSF flow cytometry greatly improves diagnostic accuracy in CNS hematologic malignancies. Neurology 2007, 68:1674-1679.
• [95]Schroers R, Baraniskin A, Heute C, Vorgerd M, Brunn A, Kuhnhenn J, Kowoll A, Alekseyev A, Schmiegel W, Schlegel U, Deckert M, Pels H: Diagnosis of leptomeningeal disease in diffuse large B-cell lymphomas of the central nervous system by flow cytometry and cytopathology. Eur J Haematol 2010, 85:520-528.
• [96]Ahluwalia MS, Wallace PK, Peereboom DM: Flow cytometry as a diagnostic tool in lymphomatous or leukemic meningitis: ready for prime time? Cancer 2012, 118:1747-1753.
• [97]French CA, Dorfman DM, Shaheen G, Cibas ES: Diagnosing lymphoproliferativ disorders involving the cerebrospinal fluid: increased sensitivity using flow cytometric analysis. Diagn Cytopathol 2000, 23:369-374.
• [98]Rhodes CH, Glantz MJ, Glantz L, Lekos A, Sorenson GD, Honsinger C, Levy NB: A comparison of polymerase chain reaction examination of cerebrospinal fluid andconventional cytology in the diagnosis of lymphomatous meningitis. Cancer 1996, 77:543-548.
• [99]Davidson B, Risberg B, Berner A, Smeland EB, Torlakovic E: Evaluation of lymphoid cell populations in cytology specimens using flow cytometry and polymerase chain reaction. Diagn Mol Pathol 1999, 8:183-188.
• [100]van den Bent MJ, Lamers CH, van 't Veer MB, Sillevis Smitt PA, Bolhuis RL, Gratama JW: Increased levels of soluble CD27 in the cerebrospinal fluid are not diagnostic for leptomeningeal involvement by lymphoid malignancies. Ann Hematol 2002, 81:187-191.