Emergent Radiotherapy for Leukemia-Induced Cranial Neuropathies Refractory to Intrathecal Therapy

Abstract

Neurologic symptoms from leukemic infiltration of the central nervous system are an oncologic emergency, and expeditious treatment is required to preserve function. We report the case of a 44-year-old patient with relapsed acute myeloid leukemia (AML) who developed sub-acute cranial neuropathies refractory to treatment with intrathecal (IT) chemotherapy. The patient was therefore treated with an emergent course of whole-brain radiotherapy, resulting in immediate improvement and subsequent resolution of cranial neuropathies. This case illustrates that while central nervous system involvement by AML is rare, radiotherapy remains an effective modality to avoid long-term morbidity in patients failing to respond to systemic or IT chemotherapy.

Keywords: acute myeloid leukemia (aml); cns manifestations; palliative radiation therapy; rare eye disorders; whole brain radiation.

Figure 1. Right eye ptosis at presentation and over the course of radiotherapy.

(A) Patient at presentation to the emergency department with right eye ptosis. (B) Patient after two fractions of radiotherapy noted to have mild improvement in his right eye ptosis. (C) Patient at completion of five fractions of radiotherapy with continuing improvement in right eye ptosis. (D) Patient two days after completion of radiotherapy noted to have significant improvement in right eye ptosis. (E) Patient at one month following completion of radiotherapy with resolution of right eye ptosis.

Figure 2. Axial T1 post-contrast MRI images.

(A) Red arrow pointing to abnormal enhancement of the cisternal segment of the left trigeminal nerve. (B) Red arrow pointing to abnormal enhancement involving the distal cisternal and cavernous segment of the right oculomotor nerve.

Figure 3. Radiation treatment plan.

(A) Radiation treatment plan of 15 Gy in five fractions using 6-MV opposed lateral photon beams. (B) Digitally reconstructed radiograph of the treatment field with an inferior border at C2-C3.