Peterson B A, Brunning R D, Bloomfield C D, Hurd D D, Gau J A, Peng G T, Goldman A I
Department of Medicine, University of Minnesota Health Sciences Center, Minneapolis.
Am J Med. 1987 Sep;83(3):464-70. doi: 10.1016/0002-9343(87)90756-x.
To identify adults with acute nonlymphocytic leukemia at risk for the development of central nervous system involvement, we performed periodic cerebrospinal fluid examinations on patients in remission. Among 58 consecutive patients monitored during first remission, central nervous system leukemia developed in nine (16 percent). Four patients, including one who was symptomatic, had central nervous system leukemia detected simultaneously with marrow relapse. Five additional patients were asymptomatic and continue to have bone marrow remission. Following central nervous system and systemic treatment, two of these five patients have never had relapse, and three had relapse in the bone marrow five, 10, and 21 months later. Factors at diagnosis associated with the subsequent development of central nervous system leukemia were elevated leukocyte count, serum lysozyme and lactate dehydrogenase, extramedullary infiltration including splenomegaly, and monocytic (FAB M4 or M5a) morphology. In six of 17 patients (35 percent) with monocytic morphology, central nervous system leukemia developed compared with only three of 41 patients (7 percent) with other subtypes (p = 0.02). Discriminant analysis identified leukocyte count, splenomegaly, and M4 or M5a morphology as the most important risk factors and led to a mathematical formula that correctly identified 90 percent of the patients. Although the risk of central nervous system leukemia in adults with acute nonlymphocytic leukemia is too low to justify routine prophylaxis, those patients recognized to be at a greater risk should receive prophylaxis or be monitored closely with periodic lumbar punctures.
为了确定有发生中枢神经系统受累风险的急性非淋巴细胞白血病成人患者，我们对缓解期患者进行了定期脑脊液检查。在首次缓解期接受监测的58例连续患者中，9例（16%）发生了中枢神经系统白血病。4例患者，包括1例有症状的患者，在骨髓复发时同时检测出中枢神经系统白血病。另外5例患者无症状，骨髓持续缓解。在接受中枢神经系统和全身治疗后，这5例患者中有2例从未复发，3例分别在5、10和21个月后骨髓复发。诊断时与随后发生中枢神经系统白血病相关的因素包括白细胞计数升高、血清溶菌酶和乳酸脱氢酶升高、髓外浸润（包括脾肿大）以及单核细胞（FAB M4或M5a）形态。17例单核细胞形态患者中有6例（35%）发生了中枢神经系统白血病，而其他亚型的41例患者中只有3例（7%）发生（p = 0.02）。判别分析确定白细胞计数、脾肿大以及M4或M5a形态是最重要的危险因素，并得出了一个能正确识别90%患者的数学公式。虽然成人急性非淋巴细胞白血病患者发生中枢神经系统白血病的风险过低，不足以证明常规预防的合理性，但那些被认为风险较高的患者应接受预防或通过定期腰椎穿刺进行密切监测。
