Impact of Obesity on Lumbar Puncture Outcomes in Adults with Acute Lymphoblastic Leukemia and Lymphoma: Experience at an Academic Reference Center
-
José Carlos Jaime-Pérez
,
Guillermo Sotomayor-Duque
,
Patrizia Aguilar-Calderón
,
Lorena Salazar-Cavazos
,
David Gómez-Almaguer
Abstract
Background: Lumbar puncture (LP) is a hematology procedure that can require repeated attempts leading to traumatic LP (TLP), which has been related to the central nervous system (CNS) relapse. LP success can depend on the size and anatomy of the patient and the skill of the hematologist. The main objective was to determine the influence of body mass index (BMI) on LP outcomes.
Materials and Methods: Adults with lymphoid malignancies requiring LP were included prospectively over one year; hematology residents performed most procedures. A 22-gauge Quincke needle was employed. Comparison between non-traumatic vs. traumatic LPs according to BMI, CNS relapse, and residents’ year was performed.
Results: Fifty-four patients with a mean age of 31.5±15.57 years were included. Diagnosis was Acute Lymphoblastic Leukemia-B (74%), Acute Lymphoblastic Leukemia-T (13%) and Non-Hodgkin Lymphoma (13%). 227 LPs were performed, 121 (53.3%) successful, 98 (43.2%) traumatic, 11 (11.2%) TLPs were macroscopically detectable and 87 (88%) microscopic; 8 (3.5%) were dry-taps. Median time between punctures was 11 days (1-202). Median BMI was 25 (22.8-39.6). Main indication for LP was prophylactic (74.5%); 39.2% were performed by first-year, 35.2% by second-year, 19.6% by third-year hematology residents. No difference (p = 0.145) for a TLP was found among residents. A BMI ≥30 (p = 0.040), non-palpable intervertebral space (p = 0.001) and more than one attempt (p = 0.001) were significant for TLP. TLP was not associated with CNS relapse (p = 0.962).
Conclusion: Obesity predicted a TLP. A traumatic puncture did not increase the risk of CNS relapse at one-year follow-up.
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2. Galati D, Di Noto R, Del Vecchio L. Diagnostic strategies to investigate cerebrospinal fluid involvement in haematological malignancies. Leuk Res. 2013; 37(3):231–7.
3. Smith M, Arthur D, Camitta B, et al. Uniform approach to risk classification and treatment assignment for children with acute lymphoblastic leukemia. J Clin Oncol. 1996; 14(1):18–24.
4. Sahebkar-Moghaddam F, Adornato BT. The failed lumbar puncture. Neurology. 2005; 64(7):E24.
5. Edwards C, Leira EC, Gonzalez-Alegre P. Residency Training: A failed lumbar puncture is more about obesity than lack of ability. Neurology. 2015; 84(10):e69–72.
6. Barreras P, Benavides DR, Barreras JF, et al. A dedicated lumbar puncture clinic: performance and short-term patient outcomes. J Neurol. 2017; 264(10):2075–2080.
7. Lin N, Li Y, Bebawy JF, et al. Abdominal circumference but not the degree of lumbar flexion affects the accuracy of lumbar interspace identification by Tuffier’s line palpation method: an observational study. BMC Anesthesiol. 2015; 15: 9.
8. Shah KH, McGillicuddy D, Spear J, et al. Predicting difficult and traumatic lumbar punctures. Am J Emerg Med. 2007; 25(6):608–11.
9. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014; 311(8):806–14.
10. Cervera SB, Campos-Nonato I. Obesidad en México: epidemiología y políticas de salud para su control y prevención. Gac Med Mex. 2010; 146(6):397–407.
11. Jabbour E, Thomas D, Cortes J, et al. Central nervous system prophylaxis in adults with acute lymphoblastic leukemia: current and emerging therapies. Cancer. 2010; 116(10):2290–300.
12. Flores-Jimenez JA, Gutierrez-Aguirre CH, Cantu-Rodriguez OG, et al. Safety and cost-effectiveness of a simplified method for lumbar puncture in patients with hematologic malignancies. Acta Haematol. 2015; 133(2):168–71.
13. Boon JM, Abrahams PH, Meiring JH, et al. Lumbar puncture: anatomical review of a clinical skill. Clin Anat. 2004; 17(7):544–53.
14. Barranco-Lampón G, Rozen-Fuller E, Olarte-Carrilo I, et al. Association between traumatic lumbar puncture and the risk of central nervous system relapse in adults with acute lymphoblastic leukaemia. Rev Med Hosp Gen Méx. 2015; 78(3):124–128.
15. Peterson MA, Pisupati D, Heyming TW, et al. Ultrasound for routine lumbar puncture. Acad Emerg Med. 2014; 21(2):130–6.
16. Gajjar A, Harrison PL, Sandlund JT, et al. Traumatic lumbar puncture at diagnosis adversely affects outcome in childhood acute lymphoblastic leukemia. Blood. 2000; 96(10):3381–4.
17. Mosteller. R.D. Simplified Calculation of Body Suface Area. N Engl J Med. 1987; 317(17):1098.
18. Vavricka SR, Walter RB, Irani S, et al. Safety of lumbar puncture for adults with acute leukemia and restrictive prophylactic platelet transfusion. Ann Hematol. 2003; 82(9):570–3.
19. National Institute of Cancer. Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. NIH Publ [Internet]. 2010; 2009:0–71. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcaev3.pdf
20. Jaime-Pérez JC, Jiménez-Castillo RA, Herrera-Garza JL, et al. Survival Rates of Adults With Acute Lymphoblastic Leukemia in a Low-Income Population: A Decade of Experience at a Single Institution in Mexico. Clin Lymphoma Myeloma Leuk. 2016; 17(1):60–68.
21. Jaime-Perez JC, Gamboa-Alonso CM, Vázquez -Mellado de Larracoechea A, et al. Non-Hodgkin Lymphomas: Impact of Rituximab on Overall Survival of Patients with Diffuse Large B-Cell and Follicular Lymphoma. Arch Med Res. 2015; 46(6):454–61.
22. Pitkänen MT, Förster JG. [Complications caused by lumbar puncture]. Duodecim. 2014; 130(18):1834–42 [Article in Finnish].
23. Vilming ST, Kloster R, Sandvik L. The importance of sex, age, needle size, height and body mass index in post-lumbar puncture headache. Cephalalgia. 2001; 21(7):738–43.
24. Li J, Li X, Tong X, et al. Investigation of the optimal duration of bed rest in the supine position to reduce complications after lumbar puncture combined with intrathecal chemotherapy: a multicenter prospective randomized controlled trial. Support Care Cancer. 2018; 26(9):2995–3002.
25. Kiki I, Gundogdu M, Alici HA, et al. A simple, safe and effective approach to prevent postdural puncture headache: epidural saline injection. Eurasian J Med. 2009; 41(3):175–179.
26. Arevalo-Rodriguez I, Muñoz L, Godoy-Casasbuenas N, et al. Needle gauge and tip designs for preventing post-dural puncture headache (PDPH). Cochrane Database Syst Rev. 2017 ;( 4):1–214.
27. Marwaha RK, Kulkarni KP, Bansal D, et al. Central nervous system involvement at presentation in childhood acute lymphoblastic leukemia: management experience and lessons. Leuk Lymphoma. 2010; 51(2):261–8.
28. Shaikh F, Voicu L, Tole S, et al. The risk of traumatic lumbar punctures in children with acute lymphoblastic leukaemia. Eur J Cancer. 2014; 50(8):1482–9.
29. Rech A, de Carvalho GP, Meneses CF, et al. The influence of traumatic lumbar puncture and timing of intrathecal therapy on outcome of pediatric acute lymphoblastic leukemia. Pediatr Hematol Oncol. 2005; 22(6):483–8.
30. Gómez-Almaguer D, Marcos- Ramírez-ER, Montaño-Figueroa EH, et al. Acute Leukemia Characteristics are Different Around the World: the Mexican Perspective. Clin Lymphoma Myeloma Leuk. 2017; 17(1):46-51.
31. Jaime-Pérez JC, Treviño-Reyna G, Aguilar-Calderón P, et al. Contributions of a regional approach to document hematologic disease in Mexico: a 10-year experience in an open population. Hematology. 2018; 23(10):803-809.
32. Ning S, Kerbel B, Callum J, et al. Safety of lumbar punctures in patients with thrombocytopenia. Vox Sang. 2016; 110(4):393–400.
33. Estcourt LJ, Ingram C, Doree C, et al. Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia. Cochrane Database Syst Rev. 2016 ;( 5):CD011980.
34. Breuer AC, Tyler HR, Marzewski DJ, et al. Radicular vessels are the most probable source of needle‐induced blood in lumbar puncture. Significance for the thrombocytopenic cancer patient. Cancer. 1982; 49(10):2168–72.
35. Craig F, Stroobant J, Winrow A, et al. Depth of insertion of a lumbar puncture needle. Arch Dis Child. 1997; 77(5):450.
2. Galati D, Di Noto R, Del Vecchio L. Diagnostic strategies to investigate cerebrospinal fluid involvement in haematological malignancies. Leuk Res. 2013; 37(3):231–7.
3. Smith M, Arthur D, Camitta B, et al. Uniform approach to risk classification and treatment assignment for children with acute lymphoblastic leukemia. J Clin Oncol. 1996; 14(1):18–24.
4. Sahebkar-Moghaddam F, Adornato BT. The failed lumbar puncture. Neurology. 2005; 64(7):E24.
5. Edwards C, Leira EC, Gonzalez-Alegre P. Residency Training: A failed lumbar puncture is more about obesity than lack of ability. Neurology. 2015; 84(10):e69–72.
6. Barreras P, Benavides DR, Barreras JF, et al. A dedicated lumbar puncture clinic: performance and short-term patient outcomes. J Neurol. 2017; 264(10):2075–2080.
7. Lin N, Li Y, Bebawy JF, et al. Abdominal circumference but not the degree of lumbar flexion affects the accuracy of lumbar interspace identification by Tuffier’s line palpation method: an observational study. BMC Anesthesiol. 2015; 15: 9.
8. Shah KH, McGillicuddy D, Spear J, et al. Predicting difficult and traumatic lumbar punctures. Am J Emerg Med. 2007; 25(6):608–11.
9. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014; 311(8):806–14.
10. Cervera SB, Campos-Nonato I. Obesidad en México: epidemiología y políticas de salud para su control y prevención. Gac Med Mex. 2010; 146(6):397–407.
11. Jabbour E, Thomas D, Cortes J, et al. Central nervous system prophylaxis in adults with acute lymphoblastic leukemia: current and emerging therapies. Cancer. 2010; 116(10):2290–300.
12. Flores-Jimenez JA, Gutierrez-Aguirre CH, Cantu-Rodriguez OG, et al. Safety and cost-effectiveness of a simplified method for lumbar puncture in patients with hematologic malignancies. Acta Haematol. 2015; 133(2):168–71.
13. Boon JM, Abrahams PH, Meiring JH, et al. Lumbar puncture: anatomical review of a clinical skill. Clin Anat. 2004; 17(7):544–53.
14. Barranco-Lampón G, Rozen-Fuller E, Olarte-Carrilo I, et al. Association between traumatic lumbar puncture and the risk of central nervous system relapse in adults with acute lymphoblastic leukaemia. Rev Med Hosp Gen Méx. 2015; 78(3):124–128.
15. Peterson MA, Pisupati D, Heyming TW, et al. Ultrasound for routine lumbar puncture. Acad Emerg Med. 2014; 21(2):130–6.
16. Gajjar A, Harrison PL, Sandlund JT, et al. Traumatic lumbar puncture at diagnosis adversely affects outcome in childhood acute lymphoblastic leukemia. Blood. 2000; 96(10):3381–4.
17. Mosteller. R.D. Simplified Calculation of Body Suface Area. N Engl J Med. 1987; 317(17):1098.
18. Vavricka SR, Walter RB, Irani S, et al. Safety of lumbar puncture for adults with acute leukemia and restrictive prophylactic platelet transfusion. Ann Hematol. 2003; 82(9):570–3.
19. National Institute of Cancer. Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. NIH Publ [Internet]. 2010; 2009:0–71. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcaev3.pdf
20. Jaime-Pérez JC, Jiménez-Castillo RA, Herrera-Garza JL, et al. Survival Rates of Adults With Acute Lymphoblastic Leukemia in a Low-Income Population: A Decade of Experience at a Single Institution in Mexico. Clin Lymphoma Myeloma Leuk. 2016; 17(1):60–68.
21. Jaime-Perez JC, Gamboa-Alonso CM, Vázquez -Mellado de Larracoechea A, et al. Non-Hodgkin Lymphomas: Impact of Rituximab on Overall Survival of Patients with Diffuse Large B-Cell and Follicular Lymphoma. Arch Med Res. 2015; 46(6):454–61.
22. Pitkänen MT, Förster JG. [Complications caused by lumbar puncture]. Duodecim. 2014; 130(18):1834–42 [Article in Finnish].
23. Vilming ST, Kloster R, Sandvik L. The importance of sex, age, needle size, height and body mass index in post-lumbar puncture headache. Cephalalgia. 2001; 21(7):738–43.
24. Li J, Li X, Tong X, et al. Investigation of the optimal duration of bed rest in the supine position to reduce complications after lumbar puncture combined with intrathecal chemotherapy: a multicenter prospective randomized controlled trial. Support Care Cancer. 2018; 26(9):2995–3002.
25. Kiki I, Gundogdu M, Alici HA, et al. A simple, safe and effective approach to prevent postdural puncture headache: epidural saline injection. Eurasian J Med. 2009; 41(3):175–179.
26. Arevalo-Rodriguez I, Muñoz L, Godoy-Casasbuenas N, et al. Needle gauge and tip designs for preventing post-dural puncture headache (PDPH). Cochrane Database Syst Rev. 2017 ;( 4):1–214.
27. Marwaha RK, Kulkarni KP, Bansal D, et al. Central nervous system involvement at presentation in childhood acute lymphoblastic leukemia: management experience and lessons. Leuk Lymphoma. 2010; 51(2):261–8.
28. Shaikh F, Voicu L, Tole S, et al. The risk of traumatic lumbar punctures in children with acute lymphoblastic leukaemia. Eur J Cancer. 2014; 50(8):1482–9.
29. Rech A, de Carvalho GP, Meneses CF, et al. The influence of traumatic lumbar puncture and timing of intrathecal therapy on outcome of pediatric acute lymphoblastic leukemia. Pediatr Hematol Oncol. 2005; 22(6):483–8.
30. Gómez-Almaguer D, Marcos- Ramírez-ER, Montaño-Figueroa EH, et al. Acute Leukemia Characteristics are Different Around the World: the Mexican Perspective. Clin Lymphoma Myeloma Leuk. 2017; 17(1):46-51.
31. Jaime-Pérez JC, Treviño-Reyna G, Aguilar-Calderón P, et al. Contributions of a regional approach to document hematologic disease in Mexico: a 10-year experience in an open population. Hematology. 2018; 23(10):803-809.
32. Ning S, Kerbel B, Callum J, et al. Safety of lumbar punctures in patients with thrombocytopenia. Vox Sang. 2016; 110(4):393–400.
33. Estcourt LJ, Ingram C, Doree C, et al. Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia. Cochrane Database Syst Rev. 2016 ;( 5):CD011980.
34. Breuer AC, Tyler HR, Marzewski DJ, et al. Radicular vessels are the most probable source of needle‐induced blood in lumbar puncture. Significance for the thrombocytopenic cancer patient. Cancer. 1982; 49(10):2168–72.
35. Craig F, Stroobant J, Winrow A, et al. Depth of insertion of a lumbar puncture needle. Arch Dis Child. 1997; 77(5):450.
| Files | ||
| Issue | Vol 13, No 3 (2019) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/ijhoscr.v13i3.1274 | |
| Keywords | ||
| Acute lymphoblastic leukemia; CNS relapse; Lumbar puncture; Obesity; Traumatic lumbar puncture | ||
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Jaime-Pérez JC, Sotomayor-Duque G, Aguilar-Calderón P, Salazar-Cavazos L, Gómez-Almaguer D. Impact of Obesity on Lumbar Puncture Outcomes in Adults with Acute Lymphoblastic Leukemia and Lymphoma: Experience at an Academic Reference Center. Int J Hematol Oncol Stem Cell Res. 2019;13(3):146-152.
