Preleukemic states in children with acute lymphoblastic leukemia

Transient Pancytopenia Subsequently Diagnosed With Acute Leukemia: A Report of 4 Cases of Acute Lymphoblastic Leukemia and Acute Myeloid Leukemia

A transient pancytopenic phase has been described in pediatric leukemia. The characteristic complete recovery of peripheral counts can obscure a clinician's suspicion for malignancy and may impact subsequent follow-up care. The authors describe 4 pediatric patients that had transient pancytopenia with an initial abnormal marrow finding. These patients were subsequently diagnosed with acute leukemia within 5 months of presentation. Awareness of this phenomenon by the provider and education of families may help with the appropriate and timely diagnosis of subsequent leukemia.

The distinguishable DNA whole genome methylation profile of 2 cases of pediatric precursor B acute lymphoblastic leukaemia (BCP ALL) with prodromal, preleukemic phase: A case report

RATIONALE

A prolonged, prodromal phase before definitive paediatric precursor B acute lymphoblastic leukaemia (BCP ALL) diagnosis is rarely observed.

PATIENTS CONCERNS

In the first, the patient presented with an aplastic preleukemic phase, whilst the second presented with a rheumatic-like preliminary phase.

DIAGNOSES

The case reports of two patients with BCP ALL with a prodromal phase lasting a few weeks are presented.

INTERVENTIONS AND OUTCOMES

DNA whole genome profile methylation analysis of bone marrow cells obtained at diagnosis revealed a pattern of methylation that was readily distinguishable from both healthy and standard course BCP ALL bone marrow samples.

LESSONS

The biological implication of this observation remains unclear, with many differentially methylated loci involved in many processes like neurogenesis, cell projection organization and adhesion along with leucocyte activation and apoptosis. The prevalence and clinical significance of these methylation changes is unknown but this data indicates that the epigenetic basis of BCP ALL with a prolonged, prodromal phase requires a more detailed assessment.

Genetic lesions in a preleukemic aplasia phase in a child with acute lymphoblastic leukemia

In a small fraction ( approximately 2%) of cases of childhood acute lymphoblastic leukemia (ALL) clinical presentation of leukemia is preceded, some 2-9 months earlier, by a transient, remitting phase of nonclassical aplastic anemia, usually in connection with infection. The potential "preleukemic" nature of this prodromal phase has not been fully explored. We have retrospectively analyzed the blood and bone marrow of a child who presented with aplastic anemia 9 months before the development of ETV6-RUNX1 fusion gene positive ALL. High resolution SNP genotyping arrays identified 11 regions of loss of heterozygosity, with and without concurrent copy number changes, at the presentation of ALL. In all cases of copy number change, the deletion or gain identified by single nucleotide polymorphism (SNP) analysis was confirmed in the ALL blasts by FISH. Retrospective analysis of aplastic phase bone marrow showed that the ETV6-RUNX1 fusion was present along with all of the additional genetic changes assessed, albeit subclonal to ETV6-RUNX1. These data identify for the first time the leukemic genotype of an aplasia preceding clinical ALL and indicate that multiple secondary genetic abnormalities can contribute to a dominant subclone several months before a diagnosis of ALL. These data have implications for the biology of ALL and for management of similar patients.

Bone marrow aplasia with prominent atypical plasmacytic proliferation preceding acute lymphoblastic leukemia

A two-year-old boy presented with pancytopenia. Bone marrow examination revealed an aplastic marrow with prominent immature plasma cell proliferation, which mimicked plasma cell leukemia. Immunohistochemistry, however, revealed a polyclonal population consistent with a reactive process, excluding plasma cell neoplasia. Administration of granulocyte-colony stimulating factor resulted in recovery of normal hematopoiesis with resolution of plasmacytosis. Seven months later, the patient had an elevated white blood cell count and bone marrow findings diagnostic of acute lymphoblastic leukemia. To the best of our knowledge this is the first reported case of bone marrow aplasia with prominent polyclonal plasmacytosis presenting as a prodrome of acute lymphoblastic leukemia in childhood.

Pancytopenic prodrome (pre-ALL) of acute lymphoblastic leukemia in adults: possible pathogenesis

We report two cases of adult acute lymphoblastic leukemia presenting with preleukemic phase of pancytopenia with a few abnormal lymphoid cells in bone marrow aspirates. The initial diagnosis of each case was suspicious aplastic anemia and hypoplastic anemia. Both cases progressed to overt acute lymphoblastic leukemia within 1 year. We suggest that initial pancytopenic phase (pre-ALL) may precede the diagnosis of acute lymphoblastic leukemia in adults and differential diagnosis from myelodysplastic syndrome and primary aplastic anemia will be needed. We also suggest that primary bone marrow lymphoma and "primary unknown metastatic lymphoma of bone marrow" may be possible as the pathogenesis in a case like ours.

Quantitative flow cytometry can predict childhood acute lymphoblastic leukaemia presenting with aplasia

Acute lymphoblastic leukaemia (ALL) presenting as a transient pancytopenia is known to occur in children and less commonly in adults. The period of pancytopenia usually resolves after about 5-38 weeks, to be followed by overt ALL. The pathogenesis is not known and there are no specific cytogenetic abnormalities. Diagnosis is often difficult during the period of bone marrow hypoplasia. Quantitative flow cytometry can help to establish early diagnosis, and can be used on more patients presenting in a similar way.

Childhood acute lymphocytic leukemia with a preleukemic phase: report of an associated translocation and review of the literature

A fourteen month old boy presented with hepatosplenomegaly and pancytopenia. An extensive evaluation, including bone marrow aspiration and biopsies of both liver and lymph nodes, revealed a polyclonal B cell proliferation consistent with a reactive process, with no evidence of leukemia. After receiving transfusions of red cells and platelets, his blood counts recovered. Five weeks later, he returned with an elevated white blood count and bone marrow findings diagnostic of acute lymphocytic leukemia. The leukemic blasts contained a novel chromosomal translocation, t(5;14) (q34;q12). We describe the clinical, immunophenotypic and cytogenetic features of this case, review the literature of acute lymphocytic leukemia associated with a preleukemic phase, and discuss the relationship of this clinical entity to the 5q-abnormality associated with myelodysplasia.

Severe aplastic anemia preceding acute lymphoblastic leukemia

BACKGROUND

Bone marrow aplasia preceding acute lymphoblastic leukemia (ALL) is a rare condition that usually affects children. The ALL generally follows the recovery of normal blood counts and most commonly occurs within 6 months of the onset of aplasia. The case of a patient with severe aplastic anemia is reported in whom ALL developed 15 months after the initial diagnosis of aplastic anemia. A literature search found 23 cases of ALL after a period of aplasia or hypoplasia. This patient's disease, however, was different from all previously reported ones. The severe aplasia lasted 15 months before being followed by ALL. There was no recovery of blood counts before the onset of ALL.

METHODS

A review of the literature found 23 case reports in which aplasia or hypoplasia preceded ALL; these patients also had pancytopenia of the peripheral blood. Excluded from this review were patients whose bone marrow was hypoplastic, but who did not have pancytopenia because these did not have "aplastic anemia" as their initial disease.

RESULTS

Analysis of the reported patients showed that most were girls 10 years of age or younger. There was an overwhelming prevalence of fever, which in several instances, might have had an infectious cause. ALL most commonly occurred within 6 months of the aplasia and usually followed the recovery of normal blood counts.

CONCLUSIONS

Patients with ALL after a prolonged period of aplasia have several common characteristics including female sex, young age, and the prevalence of fever, often associated with an infectious illness. ALL usually follows the recovery of blood counts and occurs within 6 months of the onset of aplasia. The pathophysiology of this patient's disease(s) is still unclear. He could have had two unrelated disorders or a two-step leukemic process that followed a stem cell "insult." This patient had an antecedent hepatitis A infection 3 months before aplasia occurred. However, the authors were unable to identify with certainty any other event that might have caused additional bone marrow injury.

Distinction between aleukaemic prodrome of childhood acute lymphoblastic leukaemia and aplastic anaemia

AIMS

To document the features of the so-called aplastic presentation of childhood acute lymphoblastic leukaemia (ALL) and to determine whether this prodrome can be distinguished from aplasia.

METHODS

The peripheral blood and bone marrow appearances of all cases of childhood ALL presenting in one health region of England in 13 years and eight months were reviewed. All cases presenting with cytopenia without circulating blasts and marrow aspirates with no infiltrate of blasts were studied in detail.

RESULTS

Four of 305 (1.3%) children presented in this way. All four had reticulin fibrosis and increased cellularity in all or part of the marrow biopsy specimen. All were girls. Three had common and one surface membrane immunoglobulin positive ALL. Reassessment of this prodrome, by combining the features of four previously reported series of similar cases with the present one, highlighted the female preponderance (19 of 22 cases), bone marrow fibrosis (10 of 11 evaluable cases), prominent bone marrow lymphocytes (14 of 22 cases) and temporary recovery (all 12 evaluable cases). Six of 14 evaluable cases had bone marrow biopsy specimen appearances of apparently uniform hypocellularity, but only one of these did not have fibrosis.

CONCLUSIONS

If, in addition to an aspirate, a bone marrow trephine biopsy is carried out the prodrome can be distinguished from aplasia in most cases. The similarity of this prodrome to aplastic anaemia is merely superficial. Clinicians and morphologists may fail to appreciate the implications of this mode of presentation if the term "aplastic" continues to be used to describe this aleukaemic prodrome of ALL.

Neutropenia preceding acute lymphoblastic leukaemia

Images

Acute lymphoblastic leukaemia after bone marrow transplantation for aplastic anaemia

An 11.5-year-old girl developed acute lymphoblastic leukaemia 7 months after bone marrow transplantation for severe aplastic anaemia. Before transplantation there were neither morphologic nor cytogenetic abnormalities to suggest preleukaemia. The conditioning regimen consisted only of cyclophosphamide. At the time of development of acute lymphoblastic leukaemia, chromosome analysis showed the blasts to be of host origin with clonal abnormalities including monosomy 7. Such a preleukaemic syndrome presenting as severe aplastic anaemia is a very rare event (the case reported here is the only one of 436 patients in Seattle) and cannot be reliably excluded before transplantation.

Bone marrow necrosis preceding acute lymphoblastic leukemia in childhood

Two patients who presented with bone marrow necrosis and eventually developed acute lymphocytic leukemia are reported, and similar cases in the literature are reviewed. Both patients responded to chemotherapy. Several possible mechanisms are discussed. Bone marrow necrosis appears to be another condition preceding acute lymphocytic leukemia in children.