Acute leukemia occurring 19 years after treatment of acute lymphoblastic leukemia

Neurocognitive outcomes following fetal exposure to chemotherapy for gestational breast cancer: A Canadian multi-center cohort study

Background

Limited knowledge exists on outcomes of children exposed prenatally to chemotherapy for breast cancer (BC). The purpose of this study was to compare long-term neurocognitive, behavioral, developmental, growth, and health outcomes of children exposed in-utero to chemotherapy for BC.

Methods

This is a multi-center matched cross-sectional cohort study involving seven cancer centers across the region of Southern Ontario (Canada), and the Hospital for Sick Children (Toronto, Ontario). Using standardized psychological and behavioral tests, we compared cognitive and behavioral outcomes in children exposed to chemotherapy during pregnancy for BC to age-matched pairs exposed to known non-teratogens.

Results

We recruited 17 parent-child pairs and their matched controls. There were more preterm deliveries in the chemotherapy-exposed group compared to controls (p < 0.05). Full Scale IQ of children in the chemotherapy group was significantly confounded by maternal IQ and prematurity. Exposed children born at term were not different in cognitive outcomes. Children from both groups were similar in their developmental milestones, pediatric anthropometric measurements and health problems. There were no cases of autoimmune cytopenia.

Conclusions

This is the first Canadian prospective comparative study designed to assess pediatric cognition following prenatal exposure to chemotherapy for BC. Chemotherapy was not found to be neurotoxic in this cohort and did not affect pediatric health. The decision to plan a preterm birth for initiating or continuing chemotherapy treatment must be taken into consideration in context of pediatric implications. While these results may assist in such decision making, replication with a larger sample is needed for more conclusive findings.

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Limited knowledge exists on outcomes of children exposed prenatally to chemotherapy for breast cancer (BC).

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We compared cognitive and behavioral outcomes in children exposed to chemotherapy during pregnancy for BC to controls.

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FSIQ of children in the chemotherapy group was significantly confounded by prematurity.

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Chemotherapy was not found to be neurotoxic and did not affect pediatric health.

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Pediatric implications of planned preterm birth for further treatment should be considered.

Management of Hematologic Malignancies: Special Considerations in Pregnant Women

The diagnosis and management of hematologic malignancy during pregnancy is a significant challenge. This is due to both medical and ethical considerations regarding when and how to treat this special sub-group of patients. Recurring uncertainties remain around appropriate imaging techniques, timing and dosage of chemotherapy, and timing of delivery. In this article we examine and summarize current literature in this field to assist physicians in their understanding and management of this patient group. Special attention has been given to diagnostic and staging procedures, risks associated with chemotherapy at different stages of gestation, and chemotherapy-dose adaption during pregnancy. In addition, recommended guidelines for management of lymphoma, leukemia, and planning delivery are discussed. A multidisciplinary team approach is critical for patient care, as is shared decision making with the patient and family.

Non-Hodgkin lymphomas in pregnancy: tackling therapeutic quandaries

Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) often present with systemic symptoms such as fatigue, shortness of breath and night sweats, mimicking pregnancy-related features which may result in delayed disease diagnosis. Furthermore, the wish to avoid investigational imaging, aiming to protect the fetus from radiation exposure, may lead to a further delay, which does not often result in significant changes in HL clinical nature and patient outcome. In contrast, a more aggressive behavior (i.e., advanced disease stage and reproductive organ involvement) of most NHL types diagnosed in pregnancy may require urgent therapeutic intervention to prevent disease progression. Current management of pregnancy-associated NHL depends on histological subtype of the disease, gestational stage at diagnosis and the urgency of treatment for a specific patient. Patients diagnosed with indolent lymphoma may often be just followed, whereas those presenting with aggressive or highly aggressive disease need to be urgently treated with chemoimmunotherapy, either after undergoing an elective pregnancy termination if diagnosed at an early gestational stage, or with pregnancy preservation, if diagnosed later. Supportive care of NHL is also important; however, granulocyte colony stimulating factor (G-CSF) which is commonly used outside of pregnancy, should be cautiously employed, considering its established teratogenicity in animals, though this is less proven in humans. In conclusion, given the paucity of studies prospectively evaluating the outcome of pregnant women with NHL, international efforts are warranted to elucidate critical issues and develop guidelines for the management of such patients.

Lower leukocytes at initial diagnosis may predict poor outcome of very late relapse of acute lymphoblastic leukemia

We have reported a rare case of acute lymphoblastic leukemia (ALL) recurring 19 years after the first presentation. Since 1984, 36 relapse cases 10 years or more after the first diagnosis have been reported. All cases were childhood ALL with a low to standard risk. Twenty-six attained CR2, and 18 of them remained in sustained CR2. The sustained CR2 ratio was 80% without transplantation. Sustained CR2 ratio was significantly lower in patients with lower leukocytes (<10 x 10(9)l(-1)) at initial presentation. A very late relapse of ALL remains chemosensitive, and its prognosis is not unfavorable.

Pregnancy-associated breast cancer -- special features in diagnosis and treatment

For obvious psychological reasons it is difficult to associate pregnancy -- a life-giving period of our existence -- with life-threatening malignancies. Symptoms pointing to malignancy are often ignored by both patients and physicians, and this, together with the greater difficulty of diagnostic imaging, probably results in the proven delay in the detection of breast cancers during pregnancy. The diagnosis and treatment of breast cancer are becoming more and more important, as the fulfillment of the desire to have children is increasingly postponed until a later age associated with a higher risk of carcinoma, and improved cure rates of solid tumors no longer exclude subsequent pregnancies. The following article summarizes the special features of the diagnosis and primary therapy of pregnancy-associated breast cancer with particular consideration of cytostatic therapy.

Cervical neoplasia during pregnancy: Diagnosis, management and prognosis

Pregnancy represents an exceptional opportunity for the early diagnosis of cervical cancer since visual inspection, cytological examination and bimanual palpation are considered to be part of routine antenatal care. An abnormal cervical smear should generally be managed as in the non-pregnant state. However, colposcopy and biopsies are mainly intended to exclude invasive disease because a conservative approach is preferred in cases of pre-invasive disease. The only absolute indication for conization in pregnancy is to rule out (micro-)invasive disease or make the diagnosis of invasive carcinoma when such a diagnosis will alter the timing or mode of delivery. Overall, earlier stages of cervical cancer are encountered during pregnancy compared with the general population. Although stage of disease and gestational age will largely influence the timing of the interventions, treatment of invasive cervical cancer is similar to the non-pregnant state. In strongly desired pregnancies, the use of neo-adjuvant chemotherapy in order to obtain fetal maturity should be considered and discussed with the patient. Although good evidence supports short-term safety, long-term data regarding the in-utero exposure of cytotoxic drugs need to be consolidated. After stratifying for stage, the outcome is similar to the non-pregnant state.

Very late central nervous system relapse in a patient with B cell lymphoblastic lymphoma

Very late relapse of lymphoblastic lymphoma (LBL) is very rare. We report a case of a patient who developed central nervous system (CNS) relapse of LBL 16 years after the onset of the primary disease. An 8-year-old girl was hospitalized with a skin tumor in the occipital region on November 27, 1984. Examination of a biopsy of the skin tumor showed typical features of non-Hodgkin's lymphoma (diffuse medium-sized cell type). She received multiagent chemotherapy and went into remission. On July 4, 2000, she was hospitalized with persistent headache. Cranial magnetic resonance imaging showed a cerebellar lesion, which was hypointense on T1-weighted images and of heterogeneous intensity on T2-weighted images. A midline suboccipital craniotomy was performed and pathological examination revealed a diffuse proliferation of lymphoid cells, which were positive for terminal deoxynucleotidyl transferase, but negative for CD45RO, CD3 and CD20. Tumor cells stained positively for CD10, CD22, CD38 and HLA-DR. Revised immunohistochemistry of the primary specimens of skin tumor obtained 16 years earlier revealed a phenotype similar to that of the CNS disease. Polymerase chain reaction products for the immunoglobulin gene from both the skin and cerebellar specimens were an identical size. Thus, the original diagnosis of diffuse medium-sized lymphoma was revised to B cell LBL. An isolated CNS relapse of LBL was apparent in the present case. After salvage chemotherapy, the patient underwent high-dose chemotherapy with autologous peripheral blood stem cell support and subsequent craniospinal irradiation. She went into a lasting complete remission.

Use of chemotherapy during human pregnancy

When cancer is diagnosed in a pregnant woman, life-saving chemotherapy for the mother poses life-threatening concerns for the developing fetus. Depending on the type of cancer and the stage at diagnosis, chemotherapy cannot necessarily be delayed until after delivery. Women diagnosed with acute lymphoblastic leukaemia who decline both termination and chemotherapy often die with the previable fetus in utero. Safe use of chemotherapy, especially during the second and third trimester, have been reported, and pregnant women with cancer can accept therapy without definite neonatal harm. Here, we review the use of chemotherapy in pregnancy by trimester of exposure and summarise neonatal outcomes, including malformations, perinatal complications, and oldest age of neonatal follow-up. We will also discuss the modes of action of the drugs used and look at the multiagent regimens recommended for use during pregnancy.

Relapse of acute lymphoblastic leukemia in pregnancy: survival following chemoirradiation and autologous transfer of interleukin-2-activated stem cells

Four cases of relapse of acute lymphoblastic leukemia (ALL) in pregnancy have been reported previously. During the past 2 decades, ALL has become curable in a majority of children, many of whom have entered their reproductive years. Thus, additional occurrences of relapsing ALL during pregnancy can be anticipated. We present the fifth case in the English-language medical literature of recurrent ALL in pregnancy. A 20-year-old woman with ALL experienced a relapse during the third trimester of her first pregnancy. Reinduction therapy was started with vincristine and prednisone and the baby was delivered 3 weeks later. Umbilical cord blood was collected and stored. The patient then received intensive chemotherapy with whole body radiotherapy and autologous peripheral blood stem cell rescue. The ALL has been in second remission for 22 months. Our patient is the only current survivor of a relapse of ALL during pregnancy. In addition, the collection of umbilical cord blood from a pregnant woman with leukemia has not been reported previously.

Pregnancy during therapy for childhood acute lymphoblastic leukemia: two case reports and a review of the literature

PURPOSE

The incidence and consequences of pregnancy during therapy for childhood acute lymphoblastic leukemia (ALL) are largely unknown. To explore the issues involved in this complication of ALL treatment, two recent cases are presented.

PATIENTS

Two 15-year-old girls with "high risk" ALL became pregnant while receiving maintenance therapy.

RESULTS

In one case, the patient experienced a spontaneous abortion at approximately 5 to 6 weeks gestation. The patient completed maintenance therapy and is in remission 8 months after the end of treatment. The second patient, known to be non-compliant during therapy, was found to be 5 months pregnant at the end of maintenance therapy. She developed HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), was induced at approximately 34 weeks, and delivered an apparently normal baby girl. Both the patient and her baby continue to do well 10 months after delivery.

CONCLUSIONS

A variety of factors may influence the incidence of pregnancy during ALL therapy. Gonadal function, which is likely to return to normal during maintenance therapy, may also be affected by alterations in the dose intensity of treatment. Social factors may also alter the incidence of pregnancy. Adverse effects on the fetus are more likely to occur in the first trimester, depending on the drug or drugs used. Although all chemotherapies may have mutagenic and teratogenic effects, they do not invariably cause abnormalities. Survival of adolescents who become pregnant during treatment does not appear to be adversely affected when therapy is not modified or discontinued.

Relapse of precursor B-cell acute lymphoblastic leukemia as an isolated central nervous system mass lesion 9 years after initial diagnosis

Seven years after completion of chemotherapy for acute lymphoblastic leukemia, diagnosed at the age of 5 years, a black female presented with signs of increased intracranial pressure. Neuroimaging showed a large enhancing extra-axial occipital tumor mass. The resection specimen showed morphologic, cytogenetic, and immunophenotypic features consistent with relapse of the primary leukemia. Bone marrow examination was negative for malignancy. The long duration of complete remission followed by the formation of a mass in the central nervous system are highly unusual features of recurrent acute lymphoblastic leukemia.

Relapse of acute lymphoblastic leukaemia 14 years after presentation: use of molecular techniques to confirm true re-emergence

Late relapse after successful treatment of acute lymphoblastic leukaemia (ALL) in children is well-recognized but rare. It is often uncertain whether this represents a true relapse of the original disease or a second malignancy. We present the case of a patient who relapsed 14 years after the original diagnosis of childhood ALL in whom both the original leukaemic cells and those taken at relapse had an identical T cell receptor gamma (TCRG) gene rearrangement. This analysis confirms that this relapse is a true re-emergence of the patient's original disease. The term 'cure' should be used with caution in childhood ALL, even after long periods in continuous remission.

Late relapses after treatment for acute lymphoblastic leukemia in childhood: a population-based study from the Nordic countries

Seven late relapses of acute lymphoblastic leukemia occurring 5.5 to 12.3 years after cessation of therapy are reported in 986 patients who had discontinued treatment for leukemia acquired before the age of 15. The study covers patients from the five Nordic countries. Of the 434 patients with ALL who had passed 5 years of follow-up without recurrence, seven have subsequently relapsed so far; an estimated cumulative proportion of 6.9% within the 10 years. In addition, we report a girl 15.9 years old at diagnosis who relapsed 7.3 years after cessation of therapy. These findings confirm that "cure" of acute lymphoblastic leukemia treated in the 1970s cannot be considered definite, even 5 years after discontinuation of therapy.

Late relapses in acute lymphoblastic leukemia

Two children presented with relapsed acute lymphoblastic leukemia 6 years and 8 years after cessation of maintenance treatment. Relapses this length of time off treatment are unusual, with only 7 previously reported cases. It is often unclear whether the relapse is of the original disease or a second leukemia, and our results in both cases suggest relapse of their primary disease.

Very late recurrence of childhood acute lymphoblastic leukemia treated with chemoimmunotherapy: a report of three cases occurring 19, 11, and 9 years after discontinuation of chemotherapy

Current therapeutic modalities for childhood acute lymphoblastic leukemia (ALL) are associated with a high cure rate, and recurrences more than 4 years after therapy cessation are very unusual. We report three cases of exceptionally late recurrences of childhood ALL after cessation of chemotherapy (CT) given for respective periods of 8, 7, and 24 months. CT was followed by maintenance immunotherapy (IMT) with Bacillus Calmette-Guérin (BCG) and allogeneic leukemic lymphoblasts pretreated with formaldehyde or irradiated in vitro. Leukemic recurrences were observed 19, 11, and 9 years after cessation of CT and appeared morphologically similar to the original blasts. A second complete remission was easily achieved in all three patients, but two went on to repeated relapse (one has died following the fourth recurrence). We speculate that some residual leukemic cells, remaining after the inadequate, short-term CT, were responsible for these unusual evolutions, and we question a possible delaying role of IMT in prolonging remission. Other possible etiologies are discussed.

Immunohistochemical detection of post-therapy residual testicular lymphoblasts in childhood acute lymphoblastic leukemia (ALL)

The aim of this study was to evaluate the diagnostic value of immunohistochemistry with monoclonal antibodies (MoAbs) in detecting residual blast cells in testicular biopsies from children with acute lymphoblastic leukemia (ALL). In a prospective study of 26 patients, testicular biopsies were performed after completion of therapy, and the average follow-up after biopsies was 29 months. After immunostaining, seven patients with negative biopsies on routine histology showed scattered, strongly calla-positive cells as well as cells reacting with anti-B (CD22) MoAb. Among these seven patients with residual blast cells, four had relapsed either in testes (n = 1), bone marrow and testes (n = 1), or in the bone marrow (n = 2). In contrast, among the 15 patients without residual blast cells, all but 1 remained in complete remission. In four other cases no definite conclusion was possible after immunohistochemical study. Four testicular biopsies from patients with occult infiltration were used as positive controls. Negative controls consisted of testicular biopsies from children with testicular ectopia and postmortem testicular tissue specimens. Results suggest that the risk of relapse is significantly higher in patients with positive immunohistochemical findings indicating persistent residual blast cells. However, the predictive value of these findings requires confirmation on a larger number of cases to have therapeutic implications.