Ovarian tumors in relapsing acute lymphoblastic leukemia: a review of 23 cases

Extramedullary Leukemia, Presenting at the Cervix of the Uterus

Extramedullary relapse of leukemia is encountered more often than in the past. The reason is that leukemia survival rates increase with improved treatment schemes. We present a rare case of involvement of the cervix of the uterus in an adult B Acute Lymphocytic Leukemia (B-ALL) survivor. Relapses affect various organs but rarely the female genital tract. Nevertheless, in this case, a woman with a history of induced amenorrhea due to treatment for leukemia presented to the gynecologist because of vaginal spotting. Colposcopy evaluation of the vagina/cervix, sonography and cytological and histological sampling established the diagnosis of leukemia relapse in the cervix of the uterus. Under these circumstances, our study highlights the rare extramedullary presentation of leukemia in the cervix of the uterus of a young lady considered to be disease-free and listed for bone marrow transplantation. In this rare case of relapse in the cervix of the uterus, Pap smears alarmed physicians, and radiology examinations assisted the diagnostic workup. Still, only biopsy, microscopic evaluation, and immunohistochemistry studies established the exact diagnosis. Prognosis in the situation of extramedullary disease relapse in the female genital tract was poor, but gynecologists' high suspicion led to a prompt diagnosis. Survival is in general limited, but together with high suspicion, multidisciplinary team involvement is imperative to improve the reduced chances of survival.

5T4 oncofetal antigen is expressed in high risk of relapse childhood pre-B acute lymphoblastic leukemia and is associated with a more invasive and chemotactic phenotype

Although the overall prognosis in childhood acute lymphoblastic leukemia (ALL) is good, outcome after relapse is poor. Recurrence is frequently characterized by the occurrence of disease at extramedullary sites, such as the central nervous system and testes. Subpopulations of blasts able to migrate to such areas may have a survival advantage and give rise to disease recurrence. Gene expression profiling of 85 diagnostic pre-B-ALL bone marrow samples revealed higher 5T4 oncofetal antigen transcript levels in cytogenetic high-risk subgroups of patients (P<0.001). Flow cytometric analysis determined that bone marrow from relapse patients have a significantly higher percentage of 5T4-positive leukemic blasts than healthy donors (P=0.005). The high-risk Sup-B15 pre-B-ALL line showed heterogeneity in 5T4 expression, and the derived, 5T4(+) (Sup5T4) and 5T4(-) (Sup) subline cells, displayed differential spread to the omentum and ovaries following intraperitoneal inoculation of immunocompromised mice. Consistent with this, Sup5T4 compared with Sup cells show increased invasion in vitro concordant with increased LFA-1 and VLA-4 integrin expression, adhesion to extracellular matrix and secretion of matrix metalloproteases (MMP-2/-9). We also show that 5T4-positive Sup-B15 cells are susceptible to 5T4-specific superantigen antibody-dependent cellular toxicity providing support for targeted immunotherapy in high-risk pre-B-ALL.

Ovarian and multiple lymph nodes recurrence of acute lymphoblastic leukemia: a case report and review of literature

Ovarian involvement of acute lymphoblastic leukemia (ALL) without relapse in the bone marrow or other extramedullary site is rare. We report a case of ovarian relapse in a 13-year-old girl who was diagnosed with ALL at the age of 11. A complete remission was induced with the Children Cancer Group 1882 protocol for high-risk-groups. After maintenance chemotherapy, the patient remained in relatively good health for the next 4 months. The patient presented with intermittent colicky right lower quadrant pain of 1-day duration. The pelvic ultrasound (US) showed a lobulated mixed echogenic mass in the right ovary, and an exploratory laparotomy was performed. Although uncommon, ovarian recurrence after treatment for ALL should be considered in patients with suggestive symptoms. Regular pelvic US is easy to perform and has no side effects and can help detect ovarian tumors early in ALL survivors.

MR features of isolated uterine relapse in an adolescent with acute lymphoblastic leukaemia

Relapses of lymphoblastic leukaemia traditionally involve the central nervous system and testes in boys. Involvement of the female pelvic organs is frequently found at autopsy; however, involvement of the cervical uterus is rare and even less commonly symptomatic. A 13-cm uterine mass was discovered in a 15-year-old adolescent with a history of lymphoblastic leukaemia during childhood. Pelvic MRI was the best tool to assess the size, characteristics and invasive nature of this lesion of the uterine cervix. To our knowledge, this is a unique case in that we describe the MRI appearance of a relapsing lymphoblastic leukaemic mass both before and after treatment.

Late ovarian relapse of TEL/AML1 positive ALL confirming that TEL deletion is a secondary event in leukemogenesis

We describe here a late extramedullary ovarian relapse in an 18-year-old female who was diagnosed with hypotetraploid cell acute lymphoblastic leukaemia (cALL) at the age of 6. At both occurrences of the disease cells were analyzed by morphology, immunophenotyping, cytogenetics and molecular methods. TEL/AML1 was detected by RT-PCR and FISH analysis in both events. We demonstrated, using detection of IGH/TCR rearrangements and TEL/AML1 breakpoints sequencing that the cells were clonally related. Moreover, interphasic FISH using TEL and AML1 probes showed the loss of a second TEL at the time of relapse. This observation confirms that TEL/AML1 alone is not sufficient to trigger ALL and that TEL deletion is a secondary event in leukemogenesis. To our knowledge, it is the first complete description of extramedullary ALL relapse combining all methodologies.

Childhood acute lymphoblastic leukemia relapse in the uterine cervix

PURPOSE

Extramedullary relapse outside the testes and CNS is rare in children with acute lymphoblastic leukemia (ALL). We describe a case of a recurrence of ALL in the uterine cervix during hematopoietic remission.

RESULTS

Primary recurrence in the uterine cervix was diagnosed by cytology with immunochemistry 43 months after initial diagnosis. She was successfully treated with systemic chemotherapy, without hysterectomy or irradiation. She remains in second complete remission 54 months after relapse.

CONCLUSIONS

Immunocytochemistry using monoclonal antibodies against cell surface antigens made the cytologic diagnosis of leukemic relapse in the uterine cervix possible. Systemic chemotherapy is the first treatment of choice for ALL recurrence in the genital tract in a patient without poor prognostic factors in order to spare gonadal function and reproductive potential.

Relapse of acute lymphoblastic leukemia in the inferior rectus muscle of the eye

BACKGROUND

Extramedullary involvement of acute lymphoblastic leukemia (ALL) in sites outside the central nervous system (CNS) or testes is rare and may signal a refractory form of leukemia.

METHODS

The authors describe a child with ALL who experienced a relapse involving the inferior rectus muscle of the eye. This patient had been treated with a bone marrow transplant for previous bone marrow and ovarian relapse.

RESULTS

The patients had a pre-B ALL with a t(1;19) chromosomal translocation and previously had experienced relapse during therapy. At the time of the muscle relapse, she had pancreatomegaly consistent with leukemic infiltration but no CNS or bone marrow disease.

CONCLUSIONS

Relapse of ALL in unusual sites may indicate disease that is particularly difficult to eradicate. Factors in addition to age and leukocyte count at diagnosis determined risk. Additional research is needed to define these factors and develop more effective therapy.