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Sahu KK, Malhotra P, Uthamalingam P, Prakash G, Bal A, Varma N, Varma SC. Chronic Myeloid Leukemia with Extramedullary Blast Crisis: Two Unusual Sites with Review of Literature. Indian J Hematol Blood Transfus 2014; 32:89-95. [PMID: 27408365 DOI: 10.1007/s12288-014-0471-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/20/2014] [Indexed: 11/26/2022] Open
Abstract
Extramedullary blast crisis (EBC) in chronic myeloid leukemia (CML) is a rare phenomenon and represents infiltration of leukemic blasts in areas other than bone marrow. Lymph node is the most common site of involvement by EBC. We herein present a case of CML who suffered from two discrete episodes of EBC at atypical locations (scalp and paravertebral) within an interval duration of nine months. A-38-year-old female was diagnosed as a case of CML with extramedullary blast crisis in scalp at presentation. She received treatment with imatinib 600 mg once daily through Novartis Oncology Access Program (NOA). She achieved hematological remission. However nine months later she was readmitted with spinal shock due to cord compression secondary to paraspinal chloroma. She was started on tablet Nilotinib in view of failure to 1st line therapy. Her compressive myelopathy was treated with pulses of high dose dexamethasone. However soon she died due to pneumonia.
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Affiliation(s)
- Kamal Kant Sahu
- Department of Clinical Hematology, Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology, Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Preithy Uthamalingam
- Department of Histopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Gaurav Prakash
- Department of Clinical Hematology, Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Neelam Varma
- Department of Hematopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Subhash Chandar Varma
- Department of Clinical Hematology, Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Wei J, Huang M, Wang Y, Zhou J. Sudden extramedullary blast crisis of chronic myeloid leukemia manifesting as T-cell lymphoblastic lymphoma. ACTA ACUST UNITED AC 2013; 36:119-22. [PMID: 23486000 DOI: 10.1159/000348681] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic myeloid leukemia (CML) is usually diagnosed in the chronic phase. An extramedullary blast crisis mimicking a T-cell lymphoma is a rare finding. CASE REPORT A 35-year-old man presented with multiple lymphadenopathy 2 months after diagnosis of Philadelphia chromosome (Ph)-positive CML in the chronic phase. Cervical lymph node biopsy later indicated an extramedullary blast crisis resembling T-cell lymphoblastic lymphoma (TLBL). The tumor mass was composed of primitive lymphoid cells expressing terminal deoxynucleotidyl transferase (TdT), CD3, CD43, CD5, CD99, and Bcl-2. Although the pathological diagnosis, confirmed by 2 independent pathological centers, was more typical of TLBL, fluorescence in situ hybridization (FISH) analysis showed the bcr-abl fusion gene within the blastic tumor cells. The FISH finding confirmed that the mass represented an extramedullary, immature blastic transformation of CML rather than a de novo T-cell lymphoma. CONCLUSION The diagnosis of de novo TLBL should be suspected before excluding the extramedullary blast phase of CML.
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Affiliation(s)
- Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Abstract
Recurrent or residual leukemia found in extramedullary sites after intensive treatments adversely affects prognosis. To summarize the sites and outcomes when extramedullary relapses have been reported after stem cell transplants, and to elucidate when long survival has been achieved, 207 cases were analysed. Authors were contacted for follow-up information. The most commonly reported sites are soft tissue in acute leukemias and bone in CML. Extramedullary relapse occurred typically within 2 years in ALL, but later in one-third of myeloid leukemias. Most testicular relapses reported in AML followed non-TBI conditioning. Marrow relapse was not inevitable if aggressive treatment was begun early. Local therapy alone was generally inadequate. Intensive therapy has produced lengthy remissions in cases of acute leukemias involving various sites, whereas CML cases, particularly involving bone, were most resistant to treatment. Heightened awareness and aggressive treatment should improve the prospect for cure after extramedullary relapse.
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MESH Headings
- Adolescent
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bone Neoplasms/pathology
- Bone Neoplasms/therapy
- Female
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Male
- Middle Aged
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/therapy
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/pathology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy
- Soft Tissue Neoplasms/pathology
- Soft Tissue Neoplasms/therapy
- Stem Cell Transplantation
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Raanani P, Trakhtenbrot L, Rechavi G, Rosenthal E, Avigdor A, Brok-Simoni F, Leiba M, Amariglio N, Nagler A, Ben-Bassat I. Philadelphia-chromosome-positive T-lymphoblastic leukemia: acute leukemia or chronic myelogenous leukemia blastic crisis. Acta Haematol 2005; 113:181-9. [PMID: 15870488 DOI: 10.1159/000084448] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2004] [Accepted: 12/13/2004] [Indexed: 11/19/2022]
Abstract
The Ph1 chromosome has rarely been reported in T-lineage acute lymphoblastic leukemia (T-ALL), and the clinical relevance of this translocation in T-ALL is currently unknown. In chronic myelogenous leukemia (CML) some data indicate derivation of T-cells from the leukemic clone and only a few cases of T-derived blastic crisis have been reported and quite often disputed. Particularly in cases identified initially in blastic crisis it may be difficult to distinguish those from Ph1-positive T-ALL. We herein report 2 patients who presented with a clinical picture of Ph1-positive T-ALL and who raised a differential diagnosis from T-cell blastic crisis of CML. We review the literature and suggest clinical and laboratory features that can help in the diagnosis. According to our literature review, 23 cases of Ph1-positive T-ALL and 44 cases of T-cell blastic crisis of CML, including ours, were reported. Some major differences between the two entities could help in establishing a diagnosis of Ph1-positive T-cell blastic crisis of CML vs. Ph1-positive T-ALL: Male sex and younger age was more predominant in T-ALL. While in most cases of CML blastic crisis there was a history of CML there was no such history in the T-ALL cases. Medullary involvement with lymphoblastic leukemia was present in all cases of T-ALL but only in about half of the cases of CML blastic crisis. None of the CML-blastic crisis cases tested by RT-PCR showed the minor breakpoint transcript, while 2 cases with T-ALL had the minor breakpoint transcript and 1 had both transcripts. Combined morphologic and FISH analysis can help to distinguish between the two entities and was applied in one of our cases. Although both entities carry a severe prognosis, differentiating between them might have clinical relevance, especially in the imatinib era.
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MESH Headings
- Blast Crisis/genetics
- Blast Crisis/pathology
- Cell Lineage/genetics
- Diagnosis, Differential
- Female
- Fusion Proteins, bcr-abl/genetics
- Humans
- In Situ Hybridization, Fluorescence
- Karyotyping
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Leukemia-Lymphoma, Adult T-Cell/genetics
- Leukemia-Lymphoma, Adult T-Cell/pathology
- Male
- Middle Aged
- Philadelphia Chromosome
- Reverse Transcriptase Polymerase Chain Reaction
- Translocation, Genetic/genetics
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Affiliation(s)
- Pia Raanani
- Institute of Hematology, Sheba Medical Center and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Matsuda M, Morita Y, Shimada T, Miyatake J, Hirase C, Tanaka M, Tatsumi Y, Maeda Y, Kanamaru A. Extramedullary Blast Crisis Derived from 2 Different Clones in the Central Nervous System and Neck during Complete Cytogenetic Remission of Chronic Myelogenous Leukemia Treated with Imatinib Mesylate. Int J Hematol 2005; 81:307-9. [PMID: 15914360 DOI: 10.1532/ijh97.04188] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We describe a patient with Philadelphia chromosome (Ph)-positive chronic myelogenous leukemia (CML) who developed an extramedullary blast crisis in the central nervous system (CNS) and then a subcutaneous tumor of the neck during treatment with imatinib mesylate. Administered 400 mg of imatinib mesylate after the diagnosis of chronic-phase CML, the patient achieved a complete cytogenetic remission 4 months later. However, he developed a mixed myeloid/B-cell blast crisis with additional karyotype abnormalities only in the CNS during a complete cytogenetic remission in the bone marrow. Several doses of intrathecal chemotherapy and whole-brain irradiation were effective in treating the blast crisis in the CNS. After 7 months of complete cytogenetic remission, the patient experienced a subcutaneous tumor in the right neck. A biopsy of the tumor revealed a mixed myeloid/T-cell blast crisis. The cytogenetic analysis showed that the blast crisis clone in the neck tumor was different from that of the CNS. An increased dose of imatinib mesylate was ineffective in treating the neck tumor. Irradiation to the right neck was therefore undertaken. This case suggests that the development of a clone resistant to imatinib mesylate is not always detected in the bone marrow and that multiple Ph-positive clones have the potential to become transformed into a blast crisis.
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Affiliation(s)
- Mitsuhiro Matsuda
- Division of Hematology, Nephrology and Rheumatology, Department of Internal Medicine, Kinki University School of Medicine, Osaka 589-8511, Japan.
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Rossetti JM, Lister J, Shadduck RK, Bloom E, Geyer SJ, Caushaj PF, Homann J, Papasavas P, Cedar M. Localized lymphoid relapse in the pancreas following allogeneic hematopoietic stem cell transplant for chronic myelogenous leukemia. Leuk Lymphoma 2003; 44:1071-4. [PMID: 12854913 DOI: 10.1080/1042819031000068089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The incidence of isolated extramedullary disease (EMD) following allogeneic hematopoietic stem cell transplant (allo-HSCT) for chronic myelogenous leukemia (CML) is not fully known. One review found the incidence of isolated myeloid EMD, or granulocytic sarcoma (GS), in an allo-HSCT treated CML/myelodysplastic subgroup to be just 0.22%. The incidence of lymphoid EMD in similar patients is extremely rare with only two cases reported in the literature. While the etiology of EMD in the post-transplant setting is not entirely clear, there may be inefficacy of immune surveillance function outside of the bone marrow cavity. Isolated CML GS following allo-HSCT carries a median interval to bone marrow relapse between 7 and 10 months and a median survival of 12 months. Less is known about lymphoid EMD. The treatment in these cases is ill defined with modalities ranging from involved field radiation to second allo-HSCT. We present a case of isolated pancreatic lymphoid EMD diagnosed 15 months after allo-HSCT for CML. Our patient was also treated with withdrawal of his immunosuppressive regimen. Unfortunately, at just over 4 months following pancreatic resection, he developed systemic relapse and died. While EMD can occur anywhere in the body, CML associated pancreatic EMD is not previously reported.
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Affiliation(s)
- J M Rossetti
- Western Pennsylvania Cancer Institute, The Western Pennsylvania Hospital, 4800 Friendship Avenue, Suite 2303, Pittsburgh, PA 15224, USA.
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Rodríguez-Pinilla SM, Gonzalez MAM, Sanchez PM. Pathologic quiz case: systemic lymphadenopathy in a patient with chronic myelogenous leukemia. Arch Pathol Lab Med 2003; 127:e249-50. [PMID: 12708924 DOI: 10.5858/2003-127-e249-pqcsli] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Okazuka K, Toba K, Kawai K, Nikkuni K, Tsuchiyama J, Momoi A, Kanazawa N, Nagai K, Suzuki N, Aizawa Y. Extramedullary T lymphoid blast crisis representing an additional translocation, t(6;8)(q25;q22) in a patient with Philadelphia-positive chronic myelogenous leukemia after allogeneic bone marrow transplantation. Leuk Res 2001; 25:1089-94. [PMID: 11684281 DOI: 10.1016/s0145-2126(01)00078-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A patient with extramedullary crisis from chronic myelogenous leukemia after allogeneic bone marrow transplantation is reported. A pathological neck lymph node observed after transplantation revealed pre-T lymphoblastic phenotype, and the fluorescence in situ hybridization (FISH) analysis showed recipient type sex chromosomes and bcr/abl fusion gene. The cells represented an additional translocation, t(6;8)(q25;q22). No rearrangements of the T-cell receptor (TCR) beta, gamma or delta chain genes were observed. The absence of TCR rearrangement indicated the clonogenic involvement of pluripotent hematopoietic stem cells by Philadelphia chromosome. Bone marrow specimens at that time showed donor type sex chromosomes and no bcr/abl-positive cells by FISH.
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MESH Headings
- Blast Crisis
- Bone Marrow Transplantation
- Chromosomes, Human, Pair 6
- Chromosomes, Human, Pair 8
- Gene Rearrangement, T-Lymphocyte
- Humans
- Immunophenotyping
- In Situ Hybridization, Fluorescence
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Lymph Nodes/immunology
- Male
- Middle Aged
- Translocation, Genetic
- Transplantation, Homologous
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Affiliation(s)
- K Okazuka
- First Department of Internal Medicine, Niigata University School of Medicine, Asahimachi-dori 1, Niigata City 951-8520, Japan
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Nadal E, Cervantes F, Rosiñol L, Talarn C, Montserrat E. Hypercalcemia as the presenting feature of t-cell lymphoid blast crisis of ph-positive chronic myeloid leukemia. Leuk Lymphoma 2001; 41:203-6. [PMID: 11342375 DOI: 10.3109/10428190109057972] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Hypercalcemia is a rare complication of chronic myeloid leukemia (CML), usually seen in the accelerated or blastic phases of the disease and associated with a poor prognosis. T-cell lymphoid phenotype is also an infrequent finding in the blast crisis (BC) of CML. A CML patient who had hypercalcemia as the presenting feature of a T-cell BC is reported. She was a 78 year-old woman who, at four months of CML diagnosis, developed weakness, bone pain, and mental confusion, with hypercalcemia being subsequently found. Although the peripheral blood and bone marrow were consistent with the chronic phase of CML, mediastinal enlargement, a soft tissue mass adjacent to the iliac bone, and multiple osteolytic lesions were seen. Serum levels of parathyroid hormone (PTH) and PTH-related peptide were normal, whereas the search for a second neoplasm was negative. The hypercalcemia initially responded to conventional treatment, but it reappeared two weeks later. Coincidentally, a high proportion of blast cells of T-cell origin at the cortical thymocyte stage were observed in the patient's peripheral blood and bone marrow, and she died shortly afterwards.
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Affiliation(s)
- E Nadal
- Institute of Hematology and Oncology, Hematology Department, Postgraduate School of Hematology Farreras Valentí, IDIBAPS, Hospital Clinic, University of Barcelona, Spain, Villarroel 170, 08036 Barcelona, Spain.
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Hematotherapy Literature Watch. JOURNAL OF HEMATOTHERAPY 1999; 8:223-8. [PMID: 10349916 DOI: 10.1089/106161299320505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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