Congenital leukaemia: the Dutch experience and review of the literature

Characteristics and treatment of acute myeloid neoplasms with cutaneous involvement in infants up to 6 months of age: A retrospective study

BACKGROUND

Myeloid neoplasms account for 50% of cases of pediatric leukemias in infants. Approximately 25%-50% of patients with newborn leukemia have cutaneous extramedullary disease (EMD). In less than 10% of patients, aleukemic leukemia cutis or isolated extramedullary disease with cutaneous involvement (cEMD) occurs when skin lesions appear prior to bone marrow involvement and systemic symptoms. Interestingly, in acute myeloid leukemia with cutaneous EMD (AML-cEMD) and cEMD, spontaneous remissions have been reported.

METHOD

This is a multicentric retrospective cohort study aiming to describe characteristics, treatment, and outcome of infants with either cEMD or presence of cutaneous disease with involvement of the bone marrow (AML-cEMD). This study included patients born between 1990 and 2018 from Italy, the Netherlands, Switzerland, and the United States, diagnosed between 0 and 6 months of life with cEMD or AML-cEMD. Descriptive statistics, Fisher's exact test, Kaplan-Meier method, and log rank test were applied.

RESULTS

The cohort consisted of n = 50 patients, including 42 AML-cEMD and eight cEMD patients. The most common genetic mutation found was a KMT2A rearrangement (n = 26, 52%). Overall 5-year event-free survival (EFS) and overall survival (OS) were 66% [confidence interval (CI): 51-78] and 75% [CI: 60-85], respectively. In two patients, complete spontaneous remission occurred without any therapy. Central nervous system (CNS) involvement was found in 25% of cEMD patients. No difference in outcomes was observed between the AML-cEMD and cEMD groups, but none of the latter patients included in the study died. KMT2A rearrangements were not associated with poorer prognosis.

CONCLUSION

In the largest cohort to date, our study describes the characteristics of infants with cutaneous involvement of myeloid neoplasms including cytomolecular findings and survival rates. Further prospective biologic and clinical studies of these infants with myeloid neoplasms will be required to individualize therapy for this rare patient population.

[SFCE harmonization workshops: Neonatal acute myeloid leukemia]

Neonatal acute myeloid leukemias (AML) occurred within the first 28 days of life and constitute only a small proportion of all AL. They are distinguished from leukemias of older children by their clinical presentation, which frequently includes cutaneous localizations ("blueberry muffin rash syndrome") and a leukocytosis above 50 ×109/L. This proliferation may be transient, causing a transient leukemoid reaction in a background of constitutional trisomy 21 ("Transient Abnormal Myelopoieseis" or TAM) or Infantile Myeloproliferative Disease in the absence of constitutional trisomy 21 ("Infantile Myeloproliferative Disease" or IMD). In cases of true neonatal AML, the prognosis of patients is poor. Overall survival is around 35 % in the largest historical series. This poor prognosis is mainly due to the period of onset of this pathology making the use of chemotherapy more limited and involving many considerations, both ethical and therapeutic. The objective of this work is to review this rare pathology by addressing the clinical, biological, therapeutic and ethical particularities of patients with true neonatal AML or transient leukemoid reactions occurring in a constitutional trisomy 21 (true TAM) or somatic background (IMD).

Aleukemic congenital leukemia cutis preceding monocytic leukemia with favorable outcome: A case report

A newborn girl had typical "blueberry muffin" skin lesions, which shows histopathologic features of monocytic leukemia cutis. The systemic leukemia was demonstrated after one month of life. She was treated by chemotherapy, including induction and three consolidation cures, according to the ELAM02 protocol, which led to complete remission. This case report with congenital form of AML5 cutaneous localization, preceding systemic involvement, with a 5-year follow-up and positive outcome is remarkable.

Infantile B-cell acute lymphoblastic leukaemia with the highest recorded count of white blood cells in the literature: case report and literature review

Introduction

Infantile leukaemia is an uncommon haematological cancer that manifests within the first year of life. This malignancy is highly aggressive and possesses distinctive immunophenotypic, cytogenetic, and molecular attributes. It can originate from either myeloid or lymphoid cells. It often exhibits a higher incidence among females.

Case presentation

A 1-month-old male infant, initially seemingly healthy, presented with irritability and feeding difficulties. Born without complications, routine neonatal assessments appeared normal, and physical examination revealed no abnormalities. However, laboratory tests indicated an extremely high white blood cell count, low platelets, and elevated haemoglobin. Further examinations showed a white blood cell count of 1450 × 106/l with a blood film revealing significant leukocytosis dominated by blast cells. Abdominal ultrasound confirmed hepatosplenomegaly which was not present during pregnancy. Subsequent bone marrow analysis and flow cytometry established a diagnosis of B-cell acute lymphoblastic leukaemia (B-ALL).

Clinical discussion

It is rare for infantile ALL to manifest within the first month after birth. In most cases, the diagnosis is established before birth. When characteristic signs such as hepatosplenomegaly, leukaemia cutis, or infiltrative involvement of the extramedullary and central nervous systems are present, postnatal diagnoses are relatively straightforward. However, there are instances where children present with non-specific and ambiguous symptoms that resemble other medical conditions.

Conclusion

This case underscores the importance of paediatricians being vigilant and attuned to the subtle indicators that differentiate common illnesses from serious conditions such as infantile ALL.

Congenital leukemia: A case report and review of literature

BACKGROUND

Acute leukemia in newborns is also known as neonatal or congenital leukemia (CL) and is a rare disease with an incidence rate of 1-5 per 1000000 live births. After birth, infants with CL exhibit infiltrative cutaneous nodules, hepatosplenomegaly, thrombocytopenia, and immature leukocytes in the peripheral blood. These symptoms are frequently accompanied by congenital abnormalities including trisomy 21, trisomy 9, trisomy 13, or Turner syndrome. Despite significant advances in disease management, the survival rate is approximately 25% at 2 years.

CASE SUMMARY

Here, we document a case of trisomy 21-related acute myeloid leukemia (AML) in a female neonate. The baby was sent to the neonatal intensive care unit because of anorexia, poor responsiveness, and respiratory distress. She was diagnosed with AML based on bone marrow aspiration and immunophenotyping. Genetic sequencing identified a mutation in the GATA1 gene. After receiving the diagnosis, the parents decided against medical care for their child, and the baby died at home on day 9 after birth.

CONCLUSIONS

The newborn infant was diagnosed with trisomy 21-related AML. Genetic sequencing identified a mutation in the GATA1 gene. The parents abandoned medical treatment for their infant after receiving the diagnosis, and the infant died at home on the 9th day after birth.

Enlarged Abdominal Lymph Node as a Cause of Polyhydramnios in the Course of Congenital Neonatal Leukaemia: A Case Report and Review of the Literature on Foetal Abdominal Tumours with Coexisting Polyhydramnios

Polyhydramnios represents a complication found in 0.2–2% of pregnancies, and it is usually diagnosed between 31 and 36 weeks of pregnancy. Although most cases of polyhydramnios are idiopathic, maternal diabetes or foetal malformations constitute frequent causes of the excessive accumulation of the amniotic fluid. Considering the latter, polyhydramnios may rarely be caused by foetal abdominal tumours, with the incidence rate of 2–14 cases per 100,000 live births. Congenital neonatal leukaemia (CNL) is a rare disease with a reported incidence rate of 5–8.6 cases per million live births. In the prenatal period, the ultrasound abnormalities associated with CNL include hepatomegaly and splenomegaly. In this paper, we presented a case of polyhydramnios caused by mechanical pressure on the foetal gastrointestinal tract by an enlarged lymph node in the course of CNL, as well as reviewing the available literature on foetal abdominal tumours with concurrent polyhydramnios.

Identifying Leukemia-associated Immunophenotypes in Acute Myeloid Leukemia Patients Using Multiparameter Flow Cytometry

Objectives

We sought to identify leukemia-associated immunophenotypes (LAIPs) in 50 acute myeloid leukemia (AML) patients at diagnosis using an eight-color multiparameter flow cytometry (MFC) panel and to detect if they showed any alteration in relapsed/refractory cases.

Methods

We used the eight-color MFC panel with CD45/side scatter log gating strategy to analyze LAIPs in 50 AML patients presenting to Alexandria University Hospitals, Egypt at diagnosis and relapse and refractory cases. Twenty age and sex matched bone marrow samples from patients performing bone marrow aspirate for non-malignant hematological indications were included as controls.

Results

LAIPs were observed in 43 (86.0%) cases. Only one aberrant immunophenotype was identified in four cases (9.3%), while two to 12 aberrant immunophenotypes were found in the other 39 (90.7%) cases. Strong LAIPs were obtained by combining CD2, CD4, CD56, with either CD34 or CD117, in contrast to CD19, which has to be combined with CD117. Refractory cases showed the presence of the same LAIPs at both initial diagnosis and persistent disease. One case showed the acquisition of new LAIPs after relapse.

Conclusions

The good choice of LAIPs depends on their specificity rather than their frequency. The results of this study can help in increasing the sensitivity of LAIPs strategy in minimal residual disease using MFC in AML patients, which is considered an important post-diagnosis parameter associated with prognosis and clinical outcome.

Sudden unexpected death caused by infantile acute lymphoblastic leukaemia

A 7-week-old girl with a normal birth history suddenly developed respiratory distress while feeding. Cardiopulmonary resuscitation was initiated at home after she had a cardiac arrest and was continued in the emergency room but all efforts at resuscitation proved unsuccessful and she died 2 h after presentation. Investigations performed in the emergency room revealed that she had a significantly high white blood cell count and severe anaemia. The cause of death was identified as KMT2A-rearranged infantile acute lymphoblastic leukaemia based on cytogenetic tests. She had no abnormalities at the 4-week check-up; however, she developed a skin nodule on her abdomen thereafter, and the family did not consult a doctor for fear of contracting COVID-19. Early detection and diagnosis could have changed the prognosis of the patient. The present case highlights the negative impact of the reduction of outpatient consultations during the COVID-19 pandemic.

Infantile leukemia-What factors determine its distinct biological nature? Clinicopathological study of 78 cases

INTRODUCTION

Infantile leukemia encompasses a heterogeneous group which needs stratifying for treatment selection.

METHODS

We collected 78 cases of infantile leukemia and retrospectively analyzed their clinicopathological data.

RESULTS

Infantile leukemia featured a ratio of acute myeloid leukemia (AML) to B-lymphoblastic leukemia (B-ALL) of 1:2, with a better survival for AML than B-ALL (median survival 36 vs 24 months). When stratified by age, "early" infantile B-ALL (2-6 months) showed a high rate of KMT2A rearrangement (100%), similar to the rate seen in congenital B-ALL (1 month) (100%) and higher than seen in "late" infantile B-ALL (≥7 months) (68%). The three categories of infantile B-ALL exhibited an age-dependent increase in survival (median survival 8.5, 24, and >24 months, respectively). The age-dependent survival benefit remained after excluding the cases negative for KMT2A rearrangement. Conversely, infantile AML lacked an age-dependent pattern of survival.

CONCLUSION

The clinical outcome of infantile leukemia depends on the type of leukemia. Given the age-dependent survival, infantile B-ALL can be divided into three subcategories.

Congenital acute myeloid leukemia: challenges and lessons. A 15-year experience from the UK

Congenital Acute Myeloid leukemia (CAML) is a rare leukemia diagnosed within the first 28 days of life. Dismal survival rates of approximately 25% at two years from diagnosis have not improved despite multiple treatment protocols, and there lacks international consensus for optimal management of these vulnerable patients. We report a retrospective analysis of our fifteen-year experience from a large UK tertiary pediatric center, focusing on treatment modalities and outcomes, including late therapeutic toxicities. To our knowledge, this is the first UK series of congenital leukemia patients reported. Twelve patients with a median age of 16.4 days (1-60) were diagnosed with CAML in fifteen years. All patients presented unwell; 92% demonstrating skin involvement. 10 (83%) received chemotherapy; with 1 death at presentation and 1 spontaneous remission. 5 (42%) received subsequent stem cell transplant. Only 4 (33%) remain alive, with 5 (42%) dying in disease remission with treatment-related mortality. Documented cardiotoxicity was observed in 3 (25%) patients, with a further 2 (17%) suspected but not receiving postmortem. Treatment of congenital AML raises challenging diagnostic, therapeutic and ethical questions and requires multi-center, international collaboration to see improvements.

Neonatal Dermatology: The Normal, the Common, and the Serious

The objective of this review is to help practitioners of neonatal and pediatric medicine become more familiar with diagnosing and managing neonatal skin conditions. This article will discuss normal neonatal skin care and benign and common rashes, as well as some of the serious dermatologic conditions that require specialists for further evaluation and/or treatment.

Neonatal Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia (ALL) in a neonate can have a similar clinical appearance to other serious pathology and should be considered in the ill-appearing infant. We present the case of a 24-hour-old male infant born to a mother with limited prenatal care who was brought to the pediatric emergency department with a rash and decreased movement. His initial white blood cell count was 822 × 10 cells/L. Cytogenetics showed a complex t (9;19;11) translocation, indicating a diagnosis of neonatal ALL. Given the morbidity and mortality rate among infants with neonatal ALL, his parents elected not to pursue cancer-directed therapy in favor of symptomatic care.

Analysis of 59 cases of congenital leukemia reported between 2001 and 2016

Congenital leukemia (CL), defined as manifestations of leukemia within the first 4 weeks of life, is a rare condition with an estimated incidence of only 1 to 5 per million live births. Despite extensive research and the clinical application of new therapies, the prognosis of CL remains poor. Few large-scale studies have investigated the factors affecting the outcomes of infants with CL. Here, we conducted a retrospective study and analysis of CL cases published in the English language from 1 January 2001 to 1 May 2016. Our goal was to provide updated information about this rare disease and to investigate factors that may affect the outcomes of patients with CL.

Uncommon Neonatal Skin Lesions

Certain rashes and cutaneous lesions in a newborn can be clues to more concerning diseases and conditions if recognized and evaluated promptly. Langerhans cell histiocytosis, cutaneous forms of cancer (such as leukemia cutis, neuroblastoma, and rhabdomyosarcoma), developmental abnormalities such as neural tube or spinal dysraphism, and aplasia cutis congenita, nutritional deficiency, and immunodeficiency all have a range of cutaneous findings that will be reviewed herein to guide diagnosis and management. [Pediatr Ann. 2019;48(1):e30-e35.].

Prenatally Diagnosed Infant AML

We report the first case of a fetus with acute myeloid leukemia, without Down syndrome, diagnosed in utero. A cordocentesis sample prepared to investigate hepatomegaly led to further evaluations revealing acute myeloid leukemia, monocytic type, in the fetus. Cytogenetic analysis showed mixed lineage leukemia duplication, no gene disruption or trisomy. Planned treatment included intrauterine exchange transfusion to extend gestation, low-dose chemotherapy at birth, and full chemotherapy once stable. Before any intervention, the child was delivered emergently for maternal condition and died 2 hours later. Although it is now possible to diagnose hematologic malignancy in a fetus, there is little information to direct management.

FISH identifies a KAT6A/CREBBP fusion caused by a cryptic insertional t(8;16) in a case of spontaneously remitting congenital acute myeloid leukemia with a normal karyotype

Cytogenetics can inform risk stratification in pediatric acute myeloid leukemia (AML). We describe the first case of a newborn with leukemia cutis found to have AML harboring a cryptic insertional t(8;16)(p11.2;p13.3) with associated KAT6A/CREBBP fusion identified exclusively by fluorescence in situ hybridization (FISH). Expectant management resulted in spontaneous leukemia resolution. The identification of t(8;16)(p11.2;p13.3) may serve as a biomarker for spontaneous remission in congenital AML. FISH for this translocation is warranted in congenital AML with a normal karyotype, and patients with KAT6A/CREBBP fusion should be conservatively managed. While 50% of spontaneously remitting congenital AML with t(8;16)(p11.2;p13.3) may recur, high salvage rates are attained with standard therapy.

Neonates with cancer and causes of death; lessons from 615 cases in the SEER databases

Neonatal tumors are rare with no standard treatment approaches to these diseases, and the patients experience poor outcomes. Our aim was to determine the distribution of cancers affecting neonates and compare survival between these cancers and older children. We analyzed SEER data (1973-2007) from patients who were younger than 2 years at diagnosis of malignancy. Special permission was granted to access the detailed (i.e., age in months) data of those patients. The Chi-square Log-rank test was used to compare survival between neonates (aged <1 month) and older children (>1 month to <2 years). We identified 615 neonatal cancers (454 solid tumors, 93 leukemia/lymphoma, and 68 CNS neoplasms). Neuroblastoma was the most common neonatal tumor followed by Germ cell tumors. The 5-year overall survival (OS) for all neonates was 60.3% (95% CI, 56.2-64.4). Neonates with solid tumors had the highest 5-year OS (71.2%; 95% CI, 66.9-75.5), followed by those with leukemia (39.1%; 95% CI, 28.3-49.9) or CNS tumors (15%; 95% CI, 5.4-24.6). Except for neuroblastoma, all neonatal tumors showed inferior outcomes compared to that in the older group. The proportion of neonates who died from causes other than cancer was significantly higher than that of the older children (37.9% vs. 16.4%; P < 0.0005). In general, the outcome of neonatal cancers has not improved over the last 34 years. The distribution of neonatal cancer is different than other pediatric age groups. Although the progress in neonatal and cancer care over the last 30 years, only death from noncancer causes showed improvement. Studying neonatal tumors as part of national studies is essential to understand their etiology, determine the best treatment approaches, and improve survival and quality of life for those patients.

Acute lymphoblastic congenital leukemia as a cause of perinatal death following massive cerebral hemorrhage

Background

Congenital leukemia is a rare condition and most commonly found in infants with Down syndrome. The occurrence in newborns without a genetically predisposing syndrome is extremely infrequent.

Highlights

We describe a case of peripartal fetal death at 30 weeks and 4 days of gestation. Emergency cesarean section was performed after a previously uncomplicated pregnancy because of pathologic fetal heart rate tracing and suspected intracranial hemorrhage on ultrasound imaging. Resuscitation of the newborn was unsuccessful and stopped after 30 min, when ultrasound of the fetus confirmed very severe intracranial and intraabdominal bleeding. Autopsy was performed after informed consent and demonstrated evidence of acute lymphoblastic leukemia in the bone marrow, associated with wide spread visceral involvement.

Conclusion

Perinatal fetal demise due to congenital leukemia is exceedingly rare and can occur unexpectedly in the third term after a normal pregnancy. We here report the clinical and pathologic findings, discuss the pathogenesis of fetal leukemia and its clinical manifestations along with a thorough review of the relevant literature.

Congenital Acute Myeloid Leukaemia with Pseudo-Chediak-Higashi Like Granules: A Case Report

Congenital leukaemia is a very rare entity comprising 0.8% of all childhood leukaemias. Pseudo-Chediak-Higashi Anomaly (PCHA) in acute leukaemia is a rarely described entity. However, co-existence of congenital myeloid leukaemia with PCHA is a very rare entity and to the best of our knowledge has not been described in literature till date. A full term new-born presented on the 27^th day of life with severe gastroenteritis. Complete blood counts and peripheral smear examination revealed leucocytosis with presence of 76% blast cells. Approximately 15% of these blast cells showed presence of pseudo-Chediak-Higashi like granules. The diagnosis of acute myeloid leukaemia was confirmed by flow cytometry. The case report is presented due to its rarity and to highlight the differential diagnosis and clinical implications of this entity.

Successful Unrelated Stem Cell Transplantation in an Infant With Congenital Acute Myelogenous Leukemia FAB M5 Showing Massive Cutaneous Infiltrations--A Challenging Multidisciplinary Approach

The multidisciplinary management of a male neonate presenting with congenital acute myelogenous leukemia of monoblastic phenotype is reported using conventional chemotherapy, high dose conditioning, and matched unrelated donor stem cell transplantation. These therapies were combined to add a graft versus leukemia effect to the treatment. Although chimerism studies showed a decrease of donor white blood cells, T-cells remained stable of allogeneic origin. We hypothesize that a continuous graft versus leukemia effect results in minimal residual disease negativity for now more than 18 months since stem cell transplantation.

The Skin as an Early Expression of Malignancies in the Neonatal Age: A Review of the Literature and a Case Series

Skin lesions are a frequent finding in childhood, from infancy throughout adolescence. They can arise from many conditions, including infections and inflammation. Most neonatal rashes are benign and self-limiting and require no treatment. Other conditions may be an expression of malignancy or may be a marker for other abnormalities, such as neural tube defects. Therefore, skin lesions require an extensive evaluation and close follow-up to ensure the best possible outcome. This paper briefly reviews the main tumor types presenting with cutaneous involvement in neonates, followed by the description of some patients admitted to our Neonatal Intensive Care Unit with an early skin expression of malignancies.

Congenital Acute Myeloid Leukemia with Unique Translocation t(11;19)(q23;p13.3)

Congenital leukemia is rarely encountered in clinical practice, even in tertiary children's hospitals. Leukemia may cause significant coagulopathy, putting the patient at risk of intracranial hemorrhage. In this case, the authors present a female infant with a unique mixed phenotypic congenital acute myeloid leukemia showing mixed-lineage leukemia (MLL) rearrangement and severe coagulopathy resulting in a large subdural hematoma. Despite the fatal outcome in this case, neurosurgical treatment of patients with acute myeloid leukemia should be considered if coagulopathy and the clinical scenario allow.

Neonatal Acute Megakaryoblastic Leukemia Presenting with Leukemia Cutis and Multiple Intracranial Lesions Successfully Treated with Unrelated Cord Blood Transplantation

Neonatal acute megakaryoblastic leukemia (AMKL) without Down syndrome (DS) is an extremely rare disorder. We report of a one-day-old male infant without DS who developed AMKL with leukemia cutis and right facial nerve palsy. Magnetic resonance imaging of the patient's brain revealed multiple intracranial tumors. A biopsy specimen of the skin lesion was suggestive of AMKL, but the bone marrow leukemic cells were less than 5% of the marrow nucleated cells. The skin and intracranial lesions had spontaneously regressed within one and a half months, but the patient's anemia and thrombocytopenia gradually worsened and the leukemic cells in the bone marrow gradually increased to more than 20% of the nucleated cells. In addition, multiple intracranial lesions reappeared at 72 days of life. We diagnosed the patient with AMKL, and chemotherapy followed by unrelated cord blood transplantation after a reduced-intensity conditioning regimen resulted in sustained complete remission. At present, the patient is well, and he has demonstrated normal development for five years.

A Newborn with Congenital Mixed Phenotype Acute Leukemia After In Vitro Fertilization

Congenital leukemia is a rare disease. The majority of cases of this disease are acute myelogenous leukemia (AML). Congenital acute lymphoblastic leukemia (ALL) is rare and most often is of B cell lineage. Rarely, some cases have been designated biphenotypic or mixed phenotype acute leukemia (MPAL). Herein, we report a preterm newborn referred to us as a result of the appearance of blue-violaceous dermal nodules on her body at birth. She was a twin and the product of an in vitro fertilization (IVF) pregnancy. Physical examination showed jaundice, hepatosplenomegaly, and peripheral facial nerve palsy in addition to dermal nodules. Bone marrow aspiration showed 40% blasts of lymphoid lineage; skin biopsy and its immunohistochemistry revealed myeloblastic infiltration of the dermis. Cytogenetic analysis (46,XX), fluorescence in situ hybridization (FISH) analysis, and cranial magnetic resonance were normal. The patient was diagnosed with congenital MPAL, and an association between IVF and congenital leukemia was suggested.

Neonatal acute lymphocytic leukaemia: an unusual presentation of a rare disease

Infantile acute lymphocytic leukaemia (ALL) seldom presents within the first month of life. Most are diagnosed before birth. Postnatal diagnoses are easily recognisable when characteristic features are present, namely hepatosplenomegaly, leukaemia cutis or infiltrative disease of the extramedullar and central nervous system. However, some children present with vague and non-specific symptoms masquerading as other diseases. We report an unusual presentation of infantile ALL in a 19-day-old infant, who struggled with feeding after a diagnosis of gastro-oesophageal reflux disease since birth. To the best of our knowledge, this is the youngest case report of neonatal ALL, presenting with vomiting, lethargy and dehydration. The neonate presented to our paediatric assessment unit acutely due to progression of her symptoms. General physical examination was unremarkable apart from signs of lethargy and dehydration. Blood investigation revealed an incidental finding of high white cells, including 90% blast cells. Early diagnosis in this case meant early treatment and a good prognosis.

Neonatal leukaemia cutis

Neonatal leukaemia cutis is a significant neoplasm that may represent a cutaneous manifestation of systemic leukaemia, usually of myeloblastic type. Rarely, it may be or appear to be limited to skin, in which case it is called neonatal aleukaemic leukaemia cutis. By definition, it presents within the first 4 weeks of life and often has a 'blueberry muffin baby' appearance of magenta coloured nodules affecting almost any area of the skin, usually sparing mucous membranes, palms and soles. This clinical pattern is more commonly associated with neonatal infections such rubella and toxoplasmosis, and may be evident with other neonatal neoplasms such as neuroblastoma. Due to the morbidity associated with chemotherapy and reported cases of spontaneous remission without systemic progression in those with neonatal aleukaemic leukaemia cutis without 11q23 translocation, the authors not treating the child with chemotherapy, but to simply monitor for fading of the violaceous nodules, and watch for possible signs of systemic leukaemia.

Clinical and molecular epidemiology of neonatal leukemia in Brazil

The clinical and molecular findings of 77 cases of neonatal leukemia (NL) and 380 of infant leukemia (IL) were selected to distinguish features between NL and IL. Somatic gene mutations associated with acute leukemia including FLT3, RAS and PTPN11 were revisited. There were 42 cases of congenital leukemia associated with Down syndrome (DS) and 39 of these cases presented features of acute myeloid leukemia (AML)-M7. Twenty-seven of the DS cases underwent spontaneous remission and were reclassified as a transient myeloproliferative disorder. GATA1 mutations were found in 70% of these cases. In non-DS, frequent abnormalities were MLL rearrangements, mainly MLL-AFF1 in acute lymphoblastic leukemia and MLL-MLLT3 in AML. The FLT3 mutation was not found, while RAS (n = 4) and PTPN11 (n = 2) mutations were identified and reported for the first time in NL. There was substantial evidence to support that somatic abnormalities occur in utero. Thus, congenital leukemia is a good model for understanding leukemogenesis.

Congenital leukemia of fetus with acquired AML1 gene duplication

Congenital leukemia is very rare, and its prevalence according to recently published papers is from 1 to 5 per million live births. This can be often diagnosed in postpartum throughout bone marrow biopsy, showing abnormal proliferation of immature blasts and granulocytic precursors. Hepatosplenomegaly is the most common feature which is found during perinatal examinations, that diagnosing is difficult during perinatal period. Hepatosplenomegaly can occur not only in congenital leukemia but in many other cases such as infection which is the most common cause. In other words, congenital leukemia is the one of the rare causes of hepatosplenomegaly. However, this case shows the fetus with the features of hepatosplenomegaly during perinatal period and being diagnosed as congenital leukemia associated with acquired AML1 gene duplication in postpartum through bone marrow biopsy. Due to its rare instance, we are to describe the case with a review of literatures.

Neonatal cancer

Neonatal cancer is rare and comprises a heterogeneous group of neoplasms with substantial histological diversity. Almost all types of paediatric cancer can occur in fetuses and neonates; however, the presentation and behaviour of neonatal tumours often differs from that in older children, leading to differences in diagnosis and management. The causes of neonatal cancer are unclear, but genetic factors probably have a key role. Other congenital abnormalities are frequently present. Teratoma and neuroblastoma are the most common histological types of neonatal cancer, with soft-tissue sarcoma, leukaemia, renal tumours, and brain tumours also among the more frequent types. Prenatal detection, most often on routine ultrasound or in the context of a known predisposition syndrome, is becoming more common. Treatment options pose challenges because of the particular vulnerability of the population. Neonatal cancer raises diagnostic, therapeutic, and ethical issues, and management requires a multidisciplinary approach.

A 7-week-old boy with violaceous patches and skin nodules. Leukemia cutis

A 7-week-old boy presented to the pediatric dermatology clinic for evaluation of diffuse blue lesions on the skin. The mother first noticed a bluish lesion on the left thigh at 6 to 7 weeks of age. The child quickly developed several similar lesions and deeper nodules on the head, arms, and trunk. He had a history of ankyloglossia and subsequent uncomplicated repair, as well as a sister with neonatal anemia. He was otherwise well and thriving. Review of systems was unremarkable. His birth involved an uncomplicated delivery, with negative maternal serology. There was no history of maternal infection or recent exposure to infection. Physical exam revealed a well-appearing, non-dysmorphic, vigorous infant. Skin exam was notable for numerous dusky erythematous and violaceous-blue patches and nodules on the anterior scalp, bilateral arms, legs, face, and trunk - including the diaper area. Lesions ranged in size from 1 to 3 cm. The nodules were firm and non-tender. The remainder of his physical examination was normal without abnormal lymphadenopathy or hepatosplenomegaly noted. No mucosal lesions were noted. A biopsy was performed on a thigh lesion.

Involvement of Gpr125 in the myeloid sarcoma formation induced by cooperating MLL/AF10(OM-LZ) and oncogenic KRAS in a mouse bone marrow transplantation model

Oncogenic N-/KRAS mutations were frequently associated with MLL/AF10 in acute myeloid leukemia with myeloid sarcoma (MS). To study the cooperating leukemogenesis by MLL/AF10 and KRAS mutation, we retrovirally transduced MLL/AF10(OM-LZ) and KRASG12C into mouse bone marrow cells and generated two immortalized cell lines. The cells carrying cooperating MLL/AF10(OM-LZ) and KRASG12C had immature myelomonocytic phenotypes. Compared to a previously established cell line carrying MLL/AF10(OM-LZ) alone, cooperation of MLL/AF10(OM-LZ) with KRASG12C blocked the cells at a more immature myelomonocytic stage with reduced expression of monocyte/macrophage markers. The mice transplanted with the cells carrying cooperating MLL/AF10(OM-LZ) and KRASG12C, liked those transplanted with the cells carrying MLL/AF10(OM-LZ) alone, induced myeloproliferative disease-like myeloid leukemia, but in a shorter latency and formed multiple MS at the adipose tissues of skin, peritoneum and intraperitoneal cavity. Cooperation of MLL/AF10(OM-LZ) with KRASG12C increased cell adhesion via upregulation of an adhesion G-protein-coupled receptor Gpr125. Knockdown of Gpr125 in the cells by short hairpin RNA reduced cell aggregation and diminished MS formation in the transplanted mice. Our results indicated that upregulation of Gpr125 by cooperating MLL/AF10(OM-LZ) and KRASG12C promoted cell adhesion and contributed to the MS formation.

Extreme hyperleucocytosis of the premature

Physiological leucocytosis is common in neonates. Leukemoid reaction is defined as a variable degree of leucocytosis with immature precursors, similar to that occurring in leukaemia but because of other causes. Leukemoid reactions are well-recognised in the neonatal intensive care unit population and are associated with antenatal corticosteroids, Down's syndrome, chorioamnionitis, funisitis and perinatal infections. However, extreme hyperleucocytosis, exceeding a white blood cell count of 100×10(9)/l is rare. In the 7-year period from 2005 to 2012 three premature infants in our hospital presented with extreme hyperleucocytosis. Since there were no signs of neonatal leukaemia, transient myeloid disorder or leucocyte adhesion defect, a leukemoid reaction owing to antenatal corticosteroids, chorioamnionitis and funisitis was diagnosed. No obvious complications of hyperleucocytosis were observed. Therapy was not necessary and the leucocytes normalised spontaneously. In our small case series, extreme hyperleucocytosis in prematures occurred in the absence of leukaemia and had a mild course.

Congenital papulonodular eruption: presenting sign of congenital leukaemia cutis

Congenital leukaemia (CL) is a rare malignancy that accounts for < 1% of cases of childhood leukaemias. Leukaemia cutis (LC) refers to cutaneous infiltration with leukaemic cells, and is seen in 30-50% of CL cases. It may precede, follow or occur simultaneously with leukaemia. If left untreated, the prognosis is usually poor, but early diagnosis and treatment may result in a favourable prognosis. We report a case of congenital leukaemia cutis with a progressive, violaceous papulonodular eruption (a 'blueberry muffin' rash), which had been noted at birth, as a presenting sign of acute myeloid leukaemia (AML), which on investigation was classified as AML, FAB M2 type with a t(8; 21)(p11;q22) chromosomal defect. The patient had a favourable response to AML chemotherapy.