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Sun Q, Chen W, Wang A, Yang Z, Chen G, Zhu Z. Treatment of a Patient with Acute Promyelocytic Leukemia with Multiple Isolated Relapses in the Central Nervous System: A Case Report and Mini-Review of the Literature. Case Rep Hematol 2024; 2024:5593775. [PMID: 38737168 PMCID: PMC11087148 DOI: 10.1155/2024/5593775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/14/2024] Open
Abstract
The efficacy of therapeutics for acute promyelocytic leukemia (APL) has exhibited an increase in recent years. Only a few patients experience relapse, including extramedullary relapse, and in patients with extramedullary relapse, the central nervous system (CNS) is the most common site. To date, there is no expert consensus or clinical guidelines available for CNS relapse, at least to the best of our knowledge. The optimal therapeutic strategy and management options for these patients remain unclear. The present study reports the treatment of a patient with APL with multiple isolated relapses in the CNS. In addition, through a mini-review of the literature, the present study provides a summary of various reports of this disease and discusses possible treatment options for these patients.
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Affiliation(s)
- Qixin Sun
- Departments of Geriatric Hematology and Oncology, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| | - Wenyi Chen
- Departments of Medical Records, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| | - Ahui Wang
- Departments of Clinical Laboratory, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| | - Zili Yang
- Departments of Geriatric Critical Care Medicine, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| | - Guiping Chen
- Departments of Geriatric Hematology and Oncology, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| | - Zhigang Zhu
- Departments of Geriatric Hematology and Oncology, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
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2
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Hartzell C, McLaughlin J, Nasibli J, Bains A. Myeloid sarcoma mimicking suprasellar meningioma in acute promyelocytic leukaemia. Pathology 2022; 54:955-957. [PMID: 35249746 DOI: 10.1016/j.pathol.2021.12.291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/23/2021] [Accepted: 12/02/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Connor Hartzell
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - John McLaughlin
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Jalil Nasibli
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Ashish Bains
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, USA.
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3
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Isolated central nervous system relapse of acute promyelocytic leukemia with altered morphology in an asymptomatic patient. Blood Cells Mol Dis 2021; 92:102616. [PMID: 34634584 DOI: 10.1016/j.bcmd.2021.102616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 11/23/2022]
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4
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Zhang X, Chen J, Wang W, Li X, Tan Y, Zhang X, Qian W. Treatment of Central Nervous System Relapse in Acute Promyelocytic Leukemia by Venetoclax: A Case Report. Front Oncol 2021; 11:693670. [PMID: 34290987 PMCID: PMC8287827 DOI: 10.3389/fonc.2021.693670] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/28/2021] [Indexed: 01/31/2023] Open
Abstract
Extramedullary relapse of acute promyelocytic leukemia is a rare phenomenon and is associated with a poor prognosis, with the central nervous system being the most common site of relapse. The current treatments are still limited. Venetoclax, a selective inhibitor of BCL2, is a small molecule that can cross the blood-brain barrier and shows a potential efficacy in the treatment of chronic lymphocytic leukemia with central nervous system involvement. Although venetoclax has also been used in the treatment of acute myeloid leukemia in recent years, there are no reports of its use in the treatment of central nervous system relapse in acute promyelocytic leukemia. Here, we report a case of central nervous system relapse in acute promyelocytic leukemia that achieved complete remission after oral treatment with venetoclax. The presence of venetoclax in the patient’s CSF was confirmed by testing CSF and plasma by mass spectrometry. The concentration of venetoclax in CSF was approximately 1/300 of that in plasma trough concentration. The treatment experience in this case demonstrates the potential ability of venetoclax to treat of central nervous system relapse/involvement in acute promyelocytic leukemia, thus providing a new treatment option for this kind of patient.
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Affiliation(s)
- Xuzhao Zhang
- Department of Hematology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jinliang Chen
- Center of Clinical Pharmacology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Weiqin Wang
- Department of Hematology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xian Li
- Department of Hematology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yanbin Tan
- Department of Radiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaohong Zhang
- Department of Hematology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wenbin Qian
- Department of Hematology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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5
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Molica M, Mazzone C, Ottone T, Niscola P, Abruzzese E, Fratoni S, Voso MT, de Fabritiis P. Case Report: Very Late, Atypical Extra-Medullary Relapse in a Patient With Acute Promyelocytic Leukemia (APL) Rescued With a Transplant-Free Approach. Front Oncol 2021; 11:699886. [PMID: 34268125 PMCID: PMC8276173 DOI: 10.3389/fonc.2021.699886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/11/2021] [Indexed: 12/01/2022] Open
Abstract
Relapses of acute promyelocytic leukemia (APL) beyond 7 years from the first molecular remission are exceptional, and it is unclear whether these relapses represent a new, therapy-related leukemia rather than a delayed relapse of the original leukemic clone. The increase extra-medullary relapses (ER) in the era of all-trans retinoic acid (ATRA) therapy suggests a potential correlation between ATRA therapy and ER, and several potential explanations have been proposed. The gold standard post-remission approach, particularly for patients in late relapse, has not yet been established. The benefit of a transplant approach has been questioned in this setting because continuing ATRA-arsenic trioxide (ATO) might be curative. Here we report on the case of an APL patient who relapsed 9 years after achieving her first molecular complete remission (mCR) and who showed an atypical isolated localization at nodal sites, including the into- and peri-parotid glands. Genomic PML/RARa breakpoint analysis detected the same bcr3 PML/RARa hybrid gene in DNA purified from bone marrow and lymph nodes, suggesting that the relapse was because of the reemergence of the initial clone. This case shows that APL, treated with ATRA and cytotoxic drugs, may still emerge in extra-medullary sites even after a very prolonged mCR and could be salvaged with an ATO-based protocol, not including a transplant approach.
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Affiliation(s)
| | | | - Tiziana Ottone
- Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | | | | | - Stefano Fratoni
- Surgical Pathology, Hematopathology Unit, St. Eugenio Hospital, Rome, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Paolo de Fabritiis
- Haematology Unit, St. Eugenio Hospital, Rome, Italy
- Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
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6
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Central Nervous System Double Relapse of Acute Promyelocytic Leukemia and Acute Myelomonocytic Leukemia. Case Rep Hematol 2019; 2019:4907352. [PMID: 31929922 PMCID: PMC6935803 DOI: 10.1155/2019/4907352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 10/17/2019] [Indexed: 11/17/2022] Open
Abstract
Relapse of acute promyelocytic leukemia (APL) and non-M3-acute myeloid leukemia in the central nervous system (CNS) are rare events. Here, we describe a case of simultaneous relapses of APL and acute myelomonocytic leukemia on the CNS of a patient after allogeneic bone marrow transplant. This extremely unusual case highlights the difficulties that CNS leukemia relapses pose in the post-transplant setting.
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7
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Chadburn A, Chen YH, Nayar R, Young A, Sumpter I, Lee C, Gill M, Gao J. Limited Tissue Samples: Hematopoietic Lesions - Three Case Examples of Judicious Use of Limited Material. Acta Cytol 2019; 64:71-80. [PMID: 31063996 DOI: 10.1159/000496570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/21/2018] [Indexed: 01/16/2023]
Abstract
In the era of smaller and smaller biopsies submitted to pathology departments for diagnosis and the advent of personalized medicine, it has become imperative to efficiently and effectively use patient material to reach individualized, actionable diagnoses. The use of fine needle aspirates and core biopsies as acceptable methods for obtaining sufficient material for hematopoietic neoplasms under nonemergent conditions is debatable. There are, however, scenarios where only limited material is obtainable due to anatomic site, size of the lesion or condition of the patient. In these types of settings, thoughtful approaches and unconventional means are often necessary to reach a diagnosis. In this article, we describe three such scenarios and the unique tactics taken in each to obtain a personalized actionable diagnosis.
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Affiliation(s)
- Amy Chadburn
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA,
| | - Yi-Hua Chen
- Department of Pathology, Northwestern Medicine - Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ritu Nayar
- Department of Pathology, Northwestern Medicine - Feinberg School of Medicine, Chicago, Illinois, USA
| | - April Young
- Anatomic Pathology, Department of Pathology, Stanford Health Care, Stanford, California, USA
| | - Ingrid Sumpter
- HematoGenix Laboratory Services, Tinley Park, Illinois, USA
| | - Christopher Lee
- Department of Pathology, Northwestern Medicine - Feinberg School of Medicine, Chicago, Illinois, USA
| | - Manjot Gill
- Department of Ophthalmology, Northwestern Medicine - Feinberg School of Medicine, Chicago, Illinois, USA
| | - Juehau Gao
- Department of Pathology, Northwestern Medicine - Feinberg School of Medicine, Chicago, Illinois, USA
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8
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Bochtler T, Fröhling S, Weichert W, Endris V, Thiede C, Hutter B, Hundemer M, Ho AD, Krämer A. Evolution of a FLT3-TKD mutated subclone at meningeal relapse in acute promyelocytic leukemia. Cold Spring Harb Mol Case Stud 2016; 2:a001123. [PMID: 27626069 PMCID: PMC5002926 DOI: 10.1101/mcs.a001123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Here, we report the case of an acute promyelocytic leukemia (APL) patient who—although negative for FLT3 mutations at diagnosis—developed isolated FLT3 tyrosine kinase II domain (FLT3-TKD)-positive meningeal relapse, which, in retrospect, could be traced back to a minute bone marrow subclone present at first diagnosis. Initially, the 48-yr-old female diagnosed with high-risk APL had achieved complete molecular remission after standard treatment with all-trans retinoic acid (ATRA) and chemotherapy according to the AIDA (ATRA plus idarubicin) protocol. Thirteen months after the start of ATRA maintenance, the patient suffered clinically overt meningeal relapse along with minute molecular traces of PML/RARA (promyelocytic leukemia/retinoic acid receptor alpha) in the bone marrow. Following treatment with arsenic trioxide and ATRA in combination with intrathecal cytarabine and methotrexate, the patient achieved a complete molecular remission in both cerebrospinal fluid (CSF) and bone marrow, which currently lasts for 2 yr after completion of therapy. Whole-exome sequencing and subsequent ultradeep targeted resequencing revealed a heterozygous FLT3-TKD mutation in CSF leukemic cells (p.D835Y, c.2503G>T, 1000/1961 reads [51%]), which was undetectable in the concurrent bone marrow sample. Interestingly, the FLT3-TKD mutated meningeal clone originated from a small bone marrow subclone present in a variant allele frequency of 0.4% (6/1553 reads) at initial diagnosis. This case highlights the concept of clonal evolution with a subclone harboring an additional mutation being selected as the “fittest” and leading to meningeal relapse. It also further supports earlier suggestions that FLT3 mutations may play a role for migration and clonal expansion in the CSF sanctuary site.
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Affiliation(s)
- Tilmann Bochtler
- Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany;; Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany
| | - Stefan Fröhling
- Department of Translational Oncology, National Center for Tumor Diseases and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;; Section for Personalized Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;; DKFZ-Heidelberg Center for Personalized Oncology (HIPO), 69120 Heidelberg, Germany
| | - Wilko Weichert
- Institute of Pathology, Technical University of Munich, 81675 Munich, Germany;; Institute of Pathology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Volker Endris
- Institute of Pathology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Christian Thiede
- Department of Internal Medicine I, University of Dresden, 01307 Dresden, Germany
| | - Barbara Hutter
- Division of Applied Bioinformatics, National Center for Tumor Diseases and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Michael Hundemer
- Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany
| | - Anthony D Ho
- Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany
| | - Alwin Krämer
- Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany;; Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany
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9
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He Z, Tao S, Deng Y, Chen Y, Song L, Ding B, Chen K, Yu L, Wang C. Extramedullary relapse in lumbar spine of patient with acute promyelocytic leukemia after remission for 16 years: a case report and literature review. Int J Clin Exp Med 2015; 8:22430-22434. [PMID: 26885224 PMCID: PMC4730010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/05/2015] [Indexed: 06/05/2023]
Abstract
Acute promyelocytic leukemia (APL) is a common myeloid leukemia. At the newly diagnosed stage, it can be fatal because of the serious complication-disseminated intravascular coagulation. With the advent and early application of all-trans retinoic acid, most APL patients can achieve a long-term survival, and only a minority of patients will develop extramedullary relapse after remission. The most common site of extramedullary relapse is central nervous system, while other sites are relatively rare. Here, we report a particularly rare APL patient who experienced extramedullary relapse with lumbar spine as the isolated site after a rather long time of remission for 16 years. At the time of relapse, the main clinical manifestations of the patient are obvious low back pain, weakness in lower limbs and limitation of activity. After treatment of local radiotherapy combined with ATRA and arsenic trioxide, the patient achieved and maintained a second complete remission by now.
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Affiliation(s)
- Zhengmei He
- Department of Hematology, Huai'an First People's Hospital, Nanjing Medical University Huai'an 223300, China
| | - Shandong Tao
- Department of Hematology, Huai'an First People's Hospital, Nanjing Medical University Huai'an 223300, China
| | - Yuan Deng
- Department of Hematology, Huai'an First People's Hospital, Nanjing Medical University Huai'an 223300, China
| | - Yue Chen
- Department of Hematology, Huai'an First People's Hospital, Nanjing Medical University Huai'an 223300, China
| | - Lixiao Song
- Department of Hematology, Huai'an First People's Hospital, Nanjing Medical University Huai'an 223300, China
| | - Banghe Ding
- Department of Hematology, Huai'an First People's Hospital, Nanjing Medical University Huai'an 223300, China
| | - Kankan Chen
- Department of Hematology, Huai'an First People's Hospital, Nanjing Medical University Huai'an 223300, China
| | - Liang Yu
- Department of Hematology, Huai'an First People's Hospital, Nanjing Medical University Huai'an 223300, China
| | - Chunling Wang
- Department of Hematology, Huai'an First People's Hospital, Nanjing Medical University Huai'an 223300, China
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10
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Extramedullary relapse in RARA rearrangement-negative acute promyelocytic leukemia successfully treated in combination with chemotherapy, local radiotherapy, and cord blood transplantation. J Pediatr Hematol Oncol 2015; 37:e234-7. [PMID: 25493455 DOI: 10.1097/mph.0000000000000293] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
RARA rearrangement-negative acute promyelocytic leukemia (APL) is uncommon, and its extramedullary relapse is extremely rare. We report a 5-year-old girl with RARA rearrangement-negative APL, which recurred solely at the external auditory canal and mastoid air cells. She was successfully treated with chemotherapy, local radiotherapy, and unrelated cord blood transplantation. She has maintained complete remission for 24 months after transplantation. The clinical features and our therapeutic strategy in this patient will provide valuable information for extramedullary relapse of RARA rearrangement-negative APL.
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11
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Mishra J, Gupta M. Cerebrospinal fluid involvement in acute promyelocytic leukaemia at presentation. BMJ Case Rep 2015; 2015:bcr-2014-208418. [PMID: 25754165 DOI: 10.1136/bcr-2014-208418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In acute promyelocytic leukaemia (APL), extramedullary disease (EMD) is rare but can occur in those who relapse following therapy. Although the most common site of EMD in APL is central nervous system (CNS) and skin, CNS involvement in recently diagnosed patients with APL is very rare and rarely described. We report cerebrospinal fluid involvement in a case of APL, on day 3 of induction therapy.
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Affiliation(s)
- Jyoti Mishra
- Department of Pathology, School of Medical Sciences and Research, Greater Noida, Uttar Pradesh, India
| | - Mayank Gupta
- Department of General Pathology, Christian Medical College, Vellore, Tamil Nadu, India
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12
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Mittal R, Chopra A, Soni S, Bakhshi S, Kumar R. "Tear drops" in the cerebrospinal fluid: Correct by scatter, but pathognomonic by site. CYTOMETRY PART B-CLINICAL CYTOMETRY 2014; 88:204-6. [PMID: 25257969 DOI: 10.1002/cyto.b.21191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 09/05/2014] [Accepted: 09/07/2014] [Indexed: 12/26/2022]
Abstract
Extramedullary relapse in acute promyelocytic leukemia (APL) is rare, but occurs most commonly in central nervous system (CNS), generally in high-risk cases (total leucocyte count≥10,000/µL, atypical morphology or disseminated intravascular coagulation at presentation), and concomitant with bone marrow (BM) relapse. Here, we describe a case of APL who except for CD56 positivity was low risk but had a CNS relapse without concomitant BM involvement. Diagnosis of isolated CNS relapse was based on characteristic tear-drop pattern for CD45/side scatter plot on flow cytometry, a full compatible immunophenotype and cytomorphology in the cerebrospinal fluid. The case illustrates the value of the latter and the importance of including CD56 in risk assessment of APL.
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Affiliation(s)
- Reena Mittal
- Laboratory Oncology Unit, Dr. BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-, 110029, India
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13
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Sahin DG, Gunduz E, Akay OM, Gulbas Z. Central nervous system relapse in a patient with acute promyelocytic leukaemia: does the risk stratification matter? BMJ Case Rep 2013; 2013:bcr-2013-009456. [PMID: 23749823 DOI: 10.1136/bcr-2013-009456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Extramedullary relapse is an uncommon complication of acute promyelocytic leukaemia (APL). The most common site of extramedullary relapse is the central nervous system (CNS), and the majority of CNS relapses occur in patients with high-risk disease in which white blood cell count at presentation is greater than 10×10(3)/μL. The best management of such patients is still controversial. We describe a 47-year-old man with APL who developed two CNS relapses which were diagnosed through the presence of t(15;17)(q22;q21) on PCR of the cerebrospinal fluid (CSF), despite presenting initially with intermediate-risk disease. We conclude that the intermediate risk group is very heterogeneous and these patients sometimes may behave like high-risk patients. Also, clinicians should take into account symptoms that can be related to CNS relapse in patients with APL and consider lumbar puncture even if radiological imaging does not reveal anything.
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Affiliation(s)
- Deniz Goren Sahin
- Department of Hematology, Eskisehir Osmangazi University, Eskisehir, Turkey.
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