Case 297

Submitting Author: Tang, Guilin, MD, PhD
Institution: MD Anderson Cancer Center
Additional authors:Sa Wang
Session: B Lymphoblastic Leukemia/Lymphoma

HISTORY

65 year-old Caucasian female presented with left breast lump in 2/2009. She underwent a lumpectomy and axillary lymph nodes dissection 3/2009, which revealed invasive carcinoma with predominantly mucinous differentiation as well as minor invasive ductal components. Two out of 22 lymph nodes were positive for malignancy. Subsequently, the patient received weekly Taxol for 12 weeks, and three cycles of FAC (5-fluorouracil, doxorubicin, and cyclophosphamide) chemotherapy. She also received adjuvant radiation therapy, which was completed in early 2010.

On 08/16/2010, the patient had a complete blood count which showed Hb 9.4 g/dl, WBC 236x10^9/L, platelet 38x10^9/L, and 51% of blasts.

DETAILS

Bone marrow biopsy and aspirate smear were performed.

BM smear differentiation: Blasts 94%, granulocytes 1%, erythroblasts 3%, lymphocytes 2%. Blasts were negative for MPO.

BM biopsy: Cellularity: ≈ 95%

Megakaryocytes: decreased in number, unremarkable morphology

Infiltrate: Sheets of immature cells

IMMUNOHISTOCHEMISTRY AND FLOW CYTOMETRY

The blasts are positive for: CD19, CD22, CD34 (small subset), CD52 (small subset), CD58, cCD79a and CD81, cIgM , and HLA-DR; negative for CD10, CD20, CD25, CD66, surface light chain, myeloid markers (CD13, CD33, CD117) and T cell markers (cCD3, CD5, CD7)

CYTOGENETIC FINDINGS

46,XX,t(4;11)(q21;q23)[19]/47,XX,+X,t(4;11)(q21;q23),-7,+8[1]

INTERESTING FEATURES

Patient had a prior history of malignancy and received cytotoxic therapy. One and half year later, she developed B-acute lymphoblastic leukemia (B-ALL). Is this therapy-related or a random event? If it is therapy-related, how is it different from therapy-related acute myeloid neoplasm?

PROPOSED DIAGNOSIS

Therapy-related ALL

CONSENSUS DIAGNOSIS

Therapy-related B-acute lymphoblastic leukemia with t(4;11)(q21;q23)