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  Table of Contents  
LETTER TO EDITOR
Year : 2014  |  Volume : 51  |  Issue : 3  |  Page : 398
 

Chronic myeloid leukemia in acute lymphoblastic leukemia survivor: A case report


Department of Medical Oncology, Cancer Institute (WIA), Chennai, India

Date of Web Publication10-Dec-2014

Correspondence Address:
Dr. S Cyriac
Department of Medical Oncology, Cancer Institute (WIA), Chennai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.146783

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How to cite this article:
Cyriac S, Philip A, Ganesan P, Kannan K, Sagar T G. Chronic myeloid leukemia in acute lymphoblastic leukemia survivor: A case report. Indian J Cancer 2014;51:398

How to cite this URL:
Cyriac S, Philip A, Ganesan P, Kannan K, Sagar T G. Chronic myeloid leukemia in acute lymphoblastic leukemia survivor: A case report. Indian J Cancer [serial online] 2014 [cited 2019 Sep 22];51:398. Available from: http://www.indianjcancer.com/text.asp?2014/51/3/398/146783


Sir,

Secondary chronic myeloid leukemia (CML) is a rare phenomenon. The only risk factor described for CML is radiation. [1] There have been case reports in literature where survivors of various malignancies develop CML after a latent period. [2],[3] The significance of this observation is largely unknown though many patients are exposed to radiation therapy as part of treatment programmes.

Mr. G was 24-year-old in 1984 when he was diagnosed to have acute lymphoblastic leukemia (ALL), FAB L1 subtype. The immunophenotype and cytogenetic details were not available those days. He received multiagent chemotherapy which included vincristine, daunorubicin, L-Asparaginase, cytarabine, cyclophosphamide, multiple doses of intrathecal methotrexate and 10 months of oral maintenance with methotrexate and 6 mercaptopurine. Patient was given 24 Gy of cranial radiation also. He was kept under regular follow up. Seventeen years later, he presented to us with bone pains. Clinically, he did not have anemia or peripheral lymphadenopathy. Spleen could not be appreciated. His investigations were as follows: Hb - 10.9 g/dl, Total count - 64600/mm 3 , Platelet count - 2.04 lakhs/m 3 . Peripheral smear showed immature myeloid cells and hence a bone marrow aspiration was done which was suggestive of myeloid hyperplasia [Figure 1]. BCR - ABL qualitative test was positive. After making a diagnosis of CML, he has been initiated on Imatinib and is doing well. The cytogenetic response assessment is not yet made.
Figure 1: Bonemarrow picture demonstrating myeloid cell hyperplasia

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Secondary CML in ALL survivors is very rare with only two cases reported so far on literature review. In a cohort of 2169 ALL survivors in St Judes hospital, only two patients had CML. [4] The reasons for secondary CML in ALL survivors are purely hypothetical. It may be that more and more pediatric and adolescent ALL patients are getting cured and surviving to face second cancers like CML which typically occurs at a later age. For our patient, definitely the cranial irradiation might have contributed for the second event. Drugs like alkylating agents and topoisomerase inhibitors are held responsible for therapy related acute myeloid leukemia (t-AML), but not for CML. A Children's Cancer Group analysis demonstrated that the cumulative incidence of developing a second neoplasm was 1.19% at 10 years for ALL survivors. [5] However, higher incidence upto 10.5% has been noticed with 30 year follow up study by Hijiya et al. [4] With cure rates of ALL nearing 90%, we should be more stringent on long term follow up.

 
  References Top

1.
Druker BJ, Lee SJ. Chronic leukemias. Section1: Chronic Myelogenous Leukemia. In: DeVita, Vincent T. Lawrence, Theodore S, Rosenberg, Steven A, editors. Devita, Hellman and Rosenberg's Cancer: Principles and Practice of Oncology, 8 th ed. New York: Lippincott Williams and Wilkins; 2008. p. 2268.  Back to cited text no. 1
    
2.
Ramanarayanan J, Dunford LM, Baer MR, Sait SN, Lawrence W, McCarthy PL. Chronic myeloid leukemia after treatment of lymphoid malignancies: Response to imatinib mesylate and favorable outcomes in three patients. Leuk Res 2006;30:701-5 .  Back to cited text no. 2
    
3.
Waldman D, Weintraub M, Freeman A, Neumann Y, Rechavi G, Toren A. Favorable early response of secondary chronic myeloid leukemia to imatinib. Am J Hematol 2004;75:217-9.  Back to cited text no. 3
    
4.
Hijiya N, Hudson MM, Lensing S, Zacher M, Onciu M, Behm FG, et al. Cumulative Incidence of Secondary Neoplasms as a First Event After Childhood Acute Lymphoblastic Leukemia. JAMA 2007;297:1207-15.  Back to cited text no. 4
    
5.
Bhatia S, Sather HN, Pabustan OB, Trigg ME, Gaynon PS, Robison LL. Low incidence of second neoplasms among children diagnosed with acute lymphoblastic leukemia after 1983. Blood 2002;99:4257-64.  Back to cited text no. 5
    


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