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  Table of Contents  
LETTER TO THE EDITOR
Year : 2015  |  Volume : 52  |  Issue : 3  |  Page : 465-467
 

Secondary pancreatic involvement by precursor T-cell acute lymphoblastic leukemia presenting as acute pancreatitis


Department of Pathology, Safdarjung Hospital and V. M. M. College, New Delhi, India

Date of Web Publication18-Feb-2016

Correspondence Address:
Y K Yadav
Department of Pathology, Safdarjung Hospital and V. M. M. College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.176691

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How to cite this article:
Yadav Y K, Mallya V, Ahluwalia C, Gupta O. Secondary pancreatic involvement by precursor T-cell acute lymphoblastic leukemia presenting as acute pancreatitis. Indian J Cancer 2015;52:465-7

How to cite this URL:
Yadav Y K, Mallya V, Ahluwalia C, Gupta O. Secondary pancreatic involvement by precursor T-cell acute lymphoblastic leukemia presenting as acute pancreatitis. Indian J Cancer [serial online] 2015 [cited 2019 Sep 22];52:465-7. Available from: http://www.indianjcancer.com/text.asp?2015/52/3/465/176691


Sir,

Pancreatic infiltration with leukemic cells is a rare manifestation of acute lymphoblastic leukemia (ALL) and it is even more rare in the T-cell variant of ALL.[1] The pancreatitis in ALL is either due to hypercalcaemia or chemotherapy, direct involvement of pancreas by leukemic cells is seldom seen.[2],[3] Our case is a 25 year old non-alcoholic female who gave a short history of fever and epigastric pain (<48 hrs). On examination there was bilateral cervical lymphadenopathy and hepatosplenomegaly. Her hemoglobin was 8.4 gm/dl, total leucocyte count was 1,10,000/µl and platelets were 40,000/µl. Peripheral smear showed presence of 87% blasts cells with convoluted to irregular nuclei and scanty cytoplasm [Figure 1]. Bone marrow aspirate was diluted with blood and showed complete replacement of marrow by blasts [Figure 2]. Immunophenotyping of bone marrow aspirate showed blasts positive for CD1a, CD3, CD7 and CD34 and negative for CD13, CD10 and CD20. Patient also had concomitant elevated enzymes: Amylase - 253U/L (normal <132 U/L); lipase - 285 U/L (normal <60 U/L). Computed tomography (CT) of the thorax and abdomen showed hypodense lesions in pancreas. Pancreas was bulky but there was no necrosis seen. So, it was grade B according to Balthazar scoring. CT Severity Index score was 1 i.e., mild pancreatitis [Figure 3]. Patient had no gall stone and serum calcium level was 9.1 mg/dl. She also had no history of having received any chemotherapy. The patient received intensive treatment with analgesics along with prophylactic antibiotics, intravenous fluids and alimentation. Despite receiving prophylactic antibiotics, the patient developed pulmonary infectionand died of septicemia.
Figure 1: Peripheral smear showing blasts with convoluted nucleus. Giemsa stain, ×1000

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Figure 2: Bone marrow smear showing complete replacement by blasts. Giemsa stain, ×1000

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Figure 3: CT of the thorax and abdomen showed hypodense lesions (arrow mark) in the pancreas, suggestive of pancreatitis

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ALL is a neoplastic disorder that is rapidly fatal if untreated. T-ALL comprises about 15% of cases of childhood ALL. It is more common in adolescent than in younger children and more common in males than females. T cell ALL comprises approximately 25% of cases of adult ALL. These patients have increased risk for induction failure and early relapse.[1] Thymus, lymph nodes, skin, tonsil, spleen, CNS and testis in male may get involved.[4]

Pancreatic infiltration of leukemic cells is a very rare manifestation of acute lymphoblastic leukemia.[5] Pancreatic enlargement in ALL is unusual and pancreatic involvement is often associated with biliary obstruction, cholestasis and pancreatitis.[6]

Acute Pancreatitis in association with ALL have been reported previously, but they were mainly related to chemotherapeutic agents, namely L-asparaginase.[2] There have been a few case reports of acute pancreatitis associated with hypercalcemia due to adult T-cell leukemia (ATLL) and one case report documented invasion of the pancreas by ALL lymphoblasts in a case of ATLL.[1],[3]

In view of the above details, we conclude that pancreatitis in this patient was due to leukemic infiltration of the pancreas. Only few cases of precursor T-cell ALL with infiltration of pancreas have been reported in literature, most cases were of paediatric age group.[6],[7] Acute pancreatitis related to involvement of the pancreas by precursor T-cell leukemia in an adult is very rare and not reported so far. This case report shows clinically proven acute pancreatitis related to involvement of the pancreas by precursor T-cell leukemia in an adult.


  Conclusion Top


Acute pancreatitis associated with T cell ALL is induced not only by chemotherapy or hypercalcaemia, but can also be directly related to invasion of the pancreas by leukemic cells.

Supplementary Information [Additional file 1]

 
  References Top

1.
Mori A, Kikuchi Y, Motoori S, Watanabe J, Shinozaki M, Eguchi M. Acute pancreatitis induced by diffuse pancreatic invasion of adult T-cell leukemia/lymphoma cells. Dig Dis Sci 2003;48:1979-83.  Back to cited text no. 1
    
2.
Wlazlowski M, Celinska W, Maciejka-Kapuscinska L, Ploszynska A, Idczak E. Acute pancreatitis in children with acute lymphoblastic leukemia treated with L-asparaginase. Pol Tyg Lek1994;49:296-7.  Back to cited text no. 2
    
3.
Mantadakis E, Anagnostatou N, Smyrnaki P, Spanaki AM, Papavasiliou ES, Briassoulis G, et al. Life-threatening hypercalcemia complicated by pancreatitis in a child with acute lymphoblastic leukemia. J Pediatr Hematol Oncol 2005;27:288-92.  Back to cited text no. 3
    
4.
Borowitz MJ, Chan JK.T-lymphoblastic leukemia/lymphoma. In: Swerdlow SH, editor. World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. Lyon, France: IARC Press; 2008. p. 176-8.  Back to cited text no. 4
    
5.
Malbora B, Avci Z, Alioglu B, Tutar NU, Ozbek N. A case with mature B-cell acute lymphoblastic leukemia and pancreatic involvement at the time of diagnosis. J Pediatr Hematol Oncol 2008;30:87-9.  Back to cited text no. 5
    
6.
Collado L, Dardanelli E, Sierre S, Moguillansky S, Lipsich J. Asymptomatic leukemic-cell infiltration of the pancreas: US findings. Pediatr Radiol 2011;41:779-80.  Back to cited text no. 6
    
7.
Rausch DR, Norton KI, Glass RB, Kogan D. Infantileleukemia presenting with cholestasissecondary to massive pancreaticinfiltration. Pediatr Radiol 2002;32:360-1.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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