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LETTER TO THE EDITOR
Year : 2015  |  Volume : 52  |  Issue : 2  |  Page : 228-229
 

Ubiquitous lytic osseous lesions in acute lymphoblastic leukemia: A rare case report


1 Department of Radiodiagnosis, Sapthagiri Institute of Medical Sciences, Bangalore, Karnataka, India
2 Department of Radiodiagnosis, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
3 Department of Pathology, Sapthagiri Institute of Medical Sciences, Bangalore, Karnataka, India

Date of Web Publication5-Feb-2016

Correspondence Address:
V Annam
Department of Radiodiagnosis, Sapthagiri Institute of Medical Sciences, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175821

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How to cite this article:
Annam V, Raghuram P, Vasudeva D S, Narayana H T. Ubiquitous lytic osseous lesions in acute lymphoblastic leukemia: A rare case report. Indian J Cancer 2015;52:228-9

How to cite this URL:
Annam V, Raghuram P, Vasudeva D S, Narayana H T. Ubiquitous lytic osseous lesions in acute lymphoblastic leukemia: A rare case report. Indian J Cancer [serial online] 2015 [cited 2021 Aug 1];52:228-9. Available from: https://www.indianjcancer.com/text.asp?2015/52/2/228/175821


Sir,

Leukemia is a myeloproliferative disorder in which neoplastic blood cells diffusely invade and replace normal marrow.[1]

An 18 year old female patient presented with fever, fatigue, vomiting, chest pain, dry cough and amenorrhea since three months. Also, she complained of pain in upper limbs following a trivial injury two weeks back. On physical examination, she was pale, febrile with left cervical lymphadenopathy. Systemic examination revealed fracture of upper limb on both sides. Plain radiographs of chest [Figure 1], skull [Figure 2], dorso-lumbar spine [Figure 3], pelvis [Figure 4] and both forearms [Figure 5] reveal multiple, lytic lesions alongwith fracture neck of humerus is noted on both sides. The lytic bone lesions are both centrally and eccentrically placed with well-defined, non-sclerotic margins and narrow peripheral zone of transition. The long axis of the well-defined lesions in ribs, clavicle, humerus and forearm bones are parallel to the long axis of the bone. No periosteal reaction/trabeculae/fluid levels/calcifications/subperiosteal elevation/subperiosteal/cortical thickening/adjacent soft tissue swelling are seen. Both medulla and cortex of the bones are affected involving epiphysis, metaphysis and diaphysis. Ultrasonography of abdomen and pelvis showed no hepatospleenomegaly. A provisional diagnosis of Metastases versus Histiocytosis was made. A final diagnosis of Acute Lymphoblastic leukemia-L2 was done with peripheral smear and bone marrow studies.
Figure 1: Chest radiograph posteroanterior view shows multiple lytic lesions involving ribs, clavicle, scapula and humerus on both sides. Geographic lesion is seen in the proximal end of both humerus. Mild cardiomegaly is seen

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Figure 2: Skull radiograph lateral view reveals multiple lytic lesions involving both outer and inner tables of all the bones of the skullwell,

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Figure 3: Dorsolumbar spine radiograph anteroposterior view reveals compression fracture of D9 vertebral body with lytic lesions in D5, D6, D7 and D8 vertebral bodies and loss of pedicles of D5, D6 and D7 vertebrae. The intervertebral disk spaces between D5 and D10 are reduced. Multiple lytic lesions of ribs are also noted

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Figure 4: Pelvis radiograph anteroposterior view shows multiple lytic lesions involving the iliac, ischium and pubic bones. Also lesions are seen in femur on both sides

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Figure 5: Radiograph of forearm and hand (bilateral) anteroposterior view shows few discrete lytic lesions involving the radius, ulna and metacarpal bones

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Acute lymphoblastic leukemia (ALL) is a biologically and clinically heterogenous group of diseases characterized by a malignant proliferation of immature lymphoid cells in the bone marrow.[2] Majority of cases of acute lymphoblastic leukemia occur below the age of five years. In both children and adolescents, boys are more affected than girls.[3] Because leukemia arises from the red bone marrow, bony manifestations in adults are largely limited to the axial skeleton, whereas in children involvement occurs frequently in both axial and appendicular bones. Osteolytic lesions occur in 38 to 90% of children and 57% of adults in leukemia. The lesions are small but may coalesce to appear as a medullary or cortical tumor, resembling metastases. Larger geographic shaped lesions may form as well, and margins are usually non-sclerotic. When multiple, lesions may appear punched out, resembling myeloma. Patients may have diffuse osteopenia. In spine, leukemia involves the vertebral body more commonly due to greater distribution of red marrow. Both anterior wedging and biconcave vertebral bodies may be present.[1] In children, diffuse osteolytic lesions can occur with osteoporosis, transverse metaphyseal radiolucent bands (leukemic line), lamellar periosteal reactions and cortical erosions widespread throughout the skeleton with subperiosteal new bone formation.[4] Chemotherapy is the initial treatment of choice and consists of remission induction, intensification, and maintenance therapy.[5] Our patient was on steroids and refused to have chemotherapy. Prognosis depends on cytogenetics and immunophenotyping.[5] They were not done in our patient. However, there was progressive decrease in the white blood cell count, which indicated bad prognosis. In conclusion, we present a rare combination of multiple lytic lesions involving all the bones in an adolescent female patient masquerading as metastases.

 
  References Top

1.
Morrie E. Kricun. 'Imaging of bone tumors'. 1993. p. 92-533.  Back to cited text no. 1
    
2.
Stanley R. Frankel. Wendy Stock, John Byrd, Clara D. Bloomfield. 'Acute Lymphoblastic Leukemia' In Haskell. 'Cancer Treatment'. 2001; 5th edn:1438.  Back to cited text no. 2
    
3.
Ghai OP, Piyush Gupta VK. Paul. 6th ed. 'Textbook of Essential Pediatrics'. 2006. p. 561-2.  Back to cited text no. 3
    
4.
Hafiz MG, Islam A. Extensive skeletal lesions in childhood acute lymphoblastic leukemia. Mymensingh Med J 2009;18:88-94.  Back to cited text no. 4
    
5.
Available from: http://www. en.wikipedia.org/wiki/Acute_lymphoblastic_leukemia#Treatment. [Last accessed on 2012 Sep 23].  Back to cited text no. 5
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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