Letters to Editor

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

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. 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

Recurrent sinonasal teratocarcinosarcoma with intracranial extension: Case report

Sir, Sinonasal teratocarcinosarcoma (SNTCS) is a rare and aggressive malignant tumor. As the name implies, it 398

Figure 1: Bonemarrow picture demonstrating myeloid cell hyperplasia

nearing 90%, we should be more stringent on long term follow up. Cyriac S, Philip A, Ganesan P, Kannan K, Sagar TG Department of Medical Oncology, Cancer Institute (WIA), Chennai, India

Correspondence to:

Dr. Sanju Cyriac, E‑mail: [email protected]

References 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, 8th ed. New York: Lippincott Williams and Wilkins; 2008. p. 2268. 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. 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. 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. 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. Access this article online Quick Response Code:

Website: www.indianjcancer.com DOI: 10.4103/0019-509X.146783 PMID: *****

arises from the sinonasal tract and is characterized by the presence of benign and malignant epithelial, mesenchymal and neural components. Common sites of involvement of SNTCS are nasal cavities and paranasal sinuses. The tumor is often misdiagnosed due to rarity, the complex phenotypic composition and inadequate biopsy specimen. Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3

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

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