1. Case Report

This child was a diagnosed case of standard risk precursor B-lymphoblastic leukemia 2 years back at age of 18 months and was put on standard risk pediatric BFM chemotherapy protocol. Her treatment remained uneventful throughout induction and child was doing well till last few days of 24 month of her treatment, while she was on maintenance phase of her chemotherapy, when parents noted her unsatisfied drive to consume food. For initial 2 weeks they did not give it a strong consideration but lately at around 1 month of this complaint they got worried and sought a medical attention.

On examination the striking finding was that this child was obese (Figure 1) for her age (anthropometry Table 1 & Figure 2) and rest of the examination was normal.

At this point her haemogram and peripheral blood film examination, bone marrow and coagulogram were normal (Table 2).

Fundus examination was also normal and CSF examination (Figure 3) was suggestive of CNS relapse. An MRI examination of brain was performed which was essentially normal except for subtle hypointense lesions in thalamic area brain suggestive of leukemic infiltration (Figure 4). This child was immediately advised to go for possible allogenic stem cell transplantation.

Table 1.

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Figure 1. showing that the patient is obese with weight for age of 97 percentile as against expected of (3^rd-75^th) for her age

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Figure 2. showing that the patient is obese with weight for age of 97 percentile as against expected of (3^rd-75^th) for her age

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Figure 3. CSF examination of the patient showing about 80% blasts

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Figure 4. Magnetic resonance imaging of the patient with subtle hypointense lesions in the thalamic area of brain.

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Table 2.

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2. Discussion

ALL presumably arises from malignant transformation of B- or T-progenitor cells. ^[1] The most common cause of treatment failure in childhood ALL remains relapse which is seen in approximately 15-20% of patients. ^[2] Relapses can be medullary as well as extramedullary. The extramedullary relapses seen in testes, central nervous system and breast are considered as sanctuary sites for disease persistence. ^[9] Most ALL relapses occur during treatment or within the first 2 years after treatment completion, although relapses have been reported to occur even after 10 years from diagnosis. ^{[3, 4]} Relapse may represent preexisting drug-resistant clone, novel clone by mutation ^[5] or quiescent leukemic cell that harbors an otherwise silent fusion gene and that has escaped eradication during initial therapy. ^[6] With intensive combination chemotherapy and allogeneic hematopoietic stem cell transplantation (HSCT), 30%-50% of all children with relapsed ALL can be cured. ^{[7, 8]} Thus, most children still die despite aggressive chemo-radiotherapy approaches, including transplantation, and novel salvage regimens are needed.

3. Conclusion

Although very rare, clinician treating leukemia should keep an eye on growth pattern of children, for early detection of CNS relapse.

References

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[2]	LocatelliF, Schrapp M, Bernard ME, and Rutella S.How I treat relapsed childhood acute lymphoblastic leukemia. . October 4, 2012.
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[3]	Gaynon PS, Childhood acute lymphoblastic leukaemia and relapse. Br Haematol; 131 (5): 579-587. 2005.
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[4]	Rizzari C, Valsecchi MG, Arico M, et al Outcome of very late relapse in children with acute lymphoblastic leukemia. Haematologica; 89 (4): 427-434. 2004.
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[5]	Bailey LC, Lange BJ, Rheingold SR, Bunin NJ,Bone-marrow relapse in paediatric acute lymphoblastic leukaemia. Lancet Oncol; 9 (9):873-883. 2008.
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[6]	Ford AM, Fasching K, Panzer, Grumayer ER, Koenig M, Haas OA, Greaves MF Origins of “late” relapse in childhood acute lymphoblastic leukemia with TEL-AML1 fusion genes. Blood; 98 (3): 558-564. 2001.
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[7]	Tallen G, Ratei R, Mann G, et al. Long-term outcome in children with relapsed acute lymphoblastic leukemia after time-point and site-of-relapse stratification and intensified short-course multidrug chemotherapy: results of trial ALL-REZ BFM 90. J Clin Oncol 28 (14): 2339-2347. 2010.
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[8]	Herold R, von Stackelberg A, Hartmann R, Eisenreich B,Henze G. Acute lymphoblastic leukemia-relapse study of the Berlin-Frankfurt-Munster Group (ALL-REZ BFM) experience: early treatment intensity makes the difference. J Clin Oncol; 22 (3): 569-570. author reply 570-561. 2004.
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[9]	Memis A, Killi R, Orguc S, et al Bilateral breast involvement in acute lymphoblastic leukemia: color Doppler sonography findings. AJR (Am J Roentgenol) 165: 1011. 1995.
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