Acute Lymphoblastic Leukemia (ALL) as a secondary malignancy in adolescent patient after completion of Ewing's sarcoma chemotherapy: a case report

Abstract

OBJECTIVE: To report an adolescent patient who was diagnosed with Acute lymphoblastic leukemia (ALL) after completing Ewing sarcoma (ES) therapy. CASE: A 14 years old girl complained of left crusis tumor since 4 months before hospitalized. Tumor biopsy showed a round cell tumor, as well as immunohistochemistry which showed a positive CD99, consistent with ES. The patient had received 14 cycles chemotherapy for 7 months with regimens vincristine 1.5 mg/m2, cyclophosfamide 1200 mg/m2, dactinomycin 0.5 mg/m2, and doxorubicin 30 mg/m2. Between chemotherapy, patient also was given granulocyte colony-stimulating factor several times. Pasien also undergo 31 times radiation therapy with total 31x1.8 Gy (55.8 Gy). Two months after last chemotherapy for Ewing sarcoma, she was admitted again with prolonged fever, and pallor.Laboratorium showed leukocytosis (88.86x103uL), monocytosis (41%), severe neutropenia (0.39x103uL), severe normochromic normocytic anemia (4,3 g/dL), severe thrombocytopenia (4x103uL), reticulocytopenia (0,46%), with lymphoblast in peripheral blood smear. Bone marrow aspiration result showed lymphoblast infiltration 60% with heterogen morphology, no cluster cell non hematopoetic in bone marrow, consisten with acute lymphoblastic leukemia (ALL-L2) suspected secondary malignancy from Ewing’s Sarcoma. Patient underwent chemotherapy for high risk ALL at induction phase with combination of vincristin, daunorubicin, L-asparginase, metotrexate high dose, prednison, and 6-mercaptopurine. After completing induction phase, the patient’s condition get worsening and later died. CONCLUSION: ES survivors are at significant risk for secondary malignancies. Leukimia is one of which the most common secondary malignancies. Young children are particularly susceptible to the mutagenic effects of both chemotherapy and radiotherapy, as proven by several studies.