A 14-year-old boy was admitted for fever of 3-day duration, and palpable masses in his left axilla and breast for 1 month. Four years prior to admission, he had been diagnosed with mediastinal T-lymphoblastic lymphoma without evidence of bone marrow (BM) involvement, and had received induction chemotherapy with dexamethasone, vincristine, daunorubicin, and L-asparaginase, resulting in complete remission. The patient had completed subsequent phases of consolidation and maintenance treatment and had been off treatment for 18 months before admission. On admission, PB revealed a white blood cell count of 44.07 9 10/L, a hemoglobin level of 14.3 g/dL and a platelet count of 154 9 10/L. Serum levels of lactate dehydrogenase (LDH) and uric acid were elevated to 7,490 U/L and 10.9 mg/dL, respectively. Other laboratory findings were as follows: C-reactive protein 1.78 mg/dL, AST 126 U/L, and fibrinogen [500 mg/dL. PET/CT showed increased FDG uptake in the neck, axilla, and anterior chest wall, which had not been observed at the onset of lymphoma. PB smear showed a predominance of blast cells (about 70 %). Subsequently, BM aspirate revealed 100 % cellularity with a high percentage of blasts, which accounted for 91 % of all nucleated cells (Fig. 1a, b). The medium to large-sized blasts were round to oval shaped, with finely chromatinated nuclei with or without distinct nucleoli, and scant to moderate amounts of blue cytoplasm containing some vacuoles. The blasts were dysplastic with megaloblastoid nuclei and/or bi-or multinucleated forms. They showed positivity for periodic acid-Schiff (PAS) stain in a block-like staining pattern, but were negative for myeloperoxidase (MPO) and a-naphthyl butyrate esterase (ANBE) stains (Fig. 1c). Immunohistochemistry showed that immature blasts in the BM were negative for CD61 (Fig. 1d). Immunophenotypic analysis by flow cytometry revealed that the majority of blast population was positive for CD33 and CD41a. A small portion was also positive for CD235a (glycophorin A), CD2, CD11c, CD13, and CD14. Other antigens, including CD5, CD7, CD10, CD19, CD20, CD22, CD34, CD56, CD64, CD117, cytoplasmic CD3, cytoplasmic MPO, HLA-DR, and cytoplasmic CD79a were not detectably expressed (Fig. 1e). Cytogenetic analysis of the bone marrow cells using the Giemsa banding technique revealed the karyotype 47,XY,?8,t(12;20)(p13;q13.1)[18]/46,XY[2] (Fig. 1f). FISH analysis for the RUNX1–RUNX1T1 rearrangement revealed no fusion signal, but three signals for RUNX1T1 in 90 % of the analyzed cells. Results of FISH performed using BCR-ABL1, PML-RARA, CBFB, MLL, 5q, and 7q31 probes and HemaVision (DNA Technology, Aarhus, Denmark) screening were negative. The disease was primarily classified as a therapy-related myeloid neoplasm according to the 2008 WHO classification and the secondary diagnosis of acute myeloid leukemia of mixed megakaryocytic and erythroid origin was also made based on the combination of morphology and immunophenotypic and cytochemical findings. The patient received induction chemotherapy with cytarabine and W. Jang M. Kim (&) Department of Laboratory Medicine, The Catholic University of Korea, Seoul, Korea e-mail: microkim@catholic.ac.kr
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