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  Table of Contents    
LETTER TO EDITOR  
Year : 2019  |  Volume : 62  |  Issue : 3  |  Page : 510-512
Hodgkin's lymphoma in a patient with acute lymphoblastic leukemia while on maintenance: A rare second malignant neoplasm


1 Department of Medical Oncology, Regional Cancer Centre, Trivandrum, Kerala, India
2 Department of Pathology, Regional Cancer Centre, Trivandrum, Kerala, India

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Date of Web Publication26-Jul-2019
 

How to cite this article:
Thambi SM, Benson R, Nair SG, Vasudevan JA, Nair RA. Hodgkin's lymphoma in a patient with acute lymphoblastic leukemia while on maintenance: A rare second malignant neoplasm. Indian J Pathol Microbiol 2019;62:510-2

How to cite this URL:
Thambi SM, Benson R, Nair SG, Vasudevan JA, Nair RA. Hodgkin's lymphoma in a patient with acute lymphoblastic leukemia while on maintenance: A rare second malignant neoplasm. Indian J Pathol Microbiol [serial online] 2019 [cited 2019 Oct 17];62:510-2. Available from: http://www.ijpmonline.org/text.asp?2019/62/3/510/263506




Editor,

The improved survival in patients with childhood malignancies has caused an increase in the incidence of second malignant neoplasms. Common second malignancies that occur after leukemia treatment include brain tumors, non-Hodgkin lymphoma, thyroid cancer, and sarcomas.[1] The relative incidence of second malignant neoplasms comes to around 4%.[2] Only few cases of Hodgkin's lymphoma (HL) developing after acute lymphoblastic leukemia (ALL) have been reported so far in the literature. Here we report a case of 17-year-old male who developed HL while on maintenance.

A 17-year-old boy was evaluated with symptoms of tiredness and was diagnosed as B lymphoblastic leukemia with normal cytogenetics. He was treated with Berlin–Frankfurt–Munster (BFM)-90 protocol. After induction, consolidation, and re-induction, prophylactic cranial irradiation was started on maintenance chemotherapy (6 mercaptopurine plus methotrexate) as on BFM protocol.

On completion of 8 months of maintenance, he was evaluated with neck nodes in the neck. On clinical examination, the patient was found to have bilateral neck nodes with a maximum size of 1.5 × 1.5 cm. There were no other significant enlarged lymph nodes. A contrast-enhanced computed tomography (CT) showed multiple enlarged cervical lymph nodes (level II–IV), on both sides of the neck with central necrosis [Figure 1]. The CT scan also revealed mild hepatomegaly of size 17 cm without any focal lesions.
Figure 1: Contrast-enhanced CT showing multiple enlarged cervical lymph nodes in level II of the neck with central necrosis

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An excision biopsy from the neck node was done and it showed few atypical large mononucleate and binucleate cells with prominent nucleoli mixed with several eosinophils, occasional plasma cells, and histiocytes. Immunohistochemistry showed the atypical cells to be CD30 positive, CD15 positive, CD20 positive, and downregulated. It was diagnostic of mixed cellularity classical HL [Figure 2]. Bone marrow study was normal. A positron emission tomography (PET) scan was also done, which showed only fludeoxyglucose avid nodes in the neck. The patient was planned to be treated as HL along with continuing maintenance. After completion of chemotherapy, PET scan showed the patient to have achieved a complete response and received radiotherapy. The patient has no evidence of disease on last follow-up of 6 months after completion of maintenance therapy.
Figure 2: Histopathology slide showing (a) atypical large mononucleate and binucleate cells with prominent nucleoli. (b) Hodgkin and Reed–Sternberg cells are variably positive for CD20 [immunohistochemistry (IHC), ×400]. (c) Hodgkin and Reed–Sternberg cells are CD15 positive (IHC, ×400). (d) Hodgkin and Reed–Sternberg cells are CD30 positive (IHC, ×400)

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Therapy-associated second malignancies occur at median duration of 1–3 years of diagnosis in cases of topoisomerase II-induced secondary leukemias, while the median duration for development of radiation-induced second malignancy is around 5–9 years. HL as a second malignancy in patients with ALL was first reported in 1975.[3] Development of HL during maintenance therapy is even rarer. One of the differential diagnosis was immunodeficiency-associated lymphoproliferative disorder. They are usually aggressive B-cell neoplasm and are associated with the Epstein-Barr virus.[4]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Keegan THM, Bleyer A, Rosenberg AS, Li Q, Goldfarb M. Second primary malignant neoplasms and survival in adolescent and young adult cancer survivors. JAMA Oncol 2017;3:1554-7.  Back to cited text no. 1
    
2.
Teepen JC, van Leeuwen FE, Tissing WJ, van Dulmen-den Broeder E, van den Heuvel-Eibrink MM, van der Pal HJ, et al. Long-term risk of subsequent malignant neoplasms after treatment of childhood cancer in the DCOG LATER study cohort: Role of chemotherapy. J Clin Oncol 2017;35:2288-98.  Back to cited text no. 2
    
3.
Rosner F, Grünwald H. Hodgkin's disease and acute leukemia. Report of eight cases and review of the literature. Am J Med 1975;58:339-53.  Back to cited text no. 3
    
4.
Kim HJ, Ko YH, Kim JE, Lee SS, Lee H, Park G, et al. Epstein-Barr Virus-Associated Lymphoproliferative Disorders: Review and Update on 2016 WHO Classification. J Pathol Transl Med 2017;51:352-8.  Back to cited text no. 4
    

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Correspondence Address:
Rony Benson
Department of Medical Oncology, Regional Cancer Centre, Trivandrum - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_87_18

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    Figures

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