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Unilateral exudative retinal detachment as the sole presentation of relapsing acute lymphoblastic leukemia / Relaps Akut Lenfoblastik Losemide Tek Bulgu Olarak Unilateral Eksudatif Retina Dekolmani.

Abstract

Ocular Findings are rarely the initial symptom of leukemia, although up to 90% of all leukemia patients have fundus changes during the course of the disease. Herein we report a relapsing acute lymphoblastic leukemia patient with the sole presentation of sudden visual loss and exudative retinal detachment. An 8-year-old boy with acute lymphoblastic leukemia developed sudden visual loss during his first remission period. Bullous retinal detachment with total afferent pupillary defect was observed. Orbital magnetic resonance imaging revealed an intraocular mass lesion; simultaneously obtained bone marrow and cerebrospinal fluid samples showed no evidence of leukemic cells. Following local irradiation, and systemic and intrathecal chemotherapy the mass disappeared. Local irradiation, and systemic and intrathecal chemotherapy effectively controlled the isolated ocular relapse of acute lymphoblastic leukemia and eliminated the need for enucleation.

Key Words: Acute lymphoblastic leukemia, Exudative retinal detachment, Relapse

Ozet

Loseminin seyrinde fundus degisiklikleri tum hastalarin %90'inda gorulmesine ragmen, losemide goz tutulumu nadiren ilk bulgu olarak karsimiza cikar. Burada, ani gorme kaybi ve eksudatif retina dekolmaninin akut lenfoblastik losemili bir olguda relapsin ilk bulgusu olarak saptandigini bildiriyoruz. Sekiz yainda akut lenfoblastik losemi tanisi alan bir erkek cocukta birinci remisyon doneminde ani gorme kaybi gelisti. Total afferent pupiller defekt ile birlikte bulloz retina dekolmani tespit edildi. Orbital manyetik rezonans goruntuleme ile intraokuler kitle lezyonu oldugu belirlendi. Es zamanli yapilan kemik iligi ve beyin omurilik sivisi incelemelerinde losemik tutulum saptanmadi. Lokal radyoterapi sonrast sistemik ve intratekal kemoterapi uygulandi, kitlede rezolusyon gelisti. Sonuc olarak, akut lenfoblastik losemide gdritlebilen izole goz relapsinin kontrol altina alinmasinda lokal radyoterapi, sistemik ve intratekal kemoterapinin etkili oldugunu ve entikleasyon gereksinimini ortadan kaldirdtgint belirtiyoruz.

Anahtar Sozciikler: Akut lenfoblastik losemi, Eksudatif retina dekolmant, Relaps

Introduction

Ocular symptoms in leukemia patients may be due to the direct effect of leukemic cells on ocular tissues or secondary to such disease-related complications as anemia, thrombocytopenia, and hyperviscosity syndrome (1). Acute leukemias are associated with eye involvement more commonly than chronic leukemias (2). The choroid and retina are the most common sites of leukemic involvement (3), and leukemic involvement in the iris, ciliary body, optic nerve, and conjunctiva, as well as leukemic hypopyon have also been reported (4), (5). Herein we report a relapsing acute lymphoblastic leukemia (ALL) patient with unilateral sudden visual loss and exudative retinal detachment as the sole presentation, as well as a discussion of the outcome following local irradiation, and systemic and intrathecal chemotherapy.

Case

An 8-year-old boy diagnosed as pre-B ALL [flow cytometry; CD 10 (%92), CD 19 (%96), CD 20 (%86), CD22 (%80)] was treated according to the St. Jude Total XII.1 high-risk (HR) protocol. Cerebral spinal fluid (CSF) was normal. According to the treatment protocol, due to the risk of central nervous system relapse radiotherapy (RT) was not administered.. During the 97th week of treatment (27 months after the diagnosis) the patient developed unilateral sudden visual loss during his first remission period.

His best-corrected visual acuity was 10/10 in the right eye, whereas light perception was absent in the left eye. Color vision could not be evaluated in the left eye and was 12/12 in the right eye. There was total afferent pupillary defect in the left eye. Eye movements were full. Intraocular pressure was within normal limits in both eyes. Slit-lamp examination showed bulbous exudative retinal detachment in the left eye and a completely normal right eye (Figure 1)

[FIGURE 1 OMITTED]

Ocular ultrasonographic examination showed total retinal detachment and a mass lesion that completely filled the bulbus oculi. Hyperechoic lesions indicative of calcification were not noted. Orbital magnetic resonance imaging (MRI) showed a 2 x 1.5-cm mass lesion with irregular borders that completely filled the bulbus oculi (Figure 2). Bone marrow and CSF examinations were normal. The mass in the bulbus oculi was considered as ocular relapse, though it was not biopsy proven.

[FIGURE 2 OMITTED]

As soon as ocular relapse was diagnosed, re-induction therapy was initiated according to the St. Jude Total XIII-HR protocol (6). The patient received orbital RT at a dose of 2340 cGy in 10 fractions. Follow-up orbital. MRI showed crescent-shaped fibrotic tissue at the posterior region of the left bulbus oculi, which was considered calcification, but there was no evidence of a mass related with ocular relapse (Figure 3). Although his visual capacity didn't recover, the patient remained in remission for 18 months following ocular relapse. Extramedullary relapse treatment was continued, according to the St. Jude Total XIII-HR protocol. I had written informed consent and there is no conflict of interest related to manuscript

[FIGURE 3 OMITTED]

Discussion

Ocular involvement in children with ALL, which is typically bilateral, is usually observed with concomitant central nervous system and/or bone marrow relapse (7), (8). Improved leukemia therapies for children have resulted in prolonged remission; even with extramedullary relapses in the most common ones (bone marrow, testes, brain, and spinal cord). Ocular symptoms of ALL may be more striking than systemic symptoms, and may be the primary reason for presentation at the time of initial diagnosis. Nonetheless, exudative retinal detachment as the sole presentation of relapsing ALL in the absence of concomitant central nervous system and/or bone marrow relapse is unusual, and only 3 such cases have been reported (9-11).

The differential diagnosis in leukemic patients with exudative retinal detachment includes central serous choroidopathy, uveal effusion syndrome, choroidal neovascularization, Harada's syndrome, congenital optic disc pits., choroidal melanoma, and severe intraocular hypotony (12). All of the possibilities which were mentioned above, excluded in the present case due to age, patient history and ophthalmologic examination findings.

Primack et al. reported a 3.5-year-old boy with a history of ALL that presented with total retinal detachment during a period of remission. Painful glaucoma that was unresponsive to medical therapy necessitated enucleation. Histopathologic examination showed leukemic infiltration of the retina and optic nerve. The child remained leukemia-Free for 3 years following systemic and intrathecal chemotherapy, and craniospinal RT. This was the first reported case of relapsing ALL with retinal detachment as the sole presentation (11).

Schmiegelow et al. reported a 17-year-old female ALL patient with serous retinal detachment and choroidal hemorrhagic infiltration as the presenting signs of relapse, without concurrent bone marrow or central nervous system involvement 1 year after cessation of therapy. No malignant cells were observed in subretinal fluid obtained during choroidal biopsy performed via sclerotomy. She was treated with prednisone, topical corticosteroid, and atropine, which resulted in normalization of vision and clinical findings; however, retinal detachment and choroidal infiltration recurred 5 months later. Pars plana vitrectomy and retinotomy were performed to remove subretinal tissue, which showed that there was leukemic infiltration in the choroid and concurrent bone marrow relapse (13).

The presented patient is the fourth reported case of exudative retinal detachment as the sole presenting sign of relapsing ALL in the absence of concomitant systemic involvement. We did not confirm the presence of leukemic cells in the patient's bulbus oculi, because we did not obtain a biopsy specimen due to technical difficulties. We did observe a new growing mass in the bulbus oculi via ultrasonography and MRI, and considered the findings as leukemic relapse. As a general rule, newly observed growing mass lesions are regarded as metastasis in cancer patients unless proved .otherwise. The mass in the presented patient responded to local irradiation, and systemic and intrathecal chemotherapy. The mass disappeared, leaving behind crescent-shaped fibrotic tissue in the bulbus oculi. This response confirmed the diagnosis of the mass as leukemic infiltration. There are different therapeutic options for leukemic infiltration of the bulbus oculi in ALL patients; evisceration, enucleation, local RT, and systemic chemotherapy are methods that can be combined, according to each patient (9-11), (13), (14)

In conclusion, local irradiation, and systemic and in intrathecal chemotherapy effectively controlled the isolated ocular relapse of ALL in the presented case, and eliminated the necessity for enucleation.

Conflict of Interest Statement

The authors of this paper have no conflicts of interest, including specific financial interests, relationships, and/or affiliations relevant to the subject matter or materials included.

Address for Correspondence: Fatih Mehmet AZIK, M.D.,

Kundereli Sok. Nkapi, Ankara, Turkey

Phone: +90 312 317 99 89 E-mail: mlanhazik@yahoo.com

Received/Gelis tarihi : January 24, 2009

Accepted/Kabul tarihi : October 20, 2009

References

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(3.) Robb RM, Ervin LD, Sallan SE: An autopsy study of eye involvement in acute leukemia of childhood. Med Pedlar Oncol 1979; 6: 171-177

(4.) Fonken HA, Ellis PP: Leukemic infiltrates in the iris. Arch Ophthalmol 1966; 76: 32-36

(5.) Abramson DH, Wachtel A, Watson CW, Jereb B, Wollner N: Leukemic hypopyon. J Pediatr Ophthalmol Strabismus 1981; 18: 42-44

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(9.) Stewart MW, Gitter KA, Cohen G: Acute leukemia presenting as a unilateral exudative retinal detachment. Retina 1989; 9: 11.0-114

(10.) Tang RA, Vila-Coro AA, Wall S, Frankel LS: Case report. Acute leukemia presenting as a retinal pigment epithelium detachment. Arch Ophthalmol 1988; 106: 21-22

(11.) Primack JD, Smith ME, Tychsen L: Retinal detachment in a child as the first sign of leukemic relapse: Histopathology, MRI findings, treatment, and tumor-free follow up. J Pediatr Ophthalmol Strabismus 1995; 32: 253-256

(12.) Watzke RC: Acquired macular disease. In: Duane TD, ed. Clinical Ophthalmology. 1th ed. New York: Harper & Row Publishers Inc, 1979: 2-11

(13.) Schmiegelow K, Scherfig E, Prause JU, Jensen OA: Isolated leukemic choroidal relapse in a child with acute lymphoblastic leukemia one year off therapy, diagnosed through transvitreal retino-choroiclal biopsy. Acta Ophthalmol 1988; 66: 33-37

(14.) Birinci H, Albayrak D, Oge I, Kaman A: Ocular involvement in childhood acute lymphoblastic leukemia. J Pediatr Ophthalmol Strabismus 2001; 38: 242-244

Fatih Mehmet Azik (1), Arsen Akinci (1), Tulin Revide Sayli (1), Vildan Kosan Culha (1), Kuddusi Teberik (2), Mehmet Yasin Teke (2), Fatih Gurbuz (1)

(1) Diskapi Children's Hospital, Department of Pediatric Hematology, Ankara, Turkey

(2) Ulucanlar Eye Hospital, Ankara, Turkey
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Author:Azik, Fatih Mehmet; Akinci, Arsen; Sayli, Tulin Revide; Culha, Vildan Kosan; Teberik, Kuddusi; Teke,
Publication:Turkish Journal of Hematology
Article Type:Case study
Geographic Code:7TURK
Date:Jun 1, 2012
Words:1751
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