Intracerebral metastasis in pediatric acute lymphoblastic leukemia: A rare presentation
A 7-year-old boy presented with fatigue, fever, and generalized bone pain lasting for a month. Physical examination yielded cervical and inguinal lymphadenopathies besides hepatosplenomegaly. Complete blood count revealed hemoglobin; 9.5 g/dL, platelet; 24 × 109/L and leukocyte count; 12 × 109/L with 70% blast on the peripheral smear. Bone marrow aspiration confirmed the diagnosis of ALL - French-American-British (FAB) L2 type - and common ALL antigen (+) B ALL with flow cytometry (CD10: 89%, CD19: 82%, CD22: 94%, and TdT: 38%). Cytogenetic evaluation was 46; XY. Polymerase chain reaction (PCR) showed negative t (9;22), t (1;19), and t (11,14). No lymphoblast was demonstrated in CSF. He was enrolled in low risk arm of ALL chemotherapy protocol.[]\nAfter the 22 weeks of the therapy, he experienced generalized tonic-clonic convulsion. However, CSF evaluation and cranial magnetic resonance imaging (MRI) showed no involvement. On the 55th week; lymphoblasts were detected in CSF by cytocentrifugation during routine examination. Cranial MRI was normal again. He was retreated with St Jude TXIIIB induction protocol[] and triple intrathecal (IT) (metotrexate-cytarabine and prednisolone) therapy was performed twice a week until the clearance of the CSF. Triple IT therapy was continued monthly and craniospinal radiotherapy was also added to the protocol.\nAt the end of the treatment on 120th week, he achieved complete remission without blasts in bone marrow and CSF. He was admitted to emergency room with right hemiparesis a year later. Physical examination showed significant decrease in muscle power on the right side of the body, anisocoria, and bilateral papilledema by fundoscopic evaluation. Computerized cranial tomography (CCT) yielded a mass in size up to 6 cm in the largest diameter located in deep white matter of left anterior frontal lobe. CSF evaluation showed TdT positive lymphoblasts with high protein level (82 mg/dL). Bone marrow aspiration showed no blast again. Complete surgical resection was performed, and he gained the function of right extremities dramatically the day after the operation. Immunohistochemical staining demonstrated diffuse positivity with CD10 and patchy positivity with TdT. Owing to the diagnosis of the second isolated CNS relapse, a new chemotherapy protocol was planned, but the family refused the therapy and left the hospital.\nHe presented with decreased muscle power on the right side of the body and headache again 3 months after the operation. New cranial imaging showed the recurrence of the hyperdense lesion with the dimensions of 8 × 5 cm and midline shift []. Triple IT therapy twice a week was performed till the CSF was cleared of blasts, and St Jude ALL relapse protocol was started. The mass begun to decrease in size and was completely shrunken a month later without surgical intervention.\nHe completed ALL relapse protocol and is still in remission with no blast in CSF and bone marrow. The MRI at the end of the relapse protocol showed bilateral parietal subdural collections and gliotic-atrophic signal changes in left anterior frontal lobe [].