Isolated Eye Relapse of Acute Lymphocy tic Leukemia during Intensification Therapy with Vincristine and Prednisolone

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1 Jpn. J. Pediatr. Hematol. 2: , 1988 Case Report Isolated Eye Relapse of Acute Lymphocy tic Leukemia during Intensification Therapy with Vincristine and Prednisolone Fumio BEssHo,*1 Hiroshi KINUMAKI,*2 and Kimitugu OGINo,*3 *,Department of Pediatrics, University of Tokyo Hospital *2Department of Pediatrics, Tokyo Metropolitan Komagome Hospital *3Department of Ophthalmology, University of Tokyo Hospital Abstract A 6-year-old boy with acute lymphocytic leukemia developed hyperemia in the left conjunctiva bulbi during intensification therapy with vincristine and prednisolone 13 months after diagnosis. Ophthalmologic examination revealed cells in the anterior chamber. Examination of cytocentrifuged smears confirmed the presence of leukemic cells in the anterior chamber fluid. Bone marrow and cerebrospinal fluid were free of leukemic cells. Isolated eye relapse was diagnosed, and radiotherapy of 2,000 cgy to the left eye and systemic reinduction therapy were given with intrathecal chemotherapy. Ten months later, routine follow-up examination revealed the reappearance of cells in the left anterior chamber and the presence of cells in the contralateral anterior chamber as well. At this time bone marrow and cerebrospinal fluid were again free of leukemic cells. This case illustrates that the eyes are one of the sanctuary sites independent of the central nervous system, and that the treatment of eye relapse is very difficult. Key words: eye relapse of acute lymphocytic leukemia, hyperemia of conjunctiva bulbi, anterior chamber fluid cytology Received March 10, 1988 Reprint requests to Fumio Bessho, Department of Pediatrics, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113 Japan Although leukemic eye infiltration itself is not uncommon,1,2) isolated eye involvement as the first relapse is rare. This type of relapse after cessation of therapy has been thought to indicate that the eye is a sanctuary for leukemic processes.3) We describe here a case of acute lymphocytic

2 Isolated Eye Relapse of Acute Lymphocytic Leukemia 407 leukemia (ALL) who relapsed only in the eye during intensification therapy with prednisolone and vincristine with no evidence of relapse in any other sites. This case provides further evidence that the eye is a sanctuary. I. Case Report A 6-year-old boy who was first diagnosed as having ALL in November 1985 developed hyperemia in the left conjunctiva bulbi during the fourth intensification therapy 13 months after diagnosis. His initial features were as follows : white blood cell count 2.9 ~ 109 /l with 22% of blasts, dry bone marrow showing 82.6% of blasts, whose immunological surface markers could not be analyzed, no blasts in cerebrospinal fluid (CSF), no hepatosplenomegaly or mediastinal mass. Remission was induced with prednisolone (Pred), vincristine (VCR), and L-asparaginase without complications. After cranial irradiation of 1,800 cgy, he had been maintained on oral methotrexate (MTX) and 6-mercaptopurine (6-MP) with intermittent pulses of Pred and VCR of 3-week duration. Just before starting the fourth course of intensification therapy, bone marrow and CSF examination had confirmed complete remission. Hyperemia of conjunctiva bulbi was not associated with any subjective symptoms, such as photophobia, eye pain, or visual disturbance, and it was initially diagnosed as infective conjunctivitis. However, since it lasted too long, ophthalmologic consultation was made. Ophthalmoscopic examination revealed the presence of cells in the anterior chamber and vitreous body, as well as retinal bleeding and vasculitis in the left eye. The intraocular pressure was normal in both eyes. The right eye appeared to be normal. Left eye involvement by leukemia was suspected, and about 0.2 ml of clear fluid was obtained from the anterior chamber for cytological examination. A total of 450 cells were counted on two slides made by cytocentrifugation, and 11.9% of cells were identified as leukemic blasts (Fig. 1a), one of which showed mitosis (Fig. 1 b). Repeated bone marrow aspiration and spinal tap showed no blasts in bone marrow or CSF. The diagnosis of isolated left eye involvement of ALL was made. Radiotherapy of 2,000 cgy to the left eye was given with systemic reinduction therapy consisting of Pred, VCR, and daunorubicin, as well as intrathecal injection of Fig. 1 Photomicrographs of leukemic cells in the left anterior chamber fluid A mitotic figure is shown in B. M: macrophage. Cytocentrifuged smear. May-Grunwald-Giemsa strain. ~ 3,700.

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4 Isolated Eye Relapse of Acute Lymphocytic Leukemia 409 MTX, hydrocortisone, and cytosine arabinoside. Ten months later on maintenance therapy with oral MTX and 6-MP and intermittent pulses with Fred and VCR, routine follow-up ophthalmologic examination revealed the reappearance of cells in the left anterior chamber and also in the contralateral anterior chamber, but bone marrow and CSF were again free of leukemic cells. II. Discussion Eye involvement was not a rare manifestation before the introduction of preventive measures for central nervous system (CNS) leukemia, and it was usually a part of CNS leukemia,2) which could either precede4-6) or be concurrent with eye involvement.7) Isolated eye relapse of leukemia is very rare and often occurs after cessation of treatment, as shown in several reports. Table 1 shows characteristics of patients reported to have eye relapse without prior or concurrent CNS relapse. Of 14 patients, 9 developed eye relapse during off-therapy. Although periods between off-therapy to eye relapse were specified for only 6 patients, eye relapse developed within 1 year of off-therapy in 5 patients. On the other hand, patients, including ours, who developed eye relapse during maintenance therapy did so more than 1 year after diagnosis. These features of eye involvement are similar to testicular relapse. Moreover, the response to therapy was also similar ; that is, prognosis after eye relapse, which developed during off-therapy, is much better than when relapse occurs during treatment.15-17) Of 9 patients who developed eye relapse during off-therapy, 8 had survived 5 to 22 months despite the uncontrollable eye relapse, while most patients who developed eye relapse during therapy died or developed bone marrow relapse, CNS relapse, or both. These findings indicate that the eye is a sanctuary, as is the testis. To control local disease, irradiation to the eye seems to be essential. Local medication given as eye drops or subconjunctival injection. was effective, but response to this management was generally transient at best. However, the dose of radiation sufficient to control local disease has not been determined. Reported doses varied from 350 to 3,900 cgy; even the lowest dose seemed to be adequate in some cases, whereas a large dose such as 3,900 cgy failed to eradicate local disease in other cases. In spite of 2,000 cgy to the involved eye, the present case had a second relapse in the same eye. At the same time the contralateral eye also had leukemic infiltration, but the bone marrow and CSF again remained free of leukemia. This case illustrates that the eyes are one of the sanctuary sites independent of the central nervous system, and treatment of such eye relapse is difficult. Hyperemia of conjunctiva bulbi is one of the most frequent symptoms of eye involvement of leukemic process (Table 2), as exemplified by our patient. However, other signs and symptoms, such as photophobia, eye pain, mass in the iris, increased intraocular pressure, and hypopyon usually accompany red conjunctiva. In particular, photophobia is as frequent as hyperemia of conjunctiva. Since conjunctivitis is a common eye disease in children, it is difficult to think of leukemic eye involvement on the basis of hyperemia of conjunctiva when it is a sole manifestation. Our patient was brought in for ophthalmologic examination because of prolonged unilateral conjunctivitis. It is important to perform a Table 2 Frequency of presenting symptoms and signs of 12 patients with leukemic eye infiltration reported in the literature including cases with previous or concurrent central nervous system leukemia Data were accumulated from references 3-11, 14, and the present case.

5 410 The Japanese Journal of Pediatric Hematology Vol. 2 No. 4 (December 1988) thorough ophthalmologic examination when unexplained signs and symptoms of the eye are noted during follow-up of leukemia, and to examine anterior chamber fluid by cytocentrifugation for leukemic blasts. References 1) Allen RA, Straatsma BR : Ocular involvement in leukemia and allied disorders. Arch Ophthalmol 66: , ) Ridgway EW, Jaffe N, Walton DS : Leukemic ophthalmopathy in children. Cancer 38: , ) Ninane J, Taylor D, Day S : The eye as a sanctuary in acute lymphoblastic leukaemia. Lancet 1: , ) Rown PJ, Sloan JB: Iris and anterior chamber involvement in leukemia. Ann Ophthalmol 8: , ) Zakka KA, Yee RD, Shorr N, et al: Leukemic iris infiltration. Am J Ophthalmol 89: , ) Smith WS, Burke MJ, Wong KY: Hypopyon in acute lymphoblastic leukemia. Med Pediatr Oncol 12 : , ) Holbrook CT, Elsas FJ, Crist WM, et al : Acute leukemia and hypopyon. J Pediatr 93: , ) Masera G, Carnelli V, Uderzo C, et al : Leukaemic hypopyon in acute lymphoblastic leukemia after interruption of treatment. Arch Dis Child 54: 73-74, ) Grunewald RL, Perry MC, Henry PH : Leukemic iritis with hypopyon. Cancer 44: , ) Lin HP, Chandran S, Tan MK, et al : Hypopyon- An early sign of leukaemic relapse. Med Pediatr Oncol 8: , ) Abramson DH, Wachtel A, Watson CW, et al: Leukemic hypopyon. J Pediatr Ophthalmol Strab 18: 42-44, ) Jankovic M, Masera G, Uderzo C, et al : Recurrence of isolated leukemic hypopyon in a child with acute lymphoblastic leukemia. Cancer 57: , ) Bunin N, Rivera G, Goode F, et al : Ocular relapse in the anterior chamber in childhood acute lymphoblastic leukemia. J Clin Oncol 5: , ) Behrendt H, Wenniger-Prick LMdB: Leukemic iris infiltration as the only site of relapse in a child with acute lymphoblastic leukemia : Temporary remission with high-dose chemotherapy. Med Pediatr Oncol 13: , ) Nesbit ME, Robinson LL, Ortega JA, et al : Testicular relapse in childhood acute lymphoblastic leukemia : Association with pretreatment patient characteristics and treatment. A report for Childrens Cancer Study Group. Cancer 45: , ) Tiedemann K, Chessells JM, Sandland RM : Isolated testicular relapse in boys with acute lymphoblastic leukaemia : treatment and outcome. Br Med J 285: , ) Ortega JJ, Javier G, Toran N: Testicular infiltrate in children with acute lymphoblastic leukemia : A prospective study. Med Pediatr Oncol 12 : , 1984