Document g2oOZaQj1xY97MNvzD3brODO9

HODGKIIY'S DISEASE TERMINATING IN ACUTE LEUKEMIA S. OSTAM, D,* M. WELLSM, D,+ M. VIAMONTE, MD,$ AND D. HARKNESS,MD A patient with Hodgkin's disease, whose disease terminated 18 months after diagnosis with the almost explosive appearance of acute myelocytic leukemia, is described. The unusual relationship between Hodgkin's disease and acute leukemia is briefly discussed. THE OCCURRENCE OF A LEUKEMIC PHASE IS a rare finding in Hodgkin's disease. Only 6 cases of acute leukemia in patients with proven Hodgkin's disease have been reported in the American literature5~6 and one case in the European literature.3 T h e purpose of this communication is to report an additional case and to discuss the possible relationship between the 2 conditions, as well as the role of radiation therapy in the development of the acute leukemia. CASEREPORT A 60-year-old Filipino man was admitted to the Veterans Administration Hospital for the third time in September 1968; he died within 4 days. His symptoms began in November 1967, with the onset of fever, nigh,t sweats, anorexia, and weight loss. I n January 1968, 2 enlarged cervical and supraclavicular nodes were removed. T h e histologic appsearance was compatible with a diagnosis of Hodgkin's disease, lymphohistiocytic type (Fig. 1). T h e patient received cobalt supervoltage therapy with a dose of 4,100 rads to the cervical region and 3,000 rads to the medias- From the Division of Hematology, Department of Medicine, University of Miami School of Medicine, and the Veterans Administration Hospital, Miami, Fla*.Assistant Professor of Medlicine, University of Miami School of Medicine. t Staff Pathologist, Mount Sinai Hospital of Greater Miami; staff physician, VA Hospital. $ Associate Professor of Medicine, University of Miami School of Medicine. Address for reprints: D. R. Harkness, MD, Chief of Hematology, Veterans Administiration Hospital, 1201 N.W. 16th St., Miami, Fla. 33125. The authors are indebted to Dlr. H. Rappaport who kindly reviewed both the antemortem and postmortem pathologic materials and who was of the opinion that the leukemia was oE the acute myelocytic variety. Received for publication March 30, 1970. tinum. He was asymptomatic for only 2 weeks following therapy. I n April 1968, the lesions of herpes zoster appeared on the left side of the abdomen, and the patient was admitted for the first time to the Miami VAH. On physical examination, he was emaciated but in no acute distress. T h e only pertinent physical findings were the aforementioned herpetic lesions and a liver enlarged to 7 cm below the costal margin. T h e hematocrit was 28% and the white blood cell count was 4,750 per mm3. T h e sternal marrow was hypocelM a r with normal distribution of marrow elements. Coombs' test was positive. Liver biopsy was normal. Lymphangiography showed involvement of the retroperitoneal lymph nodes. Because of the anemia, anorexia, and fever, therapy with prednisone, 60 mg daily, was instituted. T h e hematocrit rose 8%, and Coombs' test became negative. T h e patient began to gain weight and the fever subsided initially. I n May, he received 5 mg of Velban (vinblastine sulfate, Lilly), and, in June, a new course of cobalt therapy was begun. H e received 3,000 rads to the para-aortic area and 3,000 rads to the mid-plane of the pelvis. His symptoms persisted. In August, the patient was readmitted to the hospital with fever and increasing weakness. A new left axillary node, 2 cm in diameter, was palpable. Pancytopenia was pres- ent. Following therapy with isoniazide and blood transfusions, his symptoms subsided and he was discharged. His final admission was prompted once more by increasing weakness and fever of 3 days' duration. He was acutely ill, and bilateral pulmonary consolidation was present. New shotty nodes had appeared in the right axilla and both femoral areas. T h e liver was palpable 6 cm below the costal margin. The hematocrit was 24% and the white cell count was 6400 mm3. Immature granulocytes were present and occasional Auer rods were seen in these cells. Sputum and blood cultures grew 795 796 CANCEROctober 1970 Vol. 26 FIG. 1 . Section of lymph node showing typical Sternberg-Reed cells and neoplastic and nonneoplastic histiocytes surrounded by mature well differentiated lymphocytes (H and E, ~ 8 5 0 ) . out Eschcyirhia roli in spite of antibiotic therapy. Fever persisted throughout the hospital course. On the day he died, 4 days after admission, the peripheral leukocyte count rose abruptly to 130,000 mm3 with 60% blasts, some of which had monocytoid features (Fig. 2). Auer rods were again noted in some. A diagnosis of acute myelocytic leukemia was made. Necropsy findings: Gross examination revealed moderate enlargement of both the thoracic and abdominal nodes. T h e spleen weighed 250 g and the liver 1400 g. There was an effusion of 200 cc in the right pleural cavity. The fluid was light yellow in color. Patchy necrotizing bronchopneumonia was present in both lower lobes. E. coli was cultured from these areas. T h e vertebral marrow was pale and soft. The normal architecture of every node was replaced by either undifferentiated cells identified as immature granulocytes or a proliferation composed of atypical histiocytes, Sternberg-Reed cells, malignant histiocytes, No. 4 HODGKIND'BISEASWEITH ACUTELEUKEMIA Osta et al. 797 and lymphocytes (Fig. 3). T h e acute leukemic picture predominated in the liver and spleen, although there were typical areas of Hodgkin's involvement. T h e cellular infiltration in the bone marrow was composed mainly of undifferentiated cells similar to those of the peripheral blood. Infiltration by both acute leukemia and Hodgkin's disease was present in the lungs and heart. Acute leukemic infiltrates were also found in the large intestine, pancreas, kidneys, prostate gland, adrenals, thyroid, and parathyroid glands. DISCUSSION A leukemic blood picture is an unusual occurrence in Hodgkin's disease.8 Some authors believe that existence of the 2 diseases in the same patient represents only chance occurrence of the 2 entities,z, misdiagnosed cases of reticulum cell sarcoma, or lymphosarcomas where a leukemic phase is not unusual.1. 7, 9 Ezdinli and coworkers5 reported 3 cases of myelocytic leukemia, one of which was acute, FIG. 2. Peripheral blood smear contain- ing 60% blasts. Some of these immature cells had deep inden- t a t i o n of t h e n u cleus. Lack of nuclear segmentation, pfo- nounced condensation of the chromatin and typical Auer bodies were observed in some of these immature cells (H and E, 'x3OOO). 798 CANCEROctober 1970 Vol. 26 FIG. 3. Postmortem lymph node showing complete replacement of the normal archi- tecture by either undifferentiated cells which were identified as immature granulocytes from the periph- eral blood and bone marrow smears, and/ or a proliferation of atypical histiocytes, Sternberg-Reed celIs and malignant histio- cytes and fewer mature lymphocytes (H and E, x850). among a population of patients with Hodgkin's disease. They found that the latent period between the onset of radiation therapy and the development of leukemia in their cases and those in the literature was 7 years. T h e apparent recent increase in the incidence of acute leukemia in Hodgkin's disease was postulated to be related to the higher doses of radiation therapy currently employed. Chromosomal abnormalities usually associated with leukemia were present in those cases with associated leukemia, but not in cases of Hodgkin's disease without concomitant leukemia. It was the opinion of these authors that the risk of developing leukemia is relatively small when compared to the improved management of Hodgkin's disease with supervoltage therapy. In our patient, radiation therapy had been instituted only 9 months prior to the onset of the acute leukemic process. Therefore, it is difficult to implicate it as a contributory factor in the development of acute leukemia in this patient. No. 4 HODGKIND'ISSEASWEITH ACUTELEUKEMIA Osta et al. REFERENCES 1. Adrial, M.: Leukemia and lymphoma cells. Attempt at correlation between hematological and anatomiral findings. Oncologiu 15:3-17, 1962. 2. Burnam, C. F.: Hodgkin's disease with special reference to its treatment by irradiation. ]ALMA 87:1445-52, 1926. 3. Cavallero, G., and Bo, G.: Associazione d i leucosi acuta in differenziata e di granulomatosi maligna di Hodgkin in un bambino. Pathologica 58:11@-20, 19GG. 4. Dameshek, W., and Gunz, F.: Leukemia. New York, Grune and Stratton, 1964; lp. 28. 5. Ezdinli, E., Sokal, J. E., Aunept, C. W., Kim, U., and Sandberg, A. A.: Myeloid leukemia in Hodgkin's disease: chromosomal abnormalities. Ann. Intern. Med. 71:1097-1104, 1969. 6. Lacher, M. J., and Sussman, L. N.: Leukemia and Hodgkin's disease. A n n . Intern. dfed. 59:369-78, 1963. 7. Laszlo, J., and Grode, H. E.: Granulocytic Icakemia and reticulum ccll sarcoma. Cancer 20:545-51. 1967. 8. Reed, D. M.: On the pathological changes in Hodgkin's disease with special reference to it\ ielation to tuberculosis. Johns Hopkins Hosp. Rep. 10:13396, 1902. 9. Rosenberg, S. A., Diamond, H. D., and Craver, L. F.: Lymphosarcoma: the effects of therapy and survival in 1,269 patients in a review of 30 years' experience. Ann. Intern. Med. 53977-97, 1960.