Successful treatment of secondary acute myeloid leukemia relapsing after allogeneic bone marrow transplantation with donor lymphocyte infusion failed to prevent recurrence of primary disease: a case report

Abstract

Summary:We report a case of therapy-related secondary acute myeloid leukemia occurring in a patient during treatment for anaplastic large cell lymphoma. In spite of response to induction chemotherapy and prompt bone marrow transplantation from his matched sister, the patient experienced an early leukemia relapse within 3 months of the transplant. Treatment with oral etoposide for 3 weeks followed by donor lymphocyte infusion achieved a 7-month remission from leukemia without any further treatment. Unfortunately, the patient suffered a recurrence of the primary anaplastic large cell lymphoma that was treated by resuming chemotherapy and local radiotherapy. The patient died 20 months after DLI, still in CR for his leukemia, due to ALCL progression. Keywords: anaplastic large cell lymphoma; donor lymphocyte infusion; allogeneic bone marrow transplantation; immunotherapy Relapse of a hematological malignancy after allogeneic bone marrow transplantation (BMT) is often inadequately dealt with by conventional treatment. 1 In the past few years, several authors have reported that donor lymphocyte infusion (DLI) can induce stable remissions in patients with cytogenetic or hematological relapse of chronic myeloid leukemia after BMT. 2,3 The efficacy of this approach has also been reported, though less frequently, in other malignancies. 2,4 The rationale for this treatment is based on the anti-leukemic effect of allogeneic BMT, called graft-versus-leukemia (GVL), mediated by donor lymphocytes (T cells and natural killers cells). 5 To improve the outcome of DLI in acute leukemia, an increase in the number of infused cells could be explored, but at risk of severe toxicity since GVL effect is closely associated with GVHD. Cell-reducing chemotherapy has been used before DLI to reduce tumor burden and enhance the ratio of the donor allogeneic cells to the host leukemic cells.We report a case of secondary AML (sAML) relapsing after matched related allogeneic BMT successfully treated with chemotherapy and DLI, although this treatment failed to prevent recurrence of the primary disease. Case reportAn anaplastic large cell lymphoma (ALCL) was diagnosed on bone biopsy in a 15-year-old male with bone pain (left shoulder and right leg) and osteolytic lesions (right anterior iliac spine and proximal left humerus). Immunological typing was CD30 + , T and B−. Cytogenetic analysis revealed the typical t(2;5) chromosomal translocation. Medical history revealed a family history of cancer: his father had been cured 9 year earlier of lymphoma and his grandfather had suffered from cancer of the testis and larynx.Chemotherapy was administered according to the AIEOP (Italian Association of Pediatric Hematology-Oncology) NHL 92-ALCL protocol. After an LSA2-L2-like induction and consolidation courses (Table 1), the patient was treated with maintenance phase I (weekly, alternating a couple of drugs) until completion of the 12 months of therapy, and maintenance phase II (weekly methotrexate and daily 6-mercaptopurin) for a total 24 months of therapy...