|
|
|
|
Secondary Ovarian Malignancy in an Imatinib treated Chronic Myeloid Leukemia Patient Diagnosed on Fluid Cytology
Kaveripakam Ajay Joseph1, Sana Ahuja1, Sufian Zaheer1*
1Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.
Abstract
A BCR-ABL fusion product identifies chronic myeloid leukemia as a clonal myeloproliferative tumor. Tyrosine kinase inhibitors have become more widely used to treat chronic myeloid leukemia, although there is still little known about their long-term negative effects, such as the possibility of additional cancers. The most common secondary malignancies reported in CML are localized to the gastrointestinal tract, prostate, lung, non- Hodgkins lymphoma, malignant melanoma and breast cancer. Herein, we report a case of serous papillary adenocarcinoma of the ovary in a known case of chronic myeloid leukemia on imatinib therapy for the past three years. The 46-year-old lady presented to us with massive ascites. Cytological examination revealed features of a papillary adenocarcinoma. The cytological diagnosis was further confirmed by immunohistochemistry on the cell block. Secondary ovarian adenocarcinoma following imatinib therapy for chronic myeloid leukemia is uncommon with only one case reported to date. It is important to evaluate the long-term effects of imatinib therapy especially the risk of developing secondary malignancies.
Keywords: Adenocarcinoma, Chronic myeloid leukemia, Ovarian, Secondary malignancy, Tyrosine kinase inhibitors
Chronic myeloid leukemia (CML) is a clonal myeloproliferative syndrome characterized by the t(9;22)(q34;11) chromosomal translocation. In adults, instances of this BCR-ABL (+) [Breakpoint cluster region- Abelson] myeloproliferative illness account for 15%–20% of all leukemia cases. Every year, there are 1.9 new cases of CML in 100,000 men and women.[1] Tyrosine kinase inhibitors have been added to the chronic myeloid leukemia therapy regimen, improving patient survival.[2] The efficacy and short-term adverse effects of imatinib are well known, however, data on long-term side effects is limited.[3] As a result of the declining mortality, the risk of the development of a second malignant neoplasm become significant.
The most common secondary malignancies reported in CML are localized to the gastrointestinal tract, prostate, lung, non-Hodgkins lymphoma, malignant melanoma, and breast cancer.[4-7] However, secondary ovarian cancer has been reported only by Nakazato et al. [6]
Herein, we report a case of serous papillary adenocarcinoma of the ovary in a known case of chronic myeloid leukemia on imatinib therapy for the past three years.
We report a 46-year-old female, a known case of BCR-ABL positive chronic myeloid leukemia on imatinib therapy for the past 3 years who presented with complaints of massive ascites. Cytocentrifuged deposits were prepared from 25 ml of the hemorrhagic and turbid ascitic fluid sample. The smears were cellular and displayed clusters of benign mesothelial cells, inflammatory cells, and three-dimensional and papillaroid pieces of malignant cells with a high nucleus-to-cytoplasmic ratio, sparse to moderate cytoplasm, and conspicuous nucleoli (Figure 1).
Cell block preparation was made using the alcohol-formalin method and immunohistochemistry was performed to identify the possible site of primary.[8] The cell block showed a tumor arranged as papillae with central fibrovascular cores and tumor cells exhibiting moderate pleomorphism with prominent nucleoli.
On immunohistochemistry, the cells were positive for CK7, WT1, p53 and negative for CK20 and CDX2 (Figure 2). Based on the above panel, a final diagnosis of serous papillary adenocarcinoma ovary metastasizing to ascitic fluid was made. Further, contrast enhanced computed tomography (CECT) findings were suggestive of a large right adnexal mass thus confirming the cytological diagnosis. Her CA-125 levels were also markedly elevated. Her clinical staging was International Federation of Gynecology and Obstetrics (FIGO) Stage IC for which she was taken up for debulking surgery followed by chemotherapy with docetaxel 60-75mg/m2 and carboplatin area under curve (AUC) 5-6 repeated every 3 weeks for 6 cycles. She was compliant with the treatment and tolerated the chemotherapeutic regimen well.
The recent peripheral blood film of the patient showed her to be in complete hematological remission.[9] Her tumor markers and ultrasound scan were also normal and she is presently asymptomatic.
|
|
|
|
a) |
b) |
|
|
|
|
c) |
d) |
|
|
|
