Spontaneous remission of acute lymphoblastic leukemia: A series of nine cases and a review of literature

Abstract

Aims To report a series of acute lymphoblastic leukemia (ALL) cases with spontaneous remission and provide presenting clinical and pathologic information and details of clinical course to raise awareness among oncologists and patients. Methods We identified and analyzed nine patients with ALL and spontaneous remission. Review of literature reveals an additional nine previously reported cases with similar clinical course. Results All of these patients, ranging in age from 2 to 12 years of age, presented with inciting signs and symptoms of viral or bacterial infection. All of the patients showed varying percentages of lymphoblasts (.2% to 90%) in diagnostic bone marrow biopsy. All B‐ALL cases shared a similar blast phenotype on flow cytometry with coexpression of CD19, CD10 and TdT and variable CD20 expression. All nine patients achieved spontaneous remission of their leukemia as confirmed by flow cytometry and/or bone marrow biopsy without chemotherapeutic intervention. Time to remission from presentation ranged from 1 to 8 weeks. After remission, all patients redeveloped ALL, and time from remission to reemergence ranged from 2 to 24 weeks. Conclusion Our series of cases and cases identified in literature show that ALL diagnosed with modern methods of flow cytometry and molecular analysis will recur within weeks to months from disappearance, usually with cytopenias, which provides a template for oncologic follow‐up and testing in these patients.

Spontaneous Remission of Acute Lymphoblastic Leukemia Following Candida tropicalis Fungemia

“…SR; however, has been reported more commonly in children with AML, and the interval range to relapse is 0-16 months with a mean of seven months [13]. A review of the literature regarding SR in ALL suggests a similar mean time to relapse although the size of the studies is smaller [2][3][4][7][8][9][10]12]. Given that all reported SR cases resulted in a relapse, which worsens the prognosis of ALL, we contemplate it would be favorable to implement low-dose maintenance chemotherapy following SR such as methotrexate or 6-mercaptopurine.…”

“…In leukemia specifically, the presumed immunologic mechanism of cytokine storm stems from the recent or concurrent history of febrile illness with bacterial or viral septicemia. Cytokines, including TNF-a, IFN-g, and IL-2, have been demonstrated to have anti-tumor effects in vitro [ 8 ]. It has been proposed that fungal toll-like receptors (e.g., TLR2/TLR9), especially when compounded by a cytokine storm, may shift the immune system into an activated tumor microenvironment stimulating antileukemic effects.…”

“…fungal antigens, which may cross-react with antigens on leukemic blasts leading to SR [ 11 ]. Finally, hormonal involvement has been proposed as a mechanism of SR, as profound increases in adrenocorticotropic hormone (ACTH) and cortisol are known to be released as a stress response to septicemia, and exogenous corticosteroids have been shown to aid in remission of leukemia [ 8 ]. In our case, dexamethasone was used during induction although it was discontinued at the onset of her acute deterioration.…”

Acute Lymphoblastic Leukemia cured without treatment – is That So?

“…Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy, accounting for approximately 25% of all cancers in children up to 15 years old. When left untreated, its natural history is that of uncontrolled proliferation of neoplastic lymphoblasts, resulting in decreased production of normal functional hematopoietic cells, ultimately leading to progressively worsening anemia, bleeding, infection, and fatal organ failure [1].…”