ALL radiology.pdf

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CASE REPORT

Acute lymphoblastic leukaemia: an unusual radiological

presentation

R Ali*,1, A Brooke2 and J Luker2

1Department of Oral and Dental Science, Division of Restorative Dentistry, Bristol Dental Hospital, UK; 2Department of Oral and Dental Science, Division of Oral Medicine, Pathology and Microbiology, Bristol Dental Hospital, UK 

A 14-year-old female patient attended Bristol Dental Hospital for an oral screening prior toundergoing a bone marrow transplant as treatment for her acute lymphoblastic leukaemia.Maxillofacial radiographs revealed multiple, well-defined, non-corticated radiolucent lesionsthroughout the vault of her skull and mandible. These radiological features (coupled with the

patient’s age) would have correlated with a diagnosis of Langerhans cell histiocytosis.However, a previous bone marrow biopsy confirmed that the patient did indeed have acutelymphoblastic leukaemia. The lytic lesions were present throughout her entire skeletal frameand had previously led to episodes of leg and abdominal pain. We feel that this radiologicalpresentation of leukaemia needs to be reported as these features could easily have beenconfused with other haematological or even malignant conditions.Dentomaxillofacial Radiology (2009) 38, 289–291. doi: 10.1259/dmfr/53260198

Keywords: leukaemia, well defined, non-corticated, radiolucent, lesions

Case report

The Bone Marrow Transplant (BMT) Unit at BristolChildren’s Hospital has performed over 800 transplantson both paediatric and adult patients over the last10 years. As part of their BMT work-up, all patientsare dentally screened before undergoing chemotherapyto identify any potential areas of sepsis/oral pathology.

A 14-year-old female patient attended the PrimaryCare Unit at Bristol Dental Hospital for an oral screen,prior to undergoing a BMT as treatment for her acutelymphoblastic leukaemia (ALL). The patient hadpreviously received comprehensive chemotherapy fol-lowing the diagnosis of ALL in 2006, was allergic topenicillin, and her current medications included fusidic

acid, omeprazole and septrin.Intraoral examination revealed no obvious oral

mucosal lesions and her oral hygiene was excellent.The patient was fully dentate (with the exception of allfour third molars) and there was clinical evidence of caries in both upper first permanent molars.

Bitewing radiographs confirmed the presence of earlycaries in the upper first permanent molars. A panora-mic radiograph (PR) revealed full crown development

of all four third molars and significant radiolucencies inthe body and ascending ramus bilaterally (Figure 1).

The radiolucencies seen in Figure 1 were multiple,round, well-defined and non-corticated, and extendedthroughout the body and ascending ramus of themandible bilaterally. The lesions themselves variedfrom 1–2 cm in diameter and had a monolocular‘‘punched-out’’ appearance. In certain areas, theyappeared to have eroded the bony cortex. Furtherradiological investigations were requested and a lateralskull radiograph was taken (Figure 2).

This view confirmed the presence of multiple radi-olucent areas throughout the cranial vault. These

lesions had a similar punched-out, non-corticatedappearance to those present on the PR.

Classically, multiple punched-out non-corticatedlesions are associated with malignant multiple mye-loma1 and Langerhans cell histiocytosis.2 Discussionwith the paediatric oncologist revealed that thepatient’s original referral prior to diagnosis with ALLhad been due to lower abdominal and leg pain.Radiographic investigation showed multiple radiolu-cencies in the scapula (Figure 3) and further investiga-tion showed similar radiolucencies throughout theskeletal frame. A bone marrow biopsy and haematolo-gical investigation confirmed a diagnosis of ALL.

*Correspondence to: Mr Rahat Ali, Department of Oral and Dental Science,

Bristol Dental Hospital, Lower Maudlin Street, Bristol, BS1 2LY, UK; E-mail:

rahat224@hotmail.com

Received 12 March 2008; revised 19 May 2008; accepted 19 May 2008

Dentomaxillofacial Radiology (2009) 38, 289–291’ 2009 The British Institute of Radiology

http://dmfr.birjournals.org

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