Extramedullary Leukemia, Presenting at the Cervix of the Ute
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A 30-year-old female presented with vaginal (mid-cycle) spotting. Her last gynecological assessment had been unremarkable, with the most recent cervical smear—5 years ago—being negative for intraepithelial lesion or malignancy. During the last five years and following front-line chemotherapy, the patient relapsed twice. Nevertheless, over the previous 12 months, the young lady was considered to be in complete remission (CR).In the case of relapsed ALL patients in CR, the hematooncologic best practice is considered to be Hematopoietic Stem Cell Transplantation (HSCT) and this therapeutic plan was followed in the current case. The scheme of pretransplantation chemotherapy and total body irradiation was initiated in preparation for hosting the bone marrow graft. Due to the treatment, secondary amenorrhea has been induced; however, the patient visited her gynecologist due to vaginal spotting.

The standard gynecological examination, as a means of annual preventive strategy, typically includes a visual inspection of the external genitalia, vagina, and the cervix through a speculum. Moreover, transvaginal scans (TVS) were also performed.

On speculum examination, the outer two-thirds of the vagina and the cervix at the site of the transformation zone appeared normal. However, at the posterior fornix of the vagina, a “discolored area” was seen, extending to the cervix but not reaching the transformation zone and the cervical orifice. There were no obvious signs of laceration, bleeding, or neoplastic erosion of the epithelium. However, it drew the clinical suspicion of the attending gynecologist as an “atypical lesion” which necessitated further thorough evaluation. The impression at first was of an “enlarged/stony cervix at the bimanual examination,” mimicking a common benign condition such as a cervical fibroid. For completion purposes, a TVS was performed.

Analogously with the speculum inspection, TVS revealed at the site of the “discolored lesion” a hyperechogenic area and the relevant acoustic shadow was depicted. At the same visit, samples were taken for cytological examination, including smears from the cervical OS, aimed at evaluating the transformation zone, and smears from the site of the lesion. According to the cytological report, the cytological sample reflected “infiltration of the cervix by lymphoblastic cells”. Following that, the diagnosis of disease relapse was established with extramedullary localization of leukemia. Specifically, the case presented refers to the rare finding of “nonprimary cervical disease—lymphoblastic leukemia, presenting with cervical pathology.”

Source: https://www.hindawi.com/journals/criog/2020/8492036/
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