https://orcid.org/0000-0002-8640-9776
![A 44-year-old man was referred in our hospital for asthenia, digestive disorders, faintness with fall at home. A computed tomography scan revealed a severe ruptured spleen, which immediately led to splenectomy. At this time, the blood count showed high leukocytosis (290 × 109/L) and anemia (8 g/dL) without thrombocytopenia (170 × 109/L). Blood smear examination revealed 96% of small blast cells with a high nuclear/cytoplasmic ratio and irregular nucleus (panel A; May-Grünwald-Giemsa stain, original magnification ×500). Flow cytometry detected CD45dim/cytCD3+/sCD3−/CD34−/TdT+/CD1a+/CD2+/CD5+/CD7+/CD4−/CD8+ T lymphoblasts (panel B). Surprisingly, the white blood cell count decreased drastically without treatment to 3 × 109/L 2 days later. The blast proportion also decreased to 1% with a concomitant high cell lysis rate confirmed by elevated lactate dehydrogenase (7830 U/L), suggesting that the spleen was the main source of blood blast cell dissemination. Histology confirmed massive infiltration of the spleen by cortical lymphoblastic T cells (panel Ci, hematoxylin and eosin stain [HES]; panel Cii, immunohistochemistry [IHC]). Due to an unsuccessful aspiration, bone marrow infiltration was not assessed. Molecular analysis demonstrated an unfavorable prognosis with T-cell acute lymphoblastic leukemia (T-ALL) classifier (NOTCH/FBXW7/RAS wild-type, PTEN mutation and deletion). Eleven days after splenectomy, induction chemotherapy by Group of Research on Adult ALL (GRAALL) protocol was started, which allowed a complete remission.](https://ash.silverchair-cdn.com/ash/content_public/journal/blood/136/1/10.1182_blood.2020005728/4/m_bloodbld2020005728f1.png?Expires=1765016077&Signature=uiwVBkvPcJhZudfLlb5lt2fgtBpVBTm17U~GS81m4plTAnnQixJlAXAw0kx0qnZPXGSkXbzdaS5VOnh4PQMOL9TnwwZ6ApfIAc5f5sBi3BPGh28TPqaiIV~czFt1c2WKECACVuzVSZHjCuBgdW7WwMoefWXVuBKhZa26twXb1INw63-B50U6W2CtYdQUySnSInrg~hcWkaWCJjMm6BLnTaMXL7qFz3UXDPcSeRLesI6PXbUXMkiG0Vc7ftwxdX1de3qakFWh-YulUKuG7iDJfqgewuqFnJzhyjagIoAMZBAsXfkq2SzJ3M2~3-raGh2SS7IC2dZpSzUTkKinQDMF4w__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA)
A 44-year-old man was referred in our hospital for asthenia, digestive disorders, faintness with fall at home. A computed tomography scan revealed a severe ruptured spleen, which immediately led to splenectomy. At this time, the blood count showed high leukocytosis (290 × 109/L) and anemia (8 g/dL) without thrombocytopenia (170 × 109/L). Blood smear examination revealed 96% of small blast cells with a high nuclear/cytoplasmic ratio and irregular nucleus (panel A; May-Grünwald-Giemsa stain, original magnification ×500). Flow cytometry detected CD45dim/cytCD3+/sCD3−/CD34−/TdT+/CD1a+/CD2+/CD5+/CD7+/CD4−/CD8+ T lymphoblasts (panel B). Surprisingly, the white blood cell count decreased drastically without treatment to 3 × 109/L 2 days later. The blast proportion also decreased to 1% with a concomitant high cell lysis rate confirmed by elevated lactate dehydrogenase (7830 U/L), suggesting that the spleen was the main source of blood blast cell dissemination. Histology confirmed massive infiltration of the spleen by cortical lymphoblastic T cells (panel Ci, hematoxylin and eosin stain [HES]; panel Cii, immunohistochemistry [IHC]). Due to an unsuccessful aspiration, bone marrow infiltration was not assessed. Molecular analysis demonstrated an unfavorable prognosis with T-cell acute lymphoblastic leukemia (T-ALL) classifier (NOTCH/FBXW7/RAS wild-type, PTEN mutation and deletion). Eleven days after splenectomy, induction chemotherapy by Group of Research on Adult ALL (GRAALL) protocol was started, which allowed a complete remission.
This case reveals a very unusual primary splenic T-lymphoblastic leukemia/lymphoma with a spontaneous blast cell decrease before initial treatment, highlighting a very rare blast clearance following a ruptured pathologic spleen.
A 44-year-old man was referred in our hospital for asthenia, digestive disorders, faintness with fall at home. A computed tomography scan revealed a severe ruptured spleen, which immediately led to splenectomy. At this time, the blood count showed high leukocytosis (290 × 109/L) and anemia (8 g/dL) without thrombocytopenia (170 × 109/L). Blood smear examination revealed 96% of small blast cells with a high nuclear/cytoplasmic ratio and irregular nucleus (panel A; May-Grünwald-Giemsa stain, original magnification ×500). Flow cytometry detected CD45dim/cytCD3+/sCD3−/CD34−/TdT+/CD1a+/CD2+/CD5+/CD7+/CD4−/CD8+ T lymphoblasts (panel B). Surprisingly, the white blood cell count decreased drastically without treatment to 3 × 109/L 2 days later. The blast proportion also decreased to 1% with a concomitant high cell lysis rate confirmed by elevated lactate dehydrogenase (7830 U/L), suggesting that the spleen was the main source of blood blast cell dissemination. Histology confirmed massive infiltration of the spleen by cortical lymphoblastic T cells (panel Ci, hematoxylin and eosin stain [HES]; panel Cii, immunohistochemistry [IHC]). Due to an unsuccessful aspiration, bone marrow infiltration was not assessed. Molecular analysis demonstrated an unfavorable prognosis with T-cell acute lymphoblastic leukemia (T-ALL) classifier (NOTCH/FBXW7/RAS wild-type, PTEN mutation and deletion). Eleven days after splenectomy, induction chemotherapy by Group of Research on Adult ALL (GRAALL) protocol was started, which allowed a complete remission.
This case reveals a very unusual primary splenic T-lymphoblastic leukemia/lymphoma with a spontaneous blast cell decrease before initial treatment, highlighting a very rare blast clearance following a ruptured pathologic spleen.
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![A 44-year-old man was referred in our hospital for asthenia, digestive disorders, faintness with fall at home. A computed tomography scan revealed a severe ruptured spleen, which immediately led to splenectomy. At this time, the blood count showed high leukocytosis (290 × 109/L) and anemia (8 g/dL) without thrombocytopenia (170 × 109/L). Blood smear examination revealed 96% of small blast cells with a high nuclear/cytoplasmic ratio and irregular nucleus (panel A; May-Grünwald-Giemsa stain, original magnification ×500). Flow cytometry detected CD45dim/cytCD3+/sCD3−/CD34−/TdT+/CD1a+/CD2+/CD5+/CD7+/CD4−/CD8+ T lymphoblasts (panel B). Surprisingly, the white blood cell count decreased drastically without treatment to 3 × 109/L 2 days later. The blast proportion also decreased to 1% with a concomitant high cell lysis rate confirmed by elevated lactate dehydrogenase (7830 U/L), suggesting that the spleen was the main source of blood blast cell dissemination. Histology confirmed massive infiltration of the spleen by cortical lymphoblastic T cells (panel Ci, hematoxylin and eosin stain [HES]; panel Cii, immunohistochemistry [IHC]). Due to an unsuccessful aspiration, bone marrow infiltration was not assessed. Molecular analysis demonstrated an unfavorable prognosis with T-cell acute lymphoblastic leukemia (T-ALL) classifier (NOTCH/FBXW7/RAS wild-type, PTEN mutation and deletion). Eleven days after splenectomy, induction chemotherapy by Group of Research on Adult ALL (GRAALL) protocol was started, which allowed a complete remission.](https://ash.silverchair-cdn.com/ash/content_public/journal/blood/136/1/10.1182_blood.2020005728/4/m_bloodbld2020005728f1.png?Expires=1765016078&Signature=Y9Qu86~74jT7iFdnN8fnwsFCdtpn~a2qzhTK9EkJ0Q2KMCjy7t209eXttJjm69C0c8WjI3~Mw4XjXe-EQAWCn93-vpv0dhesbdGpFbckWPO9Nr9zhLOFusauBWHONYCZcnmdOLV~14jMxo5pJoC6vLiHW7anU86Kj5Nd5UinJnWxvdFkMCyOxAhnP0xOVIK3tF-~bDW3IBZWh0IGz5m9GHXam0EIxjWGsUKgJzEA40qSmriH~y90tLYL2MWZIpvIoBhlriQ2PuHwdM-QAhDat~uxmoLzxdG~FXCmVcCL~ZPsHzoycRKP3oNG13LsTImrNVB66ceby~f45b9klXBudA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA)
