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Acute Lymphoblastic Leukemia (ALL) as a secondary malignancy in adolescent patient after completion of Ewing's sarcoma chemotherapy: a case report

  • I Putu Oka Kresna Jayadi ,
  • Anak Agung Ngurah Ketut Putra Widnyana ,
  • Ketut Ariawati ,
  • Kadek Ayu Yani Lastariana ,


OBJECTIVE: To report an adolescent patient who was diagnosed with Acute lymphoblastic leukemia (ALL) after completing Ewing sarcoma (ES) therapy.

CASE: A 14 years old girl complained of left crusis tumor since 4 months before hospitalized. Tumor biopsy showed a round cell tumor, as well as immunohistochemistry which showed a positive CD99, consistent with ES. The patient had received 14 cycles chemotherapy for 7 months with regimens vincristine 1.5 mg/m2, cyclophosfamide 1200 mg/m2, dactinomycin 0.5 mg/m2, and doxorubicin 30 mg/m2. Between chemotherapy, patient also was given granulocyte colony-stimulating factor several times. Pasien also undergo 31 times radiation therapy with total 31x1.8 Gy (55.8 Gy). Two months after last chemotherapy for Ewing sarcoma, she was admitted again with prolonged fever, and pallor.Laboratorium showed leukocytosis (88.86x103uL), monocytosis (41%), severe neutropenia (0.39x103uL), severe normochromic normocytic anemia (4,3 g/dL), severe thrombocytopenia (4x103uL), reticulocytopenia (0,46%), with lymphoblast in peripheral blood smear. Bone marrow aspiration result showed lymphoblast infiltration 60% with heterogen morphology, no cluster cell non hematopoetic in bone marrow, consisten with acute lymphoblastic leukemia (ALL-L2) suspected secondary malignancy from Ewing’s Sarcoma. Patient underwent chemotherapy for high risk ALL at induction phase with combination of vincristin, daunorubicin, L-asparginase, metotrexate high dose, prednison, and 6-mercaptopurine. After completing induction phase, the patient’s condition get worsening and later died.

CONCLUSION: ES survivors are at significant risk for secondary malignancies. Leukimia is one of which the most common secondary malignancies. Young children are particularly susceptible to the mutagenic effects of both chemotherapy and radiotherapy, as proven by several studies.


  1. Goudarzi Pour K, Alavi S, Shamsian S, Aghakhani R, Arzanian MT, Tavassol HH, et al. Secondary ALL after Successful Treatment of Ewing's Sarcoma: A Case Report. Int J Hematol Oncol Stem Cell Res. 2016;10(4):236-238.
  2. Satyarth S, Parikh S, Anand A, Sawhney J, Panchal H, Patel A, et al. Acute Lymphoblastic Leukemia as Secondary Malignancy in a Case of Ewing's Sarcoma on Treatment. Indian J Med Paediatr Oncol. 2017;38(3):354-356.
  3. Kaiser I I, Kauertz K, Zöllner SK, Hartmann W, Langer T, Jurgens H, et al. Secondary Malignancies after Ewing Sarcoma-Epidemiological and Clinical Analysis of an International Trial Registry. Cancers (Basel). 2022;14(23):5920.
  4. Vasudevan V, Cheung MC, Yang R, Zhuge Y, Fischer AC, Koniaris LG, et al. Pediatric Solid Tumors and Second Malignancies: Characteristics and Survival Outcomes. J Surg Res. 2010;160(2):184-189.
  5. Navid F, Billups C, Liu T, Krasin MJ, Rodriguez-Galindo C. Second cancers in patients with the Ewing sarcoma family of tumors. Eur J Cancer. 2008;44(7):983-991.
  6. Grunewald TGP, Cidre-Aranaz F, Surdez D, Tomazou EM, de Alava E, Kovar H, et al. Ewing sarcoma. Nat Rev Dis Prim. 2018;4(1):5.
  7. Dirksen, U. Effificacy of add-on treosulfan and melphalan high-dose therapy in patients with high-risk metastatic Ewing sarcoma: Report from the International Ewing 2008R3 trial. J. Clin. Oncol. 2020;38(1):11501
  8. Pappo AS, Dirksen U. Rhabdomyosarcoma, Ewing Sarcoma, and Other Round Cell Sarcomas. J. Clin. Oncol. 2017;36(2);168–179.
  9. Bhatia S, Sklar C. Second cancers in survivors of childhood cancer. Nat. Rev. Cancer. 2002;2(2):124–132
  10. Caruso J, Shulman DS, DuBois SG. Second malignancies in patients treated for Ewing sarcoma: A systematic review. Pediatr. Blood Cancer. 2019;66(11):e27938.
  11. Schiffman JD, Wright J. Ewing’s Sarcoma and Second Malignancies. Sarcoma 2011;1(1):736841.
  12. Friedman DN, Chastain K, Chou JF, Moskowitz CS, Adsuar R, Wexler LH, et al. Morbidity and mortality after treatment of Ewing sarcoma: A single-institution experience. Pediatr. Blood Cancer. 2017;64(11):e2656.
  13. Navid F, Billups C, Liu, T, Krasin MJ, Rodriguez-Galindo C. Second cancers in patients with the Ewing sarcoma family of tumours. Eur. J. Cancer 2008;44(7): 983–991.
  14. Kaatsch P, Reinisch I, Spix C, Berthold F, Janka-Schaub G, Mergenthaler A, et al. Case-control study on the therapy of childhood cancer and the occurrence of second malignant neoplasms in Germany. Cancer Causes Control 2009;20(1):965–980.
  15. Leavey PJ, Laack NN, Krailo MD, Buxton A, Randall RL, DuBois SG, et al. Phase III Trial Adding Vincristine-Topotecan-Cyclophosphamide to the Initial Treatment of Patients With Nonmetastatic Ewing Sarcoma: A Children’s Oncology Group Report. J. Clin. Oncol. 2021;39(36):4029–4038.
  16. Bhatia S, Krailo MD, Chen Z, Burden L, Askin FB, Dickman PS, et al. Therapy-related myelodysplasia and acute myeloid leukemia after Ewing sarcoma and primitive neuroectodermal tumor of bone: A report from the Children’s Oncology Group. Blood. 2007;109(1):46–51.
  17. Relling MV, Boyett JM, Blanco JG, Raimondi S, Behm FG, Sandlund JT, et al. Granulocyte colony-stimulating factor and the risk of secondary myeloid malignancy after etoposide treatment. Blood. 2003;101(10):3862–3867.
  18. Sultan I, Rihani R, Hazin R, Rodriguez-Galindo C. Second malignancies in patients with Ewing sarcoma family of tumors: a population-based study. Acta Oncol. 2010;49(2):237-244.
  19. Prabawa IPY, Mahartini NN, Herawati S, Mulyantari NK. Acute Erythroleukemia (AML-M6) in one-year-old boy: a case report. Bali Medical Journal. 2022;11(3):1420-1425.
  20. Sari NM, Nurazizah NA, Lesmana R, Suryawan N, Susanah S. Retrospective Study on Very Early Relapse of Childhood Acute Lymphoblastic Leukemia at a Reference Centre in Indonesia. Bali Medical Journal. 2022;11(1):44–49.
  21. Salim EJ, Ariawati K, Gustawan IW, Windiani IGAT, Gunawijaya E, Hartawan, INB. Diagnostic Accuracy of Bone Marrow Morphology to Determine Remission in Acute Lymphoblastic Leukemia Children: The Role of Minimal Residual Disease. Bali Medical Journal. 2020;9(1):366–370.
  22. Suwandari NLA, Lestari AAW, Wande IN, Wirawati IAP, Prabawa IPY. Acute Lymphoblastic Leukemia (ALL)-L2 in an adult woman: a case report. Bali Medical Journal. 2023;12(1):669–674.

How to Cite

Jayadi, I. P. O. K., Widnyana, A. A. N. K. P., Ariawati, K., & Lastariana, K. A. Y. (2024). Acute Lymphoblastic Leukemia (ALL) as a secondary malignancy in adolescent patient after completion of Ewing’s sarcoma chemotherapy: a case report. Intisari Sains Medis, 15(1), 73–77.




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I Putu Oka Kresna Jayadi
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Anak Agung Ngurah Ketut Putra Widnyana
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Ketut Ariawati
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Kadek Ayu Yani Lastariana
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