Acute cholecystitis and translocations t(14;18) and t(8;22): Rare presenting features in acute lymphoblastic leukemia which confer a poor prognosis

Extramedullary presentations of acute lymphoblastic leukemia (ALL) are rare in the absence of demonstrable disease in the peripheral blood. In addition, the translocation of t(14;18)(q32;21) which is commonly observed in follicular Non-Hodgkin's lymphoma, is not typically associated with ALL. We have observed the t(14;18)(q32:q21) and t(8;22)(q24;q11) translocations in a patient with ALL who presented with gall bladder involvement as the sole initial manifestation of her disease. The ALL cells were Tdt negative and lacked surface immunoglobulin expression, which is unusual for adult ALL cells. The patient had a poor response to standard chemotherapy. The extramedullary presentation and the unusual chromosomal translocations each portend poor prognosis in a patient with ALL. Patients who have ALL with the t(14;18)(q32;q21) and t(8;22)(q24;q11) translocations may have a unique variant of this disease and should be considered for more aggressive initial therapy or enrollment in an appropriate clinical trial.