title: Testicular relapse in childhood acute lymphoblastic leukemia: the challenges and lessons.
abstract: BACKGROUND
  Relapse of disease is documented in 15-20% of children with acute lymphoblastic leukemia (ALL). Although testicular relapse is rare with modern risk-adapted treatment protocols, earlier, the testes were a frequently encountered site of relapse and were designated as "drug sanctuaries".
  
  
  OBJECTIVE
  This descriptive study was designed to assess the pattern of testicular relapse and to identify high-risk factors.
  
  
  METHODS
  Data obtained from case records of 407 boys with ALL were analyzed. Fine needle aspiration cytology was carried out in children presenting with painless enlargement of testi(e)s. Bone marrow aspiration and cerebrospinal fluid examination were performed concomitantly to confirm or exclude disease at these sites.
  
  
  RESULTS
  Testicular relapse was documented in 30 boys. It was isolated in 17 patients and associated with bone marrow and/or central nervous system relapse in 13. At relapse, nine boys were over the age of 10 years. The majority were very early and early relapsers. Hyperleucocytosis was documented in five of 30 and seven of 137 relapsers and nonrelapsers, respectively (P = 0.04). Twelve of the 30 boys with testicular relapse were treated with testicular irradiation, reinduction and maintenance therapy. The estimated median overall survival was 33 months.
  
  
  CONCLUSIONS
  Testicular relapse, which depends on the therapy administered, may manifest several months/years after completion of treatment. The high incidence of testicular relapse in our series implicates the need of revaluation of our protocol and incorporation of high/intermediate dose methotrexate therapy upfront.
authors.affiliation: Division of Pediatric Hematology-Oncology, Advanced Pediatric Center, PGIMER, Chandigarh, India.
authors.forename: K P
authors.initials: KP
authors.lastname: Kulkarni
authors.forename: R K
authors.initials: RK
authors.lastname: Marwaha
authors.forename: A
authors.initials: A
authors.lastname: Trehan
authors.forename: D
authors.initials: D
authors.lastname: Bansal
mesh_terms: D000293:Adolescent; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001215:Asparaginase / Q000008:administration & dosage; D001932:Brain Neoplasms / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D016371:Cranial Irradiation; D006801:Humans; D007223:Infant; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage; D009364:Neoplasm Recurrence, Local / Q000628:therapy*; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000628:therapy*; D011239:Prednisolone / Q000008:administration & dosage; D015996:Survival Rate; D013736:Testicular Neoplasms / Q000628:therapy*; D016896:Treatment Outcome; D014750:Vincristine / Q000008:administration & dosage
chemical_list: D014750:Vincristine; D011239:Prednisolone; D001215:Asparaginase; D008727:Methotrexate