Acute lymphoblastic leukemia

Case contributed by Dr Ian Bickle


14 month old child presents with pain and swelling over the left knee. Not keen to walk.


Diffusely abnormal coarse appearances of the medulla of both the femur and distal tibia.

Associated periosteal reaction most pronounced at the proximal tibial diaphysis.


Images of the left femur with florid periosteal reaction.

Paraosteal soft tissue, giving layers rather like an onion.

Two enlarged lymph nodes on the medial aspect of the knee.



Plain films of the left tibia and fibula reviewed. Extensive femoral and tibia periosteal reaction and coarse altered medullary bone.

Extensive bilateral paraosteal soft tisse surrounding both femurs, most pronounced in the distal metaphyseal and epiphsyeal regions. This extends along more than half of the diaphysis on the left femur and measures upto 1.5cm in depth at the left distal metaphysis. This gives a laminated ónion skin'' apperances of the bones ( on axial images ).

The cortex of the femurs remains in tact, but altered enhancing bone marrow in the left femur is evident.

Similar findings are present in both tibias with paraosteal soft tissue upto 7mm in depth and altered bone marrow signal. The cortex of the left tibia is irregular and breeched. The distal left tibia is similarily involved.

Two morphologically abnormal lymph nodes on the medial aspect of the left knee measuring 2.8 and 1.1cm. 1cm left inguinal lymph node.

Normal pelvis.

Increased paraosteal soft tissue surrounding the left distal radial and ulna metaphyses on the localizer images.

Comment: The appearances are most suggestive of a hematological malignancy, such as leukemia.

The differential of stage IV nephroblastoma is unlikely as an ultrasound of the abdomen and both CXR/AXR has not identified a primary.


Ultrasound abdomen

Well defined 4.5cm mass in the right lobe of liver.

The retroperitoneum is normal.


Surgical biopsy report

The histology report for the surgical biopsied which was taken from the tibia.

Case Discussion

Acute lymphocytic leukemia (ALL) accounts for 15-20% of childhood leukaemias, commonly affecting young children ( 2-10 years of age ).

In children it preferentially involves the long bones, the femur being the most common site.  A variety of appearances of bony involvement may be idenfied on plain radiograph, one being permeative bone involvement, with a quarter having some form of periosteal reaction, which includes lamellar and sunburst types.  Extramedullary soft tissue is a feature of chloroma.

The differential diagnoses, as was the initial case in this child include: metastatic neuroblastoma, LCH, lymphoma and osteomyelitis.

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Case information

rID: 40019
Published: 26th May 2016
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included

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