Unusual presentation of extramedullary blast crisis in chronic myeloid leukemia:A case report

BACKGROUND Extramedullary blast crisis in chronic myeloid leukemia(CML)is an uncommon occurrence of leukemic blast infiltration in regions other than the bone marrow.Malignant infiltration of the serosal membranes should be considered in cases where CML presents with ascites or pleural effusion.CASE SUMMARY A 23-year-old female with CML presented with progressively worsening ascites and pleural effusion despite first-line tyrosine kinase inhibitor treatment.Her blood work indicated leukocytosis with myelocyte bulge and 2%blasts.Analysis of the patient’s bone marrow confirmed the chronic phase of CML.Abdominal ultrasound revealed hepatosplenomegaly with ascites.The fluid investigation of both ascites and pleural effusion revealed a predominance of neutrophils with exudate.However,no acid-fast bacilli or growth was observed after culturing.Although hydroxyurea reduced cell counts,there was no observed effect on ascites or pleural effusion.Repeat investigation of the ascitic and pleural fluid revealed a polymorphous myeloid cell population consisting of myelocytes,metamyelocytes,band forms,neutrophils and a few myeloblasts.Extramedullary blast crisis was suspected,and mutation analysis was performed.We switched the patient to dasatinib.The patient’s symptoms were relieved,and ascites and pleural effusion diminished.CONCLUSION Serosal membrane involvement in CML is extremely rare.In this case,the patient responded well to dasatinib treatment.

Chronic myeloid leukemia-from the Philadelphia chromosome to specific target drugs:A literature review

Chronic myeloid leukemia(CML)is a myeloproliferative neoplasm and was the first neoplastic disease associated with a well-defined genotypic anomaly―the presence of the Philadelphia chromosome.The advances in cytogenetic and molecular assays are of great importance to the diagnosis,prognosis,treatment,and monitoring of CML.The discovery of the breakpoint cluster region(BCR)-Abelson murine leukemia(ABL)1 fusion oncogene has revolutionized the treatment of CML patients by allowing the development of targeted drugs that inhibit the tyrosine kinase activity of the BCR-ABL oncoprotein.Tyrosine kinase inhibitors(known as TKIs)are the standard therapy for CML and greatly increase the survival rates,despite adverse effects and the odds of residual disease after discontinuation of treatment.As therapeutic alternatives,the subsequent TKIs lead to faster and deeper molecular remissions;however,with the emergence of resistance to these drugs,immunotherapy appears as an alternative,which may have a cure potential in these patients.Against this background,this article aims at providing an overview on CML clinical management and a summary on the main targeted drugs available in that context.

Development of plasma cell dyscrasias in a patient with chronic myeloid leukemia:A case report

BACKGROUND Chronic myeloid leukemia(CML)is a clonal hematopoietic stem cell disorder.Plasma cell dyscrasias are a rare heterogeneous group of hematological disorders.The co-occurrence of CML and plasma cell dyscrasias in the same patient is an extremely rare incident and has been reported in several cases in the literature.CASE SUMMARY In the present report,we described a rare case of the co-occurrence of CML and plasma cell dyscrasias in a 48-year-old man,and we discussed the reason why monoclonal gammopathy of undetermined significance progressed to smoldering multiple myeloma and eventually to multiple myeloma while being treated with dasatinib for CML.The tyrosine kinase inhibitor treatment and cytogenetic change may contribute to this phenomenon,and clonal hematopoiesis of indeterminate potential may lead to both CML and multiple myeloma cells in a patient.Future studies are warranted to further explain the hidden reasons.CONCLUSION This case highlights that gene translocation may contribute to initiation and sustainability of clonal proliferation.Moreover,the treatment with tyrosine kinase inhibitor and cytogenetic change may contribute to progression from monoclonal gammopathy of undetermined significance to smoldering multiple myeloma and eventually to multiple myeloma.

Priapism secondary to chronic myeloid leukemia treated by a surgical cavernosa-corpus spongiosum shunt: Case report

Priapism secondary to chronic myeloid leukemia(CML)is rarely observed in the clinic.Here,we present an 18-year-old patient with priapism for over 72 h due to hyperleukocytosis.Emergent interventions such as therapeutic aspiration and intracorporal injection of phenylephrine failed before a surgical corpora cavernosa-corpus spongiosum shunt was inserted to relieve symptoms.During hospitalization,bone marrow aspiration confirmed the diagnosis of CML.

MDR1 Haplotypes and G2677T/A Polymorphism Predict Imatinib Response in Tunisian Patients with Chronic Myeloid Leukemia

Background: The role of human multidrug resistance gene (MDR1) SNPs in the interindividual variability of imatinib mesylate (IM) response has received considerable attention. We aimed to study the association between SNPs of the MDR1 gene (C1236T, G2677T/A, C3435T) and IM response in chronic myeloid leukemia (CML) patients. Method: A retrospective case-control study was conducted on 48 patients with CML undergoing IM therapy. All patients were genotyped using PCR-RFLP method. Results: The genotype and allele frequencies of C1236T and C3435T were not significantly different between CML patients responders and non-responders to IM (p > 0.05). The frequencies of 2677T allele and 2677TT genotype were significantly increased in CML patients IM responders which as compared with IM non-responders (50% vs 26.9%, p = 0.013 and 27.3% vs 3.8%, p = 0.029 respectively). Whereas the 2677AA genotype and CAC haplotype were found only in CML patients IM non-responders (15.4%). Conclusion: Pretreatment genotyping of G2677A/T appears to be useful for predicting IM resistance, which may allow the best choice of drug treatment for CML patients.

Horn of plenty:Value of the international registry for pediatric chronic myeloid leukemia

Chronic myeloid leukemia(CML)in minors is a rare disease which can be effectively treated by tyrosine kinase inhibitors(TKIs)since the year 2000.A majority of pediatricians will encounter one or two CML patients in the course of their careers and will typically have to rely on written information along with their own intuition to provide care.Knowledge of response to TKIs and of agespecific side effects has an impact on the design of pediatric CML trials in many ways aiming to contribute toward greater predictability of clinical improvements.Information from a registry on a rare disease like CML offers the enormous benefit of enabling treating physicians to interact and share their collective experience.The International Registry on Pediatric CML(IR-PCML)was founded at Poitiers/France almost 10 years ago.Since then,the number of collaboration centers and in parallel of registered patients continuously increased(>550 patients as of December 2019).Ideally,from a given treatment center in a country data are transferred to a national coordinator who interacts with the IR-PCML.In the sense of quality assurance,the registry can offer dissemination of knowledge on state-of-the-art diagnostics(including reference appraisal),optimal treatment approaches,and follow-up procedures within a network that is exerting its strength via participation.With continuous growth during the recent years,very rare subgroups of patients could be identified(e.g.,CML diagnosed at age<3 years,children presenting with specific problems at diagnosis or during course of treatment)which had not been described before.Publications coming from the IR-PCML disseminated this useful information derived from patients who robustly participate and share information about their disease,among themselves and with their caregivers and clinicians.Patient input driving the collection of data on this rare leukemia is the basis for the considerable success of bringing new therapeutics into clinical use.

About a Case of Chronic Myeloid Leukemia and Pregnancy

Chronic myeloid leukemia (CML) associated with pregnancy is a very rare situation (less than one case per 100,000 pregnancies). It raises a serious ethical and therapeutic problem because chemotherapy during pregnancy can expose the fetus to various complications such as congenital malformations, abortion and intra uterine growth restriction. Inhibitors of tyrosine kinase are the most widely used molecules but without much certainly about their non-teratogenic effects. This is a report case of pregnancy occurring in a patient with Imatinib for CML replaced by Hydrea who gave birth to a healthy newborn with no congenital malformation.

Hematobiological Profile of Patients with Chronic Myeloid Leukemia at the Diagnosis in Yaoundé: A Cross-Sectional Study

Background: Chronic Myeloid Leukemia (CML) is a myeloproliferative blood neoplasia, characterized by the presence of a translocation between chromosomes 9 and 22 leading to the formation of the Philadelphia chromosome. Data on the biological profile of patients with CML at diagnosis are still lacking in sub-Saharan Africa, particularly in Cameroon. Methods: A cross-sectional study was carried out from January 2001 to July 2016 among patients recently diagnosed with CML at the Yaounde University Teaching Hospital, the Yaoundé Central Hospital and the Yaoundé General Hospital. Analyzed variables included socio-demographic, clinical presentation, the diagnosis means, biological parameters (hematological and biochemical). Sampling was consecutive. Results: We included 132 (76 males) patients with CML with a median age of 39.2 years at diagnosis. The 31 - 45 years age group was the most represented, with 40.9% of the study population. A risk factor was found in only 5 (3.8%) of patients. Clinical manifestations were recorded in only 27 (20.45%) patients, with fatigue being the commonest (10.6%). Almost all patients (128, 96.9%) have performed the karyotype while 22 (16.7%) have performed fluorescence in situ hybridization (FISH) and 4 (3.0%) the PCR. At diagnosis, 66% of the patients were in the chronic phase (CP), 11.3% in accelerated phase (AP), and 22.7% in blast crisis (BC). All patients presented hyperleukocytosis, with a white blood cell mean of 128,362/mm3. Anemia was common (77.3%), usually moderate (61.4%). Thrombocytopenia was rare (8.3%), as far as basophilia (1.2%). Among those patients, mean values of creatinine, Glutamic pyruvate transaminase (GPT) and glycemia were normal while activated partial thromboplastin time (APTT), prothrombin time (PT), plasma uric acid level, gamma glutamic transferase (GGT), lactate dehydrogenase (LDH), and inflammatory parameters (ESR and CRP) were increased. Conclusion: Patients with CML presented at their diagnosis hyperleukocytosis and anemia as hematological clues. Other biological anomalies include increased signs of cellular destruction (plasma uric acid level, LDH), coagulation perturbation and inflammatory syndrome. The chronic phase of the disease was common.

Clinical Effect of Imatinib,Nilotinib,and Dasatinib on Chronic Myeloid Leukemia in Chronic Phase

The study was conducted to explore the effect of imatinib,nilotinib,and dasatinib in the treatment of chronic myeloid leukemia(CML)patients.Around 66 patients with CML in chronic phase were selected,subsequently the patients were subdivided into 3 groups with 22 patients in each group:Group A were treated with imatinib;Group B were treated with nilotinib;and Group C were treated with dasatinib.The study showed that,at 18 months of treatment,compared with group A,the molecular biology remission rates of group B and group C were significantly higher,p<0.05;at 6 months and 18 months of treatment,compared with group A,the complete cytogenetic remission rates of group B and group C were significantly higher,p<0.05;and compared with group A,the incidences of vomiting,headache and edema in groups B and C were significantly lower,p<0.05.However,no significant different p>0.05 were observed in the complete hematologic remission rates,and the incidences of neutropenia and thrombocytopenia among the three groups.In summary,nilotinib and dasatinib are effective in the treatment of patients with CML in the chronic phase,which is significantly better than imatinib treatment.

Clinical Efficacy of Dasatinib in the Treatment of Chronic Myeloid Leukemia (CML) Patients with Different Clinical Stages

Objective:To study the efficacy of dasatinib treatment in different clinical stages of patients with chronic myeloid leukemia(CML).Methods:A total of 80 patients with chronic myeloid leukemia(CML)were selected for experimental research.According to different clinical stages,they were divided into chronic phase,accelerated phase and blast phase,and all of them were treated with dasatinib.Results:The complete cytogenetic response remission rate,complete hematologic remission rate,and major molecular biological remission rate in the chronic phase were significantly higher.Besides,the overall survival time and relapse-free survival time in the chronic phase were significantly longer,and the mortality during the follow-up period in the chronic phase was also significantly higher.Furthermore,the incidence of hematological adverse reactions of gradesⅢtoⅣin the chronic phase was significantly lower compared with the corresponding data of patients in the accelerated phase and blast phase with P<0.05.Conclusion:Different clinical stages of CML patients have different curative effects of dasatinib,which can effectively treat patients in chronic stage.

Hepatitis B reactivation in chronic myeloid leukemia patients receiving tyrosine kinase inhibitor

Hepatitis B virus(HBV) reactivation is a well-recognized complication in patients with chronic HBV infection receiving cytotoxic or immunosuppressive chemotherapy.Imatinib mesylate and nilotinib are selective Bcr/Abl tyrosine kinase inhibitors,which are now widely used in the treatment of patients with chronic myeloid leukemia.Although HBV reactivation induced by imatinib mesylate has been reported,nilotinib-related HBV reactivation has not been reported in the English literature.We report here 2 cases of HBV reactivation in chronic myeloid leukemia patients receiving imatinib mesylate and a novel case of nilotinib related HBV reactivation.

Combination of Rapamycin and Imatinib in Treating Refractory Chronic Myeloid Leukemia Myeloid Blast Crisis:a Case Report

CHRONIC myeloid leukemia (CML) is characterized by the presence of the BCR/ABL fusion gene,which is the result of a reciprocal translocation between chromosomes 9 and 22,called Philadelphia (Ph) chromosome.Imatinib mesylate (imatinib),

A novel t(3;12)(q21;p13) translocation in a patient with accelerated chronic myeloid leukemia after imatinib and nilotinib therapy

The acquisition of secondary chromosomal aberrations in chronic myeloid leukemia (CML) patients with Philadelphia chromosome-positive (Ph+) karyotype signifies clonal evolution associated with the progression of the disease to its accelerated or blastic phase. Therefore, these aberrations have clinical and biological significance. T(3;12)(q26;p13), which is a recurrent chromosomal aberration observed in myeloid malignancies, is typically associated with dysplasia of megakaryocytes, multilineage involvement, short duration of any blastic phase, and extremely poor prognosis. We have identified a recurrent reciprocal translocation between chromosomes 3 and 12 with different breakpoint at bands 3q21 in the malignant cells from a 28-year-old man. The patient was initially diagnosed as having Ph+ CML in the chronic phase. The t(3;12)(q21;p13) translocation occurred 4 years after the patient was first diagnosed with CML while undergoing tyrosine kinase inhibitor therapy. We confirmed the t(3;12)(q21;p13) translocation via fluorescence in situ hybridization assay by using whole-chromosome paint probes for chromosomes 3 and 12. Our findings demonstrate that, similar to other recurrent translocations involving 3q26 such as t(3;3) and t(3;21), the t(3;12)(q21;p13) translocation is implicated not only in myelodysplastic syndrome and acute myeloid leukemia but also in the progression of CML. These findings extend the disease spectrum of this cytogenetic aberration.

Time-series Analysis in Imatinib-resistant Chronic Myeloid Leukemia K562-cells under Different Drug Treatments

Chronic myeloid leukemia(CML) is characterized by the accumulation of active BCR-ABL protein. Imatinib is the first-line treatment of CML; however, many patients are resistant to this drug. In this study, we aimed to compare the differences in expression patterns and functions of time-series genes in imatinib-resistant CML cells under different drug treatments. GSE24946 was downloaded from the GEO database, which included 17 samples of K562-r cells with(n=12) or without drug administration(n=5). Three drug treatment groups were considered for this study: arsenic trioxide(ATO), AMN107, and ATO+AMN107. Each group had one sample at each time point(3, 12, 24, and 48 h). Time-series genes with a ratio of standard deviation/average(coefficient of variation) >0.15 were screened, and their expression patterns were revealed based on Short Time-series Expression Miner(STEM). Then, the functional enrichment analysis of time-series genes in each group was performed using DAVID, and the genes enriched in the top ten functional categories were extracted to detect their expression patterns. Different time-series genes were identified in the three groups, and most of them were enriched in the ribosome and oxidative phosphorylation pathways. Time-series genes in the three treatment groups had different expression patterns and functions. Time-series genes in the ATO group(e.g. CCNA2 and DAB2) were significantly associated with cell adhesion, those in the AMN107 group were related to cellular carbohydrate metabolic process, while those in the ATO+AMN107 group(e.g. AP2M1) were significantly related to cell proliferation and antigen processing. In imatinib-resistant CML cells, ATO could influence genes related to cell adhesion, AMN107 might affect genes involved in cellular carbohydrate metabolism, and the combination therapy might regulate genes involved in cell proliferation.

Coexistence of breakpoint cluster region-Abelson1 rearrangement and Janus kinase 2 V617F mutation in chronic myeloid leukemia: A case report

BACKGROUND The Janus kinase 2(JAK2) V617 F mutation is common in patients with breakpoint cluster region-Abelson1(BCR-ABL1)-negative myeloproliferative neoplasms,including polycythemia vera, essential thrombocythemia and primary myelofibrosis, but is rarely detected in BCR-ABL1-positive chronic myeloid leukemia(CML) patients. Here, we report a CML patient with both a BCR-ABL1 rearrangement and JAK2 V617 F mutation.CASE SUMMARY A 45-year-old Chinese woman was admitted to our department with a history of significant thrombocytosis for 20 d. Color Doppler ultrasound examination showed mild splenomegaly. Bone marrow aspiration revealed a karyotype of 46,XX, t(9;22)(q34;q11.2) in 20/20 metaphases by cytogenetic analysis,rearrangement of BCR-ABL1(32.31%) by fluorescent polymerase chain reaction(PCR) and mutation of JAK2 V617 F(10%) by PCR and Sanger DNA sequencing.The patient was diagnosed with CML and JAK2 V617 F mutation. Following treatment with imatinib for 3 mo, the patient had an optimal response and BCRABL1(IS) was 0.143%, while the mutation rate of JAK2 V617 F rose to 15%.CONCLUSION Emphasis should be placed on the detection of JAK2 mutation when CML is diagnosed to distinguish JAK2 mutation-positive CML and formulate treatment strategies.

The combination therapy of imatinib and dasatinib achieves long-term molecular response in two imatinib-resistant and dasatinibintolerant patients with advanced chronic myeloid leukemia

For patients with chronic myeloid leukemia(CML) failing imatinib therapy,second-generation tyrosine kinase inhibitors(TKIs) are recommended.Here,we describe two patients with advanced CML who failed imatinib therapy and did not tolerate the recommended dose of dasatinib,but then achieved a major molecular response with the combination of imatinib and dasatinib with no significant extramedullar/ toxicity.Our observations suggest that combination of TKIs may provide an additive/synergistic antileukemic effect.

Gene Expression Pattern of Signal Transduction in Chronic Myeloid Leukemia

To explore the transcriptional gene expression profiles of signaling pathway in Chronic myeloid leukemia (CML), a series of cDNA microarray chips were tested. The results showed that differentially expressed genes related to singal transduction in CML were screened out and the genes involved in Phosphoinositide 3-kinases (PI3K), Ras-MAPK (mitogen-activated protein kinase) and other signaling pathway genes simultaneously. The results also showed that most of these genes were up-expression genes , which suggested that signal transduction be overactivated in CML. Further analysis of these differentially expressed signal transduction genes will be helpful to understand the molecular mechanism of CML and find new targets of treatment.

Severe hemorrhagic colitis in a patient with chronic myeloid leukemia in the blastic phase after dasatinib use

Dasatinib is a second-line tyrosine kinase inhibitor used in patients with imatinib resistant or intolerant chronic myeloid leukemia (CML) and Philadelphia chromosomepositive acute leukemia. Gastrointestinal bleeding may occur in up to 7% of patients using dasatinib, although, severe dasatinib-related acute colitis had rarely been reported. Here, we present the case of a 36-year-old female who progressed to acute myeloid leukemia after fourteen months of receiving imatinib for CML in the chronic phase and was treated with a dasatinib-containing chemotherapy regimen. On day 34 of treatment, the patient developed moderate abdominal pain and bloody diarrhea with mucous. Analyses of stool specimens were negative for parasites, Clostridium difficile , and other pathogenic bacteria. The cytomegalovirus pp65 antigen was negative in her blood leukocytes. A colonoscopy revealed acute colitis, and a mucosal biopsy showed nonspecific colitis. The patient was treated with broad-spectrum antibiotics, bowel rest and hydration, and dasatinib treatment was stopped. Her bloody diarrhea improved within 72 h. After confirming cytological remission, the patient received initial course of consolidation, and dasatinib treatment was reinstated. However, hemorrhagic colitis recurred. After discontinuing dasatinib, herhemorrhagic colitis drastically improved and did not recur following the administration of nilotinib. The characteristics of our patient suggest that dasatinib treatment can lead to hemorrhagic colitis, which typically resolves after discontinuation of the drug.

Polymorphism of Human Organic Cationic Transporter1 (C480G) in Egyptian Chronic Myeloid Leukemia Patients on Imatinib

Background: Human organic cationic transporter1 (Hoct1) is a plasma membrane transporter responsible for the main influx of Imatinib into chronic myeloid leukemia (CML) cells. Single nucleotide polymorphisms (SNPs) in the gene coding for hOCT1 are important factors causing Imatinib resistance. We investigated the frequency of hOCT1 SNP C480G among Egyptian CML patients and its relation to early molecular response as an indicator of treatment outcome. Materials and Methods: Two groups of CML patients were included in this study. Group I consisted of 25 patients responding to Imatinib treatment (Imatinib responsive) and group II consisted of 25 patients resistant to Imatinib (Imatinib resistant). Response criteria were assessed according to the NCCN (National Comprehensive Cancer Network) guidelines 2017. Twenty healthy controls of matched age and sex were also included (group III). For all patients, we studied hOCT1 C480G at initial presentation using Taqman drug metabolism genotyping as well as BCR-ABL percent at diagnosis and after 3 months interval. Results: hOCT1 C480G was present in 32% of studied CML patients. CC (wild) was detected in 68% of group I and 64% of group II. CG (mutant heterozygous) was present in 28% of group I and 36% of group II while GG (mutant homozygous) was detected in only one case in group I. CG was also detected in 15% of control subjects There was no significant difference between hOCT1 C480G polymorphism and Early Molecular Response (χ2 = 0.089, p = 0.765). Conclusions: hOCT1 C480G polymorphism has no association with Imatinib resistance in Egyptian population. However, further studies on a larger number of patients are still needed to confirm this finding.

Efficacy of Nilotinib versus Imatinib in Philadelphia Positive Patients with Chronic Myeloid Leukemia in Early Chronic Phase Who Have a Warning Molecular Response to Imatinib

Background and Objectives: Chronic myeloid leukemia (CML) accounts for approximately 15% of newly diagnosed cases of leukemia in adults. In this study, the efficacy of nilotinib at 400 mg BID is compared with imatinib at 400 mg BID in CML patients with suboptimal molecular response after at least 12 months of daily dose 400 mg of imatinib therapy. Patients and Methods: This study included a total number of 50 patients, divided into two groups (25 patients each). The first group (Group I): Patients received imatinib at 400 mg BID, second group (Group II): Patients had a suboptimal molecular response to imatinib and received nilotinib at 400 mg BID in early chronic phase. During the two years period of data collection, the primary end included median survival. The secondary end included response rate, type of response, duration of response and progression free survival. Also side effects were recorded. Patients were followed up every month by complete and differential blood counts, liver function test, renal function test and (PCR) every three months for two year. Results: Nilotinib group had significantly higher frequency of major molecular response (MMR) where 23 (92%) patients achieved it while only 16 (64%) patients in Imatinib group achieved MMR (P = 0.01). Nilotinib had better toxicities profile than Imatinib. Conclusion: Both Nilotinib and high dose Imatinib achieved response in CML patients with suboptimal response with rapid and deeper molecular response, better survival outcomes and less side effects in nilotinib.