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Takatsuna K, Kurosawa S, Nakayama H, Sakurai A, Ito C, Aisa Y, Nakazato T. Unprecedented Megakaryocytic Blast Phase Transformation in Chronic Myeloid Leukemia After 16 Years of Tyrosine Kinase Inhibitor Therapy. Cureus 2024; 16:e67443. [PMID: 39310511 PMCID: PMC11415602 DOI: 10.7759/cureus.67443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2024] [Indexed: 09/25/2024] Open
Abstract
We report the case of a 51-year-old Japanese man with chronic myeloid leukemia (CML) initially diagnosed in the chronic phase. For 16 years, the patient maintained chronic phase (CP) under treatment with first- and second-generation tyrosine kinase inhibitors (TKIs), including imatinib, dasatinib, and bosutinib, none of which resulted in ABL1 mutations. However, despite long-term disease stability, the patient experienced an abrupt progression to the megakaryocytic blast phase (MBP), a rare and aggressive form of CML. In response to this progression, ponatinib, a third-generation TKI, was introduced as a fourth-line therapy. Remarkably, within 7 months of initiating ponatinib, the patient achieved a deep molecular response (DMR), evidenced by a reduction in BCR::ABL1 transcript levels to undetectable levels (MR5.0). This molecular remission enabled the patient to proceed with an allogeneic bone marrow transplantation from a human leukocyte antigen (HLA) 8/8-allele-matched unrelated donor. Post-transplantation, the patient has maintained DMR for 14 months without recurrence, despite the challenges posed by graft-versus-host disease. This case illustrates the critical role of third-generation TKIs like ponatinib in managing advanced CML phases, especially when previous therapies fail. It also emphasizes the necessity of vigilant long-term monitoring during the chronic phase to detect and address any signs of disease progression promptly.
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Affiliation(s)
- Kaworu Takatsuna
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, JPN
| | - Shuhei Kurosawa
- Division of Transfusion and Cell Therapy, Tokyo Metropolitan Cancer and Infectious Diseases Center, Tokyo, JPN
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, JPN
| | - Hitomi Nakayama
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, JPN
| | - Aki Sakurai
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, JPN
| | - Chisako Ito
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, JPN
| | - Yoshinobu Aisa
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, JPN
| | - Tomonori Nakazato
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, JPN
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Ureshino H, Shindo T, Sano H, Kubota Y, Ando T, Kidoguchi K, Kusaba K, Itamura H, Kojima H, Kusunoki Y, Miyazaki Y, Kojima K, Tanaka H, Saji H, Oshima K, Kimura S. Reconstitution of NK cells expressing KIR3DL1 is associated with reduced NK cell activity and relapse of CML after allogeneic hematopoietic stem cell transplantation. Int J Hematol 2019; 111:733-738. [PMID: 31873846 DOI: 10.1007/s12185-019-02809-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022]
Abstract
Although the prognosis of chronic myeloid leukemia (CML) in blastic crisis remains poor, some patients achieve long-term remission after allogeneic hematopoietic stem cell transplantation (allo-HSCT). This may be attributable to graft-versus-leukemia (GVL) effects by donor lymphocytes, but their regulating mechanisms are unclear. Antitumor natural killer (NK) cell immunity is assumed to be important in CML, and we have previously shown that allelic polymorphisms of killer immunoglobulin-like receptors (KIRs) and histocompatibility leukocyte antigens (HLAs) are associated with the response of CML to tyrosine kinase inhibitors. Here, we report a case of CML in blastic phase who received HLA-matched but KIR3DL1 allelic-mismatched allo-HSCT. After transplant, decreased BCR-ABL transcript levels and enhanced NK cell activity were transiently observed. However, reconstitution of KIR3DL1-expressing NK cells occurred, which was associated with diminished NK cell activity and increased BCR-ABL. This case indicates the potential significance of KIR3DL1 in NK cell-mediated GVL activity following allo-HSCT. To the best of our knowledge, this is the first report to analyze the association between sequential KIR3DL1 expression and activity of NK cells after allo-HSCT. Selecting donors with KIR3DL1-null alleles may maintain competent GVL effects and provide improved outcomes in allo-HSCT for CML.
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Affiliation(s)
- Hiroshi Ureshino
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan.,Department of Drug Discovery and Biomedical Sciences, Faculty of Medicine, Saga University, Saga, Japan
| | - Takero Shindo
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan. .,Department of Hematology/Oncology, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogo-in, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Haruhiko Sano
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Yasushi Kubota
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Toshihiko Ando
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Keisuke Kidoguchi
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Kana Kusaba
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Hidekazu Itamura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | | | | | | | - Kensuke Kojima
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | | | | | - Koichi Oshima
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan.,Department of Drug Discovery and Biomedical Sciences, Faculty of Medicine, Saga University, Saga, Japan
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Khemka R, Gupta M, Jena NK. CML with Megakaryocytic Blast Crisis: Report of 3 Cases. Pathol Oncol Res 2018; 25:1253-1258. [PMID: 30357754 DOI: 10.1007/s12253-018-0484-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 10/09/2018] [Indexed: 11/28/2022]
Abstract
Chronic myelogenous leukemia (CML) is a chronic myeloproliferative neoplasm consistently associated with the BCR-ABL1 fusion gene located in the Philadelphia chromosome. The Blast Phase is diagnosed when blasts are ≥20% of the peripheral blood white cell count or of bone marrow nucleated cells or when there is an extramedullary blast proliferation. Megakaryocytic blast crisis as the presenting manifestation of CML is extremely rare and only 7 reported cases were found in the literature. Out of 34 cases of CML-Blast Phase between April 2015 and June 2016, 3 cases showed megakaryocytic differentiation. 2 of these presented in Blast phase as the first manifestation of CML and the third case was a known case of CML-Chronic phase. Flow cytometric immunophenotyping was performed on peripheral blood/bone marrow using 6- color flow cytometer Navios. On CD45 vs SSC two distinct populations of blasts were seen in two cases and single population in the third case. All the 3 cases were positive for CD61, cCD41, cCD61 confirming the megakaryocytic lineage. The clinical features, morphologic and cytogenetic findings help in the identification and distinction of megakaryocytic blast phase of CML from Acute Megakayoblastic Leukemia. The diagnosis of such rare presentation of CML is essential for determining the choice of treatment. Therefore including a megakaryocytic marker in the primary flow cytometry panel is important so that these cases are not under-diagnosed as Acute myeloid leukemia because of expression of CD13 and CD33 only.
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Affiliation(s)
- Rashi Khemka
- Department of Oncopathology, Delhi State Cancer Institute, Dilshad Garden, Delhi, 110095, India
| | - Monica Gupta
- Department of Oncopathology, Delhi State Cancer Institute, Dilshad Garden, Delhi, 110095, India.
| | - Nehar Kanta Jena
- Department of Clinical Oncology, Delhi State Cancer Institute, Dilshad Garden, Delhi, 110095, India
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Ganapule AP, Viswabandya A, Jasper A, Patel P, Kokil G. Granulocytic sarcoma with compressive myelopathy: a rare presentation of chronic myelogenous leukemia. J Clin Diagn Res 2014; 8:QD03-4. [PMID: 25177619 PMCID: PMC4149125 DOI: 10.7860/jcdr/2014/9319.4640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 05/20/2014] [Indexed: 11/24/2022]
Abstract
Granulocytic sarcoma occurs most commonly in acute myelogenous leukemia. The appearance of granulocytic sarcoma in chronic myelogenous leukemia signals accelerated phase/ blast transformation. This is a rare case of undiagnosed chronic myelogenous leukemia with granulocytic sarcoma causing cord compression, which went into tumour lysis syndrome requiring dialysis after starting of steroids and radiotherapy. A 43-year-old male presented in emergency department with acute onset of flaccid paralysis. On clinical examination, there was hepatosplenomegaly and lower motor neuron paralysis in the lower limbs. The peripheral smear was consistent with chronic myelogenous leukemia in chronic phase. The MRI spine revealed para-spinal and epidural masses causing cord compression and the biopsy from the paraspinal mass was consistent with granulocytic sarcoma.
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Affiliation(s)
- Abhijeet P. Ganapule
- Assistant Professor, Department of Haematology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Auro Viswabandya
- Professor, Department of Haematology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Anita Jasper
- Assistant Professor, Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Palak Patel
- Assistant Professor, Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Gautami Kokil
- Fellow In Haematopathology, Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Karkuzhali P, Shanthi V, Usha T. A case of chronic myeloid leukaemia presenting as megakaryocytic blast crisis (AML M7). Ecancermedicalscience 2013; 7:375. [PMID: 24282446 PMCID: PMC3837489 DOI: 10.3332/ecancer.2013.375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Indexed: 11/06/2022] Open
Abstract
Acute megakaryocytic leukaemia (AMeL) is a rare subtype of acute myeloid leukaemia, which can be frequently misdiagnosed as acute myelofibrosis or myelosclerosis [1]. Chronic myeloid leukaemia (CML) presenting primarily as megakaryocytic blast crisis is very rare, with very few case reports published to date [2, 3]. This case report describes a 36-year-old woman who presented with anaemia and massive splenomegaly with peripheral blood and bone marrow showing features of AMeL. Reverse transcriptase polymerase chain reaction and gel-electrophoretic study of peripheral blood leucocytes demonstrated breakpoint cluster region–Abelson oncogene translocation encoding for p210 fusion protein. Megakaryocytic blast crisis as the primary presentation of CML is very rare and requires clinical correlation and additional cytogenetic studies to determine the diagnosis.
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Min X, Na Z, Yanan L, Chunrui L. De novo acute megakaryoblastic leukemia with p210 BCR/ABL and t(1;16) translocation but not t(9;22) Ph chromosome. J Hematol Oncol 2011; 4:45. [PMID: 22075327 PMCID: PMC3228666 DOI: 10.1186/1756-8722-4-45] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Accepted: 11/10/2011] [Indexed: 11/24/2022] Open
Abstract
Acute megakaryoblastic leukemia (AMKL) is a type of acute myeloid leukemia (AML), in which majority of the blasts are megakaryoblastic. De novo AMKL in adulthood is rare, and carries very poor prognosis. We here report a 45-year-old woman with de novo AMKL with BCR/ABL rearrangement and der(16)t(1;16)(q21;q23) translocation but negative for t(9;22) Ph chromosome. Upon induction chemotherapy consisting of homoharringtonine, cytarabine and daunorubicin, the patient achieved partial hematological remission. The patient was then switched to imatinib plus one cycle of CAG regimen (low-dose cytarabine and aclarubicin in combination with granulocyte colony-stimulating factor), and achieved complete remission (CR). The disease recurred after 40 days and the patient eventually died of infection. To the best of our knowledge, this is the first report of de novo AMKL with p210 BCR/ABL and der(16)t(1;16)(q21;q23) translocation but not t(9;22) Ph chromosome.
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Affiliation(s)
- Xiao Min
- Department of Hematology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie-Fang Avenue, Wuhan, Hubei 430030, PR China
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Al-Shehri A, Al-Seraihy A, Owaidah TM, Belgaumi AF. Megakaryocytic blast crisis at presentation in a pediatric patient with chronic myeloid leukemia. Hematol Oncol Stem Cell Ther 2010; 3:42-6. [PMID: 20231813 DOI: 10.1016/s1658-3876(10)50056-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Patients with chronic myeloid leukemia (CML) infrequently present in blast crisis (BC). While most BC are of myeloid origin, megakaryocytic BC is rare, especially at the time of CML diagnosis. We describe the first pediatric patient presenting with megakaryocytic leukemia and having BCR-ABL1 translocation as the single chromosomal abnormality. Clinical features were more suggestive of CML in megakaryocytic blast crisis than Philadelphia chromosome positive de novo AML. The patient was treated with AML-directed chemotherapy and imatinib mesylate followed by umbilical cord blood stem cell transplantation. The patient was in complete molecular response 16 months after stem cell transplantation.
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Benzamides
- Blast Crisis/pathology
- Child
- Cord Blood Stem Cell Transplantation
- Diagnosis, Differential
- Female
- Humans
- Imatinib Mesylate
- Leukemia, Megakaryoblastic, Acute/diagnosis
- Leukemia, Megakaryoblastic, Acute/pathology
- Leukemia, Megakaryoblastic, Acute/therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Megakaryocytes/pathology
- Piperazines/therapeutic use
- Pyrimidines/therapeutic use
- Remission Induction
- Treatment Outcome
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Affiliation(s)
- Ali Al-Shehri
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Sudden blastic crisis and additional chromosomal abnormalities during chronic myeloid leukemia in the imatinib era. Int J Clin Oncol 2009; 14:545-50. [DOI: 10.1007/s10147-009-0884-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 02/15/2009] [Indexed: 12/22/2022]
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Pullarkat ST, Vardiman JW, Slovak ML, Rao DS, Rao NP, Bedell V, Said JW. Megakaryocytic blast crisis as a presenting manifestation of chronic myeloid leukemia. Leuk Res 2008; 32:1770-5. [DOI: 10.1016/j.leukres.2008.02.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Revised: 02/28/2008] [Accepted: 02/28/2008] [Indexed: 11/26/2022]
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