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Shi L, Yin P, Chen C, Fan Q, Sun C, Wang D, Cheng J, Hong N. Machine learning-based model for predicting outcomes in cerebral hemorrhage patients with leukemia. Eur J Radiol 2024; 177:111543. [PMID: 38905800 DOI: 10.1016/j.ejrad.2024.111543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 05/17/2024] [Accepted: 05/31/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND AND PURPOSE Intracranial hemorrhage (ICH) in leukemia patients progresses rapidly with high mortality. Limited data are available on imaging studies in this population. The study aims to develop prediction models for 7-day and short-term mortality risk based on the non-contrast computed tomography (NCCT) image features. METHODS The NCCT image features of ICH in 135 leukemia patients between 2007-2023 were retrospectively extracted using manual assessment and radiomics methods. After multiple imputation of missing laboratory data, univariate logistic regression and least absolute shrinkage and selection operator (LASSO) were used for feature selection. Random forest models were built with comprehensive evaluation and ranking of feature importance. RESULT 135 and 129 patients were included in the studies for 7-day and short-term prognostic models, respectively. The median age of all enrolled patients was 35 years, and there were 86 male patients (63.7 %). Clinical models (validation: AUC [area under the curve] = 0.78, AUPRC [area under the precision-recall curve] = 0.73; AUC = 0.84, AUPRC = 0.86), radiomics models (validation: AUC = 0.82, AUPRC = 0.78; AUC = 0.75, AUPRC = 0.77), and the combined models (validation: AUC = 0.84, AUPRC = 0.83; AUC = 0.87, AUPRC = 0.89) predicted 7-day and short-term mortality with good predictive efficacy. Clinical decision curve analysis showed that the combined models predicted 7-day and 30-day risk of death would be more beneficial than other models. Shape features contributed significantly more than semantic features in both radiomics models and combined models (93.3 %, 52.1 %, as well as 85.2 %,37.4 %, respectively) for 7-day and 30-day mortality. CONCLUSIONS Combined models constructed based on NCCT perform well in predicting the risk of 7-day and short-term mortality in ICH patients with leukemia. Shape features extracted by radiomics are important markers for modeling the prognosis.
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Affiliation(s)
- Lu Shi
- Department of Radiology, Peking University People's Hospital, 11 Xizhimen Nandajie, Xicheng District, Beijing 100044, China.
| | - Ping Yin
- Department of Radiology, Peking University People's Hospital, 11 Xizhimen Nandajie, Xicheng District, Beijing 100044, China.
| | - Cancan Chen
- Institute of Research, Infervision Medical Technology Co., Ltd, 25F Building E, Yuanyang International Center, Chaoyang District, Beijing 100025, China.
| | - Qianrui Fan
- Institute of Research, Infervision Medical Technology Co., Ltd, 25F Building E, Yuanyang International Center, Chaoyang District, Beijing 100025, China.
| | - Chao Sun
- Department of Radiology, Peking University People's Hospital, 11 Xizhimen Nandajie, Xicheng District, Beijing 100044, China.
| | - Dawei Wang
- Institute of Research, Infervision Medical Technology Co., Ltd, 25F Building E, Yuanyang International Center, Chaoyang District, Beijing 100025, China.
| | - Jin Cheng
- Department of Radiology, Peking University People's Hospital, 11 Xizhimen Nandajie, Xicheng District, Beijing 100044, China.
| | - Nan Hong
- Department of Radiology, Peking University People's Hospital, 11 Xizhimen Nandajie, Xicheng District, Beijing 100044, China.
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Yohannan B, Martinez Gutierrez JC, Chen PR, Rios A. Middle Meningeal Artery Embolization in Acute Leukemia Patients Presenting With Subdural Hematoma. J Hematol 2024; 13:39-45. [PMID: 38644984 PMCID: PMC11027772 DOI: 10.14740/jh1215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 12/30/2023] [Indexed: 04/23/2024] Open
Abstract
Intracerebral hemorrhage is a potentially fatal complication in patients with acute leukemia and contributing factors include thrombocytopenia and coagulopathy. Patients with acute leukemia may develop subdural hematoma (SDH) spontaneously or secondary to trauma. In patients with acute leukemia and SDH, the surgical evacuation of the hematoma causes significant morbidity and mortality. New approaches and strategies to reduce the need for surgical evacuation are needed to improve outcomes in patients with acute leukemia and intracerebral hemorrhage. We report two cases of acute SDH in patients with acute leukemia successfully treated with middle meningeal artery embolization, a minimally invasive interventional radiology technique, obviating the need for a surgical intervention. The first patient with acute promyelocytic leukemia (APL) presented with coagulopathy and developed an acute SDH after a fall. The second patient with acute myeloid leukemia presented with gum bleeding and also sustained an acute SDH after a fall. Both patients underwent middle meningeal artery embolization for treating their SDHs while actively receiving induction chemotherapy for acute leukemia. Both patients had resolution of their acute SDH and are in remission from their acute leukemia. Middle meningeal artery embolization is a very effective, and within the context of this setting, a novel, minimally invasive technique for management of SDH in acute leukemia patients, which can prevent the need for surgical interventions with its associated comorbidities and high risk of fatal outcomes in patients with acute leukemia and acute SDH.
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Affiliation(s)
- Binoy Yohannan
- Division of Hematology/Oncology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Juan Carlos Martinez Gutierrez
- Division of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Peng Roc Chen
- Division of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Adan Rios
- Division of Hematology/Oncology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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3
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Chu Q, Wei W, Lao H, Li Y, Tan Y, Wei X, Huang B, Qin C, Tang Y. Machine learning algorithms for integrating clinical features to predict intracranial hemorrhage in patients with acute leukemia. Int J Neurosci 2023; 133:977-986. [PMID: 35156526 DOI: 10.1080/00207454.2022.2030327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 01/02/2022] [Accepted: 01/08/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) in acute leukemia (AL) patients leads to high morbidity and mortality, treatment approaches for ICH are generally ineffective. Thus, early identification of which subjects are at high risk of ICH is of key importance. Currently, machine learning can achieve well predictive capability through constructing algorithms that simultaneously exploit the information coming from clinical features. METHODS After rigid data preprocessing, 42 different clinical features from 948 AL patients were used to train different machine learning algorithms. We used the feature selection algorithms to select the top 10 features from 42 clinical features. To test the performance of the machine learning algorithms, we calculated area under the curve (AUC) values from receiver operating characteristic (ROC) curves along with 95% confidence intervals (CIs) by cross-validation. RESULTS With the 42 features, RF exhibited the best predictive power. After feature selection, the top 10 features were international normalized ratio (INR), prothrombin time (PT), creatinine (Cr), indirect bilirubin (IBIL), albumin (ALB), monocyte (MONO), platelet (PLT), lactic dehydrogenase (LDH), fibrinogen (FIB) and prealbumin (PA). Among the top 10 features, INR, PT, Cr, IBIL and ALB had high predictive performance with an AUC higher than 0.8 respectively. CONCLUSIONS The RF algorithm exhibited a higher cross-validated performance compared with the classical algorithms, and the selected important risk features should help in individualizing aggressive treatment in AL patients to prevent ICH. Efforts that will be made to test and optimize in independent samples will warrant the application of such algorithm and predictors in the future.
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Affiliation(s)
- Quanhong Chu
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wenxin Wei
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Huan Lao
- Medical College of Guangxi University, Nanning, Guangxi, China
- School of Computer, Electronics and Information, Guangxi University, Nanning, Guangxi, China
| | - Yujian Li
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yafu Tan
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiaoyong Wei
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Baozi Huang
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Chao Qin
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yanyan Tang
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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4
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Ashraf M, Naseeruddin G, Zahra SG, Sultan KA, Kamboh UA, Manzoor M, Farooq M, Ahmad M, Ashraf N. Intracerebral hemorrhage as the first symptomatic manifestation of chronic myeloid leukemia (chronic phase): A case report and literature review. Surg Neurol Int 2023; 14:5. [PMID: 36751457 PMCID: PMC9899481 DOI: 10.25259/sni_897_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/27/2022] [Indexed: 01/08/2023] Open
Abstract
Background Chronic myeloid leukemia (CML) is mostly asymptomatic at diagnosis. Intracerebral hemorrhage (ICH), as the first presentation of CML in its chronic phase (CP) has only once been reported in the literature. In addition, CML (CP) patients developing ICH are equally rare, with only eight cases reported. ICH is more commonly associated with CML progressing to its end stage (accelerated phase [AP] and blast crisis [BC]). The pathophysiology of ICH in CML-CP is postulated to be due to leukostasis, unlike in the CML-AP/BC, where thrombocytopenia and coagulopathy are the underlying mechanisms. This case adds to the scarce literature on a rare and challenging complication of ICH in CML-CP, especially as these patients tend to rebleed and management is uncertain. Case Description A 22-year-old male presented with a 2-week history of headaches and vomiting, associated with a 1-week history of the left-sided weakness. Initial blood work revealed hyperleukocytosis. The patient was investigated for CML with intracranial involvement. During his stay, his Glasgow coma score (GCS) dropped (from 14 to 11), prompting an urgent CT scan which revealed a large resolving ICH with perifocal edema and midline shift. A decompressive hemicraniectomy with expansion duraplasty was performed to alleviate the mass effect and reduce intracranial pressure. Three hours postoperatively, the patient developed an extradural hematoma which needed prompt evacuation. A postoperative CT revealed an improved midline shift, and after 7 days, his GCS improved to 15, and he began oncological treatment. Neurological symptoms were experienced by our patient at presentation with hyperleukocytosis on full blood count, which may implicate leukostasis as an underlying mechanism. Conclusion Even in the CP, CML patients presenting with mild neurological symptoms should be investigated to exclude intracranial bleeds. As these patients tend to rebleed, they should be conservatively managed unless there is a need to alleviate intracranial pressure.
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Affiliation(s)
- Mohammad Ashraf
- Wolfson School of Medicine, University of Glasgow, Scotland, United Kingdom,,Corresponding author: Mohammad Ashraf, Wolfson School of Medicine, University of Glasgow, Scotland, United Kingdom.
| | - Ghulam Naseeruddin
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Shah Gul Zahra
- School of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Kashif Ali Sultan
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Usman Ahmad Kamboh
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Mehwish Manzoor
- Department of Oncology, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Minaam Farooq
- School of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Manzoor Ahmad
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Naveed Ashraf
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
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Versluis J, Pandey M, Flamand Y, Haydu JE, Belizaire R, Faber M, Vedula RS, Charles A, Copson KM, Shimony S, Rozental A, Bendapudi PK, Wolach O, Griffiths EA, Thompson JE, Stone RM, DeAngelo DJ, Neuberg D, Luskin MR, Wang ES, Lindsley RC. Prediction of life-threatening and disabling bleeding in patients with AML receiving intensive induction chemotherapy. Blood Adv 2022; 6:2835-2846. [PMID: 35081257 PMCID: PMC9092400 DOI: 10.1182/bloodadvances.2021006166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/11/2022] [Indexed: 11/20/2022] Open
Abstract
Bleeding in patients with acute myeloid leukemia (AML) receiving intensive induction chemotherapy is multifactorial and contributes to early death. We sought to define the incidence and risk factors of grade 4 bleeding to support strategies for risk mitigation. Bleeding events were retrospectively assessed between day-14 and day +60 of induction treatment according to the World Health Organization (WHO) bleeding assessment scale, which includes grade 4 bleeding as fatal, life-threatening, retinal with visual impairment, or involving the central nervous system. Predictors were considered pretreatment or prior to grade 4 bleeding. Using multivariable competing-risk regression analysis with grade 4 bleeding as the primary outcome, we identified risk factors in the development cohort (n = 341), which were tested in an independent cohort (n = 143). Grade 4 bleeding occurred in 5.9% and 9.8% of patients in the development and validation cohort, respectively. Risk factors that were independently associated with grade 4 bleeding included baseline platelet count ≤40 × 109/L compared with >40 × 109/L, and baseline international normalized ratio of prothrombin time (PT-INR) >1.5 or 1.3 > 1.5 compared with ≤1.3. These variables were allocated points, which allowed for stratification of patients with low- and high-risk for grade 4 bleeding. Cumulative incidence of grade 4 bleeding at day+60 was significantly higher among patients with high- vs low-risk (development: 31 ± 7% vs 2 ± 1%; P < .001; validation: 25 ± 9% vs 7 ± 2%; P = .008). In both cohorts, high bleeding risk was associated with disseminated intravascular coagulation (DIC) and proliferative disease. We developed and validated a simple risk model for grade 4 bleeding, which enables the development of rational risk mitigation strategies to improve early mortality of intensive induction treatment.
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Affiliation(s)
- Jurjen Versluis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Manu Pandey
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Yael Flamand
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - J. Erika Haydu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Roger Belizaire
- Division of Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Mark Faber
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Rahul S. Vedula
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Anne Charles
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Kevin M. Copson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Shai Shimony
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | - Alon Rozental
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | - Pavan K. Bendapudi
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
| | - Ofir Wolach
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | | | - James E. Thompson
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Richard M. Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Daniel J. DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Donna Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Marlise R. Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Eunice S. Wang
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - R. Coleman Lindsley
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Characteristics and Outcomes of Intracranial Hemorrhage in Cancer Patients Visiting the Emergency Department. J Clin Med 2022; 11:jcm11030643. [PMID: 35160096 PMCID: PMC8837162 DOI: 10.3390/jcm11030643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/17/2022] Open
Abstract
Intracranial hemorrhage (ICH) is a dreaded complication of both cancer and its treatment. To evaluate the characteristics and clinical outcomes of cancer patients with ICH, we identified all patients with ICH who visited The University of Texas MD Anderson Cancer Center emergency department between 1 September 2006 and 16 February 2016. Clinical and radiologic data were collected and compared. Logistic regression analyses were used to determine the association between clinical variables and various outcomes. During the period studied, 704 confirmed acute ICH cases were identified. In-hospital, 7-day, and 30-day mortality rates were 15.1, 11.4, and 25.6%, respectively. Hypertension was most predictive of intensive care unit admission (OR = 1.52, 95% CI = 1.09–2.12, p = 0.013). Low platelet count was associated with both in-hospital mortality (OR = 0.96, 95% CI = 0.94–0.99, p = 0.008) and 30-day mortality (OR = 0.98, 95% CI = 0.96–1.00, p = 0.016). Radiologic findings, especially herniation and hydrocephalus, were strong predictors of short-term mortality. Among known risk factors of ICH, those most helpful in predicting cancer patient outcomes were hypertension, low platelet count, and the presence of hydrocephalus or herniation. Understanding how the clinical presentation, risk factors, and imaging findings correlate with patient morbidity and mortality is helpful in guiding the diagnostic evaluation and aggressiveness of care for ICH in cancer patients.
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Cornelissen LL, Kreuger AL, Caram-Deelder C, Huisman MV, Middelburg RA, Kerkhoffs JLH, von dem Borne PA, Beckers EAM, de Vooght KMK, Kuball J, van der Bom JG, Zwaginga JJ. Association between cardiovascular risk factors and intracranial hemorrhage in patients with acute leukemia. Eur J Haematol 2021; 108:310-318. [PMID: 34923665 DOI: 10.1111/ejh.13737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Intracranial hemorrhage is seen more frequently in acute leukemia patients compared to the general population. Besides leukemia related risk factors, also risk factors that are present in the general population might contribute to hemorrhagic complications in leukemia patients. Of those, cardiovascular risk factors leading to chronic vascular damage could modulate the occurrence of intracranial hemorrhage in these patients, as during their disease and treatment acute endothelial damage occurs due to factors like thrombocytopenia and inflammation. OBJECTIVES Our aim was to explore if cardiovascular risk factors can predict intracranial hemorrhage in acute leukemia patients. METHODS In a case control study nested in a cohort of acute leukemia patients, including 17 cases with intracranial hemorrhage and 55 matched control patients without intracranial hemorrhage, data on cardiovascular risk factors was collected for all patients. Analyses were performed via conditional logistic regression. RESULTS Pre-existing hypertension and ischemic heart disease in the medical history were associated with intracranial hemorrhage, with an incidence rate ratio of 12.9 (95% confidence interval (CI) 1.5 to 109.2) and 12.1 (95% CI 1.3 to110.7), respectively. CONCLUSION Both pre-existing hypertension and ischemic heart disease seem to be strong predictors of an increased risk for intracranial hemorrhage in leukemia patients.
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Affiliation(s)
- Loes L Cornelissen
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Aukje L Kreuger
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Camila Caram-Deelder
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Rutger A Middelburg
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jean Louis H Kerkhoffs
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Hematology, Haga teaching hospital, Den Haag, The Netherlands
| | | | - Erik A M Beckers
- Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Karen M K de Vooght
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jürgen Kuball
- Department of Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna G van der Bom
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - J J Zwaginga
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
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8
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Ren X, Huang Q, Qu Q, Cai X, Fu H, Mo X, Wang Y, Zheng Y, Jiang E, Ye Y, Luo Y, Chen S, Yang T, Zhang Y, Han W, Tang F, Mo W, Wang S, Li F, Liu D, Zhang X, Zhang Y, Feng S, Gao F, Yuan H, Wang D, Wan D, Chen H, Chen Y, Wang J, Chen Y, Wang Y, Xu K, Lang T, Wang X, Meng H, Li L, Wang Z, Fan Y, Chang Y, Xu L, Huang X, Zhang X. Predicting mortality from intracranial hemorrhage in patients who undergo allogeneic hematopoietic stem cell transplantation. Blood Adv 2021; 5:4910-4921. [PMID: 34448835 PMCID: PMC9153001 DOI: 10.1182/bloodadvances.2021004349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023] Open
Abstract
Intracranial hemorrhage (ICH) is a rare but fatal central nervous system complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, factors that are predictive of early mortality in patients who develop ICH after undergoing allo-HSCT have not been systemically investigated. From January 2008 to June 2020, a total of 70 allo-HSCT patients with an ICH diagnosis formed the derivation cohort. Forty-one allo-HSCT patients with an ICH diagnosis were collected from 12 other medical centers during the same period, and they comprised the external validation cohort. These 2 cohorts were used to develop and validate a grading scale that enables the prediction of 30-day mortality from ICH in all-HSCT patients. Four predictors (lactate dehydrogenase level, albumin level, white blood cell count, and disease status) were retained in the multivariable logistic regression model, and a simplified grading scale (termed the LAWS score) was developed. The LAWS score was adequately calibrated (Hosmer-Lemeshow test, P > .05) in both cohorts. It had good discrimination power in both the derivation cohort (C-statistic, 0.859; 95% confidence interval, 0.776-0.945) and the external validation cohort (C-statistic, 0.795; 95% confidence interval, 0.645-0.945). The LAWS score is the first scoring system capable of predicting 30-day mortality from ICH in allo-HSCT patients. It showed good performance in identifying allo-HSCT patients at increased risk of early mortality after ICH diagnosis. We anticipate that it would help risk stratify allo-HSCT patients with ICH and facilitate future studies on developing individualized and novel interventions for patients within different LAWS risk groups.
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Affiliation(s)
- Xiying Ren
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qiusha Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qingyuan Qu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xuan Cai
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Haixia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiaodong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yawei Zheng
- Center of Hematopoietic Stem Cell Transplantation, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Erlie Jiang
- Center of Hematopoietic Stem Cell Transplantation, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yishan Ye
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yi Luo
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaozhen Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ting Yang
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuanyuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Feifei Tang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Wenjian Mo
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Fei Li
- Department of Hematology, Chinese PLA General Hospital, Beijing, China
| | - Daihong Liu
- Department of Hematology, Chinese PLA General Hospital, Beijing, China
| | - Xiaoying Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuqing Feng
- Department of Hematology, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Feng Gao
- Department of Hematology, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Hailong Yuan
- Hematology Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | - Dingming Wan
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yao Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Jingzhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yuhong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ying Wang
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Kailin Xu
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Tao Lang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Xiaomin Wang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Hongbin Meng
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China; and
| | - Limin Li
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China; and
| | - Zhiguo Wang
- Bone Marrow Transplantation Department, Harbin Institute of Hematology and Oncology, Harbin, China
| | - Yanling Fan
- Bone Marrow Transplantation Department, Harbin Institute of Hematology and Oncology, Harbin, China
| | - Yingjun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Lanping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiaohui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
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9
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Wang H, Cao F, Li J, Sun K, Jin J, Wang M. Intracerebral Hemorrhage as the Initial Presentation of Chronic Myeloid Leukemia: A Case Report and Review of the Literature. Front Neurol 2020; 11:571576. [PMID: 33193017 PMCID: PMC7642366 DOI: 10.3389/fneur.2020.571576] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/14/2020] [Indexed: 12/11/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is an unusual complication in chronic myeloid leukemia (CML). Intracranial involvement, causing ICH as an initial presentation is extremely rare in CML. Herein, we reported the first case of a newly diagnosed CML patient, who presented with headaches accompanied by nausea and vomiting as the initial presentations, caused by ICH. He underwent an emergency craniotomy twice and the postoperative pathologic examination confirmed intracranial CML involvement. Interestingly, his bone marrow and cerebrospinal fluid (CSF) smear and pathological study of the involved brain tissue showed proliferation of granulocytes, which were comprised mainly of metamyelocytes and myelocytes, without any blast within the brain tissue, suggesting the stage of CML was in the chronic phase (CP). He then received dasatinib treatment and achieved complete hematologic remission in the first 3-month follow-up but failed to reach a molecular response in the 6-month follow-up. By reporting this case and reviewing relevant references, we suggested intracranial CML involvement should be considered as a potential pathogenesis of ICH when the patient presents with hyperleukocytosis. A craniotomy is mainly for intracranial decompression and benefits the diagnosis of intracranial CML involvement. Tyrosine kinase inhibitors are effective in such patients to some extent, but more appropriate treatment strategies should be investigated in further detail.
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Affiliation(s)
- Huafeng Wang
- Department of Hematology, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Lab of Hematopoietic Malignancy, Zhejiang University, Hangzhou, China
| | - Fei Cao
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianhu Li
- Zhejiang Provincial Key Lab of Hematopoietic Malignancy, Zhejiang University, Hangzhou, China.,Bone Marrow Morphology Laboratory, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Ke Sun
- Department of Pathology, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jie Jin
- Department of Hematology, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Lab of Hematopoietic Malignancy, Zhejiang University, Hangzhou, China.,Bone Marrow Morphology Laboratory, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Ming Wang
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
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10
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Cornelissen LL, Kreuger AL, Caram-Deelder C, Middelburg RA, Kerkhoffs JLH, von dem Borne PA, Beckers EAM, de Vooght KMK, Kuball J, Zwaginga JJ, van der Bom JG. Thrombocytopenia and the effect of platelet transfusions on the occurrence of intracranial hemorrhage in patients with acute leukemia - a nested case-control study. Ann Hematol 2020; 100:261-271. [PMID: 33067700 PMCID: PMC7782440 DOI: 10.1007/s00277-020-04298-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/03/2020] [Indexed: 02/04/2023]
Abstract
We designed a study to describe the incidence of intracranial hemorrhage according to severity and duration of thrombocytopenia and to quantify the associations of platelet transfusions with intracranial hemorrhage in patients with acute leukemia. In this case-control study nested in a cohort of 859 leukemia patients, cases (n = 17) were patients diagnosed with intracranial hemorrhage who were matched with control patients (n = 55). We documented platelet counts and transfusions for seven days before the intracranial hemorrhage in cases and in a “matched” week for control patients. Three measures of platelet count exposure were assessed in four potentially important time periods before hemorrhage. Among these leukemia patients, we observed the cumulative incidence of intracranial hemorrhage of 3.5%. Low platelet counts were, especially in the three to seven days preceding intracranial hemorrhage, associated with the incidence of intracranial hemorrhage, although with wide confidence intervals. Platelet transfusions during the week preceding the hemorrhage were associated with higher incidences of intracranial hemorrhage; rate ratios (95% confidence interval) for one or two platelet transfusions and for more than two transfusions compared with none were 4.04 (0.73 to 22.27) and 8.91 (1.53 to 51.73) respectively. Thus, among acute leukemia patients, the risk of intracranial hemorrhage was higher among patients with low platelet counts and after receiving more platelet transfusions. Especially, the latter is likely due to clinical factors leading to increased transfusion needs.
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Affiliation(s)
- Loes L Cornelissen
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin/LUMC, Leiden, The Netherlands
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Aukje L Kreuger
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin/LUMC, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Camila Caram-Deelder
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin/LUMC, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rutger A Middelburg
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin/LUMC, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jean Louis H Kerkhoffs
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin/LUMC, Leiden, The Netherlands
- Department of Hematology, Haga Teaching Hospital, Den Haag, The Netherlands
| | | | - Erik A M Beckers
- Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Karen M K de Vooght
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jürgen Kuball
- Department of Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J J Zwaginga
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin/LUMC, Leiden, The Netherlands
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna G van der Bom
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin/LUMC, Leiden, The Netherlands.
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
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11
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Zhao P, Hou M, Liu Y, Liu HX, Huang RB, Yao HX, Niu T, Peng J, Jiang M, Han YQ, Hu JD, Zhou H, Zhou ZP, Qiu L, Zhang LS, Wang X, Wang HQ, Feng R, Yang LH, Ma LM, Wang SQ, Kong PY, Wang WS, Sun HP, Sun J, Zhou HB, Zhu TN, Wang LR, Zhang JY, Huang QS, Liu X, Fu HX, Li YY, Wang QF, Jiang Q, Jiang H, Lu J, Zhang XH. Risk stratification and outcomes of intracranial hemorrhage in patients with immune thrombocytopenia under 60 years of age. Platelets 2020; 32:633-641. [PMID: 32614630 DOI: 10.1080/09537104.2020.1786042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Intracranial hemorrhage (ICH) is a devastating complication of immune thrombocytopenia (ITP). However, information on ICH in ITP patients under the age of 60 years is limited, and no predictive tools are available in clinical practice. A total of 93 adult patients with ITP who developed ICH before 60 years of age were retrospectively identified from 2005 to 2019 by 27 centers in China. For each case, 2 controls matched by the time of ITP diagnosis and the duration of ITP were provided by the same center. Multivariate analysis identified head trauma (OR = 3.216, 95%CI 1.296-7.979, P =.012), a platelet count ≤ 15,000/μL at the time of ITP diagnosis (OR = 1.679, 95%CI 1.044-2.698, P =.032) and severe/life-threatening bleeding (severe bleeding vs. mild bleeding, OR = 1.910, 95%CI 1.088-3.353, P =.024; life-threatening bleeding vs. mild bleeding, OR = 2.620, 95%CI 1.360-5.051, P =.004) as independent risk factors for ICH. Intraparenchymal hemorrhage (OR = 5.191, 95%CI 1.717-15.692, P =.004) and a history of severe bleeding (OR = 4.322, 95%CI 1.532-12.198, P =.006) were associated with the 30-day outcome of ICH. These findings may facilitate ICH risk stratification and outcome prediction in patients with ITP.
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Affiliation(s)
- Peng Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Yi Liu
- Department of Geriatric Hematology, Chinese PLA General Hospital, Beijing, China
| | - Hui-Xin Liu
- Department of Clinical Epidemiology, Peking University People's Hospital, Beijing, China
| | - Rui-Bin Huang
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hong-Xia Yao
- Department of Hematology, Hainan General Hospital, Haikou, China
| | - Ting Niu
- Department of Hemotology, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Ming Jiang
- Department of Hematology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yan-Qiu Han
- Department of Hematology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Jian-Da Hu
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hu Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Ze-Ping Zhou
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Lin Qiu
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Lian-Sheng Zhang
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Hua-Quan Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Ru Feng
- Department of Hematology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Lin-Hua Yang
- Department of Hematology, Second Affiliated Hospital of Shanxi Medical University, Taiyuan, China
| | - Liang-Ming Ma
- Department of Hematology, Affiliated Shanxi Big Hospital of Shanxi Medical University, Taiyuan, China
| | - Shun-Qing Wang
- Department of Hematology, Guangzhou First People's Hospital, Guangzhou, China
| | - Pei-Yan Kong
- Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Wen-Sheng Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Hui-Ping Sun
- Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Sun
- Nanfang Hospital, Nanfang Medical University, Guangzhou, China
| | - He-Bing Zhou
- Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Tie-Nan Zhu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Ru Wang
- Fuxing Hospital, Capital Medical University, Beijing, China
| | - Jing-Yu Zhang
- Department of Hematology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qiu-Sha Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yue-Ying Li
- Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
| | - Qian-Fei Wang
- Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
| | - Qian Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hao Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Jin Lu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
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12
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Outcomes and Clinical Characteristics of Intracranial Hemorrhage in Patients with Hematologic Malignancies: A Systematic Literature Review. World Neurosurg 2020; 144:e15-e24. [PMID: 32565374 DOI: 10.1016/j.wneu.2020.06.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Many clinical and demographic factors can influence survival of patients with hematologic malignancies who have intracranial hemorrhages (ICHs). Understanding the influence of these factors on patient survival can guide treatment decisions and may inform prognostic discussions. We conducted a systematic literature review to determine survival of patients with intracranial hemorrhages and concomitant hematologic malignancy. METHODS A systematic literature review was conducted and followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. PubMed/MEDLINE, Web of Science, Ovid, SCOPUS, and Embase databases were queried with the following terms: ("intracranial hemorrhages" OR "brain hemorrhage" OR "cerebral hemorrhage" OR "subdural hematoma" OR "epidural hematoma" OR "intraparenchymal hemorrhage") AND ("Hematologic Neoplasms" OR "Myeloproliferative Disorders" OR "Myelofibrosis" OR "Essential thrombocythemia" OR "Leukemia"). Abstracts and articles were screened according to inclusion and exclusion criteria that were determined a priori. RESULTS Literature review yielded 975 abstracts from which a total of 68 full-text articles were reviewed. Twelve articles capturing 634 unique patients were included in the final qualitative analysis. Median overall survival for all patients ranged from 20 days to 1.5 months while median overall survival for the subset of patients having ICH within 10 days of diagnosis of hematologic malignancy was 5 days. Intraparenchymal hemorrhages, multiple foci of hemorrhage, transfusion-resistant low platelet counts, leukocytosis, low Glasgow Coma Scale scores at presentation, and ICH early in treatment course were associated with worse outcomes. CONCLUSIONS Survival for patients with hematologic malignancies and concomitant ICHs remains poor. Early detection, recognition of poor prognostic factors, and correction of hematologic abnormalities essential to prevention and treatment of ICHs in this patient population.
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13
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Nixon S, Lieberman L, Atenafu EG, Doherty M, Murray C, Wolfe A, Brandys D, Rowland S, Kwan BY, Yu E, Lechner B, Maze D. Clinical outcomes and transfusion management following intracranial hemorrhage in patients with acute leukemia. Transfusion 2019; 60:269-274. [PMID: 31808560 DOI: 10.1111/trf.15621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/07/2019] [Accepted: 10/14/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is little evidence to guide management of patients with acute leukemia and intracranial hemorrhage (ICH). Predictors of long-term outcome following ICH are unknown. STUDY DESIGN AND METHODS This study included adult patients with acute leukemia and ICH over an 8-year period. The primary outcome was data regarding 90-day mortality. Secondary outcomes included data related to the proportion of patients receiving post-remission therapy and predictors of 90-day mortality. RESULTS ICH occurred in 101 patients; 12 patients died within 72 hours. For the 89 others, 90-day mortality was 40%. Of 43 patients who received induction, 30 achieved remission and 26 received post-remission therapy. Older age (p = 0.03) and higher white count (p = 0.02) at the time of ICH were predictive of inferior survival. During 90-day follow-up, median platelet count was 37 x 109 /L (0-1526 x 109 /L). Lower platelet count during follow-up was predictive of 90-day mortality (p = <0.01). Twenty-one percent of platelet transfusions were provided when the platelet count was less than 10 x 109 /L, 54% between 10 and 29 x 109 /L, and 25% greater than 30 x 109 /L. New or progressive ICH occurred in 23 patients. There was no difference in the median platelet transfusion trigger between patients who had new or progressive ICH and those who did not. CONCLUSION In patients with acute leukemia, survival following ICH is poor. Older age and higher white count is associated with increased mortality, perhaps reflecting higher risk disease. Following ICH in acute leukemia platelet transfusions do not appear to alter the risk of progressive bleeding or mortality.
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Affiliation(s)
- Shannon Nixon
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Lani Lieberman
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Eshetu G Atenafu
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Mary Doherty
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Cindy Murray
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Amanda Wolfe
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Danielle Brandys
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Suzanne Rowland
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Benjamin Ym Kwan
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Eugene Yu
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Breanne Lechner
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Dawn Maze
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
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14
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Subdural Hematoma in Patients with Hematologic Malignancies: An Outcome Analysis and Examination of Risk Factors of Operative and Nonoperative Management. World Neurosurg 2019; 130:e1061-e1069. [DOI: 10.1016/j.wneu.2019.07.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/06/2019] [Accepted: 07/08/2019] [Indexed: 11/19/2022]
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15
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Wang Y, Wang L, Xi Y, Li Z. Bleeding with negative coagulation screening test as initial presentation of chronic myelogenous leukemia managed by fresh frozen plasma: A case report. Medicine (Baltimore) 2019; 98:e16984. [PMID: 31464946 PMCID: PMC6736460 DOI: 10.1097/md.0000000000016984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Chronic myelogenous leukemia (CML), a clonal disorder of pluripotent stem cell, rarely presents with bleeding in chronic phase due to the function preservation of the platelets. Factor (F) XIII deficiency, an extremely rare hemorrhagic disease, can cause fatal bleeding, which has been previously described in autoimmune disorders and leukemias. PATIENT CONCERNS A 38-year-old woman with a 20-day history of spontaneous subcutaneous hemorrhage visited our hospital, who presented with intracranial hemorrhage, hematuria, and delayed hematoma after a bone marrow puncture. Initial management included cytogenetics analysis, molecular analysis, and coagulation evaluation. DIAGNOSIS Bone marrow puncture, cytogenetics, and molecular analysis indicated the diagnosis of CML. With the normal results of clotting screening tests and platelet counting, as well as the relief of bleeding after infusion of fresh frozen plasma (FFP), acquired rare bleeding disorder probably associated with factor XIII (FXIII) deficiency. INTERVENTIONS Management with anti-hyperleukocytosis and chemotherapy, hydration, alkalization, diuresis, uric acid-lowering, molecular targeted drugs, and freshly frozen plasma transfusion therapy resolved the bleeding diathesis. OUTCOMES The patient survived from the initial bleeding, however, she died. Twenty six months later due to the progression of CML. LESSONS CML can initially present as unusual bleeding, possibly related to FXIII defect. It is essential to screen coagulopathy including FXIII activity and to supplement plasma for CML patients who present initially as bleeding, which cannot be deciphered by the routine clotting screening test.
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16
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Sudden Intracranial Hemorrhage in a Patient With Atypical Chronic Myeloid Leukemia in Chronic Phase. J Pediatr Hematol Oncol 2018; 40:e553-e556. [PMID: 29227326 DOI: 10.1097/mph.0000000000001061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A 16-year-old boy was incidentally found to have hyperleukocytosis during a school physical examination. He was diagnosed with atypical chronic myeloid leukemia in chronic phase. Although treatment with hydoxyurea was started, his white blood cell count increased and he eventually developed lethal intracranial hemorrhage. Although very rare, intracranial hemorrhage should be considered as a possible complication in patients with atypical chronic myeloid leukemia, even in chronic phase, if they have hyperleukocytosis and thrombocytopenia.
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17
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Lieberman F, Villgran V, Normolle D, Boyiadzis M. Intracranial Hemorrhage in Patients Newly Diagnosed with Acute Myeloid Leukemia and Hyperleukocytosis. Acta Haematol 2017; 138:116-118. [PMID: 28858876 DOI: 10.1159/000478690] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Frank Lieberman
- Division of Hematology and Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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18
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Hori YS, Aoi M, Oda K, Fukuhara T. Presence of a Malignant Tumor as a Novel Predictive Factor for Repeated Recurrences of Chronic Subdural Hematoma. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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19
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Zhang Q, Li X, Wei Z, Ye X, Zhu L, Xie M, Xie W, Zhu J, Li L, Zhou D, Zheng Y, Yang X, Zhu M, Sun J. Risk factors and clinical characteristics of non-promyelocytic acute myeloid leukemia of intracerebral hemorrhage: A single center study in China. J Clin Neurosci 2017; 44:203-206. [PMID: 28694043 DOI: 10.1016/j.jocn.2017.06.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/19/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although high mortality in patients with acute leukemia (AL) is associated with intracranial hemorrhage (ICH), the clinical features and pathogenesis of AL patients with cerebral hemorrhage are not well known. METHODS We diagnosed 90 patients with ICH from a total of 1467 patients with non-promyelocytic AL who had been hospitalized in the First Affiliated Hospital of Medical School of Zhejiang University from January 2010 to October 2015. Moreover, the risk factors of ICH death were evaluated. RESULT Median age at ICH was 51years old, in which men accounted for 52.2%. They also accounted for 85.6% of acute myeloid leukemia. The relative incidence of ICH was the highest in M2 and M5 (60.1%). ICH presented with higher peripheral blood white blood cell count (WBC) (P<0.001), lower peripheral platelet counts (P<0.001), lower albumin (P<0.001), lower fibrous protein (P<0.001) and prolongation of prothrombin time (P<0.001) compared to those observed in the patients of NICH group; multivariate analysis, independent risk factors for death in patients with ICH include: WBC≥30.00×109/l and prothrombin time≥12.91 s. CONCLUSIONS Leukocytosis and coagulation dysfunctions might be the main pathogenesis of acute leukemia complicated with cerebral hemorrhage.
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Affiliation(s)
- Qiaolei Zhang
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China; Department of Hematology, Lishui People's Hospital, Lishui, Zhejiang Province, China
| | - Xueying Li
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Zhangyue Wei
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xiujin Ye
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China.
| | - Lixia Zhu
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Mixue Xie
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Wanzhuo Xie
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Jingjing Zhu
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Li Li
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - De Zhou
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Yanlong Zheng
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xiudi Yang
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Mingyu Zhu
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Jianai Sun
- Department of Hematology, The First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
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Yin R, Qiu CX, Dong XH, Chen YL. Subdural hemorrhages in acute lymphoblastic leukemia: case report and literature review. Chin Neurosurg J 2016. [DOI: 10.1186/s41016-016-0045-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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21
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[Fatal central nervous system hemorrhage during acute lymphoblastic leukemia induction]. Arch Pediatr 2016; 23:1260-1263. [PMID: 27743763 DOI: 10.1016/j.arcped.2016.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/14/2016] [Accepted: 08/11/2016] [Indexed: 11/22/2022]
Abstract
Intracerebral hemorrhage (ICH) remains a cause of death in hematologic malignancies. Asparaginase represents a key agent in the treatment of acute lymphoblastic leukemia (ALL). The toxicity of asparaginase includes coagulopathy such as thrombotic or bleeding tendency. We report a case of fatal cerebral hemorrhage in a 12-year-old girl treated for ALL. Cerebral hemorrhage occurred after three injections of L-asparaginase. The patient presented with hypofibrinogenemia (0.36g/L), associated with thrombocytopenia (24,000/mm3). Despite maximal medical and surgical treatment (platelets and fresh-frozen plasma transfusions, red blood cells transfusion, fibrinogen replacement therapy, and craniotomy discharge), the patient died. L-asparaginase is well known for its prothrombotic action. By inhibiting the synthesis of fibrinogen and factors V, VII, VIII, and IX, it causes an increased risk of bleeding, including intracranial bleeding. Predictive scores for ICH onset have been established but there is no consensus on the management of coagulation disorders induced by L-asparaginase. It is recommended to check fibrinogen and antithrombin (AT) blood values in order to substitute them if they drop to < 1 g/L for fibrinogen and < 60% for AT. The management of asparaginase-induced ICH does not differ from that of ICH of other origin. The risk of death is high, and surgical treatment has not proven superior to medical therapy in terms of mortality rates and 6-month survival. Further studies are needed to define consensus guidelines for coagulation disorders induced by asparaginase and also to define the specific management in cases of ICH in childhood hematological malignancies.
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Ofran Y, Tallman MS, Rowe JM. How I treat acute myeloid leukemia presenting with preexisting comorbidities. Blood 2016; 128:488-96. [PMID: 27235136 PMCID: PMC5524532 DOI: 10.1182/blood-2016-01-635060] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 05/18/2016] [Indexed: 12/23/2022] Open
Abstract
Acute myeloid leukemia (AML) is a devastating disease with an incidence that progressively increases with advancing age. Currently, only ∼40% of younger and 10% of older adults are long-term survivors. If untreated, the overall prognosis of AML remains dismal. Initiation of therapy at diagnosis is usually urgent. Barriers to successful therapy for AML are the attendant toxicities directly related to chemotherapy or those associated with inevitable aplasia. Organ dysfunction often further complicates such toxicities and may even be prohibitive. There are few guidelines to manage such patients and the fear of crossing the medico-legal abyss may dominate. Such clinical scenarios provide particular challenges and require experience for optimal management. Herein, we discuss select examples of common pretreatment comorbidities, including cardiomyopathy, ischemic heart disease; chronic renal failure, with and without dialysis; hepatitis and cirrhosis; chronic pulmonary insufficiency; and cerebral vascular disease. These comorbidities usually render patients ineligible for clinical trials and enormous uncertainty regarding management reigns, often to the point of withholding definitive therapy. The scenarios described herein emphasize that with appropriate subspecialty support, many AML patients with comorbidities can undergo therapy with curative intent and achieve successful long-term outcome.
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Affiliation(s)
- Yishai Ofran
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Martin S Tallman
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY; Division of Hematology and Medical Oncology, Weill Cornell Medical College, New York, NY; and
| | - Jacob M Rowe
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel; Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
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Cowan AJ, Altemeier WA, Johnston C, Gernsheimer T, Becker PS. Management of Acute Myeloid Leukemia in the Intensive Care Setting. J Intensive Care Med 2014; 30:375-84. [DOI: 10.1177/0885066614530959] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 12/16/2013] [Indexed: 01/18/2023]
Abstract
Patients with acute myeloid leukemia (AML) who are newly diagnosed or relapsed and those who are receiving cytotoxic chemotherapy are predisposed to conditions such as sepsis due to bacterial and fungal infections, coagulopathies, hemorrhage, metabolic abnormalities, and respiratory and renal failure. These conditions are common reasons for patients with AML to be managed in the intensive care unit (ICU). For patients with AML in the ICU, providers need to be aware of common problems and how to manage them. Understanding the pathophysiology of complications and the recent advances in risk stratification as well as newer therapy for AML are relevant to the critical care provider.
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Affiliation(s)
- Andrew J. Cowan
- Division of Hematology, University of Washington, Seattle, WA, USA
- Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
| | - William A. Altemeier
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Christine Johnston
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Terry Gernsheimer
- Division of Hematology, University of Washington, Seattle, WA, USA
- Puget Sound Blood Center, Seattle, WA, USA
| | - Pamela S. Becker
- Division of Hematology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
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Chen CY, Tai CH, Cheng A, Wu HC, Tsay W, Liu JH, Chen PY, Huang SY, Yao M, Tang JL, Tien HF. Intracranial hemorrhage in adult patients with hematological malignancies. BMC Med 2012; 10:97. [PMID: 22931433 PMCID: PMC3482556 DOI: 10.1186/1741-7015-10-97] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 08/29/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical characteristics and outcomes of intracranial hemorrhage (ICH) among adult patients with various hematological malignancies are limited. METHODS A total of 2,574 adult patients diagnosed with hematological malignancies admitted to a single university hospital were enrolled into this study between 2001 and 2010. The clinical characteristics, image reports and outcomes were retrospectively analyzed. RESULTS A total of 72 patients (48 men and 24 women) with a median age of 56 (range 18 to 86) had an ICH. The overall ICH incidence was 2.8% among adult patients with hematological malignancies. The incidence of ICH was higher in acute myeloid leukemia (AML) patients than in patients with other hematological malignancies (6.3% vs 1.1%, P = 0.001). ICH was more common among patients with central nervous system (CNS) involvement of lymphoma than among patients with CNS involved acute leukemia (P <0.001). Sites of ICH occurrence included the cerebral cortex (60 patients, 83%), basal ganglia (13 patients, 18%), cerebellum (10 patients, 14%), and brainstem (5 patients, 7%). A total of 33 patients (46%) had multifocal hemorrhages. In all, 56 patients (77%) had intraparenchymal hemorrhage, 22 patients (31%) had subdural hemorrhage, 15 patients (21%) had subarachnoid hemorrhage (SAH), and 3 patients (4%) had epidural hemorrhage. A total of 22 patients had 2 or more types of ICH. In all, 46 (64%) patients died of ICH within 30 days of diagnosis, irrespective of the type of hematological malignancy. Multivariate analysis revealed three independent prognostic factors: prolonged prothrombin time (P = 0.008), SAH (P = 0.021), and multifocal cerebral hemorrhage (P = 0.026). CONCLUSIONS The incidence of ICH in patients with AML is higher than patients with other hematological malignancies. But in those with intracranial malignant disease, patients with CNS involved lymphoma were more prone to ICH than patients with CNS involved acute leukemia. Mortality was similar regardless of the type of hematological malignancy. Neuroimaging studies of the location and type of ICH could assist with prognosis prediction for patients with hematological malignancies.
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Affiliation(s)
- Chien-Yuan Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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25
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Abstract
Acute myeloid leukemia and acute lymphoblastic leukemia remain devastating diseases. Only approximately 40% of younger and 10% of older adults are long-term survivors. Although curing the leukemia is always the most formidable challenge, complications from the disease itself and its treatment are associated with significant morbidity and mortality. Such complications, discussed herein, include tumor lysis, hyperleukocytosis, cytarabine-induced cellebellar toxicity, acute promyelocytic leukemia differentiation syndrome, thrombohemorrhagic syndrome in acute promyelocytic leukemia, L-asparaginase-associated thrombosis, leukemic meningitis, neutropenic fever, neutropenic enterocolitis, and transfussion-associated GVHD. Whereas clinical trials form the backbone for the management of acute leukemia, emergent clinical situations, predictable or not, are common and do not readily lend themselves to clinical trial evaluation. Furthermore, practice guidelines are often lacking. Not only are prospective trials impractical because of the emergent nature of the issue at hand, but clinicians are often reluctant to randomize such patients. Extensive practical experience is crucial and, even if there is no consensus, management of such emergencies should be guided by an understanding of the underlying pathophysiologic mechanisms.
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