Priapism complicating chronic granulocytic leukemia

Priapism in Patients with Chronic Myeloid Leukemia (CML): A Systematic Review

Background:

Priapism is defined as a penile erection that persists four or more hours and is unrelated to sexual stimulation. Priapism resulting from hematologic malignancy is most likely caused by venous obstruction from microemboli/thrombi and hyperviscosity caused by the increased number of circulating leukocytes in mature and immature forms. In patients with leukemia, 50% of cases of priapism are due to Chronic Myeloid Leukemia (CML). We present a systematic review of priapism in CML.

Acquisition of evidence:

An extensive literature research was carried out in PubMed, Google Scholar, SCOPUS, and Science Citation Index databases. The search included cases up to 4^th August 2020.

Synthesis of evidence:

A total of 68 articles were found and included in our review, including 3 reviews from three different centers. We found 68 articles (102 patients; figure 1) and several case reports on priapism in CML. Priapism was noticed in some patients at the first presentation of CML. However, it was infrequently reported during the start of treatment, following the stop of medication and post-splenectomy. The mean age at presentation was 27.4 years, and the mean time from onset of priapism to the time to get medical attention (presentation) was 78.2 hours. The mean white blood cell count associated with priapism was 321.29x10⁹/L, and the mean platelet count was 569 x10 ⁹/L. The chronic phase of CML was the most common phase where priapism occurred. Most patients were Asian (>50%). Nearly a quarter of patients (27.4%) developed permanent erectile dysfunction.

Conclusions:

Priapism is a urological emergency requiring urgent multidisciplinary management to prevent erectile dysfunction. Because of the relatively rare occurrence of priapism in CML patients, there is no standard treatment protocol. (www.actabiomedica.it)

Grading of symptoms in hyperleukocytic leukaemia: a clinical model for the role of different blast types and promyelocytes in the development of leukostasis syndrome

OBJECTIVE

Patients with hyperleukocytic leukaemia were graded according to the severity of symptoms possibly caused by leukostasis to evaluate the effectiveness of therapy and to test the relative contribution of blast type and count of blasts and promyelocytes in the development of leukostasis syndrome.

METHODS

Ninety-five patients (59 male, 36 female, median age 52 yr) with hyperleukocytic leukaemia [leukocytes above 50 x 10(9)/L, 48 acute myeloid leukaemia (AML), 31 chronic myeloid leukaemia (CML), 13 acute lymphoblastic leukaemia (ALL), three chronic myelomonocytic leukaemia (CMML)] were grouped according to the presence or absence and severity of neurologic, pulmonary and other symptoms into four categories (no, possible, probable and highly probable leukostasis syndrome). Age, white blood count (WBC), haemoglobin, blast count and total of blasts plus promyelocytes of these groups were compared by Mann-Whitney U-test.

RESULTS

Patients with myeloid leukaemia (AML M1/M2, CML) which scored as highly probable leukostasis showed significantly higher WBC (P = 0.011), lower haemoglobin (P = 0.004), higher peripheral blast counts (P = 0.004) and higher total of peripheral blasts plus promyelocytes (P < 0.001) compared with the lower probability groups. In leukaemia involving the monocytic lineage (AML M4/M5, CMML) no significant differences were found in any of these factors between patients with highly probable leukostasis and the other patients.

CONCLUSIONS

Our results show that a four-stage clinical grading scale is a valuable tool for analysing hyperleukocytic patient populations and evaluate the effectiveness of therapy more precisely. We further demonstrate that the mechanisms of leukostasis are different in myeloid leukaemia as compared with leukaemia with involvement of the monocytic lineage.

Priapism secondary to leukemia: Effective management with prompt leukapheresis

Priapism is a urological emergency; without prompt treatment the corpora cavernosa undergoes necrosis and fibrosis that may result in erectile dysfunction. Treatment initially involves conservative measures, such as corporeal aspiration and irrigation with saline or dilute phenylephrine. If this fails, embolization or surgical shunting is usually required. Hyperviscosity resulting from leukemia is a rare cause of priapism. We report a case of a 19-year-old man with an 18-hour history of priapism secondary to undiagnosed chronic myeloid leukaemia. We discuss the method of leukapheresis (mechanical white cell depletion) to reduce viscosity and achieve detumescence after failed aspiration.

Priapism

Priapism is a relatively uncommon condition that may present as a medical emergency associated with significant pain and anxiety in the veno-occlusive or low-flow variant. Pharmacologic advances and, specifically, the availability of intracavemosal alpha-agonist therapy have dramatically improved the prospects of resolution for patients with low-flow priapism presenting within the first few hours of the acute episode. High-flow priapism is not considered an emergency and treatment measures are typically conservative aimed at preservation of potency. Urologists, radiologists, and other health care personnel caring for the patient with priapism must be familiar with various etiologic factors implicated in low-flow and high-flow priapism to formulate a logical step-care approach. Differentiation of the low-flow from the high-flow state is perhaps the most critical initial diagnostic challenge that determines the sequence of further interventions including surgical shunts in low-flow priapism refractory to medical therapy.

The etiology, diagnosis, and treatment of priapism: review of the American Foundation for Urologic Disease Consensus Panel Report

Priapism is an important medical condition that requires immediate evaluation, and depending on etiology, may require emergency management. Based on the classification scheme offered by a recent consensus panel, priapism can be subdivided into ischemic and nonischemic types. The nonischemic type, usually the result of perineal trauma, can be treated with conservative therapy, whereas the nonischemic type, which arises from many varied causes, mandates immediate intervention. Corporal fibrosis and permanent erectile dysfunction can result from ischemic priapism that fails to resolve with therapy.

Clinical course and therapy of chronic myelogenous leukemia with interferon-alpha and chemotherapy

This article begins with a review of the natural history of chronic myelogenous leukemia (CML), with an emphasis on prognostic features. Current standard therapy of CML with interferon-alpha based regimens, and interferon-alpha, in the context of allogenic stem cell transplantation is then discussed. Finally, some potentially effective novel agents including homoharringtonine, decitabine, ATRA, and topotecan are described.

Therapeutic options in chronic myeloid leukaemia

The treatment of CML is unsatisfactory. Only bone marrow transplantation offers the possibility of cure. At present all other therapies are palliative and none has been shown to extend survival consistently. Busulphan and hydroxyurea remain the most widely used drugs for chronic phase. Intensive and non-intensive combination chemotherapy regimens have not produced significant improvement in survival. Interferon therapy is promising in patients who respond but requires further evaluation. Splenectomy does not improve survival but may be useful in selected circumstances. Extramedullary disease carries a poor prognosis and responds best to local treatment. The treatment of blast transformation is very difficult. The lymphoid variety should be recognised as response is better to appropriate treatment. Some Philadelphia (Ph) chromosome negative cases have disease which is probably identical to Ph positive disease and respond well to treatment. The others carry a very bad prognosis and respond poorly to treatment.

External expressions of internal malignancy

Paraneoplastic conditions are cancer-connected but are not produced as a direct effect of the tumor or metastasis. Some antedate the appearance of the internal malignancy; some run a course parallel to the tumor; some follow a pattern independent of the neoplasm. They occur in a small minority of patients with cancer and are, for the most part, of unknown cause. When an external disorder is present, it may act as a marker of hidden malignancy and thus contribute to its detection, or it may serve as an indicator of successful treatment. Many of the conditions described occur commonly without any underlying malignancy, but an unusual frequency of association with cancer makes their presence significant.

Hyperleucocytic retinopathy in chronic granulocytic leukaemia: the role of intensive leucapheresis

We describe three patients with chronic granulocytic leukaemia who developed impaired visual acuity in association with high leucocyte counts. Two of the patients were in the chronic phase of their disease and the third developed visual symptoms at the time of blastic transformation. Fundoscopy showed retinal haemorrhages and exudates and a vascular picture consistent with hyperviscosity. We propose the term 'hyperleucocytic retinopathy' for these appearances. Two of the patients derived rapid benefit following leucapheresis and the visual acuity of the third patient improved following treatment with cytotoxic drugs.