Physiological measurements corroborate symptomatic improvement after therapeutic leukapheresis in a pregnant woman with chronic myelogenous leukemia

SOHO State of the Art Updates and Next Questions: Chronic Myeloid Leukemia and Pregnancy: "Per Aspera Ad Astra"

Chronic myeloid leukemia (CML) has evolved from an invariably fatal disease to a chronic disorder that can be treated with targeted drugs and allows survival expectations approaching age-matched controls. Thus, pregnancy and conception in CML should not be precluded anymore; however, to ensure the well-being of both the mother and the developing fetus careful planning and management are required. Tyrosine Kinase Inhibitors (TKIs) are not genotoxic or carcinogenic but can pose a risk to the developing fetus, due to their teratogenic potential. The risk depends on the TKI and the stage of fetal development during exposure. Teratogenic risk is high in the first trimester of pregnancy when the baby's organs and structures are forming (5-12 weeks). If a female patient is on therapy it is advisable to stop therapy at the first positive pregnancy test (3-5 weeks) to maximize the length of treatment-free, and ideally to not treat until delivery. If needed, the medication plan during pregnancy may be adjusted. Interferons can be used at any time, imatinib and nilotinib have a reduced placental crossing and could be carefully used after 16 weeks, whereas dasatinib crosses the placenta and can induce problems throughout the whole gestation. Management of pregnancy in CML is complex. This manuscript is an update of the state of the art allowing healthcare providers to be informed of the different situations that can occur and their governance.

Family Planning and Pregnancy in Patients with Chronic Myeloid Leukemia

PURPOSE OF REVIEW

The goal of this review is to summarize what is known about pregnancy in women with chronic myeloid leukemia (CML): there are very few guidelines regarding how to treat women who are pregnant at the time of CML diagnosis, and similarly, few guidelines regarding family planning for women already on tyrosine kinase inhibitor therapy who might want to start family planning.

RECENT FINDINGS

Most patients with CML achieve excellent control with first line tyrosine kinase inhibitor therapy that includes either imatinib, dasatinib, nilotinib, or bosutinib. For men, tyrosine kinase inhibitor (TKI) therapy does not affect sperm number or function, and female partners of men on therapy who become pregnant do not have an increased risk of miscarriage or babies with fetal malformation. However, for women, all TKIs are teratogenic and should be avoided at least in the first trimester of pregnancy. However, a small study suggests that women who have achieved a stable deep response therapy can safely stop therapy prior to a planned pregnancy and may not need any intervention during the pregnancy. Another small study suggests that nilotinib and imatinib have the lowest rate of transfer across the placenta. Providing well-documented guidelines for women with CML is challenging as TKI therapy is teratogenic. However, valuable information can be gained from small series of patients as summarized here.

Treatment of CML in pregnancy

Since the introduction of tyrosine kinase inhibitors (TKIs) at the beginning of the millennium, the outlook for patients with chronic myeloid leukemia (CML) has improved remarkably. As such, the question of life expectancy and survival has become less problematic while quality of life and family planning have become more so. While TKIs are the cornerstone of CML management, their teratogenicity renders them contraindicated during pregnancy. In recent years, patients who satisfy standardized criteria can stop TKI therapy altogether, and indeed, in eligible patients who wish to become pregnant, these objectives overlap. However, not all patients satisfy these criteria. Some pregnancies are unplanned, and a number of patients are pregnant when diagnosed with CML. In these patients the way forward is less clear, and there remains a paucity of good evidence available to guide treatment. In this article, we summarize the relevant literature and provide a framework for clinicians faced with the challenge of managing CML and pregnancy.

Leukapheresis and Hyperleukocytosis, Past and Future

Hyperleukocytosis is a hematologic crisis caused by excessive proliferation of leukemic cells and has a relatively high early mortality due to a series of severe complications. Therefore, prompt and effective intervention is required. Leukapheresis performed using apheresis equipment to separate leukocytes from peripheral blood, at the same time returns autologous plasma, platelets and erythrocytes to the patient, is applied clinically for the treatment of hyperleukocytosis. Leukapheresis not only removes excessive leukocytes rapidly and corrects metabolic abnormalities but also alleviates the symptoms of leukostasis. In addition, the procedure of leukapheresis is generally well tolerated. Leukapheresis has become one of the most imperative adjuvant therapies to treat hyperleukocytosis, especially in the patient who was not inappropriate to cytoreduce with Ara-C or hydroxyurea. In this review, we present the background of leukapheresis development and highlight its clinical application in hyperleukocytic leukemia patients.

Writing scientific case reports for top-line journals

The venerable clinical case report has been largely reduced to the status of commodity in the present age of dedicated case report journals. Top-line clinical journals may discourage or even refuse to accept clinical case reports due to their potential adverse effect on the impact factor of the journal. But while the traditional clinical case report, that presents a case history and attempts to extrapolate a lesson from it, may have fallen out of favor, there remains a need for astute clinical observations that serve to stimulate the generation of hypotheses and may lead, ultimately, to medical breakthroughs. Clinicians are very much capable of employing scientific reasoning when approaching an unusual clinical situation. By remaining up to date with the literature, and determining, at the outset of the case, what lessons may be learned from it, they can formulate a scientific approach, using clinical methods, to result in meaningful contributions to the literature in top-line journals.

Therapeutic leukapheresis and thrombapheresis in medical emergencies

The management of hyperleukocytosis or thrombocytosis by therapeutic cytapheresis in the early 21 st century is far from codified (universal). Therapeutic cytapheresis have been proposed to achieve more rapid cytoreduction in peripheral blood than old universal support in order to quickly prevent potential complications. But, there are no randomized studies demonstrating the superiority of cytapheresis over other treatments alone. In this short review, based on our own experience (since 1980), we will give the indications and the role of cytapheresis procedures and we will try to answer the questions: when is therapeutic cytapheresis appropriate and do they still have a place in 2020, especially as a medical emergency?

Management of chronic myeloid leukemia in the setting of pregnancy: when is leukocytapheresis appropriate? A case report and review of the literature

BACKGROUND

Chronic myeloid leukemia (CML) is a common hematologic malignancy; however, its occurrence during pregnancy is unusual due to its low prevalence in females of childbearing age. There are conflicting reports of how to best manage CML in pregnancy, particularly in the setting of leukocytosis.

HEMAPHERESIS

A 30-year-old female was diagnosed with CML at 18 weeks' estimated gestational age. On initial presentation she reported fatigue, night sweats, and early satiety, and was found to have a white blood cell (WBC) count of 69.3 × 10⁹ /L and platelet count of 366 × 10⁹ /L. Her disease was managed during pregnancy using interferon-α alone despite persistent leukocytosis.

CONCLUSION

CML may be effectively managed during pregnancy, even in the setting of leukocytosis, without the application of leukocytapheresis. Management relies not only upon the coordination of drug therapy and fetal monitoring, but requires close communication between multiple medical disciplines. Leukocytapheresis has been safely performed during pregnancy and may be a suitable adjunct management strategy in pregnant patients diagnosed with CML with specific clinical presentations, such as hyperleukocytosis (WBC count > 150 × 10⁹ /L) and/or symptomatic leukostasis.