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Jeon WJ, Dalal S, Moon JH, Joung B, Nguyen M, Castillo D, Hudson J, Park K, Raghavan R, Akhtari M, Patel A. Leukostasis With Isolated Central Nervous System Involvement in Chronic Phase of Chronic Myelogenous Leukemia. J Hematol 2023; 12:187-196. [PMID: 37692864 PMCID: PMC10482607 DOI: 10.14740/jh1150] [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: 06/01/2023] [Accepted: 07/11/2023] [Indexed: 09/12/2023] Open
Abstract
Chronic myelogenous leukemia (CML) is a hematologic malignancy with unique significance to the field of hematology and oncology, specifically due to the development of tyrosine kinase inhibitors (TKIs). CML often presents with nonspecific symptoms, and the quality of life in patients with CML has drastically improved as a result of TKIs. However, complications of CML including the risk of transforming into life-threatening blast crises continue to exist. Further, as most patients are asymptomatic in the chronic phase, patients often present with serious complications associated with noncompliance to TKIs. For example, central nervous system (CNS) manifestations of CML have been reported, both as the initial presentation of undiagnosed CML and as known complication of uncontrolled CML. Hyperleukocytosis is a manifestation of uncontrolled CML and leukostasis is a complication, occurring in cases of acute myeloid leukemia (AML). Here we present a rare case of leukostasis in a patient with known CML presenting on computed tomography (CT) as intracranial masses in the chronic phase. Our goal is to discuss this rare case of leukostasis in adult CML and describe its management.
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Affiliation(s)
- Won Jin Jeon
- Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Suhani Dalal
- Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Jin Hyun Moon
- Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Bowon Joung
- Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Michael Nguyen
- Division of Medical Oncology/Hematology, Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Dani Castillo
- Division of Medical Oncology, City of Hope, Duarte, CA, USA
| | - Jessica Hudson
- Division of Anatomic and Surgical Pathology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Kiwon Park
- Department of Pharmacy, Loma Linda University, Loma Linda, CA, USA
| | - Ravi Raghavan
- Division of Anatomic and Surgical Pathology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Mojtaba Akhtari
- Division of Medical Oncology/Hematology, Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Ami Patel
- Division of Medical Oncology/Hematology, Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
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Copland M. Treatment of blast phase chronic myeloid leukaemia: A rare and challenging entity. Br J Haematol 2022; 199:665-678. [PMID: 35866251 PMCID: PMC9796596 DOI: 10.1111/bjh.18370] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/14/2022] [Accepted: 07/07/2022] [Indexed: 01/01/2023]
Abstract
Despite the success of BCR-ABL-specific tyrosine kinase inhibitors (TKIs) such as imatinib in chronic phase (CP) chronic myeloid leukaemia (CML), patients with blast phase (BP)-CML continue to have a dismal outcome with median survival of less than one year from diagnosis. Thus BP-CML remains a critical unmet clinical need in the management of CML. Our understanding of the biology of BP-CML continues to grow; genomic instability leads to acquisition of mutations which drive leukaemic progenitor cells to develop self-renewal properties, resulting in differentiation block and a poor-prognosis acute leukaemia which may be myeloid, lymphoid or bi-phenotypic. Similar advances in therapy are urgently needed to improve patient outcomes; however, this is challenging given the rarity and heterogeneity of BP-CML, leading to difficulty in designing and recruiting to prospective clinical trials. This review will explore the treatment of BP-CML, evaluating the data for TKI therapy alone, combinations with intensive chemotherapy, the role of allogeneic haemopoietic stem cell transplantation, the use of novel agents and clinical trials, as well as discussing the most appropriate methods for diagnosing BP and assessing response to therapy, and factors predicting outcome.
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Affiliation(s)
- Mhairi Copland
- Paul O'Gorman Leukaemia Research Centre, College of Medical, Veterinary & Life SciencesInstitute of Cancer Sciences, University of GlasgowGlasgowUK
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Maniam A, Zuhaimy H, Vendargon FMM, Othman O. Isolated Ocular Manifestations in Chronic Myeloid Leukaemia. Cureus 2021; 13:e19450. [PMID: 34912600 PMCID: PMC8664615 DOI: 10.7759/cureus.19450] [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] [Accepted: 11/10/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Chronic myeloid leukaemia (CML) presenting with only ocular manifestations either at the initial stage of diagnosis or at relapse is uncommon. We report two cases of CML presenting with isolated visual symptoms. CASE SERIES The first case is a 21-year-old healthy gentleman who presented with left eye painless loss of vision for a one-week duration. Visual acuity was 6/60 in the left eye and 6/6 in the right eye. There were scattered retinal haemorrhages in both eyes and a sub-macular bleed over the left eye. The full blood count revealed a high white cell count of 134.6 × 109/L. Peripheral blood smear showed hyper-leucocytosis with absolute eosinophilia and basophilia and the presence of blasts suggestive of CML thus chemotherapy was commenced. The second case is a 28-year-old in haematological, molecular, and cytogenic remission from CML for the past two years, presented with left eye painless vision loss for five days duration. Vision in the left eye was counting fingers. There was a large subretinal mass involving the left optic disc. Magnetic resonance imaging of the brain and orbit showed an elliptical orbital mass at the left globe posteriorly with diffuse thickening of the optic nerve. The patient was diagnosed as CML relapsed to the left optic nerve. He underwent intrathecal chemotherapy and orbital irradiation. CONCLUSION Both these cases are unique since the manifestation of CML was with only ocular features at the time of presentation as per in the first case during the initial diagnosis and in the second case during relapse. This highlights that it is evident that the knowledge of ocular involvement in leukaemia is crucial since the eye is the only organ where leukemic infiltration to nerves and blood vessels can be observed directly. Recognizing fundus changes in leukaemia allows earlier diagnosis and prompt treatment. These case reports highlight the importance of recognizing early fundus changes, which should allow earlier diagnosis and treatment.
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Affiliation(s)
- Anita Maniam
- Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MYS.,Department of Ophthalmology, Hospital Sultanah Aminah, Johor Bahru, MYS
| | - Hanis Zuhaimy
- Department of Ophthalmology, Hospital Sultanah Aminah, Johor Bahru, MYS
| | | | - Othmaliza Othman
- Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MYS
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Abstract
In contrast to solid cancers, which often require genetic modifications and complex cellular reprogramming for effective metastatic dissemination, leukaemic cells uniquely possess the innate ability for migration and invasion. Dedifferentiated, malignant leukocytes retain the benign leukocytes' capacity for cell motility and survival in the circulation, while acquiring the potential for rapid and uncontrolled cell division. For these reasons, leukaemias, although not traditionally considered as metastatic diseases, are in fact models of highly efficient metastatic spread. Accordingly, they are often aggressive and challenging diseases to treat. In this Perspective, we discuss the key molecular processes that facilitate metastasis in a variety of leukaemic subtypes, the clinical significance of leukaemic invasion into specific tissues and the current pipeline of treatments targeting leukaemia metastasis.
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Affiliation(s)
- Andrew E Whiteley
- Department of Medicine, Duke University, Durham, NC, USA
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA
| | - Trevor T Price
- Department of Medicine, Duke University, Durham, NC, USA
| | - Gaia Cantelli
- European Molecular Biology Laboratory, European Bioinformatics Institute, Hinxton, UK
| | - Dorothy A Sipkins
- Department of Medicine, Duke University, Durham, NC, USA.
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA.
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Kiran PK, Badarke GV, Suresh CN, Srinivas BJ, Naik R. Isolated central nervous system blast crisis in a case of chronic myeloid leukemia on dasatinib. South Asian J Cancer 2020; 7:170. [PMID: 30112332 PMCID: PMC6069336 DOI: 10.4103/sajc.sajc_63_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- P K Kiran
- Department of Medical Oncology, Healthcare Global Enterprises Hospital, Bengaluru, Karnataka, India
| | - Girish V Badarke
- Department of Hematology, Healthcare Global Enterprises Hospital, Bengaluru, Karnataka, India
| | - C N Suresh
- Department of Hematology, Healthcare Global Enterprises Hospital, Bengaluru, Karnataka, India
| | - B J Srinivas
- Department of Medical Oncology, Healthcare Global Enterprises Hospital, Bengaluru, Karnataka, India
| | - Radheshyam Naik
- Department of Medical Oncology, Healthcare Global Enterprises Hospital, Bengaluru, Karnataka, India
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Palejwala AH, O'Connor KP, Shi H, Villeneuve L, Scordino T, Glenn CA. Chronic myeloid leukemia manifested as myeloid sarcoma: Review of literature and case report. J Clin Neurosci 2019; 64:269-276. [DOI: 10.1016/j.jocn.2019.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/27/2019] [Accepted: 04/12/2019] [Indexed: 11/26/2022]
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Sivri M, Paksoy Y, Dağlı M, Keles Oğlu KS, Koplay M. An atypical isolated CNS blast crisis in chronic myeloid leukaemia. Br J Hosp Med (Lond) 2018; 79:470-471. [PMID: 30070958 DOI: 10.12968/hmed.2018.79.8.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mesut Sivri
- Specialist, Ankara Child Health and Disease Hematology Oncology Training and Research Hospital, Radiology Clinic, University of Health Sciences, 06110, Altındag, Ankara, Turkey
| | - Yahya Paksoy
- Professor, Department of Radiology, Medical Faculty of Selcuk University, Konya, Turkey
| | - Mehmet Dağlı
- Professor, Department of Internal Medicine, Division of Hematology University, Medical Faculty of Selcuk University, Konya, Turkey
| | | | - Mustafa Koplay
- Professor, Department of Internal Medicine, Division of Hematology University, Medical Faculty of Selcuk University, Konya, Turkey
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8
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Sharma PV, Ilyas O, Jobanputra Y, Casanova T, Kalidindi V, Santos N. Is it always cancer? A curious case of benign intracranial hypertension in chronic myeloid leukemia. Intractable Rare Dis Res 2018; 7:182-184. [PMID: 30181938 PMCID: PMC6119664 DOI: 10.5582/irdr.2018.01045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
28-year-old African American female with chronic myeloid leukemia (CML) presented with blurry vision for 4-5 days prior to presentation associated with right-sided headaches. Patient was on treatment for the CML but never had hematological remission. Patient saw an ophthalmologist who told her that she has bilateral optic disc swelling and advised her to get an MRI of the brain. She came to the ER due to worsening headache and blurry vision. The funduscopic examination showed significant bilateral papilledema. Laboratory evaluation revealed a leukocytosis of 240 × 103/uL with platelet count of 1,202 × 103. The white cell differential count showed 17% blasts along with myelocytes and meta-myelocytes. MRI of brain revealed non-specific CSF flair signal. Lumbar puncture (LP) showed significantly elevated opening pressures. The CSF composition was however normal. The patient felt much relief of her symptoms following the LP. The papilledema was thought to be due to benign intracranial hypertension (ICH), which was attributed to poor CSF absorption due to resistance to flow of CSF caused by the high WBC count. She received 2 cycles of leukopheresis which dropped her WBC count. She was also started on acetazolamide for the benign ICH and her symptoms improved considerably. Patients with CML can thus present with symptoms mimicking CNS involvement of the disease such as headaches and blurry vision, but that could be attributed to the poor CSF resorption given the leukocytosis rather than spread of the disease itself.
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Affiliation(s)
- Purva V. Sharma
- Department of Internal Medicine, University of Miami Palm Beach Regional Consortium, Atlantis, Fl, USA
- Address correspondence to:Dr. Purva V. Sharma, Department of Internal Medicine, University of Miami Palm Beach Regional Consortium, Atlantis, Fl 33462, USA. E-mail:
| | - Omar Ilyas
- Department of Internal Medicine, University of Miami Palm Beach Regional Consortium, Atlantis, Fl, USA
| | - Yash Jobanputra
- Department of Internal Medicine, University of Miami Palm Beach Regional Consortium, Atlantis, Fl, USA
| | | | - Venkat Kalidindi
- Department of Internal Medicine, University of Miami Palm Beach Regional Consortium, Atlantis, Fl, USA
| | - Napolean Santos
- Department of Hematology/Oncology, JFK medical Center, Fl, USA
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9
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Kumawat BL, Sharma CM, Saini PK, Garg A. Central nervous system blast crisis of chronic myeloid leukaemia misdiagnosed as tubercular meningitis. BMJ Case Rep 2018; 2018:bcr-2017-223923. [PMID: 29895576 DOI: 10.1136/bcr-2017-223923] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Chronic Myeloid Leukaemia (CML) presenting with isolated Central Nervous System (CNS) blast crisis is an uncommon entity. A 22-year-old man, diagnosed with chronic phase CML in 2011 and was in haematological and cytogenetic remission until July 2016, had acute onset headache and vomiting with meningeal signs and was admitted elsewhere, investigated by brain imaging and cerebrospinal fluid (CSF) analysis and suspected to have tubercular meningitis, for which steroids and antitubercular medications were started. The patient's sensorium further deteriorated, and Ventriculoperitoneal shunt surgery was done for hydrocephalus by a neurosurgeon. After 2 months of the illness, he was admitted to our hospital with a persistent headache, vomiting and altered sensorium. CSF for cytospin confirmed myeloid blasts. He was still in haematological remission. So, a diagnosis of isolated CNS blast crisis was made. The patient was started on triple intrathecal chemotherapy and cranial radiotherapy. He had improvement with treatment and is still in remission.
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Affiliation(s)
- Banshi Lal Kumawat
- Department of Neurology, Sawai Mansingh Medical College and Hospital, Jaipur, Rajasthan, India
| | - Chandra Mohan Sharma
- Department of Neurology, Sawai Mansingh Medical College and Hospital, Jaipur, Rajasthan, India
| | - Pankaj Kumar Saini
- Department of Neurology, Sawai Mansingh Medical College and Hospital, Jaipur, Rajasthan, India
| | - Ankur Garg
- Department of Neurology, Sawai Mansingh Medical College and Hospital, Jaipur, Rajasthan, India
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Abstract
PURPOSE OF REVIEW Acute and chronic leukemias are heterogeneous diseases and can affect any part of the body upon initial discovery. Understanding the sequela of systemic involvement is key for proper diagnosis and treatment. RECENT FINDINGS Over the decades, new research has emerged regarding neurological complications of the myeloid or lymphoid leukemias. Central nervous system involvement usually confers a poor prognosis and requires emergent treatment. Standard of care still involves systemic therapy, intrathecal administration of chemotherapeutic agents, and cranial radiation. Treatment-related side effects can occur and need to be recognized by any practitioner involved with patient care. It is imperative to understand neurologic complications from leukemia to prevent delays and initiate necessary treatment to maintain neurologic and cognitive function.
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11
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Chronic Myelogenous Leukemia Relapse Presenting With Central Nervous System Blast Crisis and Bilateral Optic Nerve Infiltration. J Neuroophthalmol 2016; 36:73-7. [DOI: 10.1097/wno.0000000000000326] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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12
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Jain A, Gupta N. Isolated CNS Blast Crises in Chronic Myeloid Leukaemia Presenting as Hypertrophic Pachymeningitis and Bilateral Optic Neuritis: A Case Report. J Clin Diagn Res 2016; 10:OE01-5. [PMID: 26894118 DOI: 10.7860/jcdr/2016/15813.7045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 11/14/2015] [Indexed: 11/24/2022]
Abstract
Extramedullary blast crises of Chronic Myeloid Leukaemia (CML) involving CNS is rare and usually accompanies systemic relapse. Isolated CNS blast relapse is an extremely uncommon event. A 35-year-old male was diagnosed with chronic phase (CP) CML two years back at our hospital and was started on imatinib 400 mg daily. Patient achieved haematological and cytogenetic remission at three and 12 months respectively but was non-compliant with medications thereafter. He presented to our emergency with headache and bilateral visual loss. CNS examination revealed neck rigidity and fundoscopy revealed disc edema with retinal vein dilatation and haemorrhages. Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis and a positive cytospin for myeloid blasts. MRI brain suggested pachymeningeal enhancement involving falx cerebri and tentorium along with bilateral optic nerve thickening. Patient maintained cytogenetic remission at current presentation. A diagnosis of isolated CNS blast crises with pachymeningitis and bilateral optic nerve involvement was made and two doses of intrathecal chemotherapy were administered. However, patient died due to a rapidly downhill course. A previously unreported finding of pachymeningitis with bilateral optic neuritis has been highlighted in this case, along with a brief review of this rare condition.
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Affiliation(s)
- Ankur Jain
- Post Graduate Student, Department of Medicine, Maulana Azad Medical College , Delhi, India
| | - Naresh Gupta
- Director Professor, Department of Medicine, Maulana Azad Medical College , Delhi, India
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Isolated central nervous system relapse in chronic myeloid leukemia. Case Rep Med 2015; 2015:232915. [PMID: 25878669 PMCID: PMC4386294 DOI: 10.1155/2015/232915] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 03/08/2015] [Accepted: 03/09/2015] [Indexed: 11/30/2022] Open
Abstract
Chronic myeloid leukemia is a myeloproliferative disorder that has three distinguished phases:
chronic, accelerated, and blastic. In extremely rare cases, the blast phase can affect the central
nervous system without concomitant bone marrow involvement. We report the case of a patient
with chronic myeloid leukemia who, despite having achieved complete cytogenetic remission in the
bone marrow for several years, experienced a blast crisis of the central nervous system following an
episode of infectious meningoencephalitis.
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14
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Park MJ, Park PW, Seo YH, Kim KH, Seo JY, Jeong JH, Kim MJ, Jeong JW, Ahn JY, Park J. A case of isolated lymphoblastic relapse of the central nervous system in a patient with chronic myelogenous leukemia treated with imatinib. Ann Lab Med 2014; 34:247-51. [PMID: 24790915 PMCID: PMC3999326 DOI: 10.3343/alm.2014.34.3.247] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 11/04/2013] [Accepted: 02/13/2014] [Indexed: 11/19/2022] Open
Affiliation(s)
- Mi-Jung Park
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Pil-Whan Park
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yiel-Hea Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyung-Hee Kim
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ja-Young Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ji-Hun Jeong
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Moon Jin Kim
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jin-Woo Jeong
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jeong-Yeal Ahn
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jinny Park
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Nishimoto M, Nakamae H, Koh KR, Kosaka S, Matsumoto K, Morita K, Koh H, Nakane T, Ohsawa M, Hino M. Dasatinib maintenance therapy after allogeneic hematopoietic stem cell transplantation for an isolated central nervous system blast crisis in chronic myelogenous leukemia. Acta Haematol 2013; 130:111-4. [PMID: 23548721 DOI: 10.1159/000347158] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 01/04/2013] [Indexed: 11/19/2022]
Abstract
A 22-year-old male with Ph-positive chronic myelogenous leukemia (CML) was started on treatment with imatinib. After 12 months of therapy, he achieved a complete cytogenetic response (CCyR). Although the CCyR persisted in his bone marrow, he developed an isolated CML blast crisis in his central nervous system (CNS) after 29 months of therapy. He underwent allogeneic hematopoietic stem cell transplantation (HSCT) following combination therapy with dasatinib, intrathecal chemotherapy and cranial irradiation. Subsequently, 168 days after allogeneic HSCT, he was started on dasatinib maintenance therapy to prevent a CNS relapse. Thirty-eight months after allogeneic HSCT, he has sustained a complete molecular response in both bone marrow and CNS. We believe dasatinib has the potential to prevent CNS relapse if used for maintenance therapy after allogeneic HSCT.
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Blast Crisis/diagnostic imaging
- Blast Crisis/pathology
- Blast Crisis/therapy
- Bone Marrow/pathology
- Brain/pathology
- Central Nervous System Neoplasms/diagnostic imaging
- Central Nervous System Neoplasms/pathology
- Central Nervous System Neoplasms/therapy
- Combined Modality Therapy
- Dasatinib
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnostic imaging
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Magnetic Resonance Imaging
- Male
- Pyrimidines/therapeutic use
- Radiography
- Recurrence
- Thiazoles/therapeutic use
- Transplantation, Homologous
- Young Adult
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Affiliation(s)
- Mitsutaka Nishimoto
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
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Fuchs M, Reinhöfer M, Ragoschke-Schumm A, Sayer HG, Böer K, Witte OW, Hochhaus A, Axer H. Isolated central nervous system relapse of chronic myeloid leukemia after allogeneic hematopoietic stem cell transplantation. BMC BLOOD DISORDERS 2012; 12:9. [PMID: 22871019 PMCID: PMC3469402 DOI: 10.1186/1471-2326-12-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 08/01/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND This case report highlights the relevance of quantifying the BCR-ABL gene in cerebrospinal fluid of patients with suspected relapse of chronic myeloid leukemia in the central nervous system. CASE PRESENTATION We report on a female patient with isolated central nervous system relapse of chronic myeloid leukemia (CML) during peripheral remission after allogeneic hematopoietic stem cell transplantation. The patient showed a progressive cognitive decline as the main symptom. MRI revealed a hydrocephalus and an increase in cell count in the cerebrospinal fluid (CSF) with around 50% immature blasts in the differential count. A highly elevated BCR-ABL/ ABL ratio was detected in the CSF, whilst the ratio for peripheral blood and bone marrow was not altered. On treatment of the malresorptive hydrocephalus with shunt surgery, the patient showed an initial cognitive improvement, followed by a secondary deterioration. At this time, the cranial MRI showed leukemic infiltration of lateral ventricles walls. Hence, intrathecal administration of cytarabine, methotrexate, and dexamethasone was initiated, which caused a significant decrease of cells in the CSF. Soon after, the patient demonstrated significant cognitive improvement with a good participation in daily activities. At a later time point, after the patient had lost the major molecular response of CML, therapy with dasatinib was initiated. In a further follow-up, the patient was neurologically and hematologically stable. CONCLUSIONS In patients with treated CML, the rare case of an isolated CNS blast crisis has to be taken into account if neurological symptoms evolve. The analysis of BCR-ABL in the CSF is a further option for the reliable detection of primary isolated relapse of CML in these patients.
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Affiliation(s)
- Mary Fuchs
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747 Jena, Germany.
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Three paths to better tyrosine kinase inhibition behind the blood-brain barrier in treating chronic myelogenous leukemia and glioblastoma with imatinib. Transl Oncol 2011; 3:13-5. [PMID: 20165690 DOI: 10.1593/tlo.09280] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 09/28/2009] [Accepted: 10/02/2009] [Indexed: 12/24/2022] Open
Abstract
Chronic myelogenous leukemia (CML) can be controlled for years with the tyrosine kinase inhibitor imatinib but because imatinib poorly penetrates the blood-brain barrier (BBB), on occasion, the CML clone will thrive and evolve to an accelerated phase in the resulting imatinib sanctuary within the central nervous system. In this, CML resembles glioblastoma in that imatinib, which otherwise may be effective, cannot get to the tumor. Although a common street drug of abuse, methamphetamine is Food and Drug Administration-approved and marketed as a pharmaceutical drug to treat attention-deficit disorders. It has shown the ability to open the BBB in rodents. We have some clinical hints that it may do so in humans as well. This short note presents three new points potentially leading to better tyrosine kinase inhibition behind the BBB: 1) Pharmaceutical methamphetamine may have a useful role in treating both CML and glioblastoma by allowing higher imatinib concentrations behind the BBB. 2) The old antidepressant and monoamine oxidase inhibitor selegiline, used to treat Parkinson disease, is catabolized to methamphetamine. Selegiline, as a nonscheduled drug,may therefore be an easier way to open the BBB, allowing more effective chemotherapy with tyrosine kinases. 3) Dasatinib is a tyrosine kinase inhibitor with a spectrum of inhibition only partially overlapping that of imatinib and a mechanism of tyrosine kinase inhibition that is different from that of imatinib. The two should be additive. In addition, dasatinib crosses the BBB poorly, and it can therefore be expected to benefit from methamphetamine-assisted entry.
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O'Brien CE, Saratsis AM, Voyadzis JM. Granulocytic Sarcoma in a Patient With Blast Crisis Mimicking a Chronic Subdural Hematoma. J Clin Oncol 2011; 29:e569-71. [DOI: 10.1200/jco.2010.33.1272] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Tan SY, Kan E, Lim WY, Chay G, Law JHK, Soo GW, Bukhari NI, Segarra I. Metronidazole leads to enhanced uptake of imatinib in brain, liver and kidney without affecting its plasma pharmacokinetics in mice. J Pharm Pharmacol 2011; 63:918-25. [DOI: 10.1111/j.2042-7158.2011.01296.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Abstract
Objectives
The pharmacokinetic interaction between metronidazole, an antibiotic–antiparasitic drug used to treat anaerobic bacterial and protozoal infections, and imatinib, a CYP3A4, P-glycoprotein substrate kinase inhibitor anticancer drug, was evaluated.
Methods
Male imprinting control region mice were given 50 mg/kg imatinib PO (control group) or 50 mg/kg imatinib PO, 15 min after 40 mg/kg PO metronidazole (study group). Imatinib plasma, brain, kidney and liver concentrations were measured by HPLC and non-compartmental pharmacokinetic parameters estimated.
Key findings
Metronidazole coadministration resulted in a double-peak imatinib disposition profile. The maximum concentration (Cmax) decreased by 38%, the area under the curve (AUC0–∞) decreased by 14% and the time to Cmax (Tmax) was earlier (50%) in plasma. Apparent volume of distribution (VSS/F) and oral clearance (Cl/F) increased by 21% and 17%, respectively. Imatinib tissue penetration was higher after metronidazole coadministration, with 1.7 and 2.1-fold AUC0–∞ increases in liver and kidney, respectively. Metronidazole increased imatinib's tissue-to-plasma AUC0–∞ ratio in liver from 2.29 to 4.53 and in kidney from 3.04 to 7.57, suggesting higher uptake efficiency. Brain Cmax was 3.9-fold higher than control and AUC0–t last was 2.3-fold greater than plasma (3.5% in control group). No tissue-plasma concentration correlation was found.
Conclusions
Metronidazole slightly decreased imatinib systemic exposure but enhanced liver, kidney and brain penetration, probably due to metronidazole-mediated inhibition of P-glycoprotein and other efflux transporters. The high brain exposure opens possibilities for treatment of glioma and glioblastoma. Renal and hepatic functions may need to be monitored due to potential renal and hepatic toxicity.
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Affiliation(s)
- Shin Yee Tan
- Department of Pharmaceutical Technology, School of Pharmacy and Health Sciences, International Medical University, Kuala Lumpur, Malaysia
| | - Elaine Kan
- Department of Pharmaceutical Technology, School of Pharmacy and Health Sciences, International Medical University, Kuala Lumpur, Malaysia
| | - Wei Yin Lim
- Department of Pharmaceutical Technology, School of Pharmacy and Health Sciences, International Medical University, Kuala Lumpur, Malaysia
| | - Grace Chay
- Department of Pharmaceutical Technology, School of Pharmacy and Health Sciences, International Medical University, Kuala Lumpur, Malaysia
| | - Jason H K Law
- Department of Pharmaceutical Technology, School of Pharmacy and Health Sciences, International Medical University, Kuala Lumpur, Malaysia
| | - Gian Wan Soo
- Department of Pharmaceutical Technology, School of Pharmacy and Health Sciences, International Medical University, Kuala Lumpur, Malaysia
| | - Nadeem Irfan Bukhari
- Department of Pharmaceutical Technology, School of Pharmacy and Health Sciences, International Medical University, Kuala Lumpur, Malaysia
| | - Ignacio Segarra
- Department of Pharmaceutical Technology, School of Pharmacy and Health Sciences, International Medical University, Kuala Lumpur, Malaysia
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Radhika N, Minakshi M, Rajesh M, Manas BR, Deepak Kumar M. Central nervous system blast crisis in chronic myeloid leukemia on imatinib mesylate therapy: report of two cases. Indian J Hematol Blood Transfus 2011; 27:51-4. [PMID: 22379297 DOI: 10.1007/s12288-011-0055-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 01/25/2011] [Indexed: 11/30/2022] Open
Abstract
Chronic myeloid leukaemia is a chronic myeloproliferative disorder characterised by a reciprocal translocation between chromosomes 9 and 22 and thereby formation of the Philadelphia chromosome. Imatinib mesylate (STI-571) is a potent and selective inhibitor of BCR-ABL tyrosine kinase and has emerged as a treatment of choice in chronic myeloid leukaemia (CML) patients in chronic phase. It has shown activity in CML patients in the chronic phase or blastic phase. However there is poor penetration of the central nervous system (CNS) by the drug or its active metabolites. Therefore the CNS acts as a sanctuary site for malignant cells for CML patients treated with Imatinib. We report cases of two CML patients on Imatinib therapy, who were in haematological remission but developed CNS disease.
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Affiliation(s)
- Narayan Radhika
- Department of Pathology, Tata Main Hospital, Jamshedpur, 831001 Jharkhand India
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21
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Epidural leukemic involvement and intracranial hemorrhage as initial manifestations in a newly diagnosed chronic myeloid leukemia patient. Ann Hematol 2010; 90:607-9. [PMID: 20827477 DOI: 10.1007/s00277-010-1061-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 08/18/2010] [Indexed: 10/19/2022]
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22
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Handolias D, Hamilton AL, Salemi R, Tan A, Moodie K, Kerr L, Dobrovic A, McArthur GA. Clinical responses observed with imatinib or sorafenib in melanoma patients expressing mutations in KIT. Br J Cancer 2010; 102:1219-23. [PMID: 20372153 PMCID: PMC2856012 DOI: 10.1038/sj.bjc.6605635] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background: Mutations in KIT are more frequent in specific melanoma subtypes, and response to KIT inhibition is likely to depend on the identified mutation. Methods: A total of 32 patients with metastatic acral or mucosal melanoma were screened for mutations in KIT exons 11, 13 and 17. Results: KIT mutations were found in 38% of mucosal and in 6% of acral melanomas. Three patients were treated with imatinib and one with sorafenib. All four patients responded to treatment, but three have since progressed within the brain. Conclusion: The observed clinical responses support further investigation of KIT inhibitors in metastatic melanoma, selected according to KIT mutation status.
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Affiliation(s)
- D Handolias
- Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
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23
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Klyuchnikov E, Kröger N, Brummendorf TH, Wiedemann B, Zander AR, Bacher U. Current Status and Perspectives of Tyrosine Kinase Inhibitor Treatment in the Posttransplant Period in Patients with Chronic Myelogenous Leukemia (CML). Biol Blood Marrow Transplant 2010; 16:301-10. [DOI: 10.1016/j.bbmt.2009.08.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2009] [Accepted: 08/31/2009] [Indexed: 01/08/2023]
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24
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Janssen JJWM, Berendse HW, Schuurhuis GJ, Merle PA, Ossenkoppele GJ. A 51-year-old male CML patient with progressive hearing loss, confusion, ataxia, and aphasia during imatinib treatment. Am J Hematol 2009; 84:679-82. [PMID: 19658186 DOI: 10.1002/ajh.21489] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Jeroen J W M Janssen
- Department of Hematology, VU University Medical Center, HV Amsterdam, The Netherlands.
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25
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Ocheni S, Iwanski GB, Schafhausen P, Zander AR, Ayuk F, Klyuchnikov E, Zabelina T, Fiedler W, Schnittger S, Hochhaus A, Brümmendorf TH, Kröger N, Bacher U. Characterisation of extramedullary relapse in patients with chronic myeloid leukemia in advanced disease after allogeneic stem cell transplantation. Leuk Lymphoma 2009; 50:551-8. [PMID: 19373652 DOI: 10.1080/10428190902755513] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Recently, higher extramedullary relapse rates following allogeneic stem cell transplantation (SCT) in myeloid malignancies were reported e.g. because of selection of poor-risk patients. We analysed five consecutive patients with post-transplant extramedullary relapse of chronic myeloid leukemia (CML) out of a total of 24 patients (21%) undergoing allo-SCT. All five patients with extramedullary relapse had clonal evolution and a history of blast phase (BP). In particular, 56% of the patients in BP had extramedullary relapse with no extramedullary relapse in patients with chronic/accelerated phase. Most frequent manifestation sites were the skeletal system, the muscles/subcutaneous tissue and the central nervous system. In one case chloroma was mimicking myositis of the lower limbs. Combined approaches were performed including irradiation (n = 4), chemotherapy (n = 2), IM (n = 2), dasatinib (n = 4), nilotinib (n = 1), a novel aurora-kinase-inhibitor (n = 1), donor lymphocytes (n = 2) or a second allo-SCT (n = 2). Transient response was achieved in one case, stable partial remissions in two cases, whereas two cases were refractory. Research should focus on prospective studies aiming to improve treatment of extramedullary relapse in stem cell recipients with CML with a special focus on the role of second generation tyrosine kinase inhibitors.
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Affiliation(s)
- Sunday Ocheni
- Clinic for Stem Cell Transplantation, University Cancer Centre Hamburg, Hamburg, Germany
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Jeong H, Shin B, Bae SY, Lee S, Ryu Y, Kim H, Kim I. Extramedullary B Lymphoblastic Crisis of CML, Presenting as a Leptomeningeal Tumor - A Case Report -. KOREAN JOURNAL OF PATHOLOGY 2009. [DOI: 10.4132/koreanjpathol.2009.43.5.482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Hoiseon Jeong
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Bongkyung Shin
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Sook Young Bae
- Department of Laboratory Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Sangho Lee
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Youngjune Ryu
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Hankyeom Kim
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Insun Kim
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
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27
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Scrideli CA, de Oliveira FM, Brassesco MS, de Paula Queiroz R, Bernardes JE, Valera ET, Tone LG. Is p190 bcr-abl rearrangement necessary for acute transformation in some p210 CML of childhood? Leuk Res 2008; 33:495-9. [PMID: 18495245 DOI: 10.1016/j.leukres.2008.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2008] [Revised: 04/07/2008] [Accepted: 04/08/2008] [Indexed: 10/22/2022]
Abstract
Chronic myeloid leukemia (CML) is a rare disease in childhood which is almost exclusively associated with bcr-abl p210 (M-bcr) rearrangements. It has been suggested that co-expression of p190 and p210 may be a pathway of CML progression in adult patients. We report two cases of pediatric patients with a diagnosis of CML who presented co-expression of the p210 and p190 transcripts during progression to the blastic phase. The present data suggest that p190 may be a secondary event in at least some cases of childhood CML, suggesting an association with progression to a blastic crisis in these patients.
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Affiliation(s)
- Carlos Alberto Scrideli
- Department of Pediatrics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Avenida Bandeirantes 3900, 14049-900 Ribeirão Preto (SP), Brazil
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