1
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Franchini M, Focosi D, Pezzo MP, Mannucci PM. Catastrophic Thrombosis: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 39151904 DOI: 10.1055/s-0044-1788790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2024]
Abstract
Catastrophic thrombosis is a severe condition characterized by a hypercoagulable tendency, leading to multiple thromboembolic events in different blood vessels, usually within a short timeframe. Several conditions have been associated with the development of catastrophic thrombosis, including the catastrophic antiphospholipid syndrome, thrombotic anti-platelet factor 4 immune disorders, thrombotic microangiopathies, cancers, the hyper-eosinophilic syndrome, pregnancy, infections, trauma, and drugs. Thrombotic storm represents a medical emergency whose management represents a serious challenge for physicians. Besides the prompt start of anticoagulation, a patient's prognosis depends on early recognition and possible treatment of the underlying condition. In this narrative review, we summarize the main characteristics of catastrophic thrombosis, analyzing the various conditions triggering such life-threatening complication. Finally, an algorithm with the diagnostic workup and the initial management of patients with catastrophic thrombosis is presented.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | | | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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2
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Song X, Chi C, Gao W, Sun W, Liu Y, Zhang X, Huang X, Zhu J, Wang Y. Biochemical risk factors and outcomes of acute promyelocytic leukemia patients with thrombotic events: a matched pair analysis. J Thromb Thrombolysis 2024; 57:828-841. [PMID: 38700714 DOI: 10.1007/s11239-024-02988-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 07/10/2024]
Abstract
Acute promyelocytic leukemia (APL) stands out as a distinctive form of acute leukemia, exhibiting a higher occurrence of thrombotic events when contrasted with other leukemia subtypes. Since thrombosis is a relatively rare but unfavorable condition with poor prognostic implications, it is crucial to determine the risk factors for thrombotic events in APL(thrombosis in large venous or arterial from onset to differentiation therapy in 30d). We performed a retrospective study involving 950 APL patients between January 2000 and October 2022, from which 123 were excluded by younger than 16 years of age, 95 were excluded by incomplete data, and 6 were excluded by thrombosis related to CVC or PICC. A total of 23 APL patients with thrombosis for inclusion in our analysis were performed a 1:5 ratio matching based on sex (perfect match) and age (within 5 years) to patients without thrombosis. These patients were continuously monitored in the outpatient department over a period of 5 years. We meticulously examined clinical and laboratory data to pinpoint the risk factors related to thrombotic events in APL. Our primary clinical endpoints were all-cause mortality and achieving complete remission, while secondary clinical outcomes included APL relapse. Thrombotic events were observed in 2.4% (23/950) of APL patients. Compared to patients without thrombosis, patients with thrombosis had higher lactate dehydrogenase (LDH) [313 (223, 486) vs. 233 (188, 367) U/L, p = 0.020], higher indirect bilirubin [11.2 (7.4, 18.6) vs.8.3 (6.0, 10.7) umol/L, p = 0.004], higher creatinine [72 (62, 85) vs. 63 (54, 74) umol/L, p = 0.026], higher CD2 expression (65.2 vs. 15.2%, p < 0.001), higher CD15 expression (60.9 vs. 24.3%, p = 0.001), and PML/RARαisoforms (p < 0.001). Multivariate-logistic-regression analysis revealed several factors that were markedly related to thrombosis, including LDH (OR≈1.003, CIs≈1.000-1.006, p = 0.021), indirect bilirubin (OR≈1.084, CIs≈1.000-1.188, p = 0.043), CD2 expression positive (OR≈16.629, CIs≈4.001-62.832, p < 0.001), and CD15 expression positive (OR≈7.747, CIs≈2.005-29.941, p = 0.003). The S-type (OR≈0.012, CIs≈0.000-0.310, p = 0.008) and L-type (OR≈0.033, CIs≈0.002-0.609, p = 0.022) PML/RARα isoforms were negatively associated with thrombosis. Kaplan-Meier curves indicated that the survival rates were remarkably varied between APL patients with and without thrombosis (HR:21.34, p < 0.001). LDH and indirect bilirubin are variables significantly associated with thrombosis in APL, S-type and L-type PML/RARαisoforms exhibit a negative association with thrombotic events. The thrombotic events of APL can predict the subsequent survival of thrombosis. The findings of our study have the potential to facilitate early detection of thrombosis and enhance the prognosis for individuals with APL who develop thrombosis. Further validation of our findings will be essential through future prospective or multicenter studies.
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Affiliation(s)
- Xiaojing Song
- Department of Emergency, Peking University People's Hospital, Beijing, 100044, China
| | - Cheng Chi
- Department of Emergency, Peking University People's Hospital, Beijing, 100044, China
| | - Weibo Gao
- Department of Emergency, Peking University People's Hospital, Beijing, 100044, China
| | - Wei Sun
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China
| | - Yang Liu
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China
| | - Xiaohui Zhang
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China
| | - Xiaojun Huang
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China
| | - Jihong Zhu
- Department of Emergency, Peking University People's Hospital, Beijing, 100044, China.
| | - Yu Wang
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China.
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3
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Kamoga D, Desikan S, Desikan R, Musuuza J. Acute myocardial infarction in an untreated patient with acute myeloid leukemia. Clin Case Rep 2024; 12:e8601. [PMID: 38487641 PMCID: PMC10937295 DOI: 10.1002/ccr3.8601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/16/2024] [Accepted: 01/29/2024] [Indexed: 03/17/2024] Open
Abstract
Key Clinical Message Acute leukemia, particularly AML, is closely associated with thrombotic events, driven by complex factors like coagulation system changes, endothelial dysfunction, and leukemic cell interactions with the vascular system. Certain chemotherapy drugs can exacerbate the prothrombotic state. Understanding these dynamics is crucial for effective thromboprophylaxis in carefully selected patients with leukemia. Abstract Thrombosis is a significant complication of acute leukemia. Thrombotic events mostly occur at diagnosis or during induction therapy. Here we report the occurrence of myocardial infarction (MI) before initiation of therapy, in a patient with acute myeloid leukemia not otherwise specified (AML NOS) who had no other significant risk factors for coronary artery disease. The occurrence of MI in this patient limited the choice of induction therapy and resulted in mortality. We discuss the pathogenesis and risk factors associated with increased thrombosis in AML and advocate for risk-adapted thromboprophylaxis in this patient population.
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Affiliation(s)
- Doreen Kamoga
- Department of Internal MedicineWhite River HealthBatesvilleArkansasUSA
| | | | - Raman Desikan
- Department of Hematology/OncologyWhite River HealthBatesvilleArkansasUSA
| | - Jackson Musuuza
- Department of Internal MedicineWhite River HealthBatesvilleArkansasUSA
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4
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Odetola O, Tallman MS. How to avoid early mortality in acute promyelocytic leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:248-253. [PMID: 38066899 PMCID: PMC10727112 DOI: 10.1182/hematology.2023000477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Acute promyelocytic leukemia (APL), a phenotypically and genotypically unique subtype of acute myeloid leukemia, has seen unprecedented advances in its management since the introduction of all-trans retinoic acid (ATRA) and arsenic trioxide. However, the phenomenal pharmacologic conversion of this once highly fatal disease to one with a long-term survival exceeding 90% among patients who survive induction remains impaired by the significant incidence of early death (ED) reaching 30% in some real-world studies. The key driver for ED in APL is catastrophic hemorrhage with a proclivity for cranial sites. Most EDs in APL are currently considered preventable. Here, we discuss the concept of early death in APL and its characteristics. Importantly, we outline implementable strategies to reduce the incidence of ED. Early recognition of APL underpins these preventive measures as significant delays in the diagnosis increase the likelihood of ED. While early administration of ATRA is often taught to all hematology trainees, this lifesaving intervention is only possible if providers, including those in emergency departments and urgent/immediate care settings, are trained to have a high index of suspicion and competence to recognize the morphologic and clinical characteristics of the disease. Other proposed strategies tackle the complications that can be present at diagnosis or arise during induction therapy and address the issues of expert consultation and protocol adherence in the management of these patients. While some of these measures appear intuitive and others aspirational, widespread adoption could bring about an era of cure for almost every patient with APL.
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Affiliation(s)
- Oluwatobi Odetola
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Martin S Tallman
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
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5
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Ni J, Chen M, Su Y, Gao Q, Liu L, Lu X. Right femoral vein and right dorsal artery thrombosis in childhood acute myeloid leukemia: A case report. Medicine (Baltimore) 2023; 102:e35121. [PMID: 37832057 PMCID: PMC10578772 DOI: 10.1097/md.0000000000035121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/17/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND It is rare for newly diagnosed (de novo) or newly treated acute myeloid leukemia (AML) complicated with thrombotic complications, especially combined arterial and venous thrombosis. METHODS We reported a 13-year-old boy diagnosed with AML and leukocytosis, who developed right femoral vein and right dorsal artery thrombosis during chemotherapy. After treatment with low molecular weight heparin, diosmin, and alprostadil, symptoms were relieved. Unfortunately, the child suffered from coagulopathy afterward, which was unexpectedly caused by vitamin K deficiency. RESULTS After supplementation with vitamin K and prothrombin complex concentrate, coagulation function recovered. CONCLUSION For childhood AML patients with high thrombotic risks, close monitoring during anticoagulant treatment was necessary. Concomitantly, we should be alert to past medication history and combined medication use, especially those that may lead to vitamin K deficiency, secondary bleeding, and coagulation disorders. Rational use of antibiotics, anticoagulants, and antitumor drugs must be guaranteed.
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Affiliation(s)
- Jiaqi Ni
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Min Chen
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Yali Su
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatric Hematology and Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Qianqian Gao
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Ultrasound, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lingjun Liu
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiaoxi Lu
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatric Hematology and Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
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6
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Zheng S, Luo S, Luo Y, Liu D, Zheng W, Peng Q. Acute pulmonary embolism combined with acute myocardial infarction as the first manifestation of acute leukemia: a case report. Front Cardiovasc Med 2023; 10:1259548. [PMID: 37771667 PMCID: PMC10525325 DOI: 10.3389/fcvm.2023.1259548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/31/2023] [Indexed: 09/30/2023] Open
Abstract
Thrombotic complications in acute myeloid leukemia (AML) are uncommon due to coagulation dysfunction and thrombocytopenia. We report a unique case of AML presenting as concomitant pulmonary embolism and atypical acute myocardial infarction. A 67-year-old male experienced persistent bilateral chest pain. Despite an unremarkable electrocardiogram, elevated D-dimer and mildly increased troponin T levels prompted further investigation, leading to the diagnosis of simultaneous pulmonary embolism and acute myocardial infarction. The patient underwent percutaneous coronary intervention and received triple antithrombotic therapy. However, antithrombotic therapy was discontinued following a sharp decline in hemoglobin and platelet counts, and the patient subsequently developed persistent fever. AML was diagnosed via bone marrow biopsy. Chemotherapy was not initiated due to the patient's deteriorating condition, and he ultimately succumbed to presumed intracranial bleeding.
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Affiliation(s)
- Shuzhan Zheng
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Sha Luo
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yong Luo
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Dan Liu
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Inflammation & Allergic Diseases Research Unit, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wenwu Zheng
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Qing Peng
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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7
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Mallah S, Owda F, Hamayel H, Enaya A, Mallah O, Abugaber D, Odeh R. Successful Management of Acute Promyelocytic Leukemia in a Patient Who Presented With Acute Ischemic Stroke on Top of Subdural Hematoma. Cureus 2023; 15:e45243. [PMID: 37842379 PMCID: PMC10576595 DOI: 10.7759/cureus.45243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Acute promyelocytic leukemia (APL), a distinct subtype of acute myelogenous leukemia (AML), is commonly associated with a heightened risk of bleeding due to coagulopathy. Thrombotic events, although less frequent, have also been linked to APL. However, the occurrence of ischemic stroke as an initial presentation of APL, particularly concomitant with central nervous system (CNS) bleeding, is exceedingly rare. The combination of these two complications is not reported in APL patients and is anticipated to carry a high mortality rate even with treatment. In this report, we describe the case of a young female patient with no significant medical history, who presented with decreased consciousness and recurrent seizures. Brain magnetic resonance imaging (MRI) revealed the simultaneous occurrence of acute ischemic stroke and acute-on-chronic subdural hematoma. The subsequent bone marrow biopsy confirmed the diagnosis of APL, displaying the characteristic positive promyelocytic leukemia (PML)-retinoic acid receptor alpha (RARA) t(15;17) translocation. The patient was promptly initiated on a high-risk AML-M3 protocol, coupled with supportive treatment through platelet transfusion. Remarkably, a favorable response to treatment was observed, and a marked improvement in her neurological parameters was observed within 2 weeks duration of treatment. Subsequent assessment through a bone marrow biopsy one month later revealed complete remission, with the PML-RARA fusion gene becoming negative following a single course of consolidation therapy.
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Affiliation(s)
- Shatha Mallah
- Department of Internal Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Fahed Owda
- Department of Internal Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Hamza Hamayel
- Department of Internal Medicine, An-Najah National University Hospital, Nablus, PSE
| | - Ahmad Enaya
- Department of Internal Medicine, An-Najah National University Hospital, Nablus, PSE
| | - Osama Mallah
- Department of Radiology, An-Najah National University Hospital, Nablus, PSE
| | - Dina Abugaber
- Department of Internal Medicine, An-Najah National University Hospital, Nablus, PSE
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Razan Odeh
- Department of Hemato-oncology, An-Najah National University Hospital, Nablus, PSE
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8
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Tondro Anamag F, Hashemi N, Sanaat Z, Khadivi Heris H, Moslemi M. Arteriovenous thrombosis, a complication of induction therapy with all-trans retinoic acid for acute promyelocytic leukemia: A case report. Clin Case Rep 2023; 11:e7856. [PMID: 37720706 PMCID: PMC10500047 DOI: 10.1002/ccr3.7856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/15/2023] [Accepted: 08/14/2023] [Indexed: 09/19/2023] Open
Abstract
We report a case of arterial and venous thrombosis during induction therapy. This case emphasizes considering some degree of caution for thrombotic events in APL patients which was represented in our case as abdominal pain. Rapid initiation of anticoagulation and preventive measures is suggested for better management of the condition.
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Affiliation(s)
- Farhad Tondro Anamag
- Hematology and Oncology Research CenterTabriz University of medical sciencesTabrizIran
| | - Negin Hashemi
- Department of Pharmacology and Toxicology, Faculty of PharmacyTabriz University of medical sciencesTabrizIran
| | - Zohreh Sanaat
- Hematology and Oncology Research CenterTabriz University of medical sciencesTabrizIran
| | | | - Mohammadreza Moslemi
- Hematology and Oncology Research CenterTabriz University of medical sciencesTabrizIran
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9
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Hermsen J, Hambley B. The Coagulopathy of Acute Promyelocytic Leukemia: An Updated Review of Pathophysiology, Risk Stratification, and Clinical Management. Cancers (Basel) 2023; 15:3477. [PMID: 37444587 DOI: 10.3390/cancers15133477] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Acute promyelocytic leukemia (APL) has a well-established mechanism and a long-term prognosis that exceeds that of any other acute leukemia. These improving outcomes are due, in part, to all-trans retinoic acid (ATRA) and arsenic trioxide (ATO), two targeted and highly active agents in this disease. However, there remains a considerable morbidity and mortality risk in APL secondary to clinically significant hemorrhagic and/or thrombotic events. Prevention and treatment of these coagulopathic complications remain significant impediments to further progress in optimizing outcomes for patients with APL. Moreover, the relative rarity of APL hinders adequately powered randomized controlled trials for evaluating APL coagulopathy management strategies. This review draws from peer-reviewed works falling between initial descriptions of APL in 1957 and work published prior to January 2023 and provides an updated overview of the pathophysiology of hemorrhagic and thrombotic complications in APL, outlines risk stratification parameters, and compiles current clinical best practices. An improved understanding of the pathophysiologic mechanisms driving hemorrhage and thrombosis along with the completion of well-designed trials of management strategies will assist clinicians in developing interventions that mitigate these devastating complications in an otherwise largely curable disease.
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Affiliation(s)
- Jack Hermsen
- University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Bryan Hambley
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, 3125 Eden Ave, Cincinnati, OH 45267, USA
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10
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Hazir KE, Simsek EC, Baldan E, Uzun HG, Bulbul H, Yarci B, Ozcan EB. Could Acute Myeloid Leukemia Have Presented Even Worse? "Uncommon Cause of Concurrently Multivessel Thrombosis". Arq Bras Cardiol 2023; 120:20220808. [PMID: 37586004 PMCID: PMC10464858 DOI: 10.36660/abc.20220808] [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: 11/30/2022] [Revised: 04/11/2023] [Accepted: 05/17/2023] [Indexed: 08/18/2023] Open
Abstract
Acute promyelocytic leukemia (APL) is a subgroup of acute myeloid leukemia (AML). Although it is known that hemorrhagic complications are common, thrombotic complications are not as rare as thought. However, myocardial infarction and ischemic stroke incidence are very rare during AML. Here, we present the astonishing case of APL diagnosed with pancytopenia in its presentation with acute myocardial infarction and ischemic stroke.
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MESH Headings
- Humans
- Leukemia, Myeloid, Acute/complications
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/epidemiology
- Leukemia, Promyelocytic, Acute/complications
- Leukemia, Promyelocytic, Acute/diagnosis
- Leukemia, Promyelocytic, Acute/epidemiology
- Thrombosis/complications
- Incidence
- Myocardial Infarction/complications
- Ischemic Stroke/complications
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Affiliation(s)
- Kutluhan Eren Hazir
- Izmir Tepecik Training and Research HospitalIzmirTurquiaIzmir Tepecik Training and Research Hospital – Cardiology, Izmir – Turquia
| | - Ersin Cagri Simsek
- Izmir Tepecik Training and Research HospitalIzmirTurquiaIzmir Tepecik Training and Research Hospital – Cardiology, Izmir – Turquia
| | - Esra Baldan
- Izmir Tepecik Training and Research HospitalIzmirTurquiaIzmir Tepecik Training and Research Hospital – Internal Medicine, Izmir – Turquia
| | - Hakan Gökalp Uzun
- Izmir Tepecik Training and Research HospitalIzmirTurquiaIzmir Tepecik Training and Research Hospital – Cardiology, Izmir – Turquia
| | - Hale Bulbul
- Izmir Tepecik Training and Research HospitalIzmirTurquiaIzmir Tepecik Training and Research Hospital – Hematology, Izmir – Turquia
| | - Bengisu Yarci
- Izmir Bozyaka Training and Research HospitalIzmirTurquiaIzmir Bozyaka Training and Research Hospital – Neurology, Izmir – Turquia
| | - Elif Busra Ozcan
- Izmir Tepecik Training and Research HospitalIzmirTurquiaIzmir Tepecik Training and Research Hospital – Internal Medicine, Izmir – Turquia
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11
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Liu B, Cui YZ, Wang SQ, Chen YQ, Wang Y, Sun XF. Calcified thrombus of the inferior vena cava and hepatic veins in acute promyelocytic leukemia: A case report and literature review. Pediatr Blood Cancer 2023:e30387. [PMID: 37114723 DOI: 10.1002/pbc.30387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Bo Liu
- Department of Cadre's Wards Ultrasound Diagnostics, Ultrasound Diagnostic Center, The First Hospital of Jilin University, Changchun, China
| | - Ying-Zhu Cui
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Shou-Qing Wang
- Department of Cadre's Wards Ultrasound Diagnostics, Ultrasound Diagnostic Center, The First Hospital of Jilin University, Changchun, China
| | - Yong-Qi Chen
- Department of Cadre's Wards Ultrasound Diagnostics, Ultrasound Diagnostic Center, The First Hospital of Jilin University, Changchun, China
| | - Yue Wang
- Department of Pediatrics Hematology, The First Hospital of Jilin University, Changchun, China
| | - Xiao-Feng Sun
- Department of Cadre's Wards Ultrasound Diagnostics, Ultrasound Diagnostic Center, The First Hospital of Jilin University, Changchun, China
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12
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Biggart R, Davies C, Joshi N. A Review of Systemic Hematological Manifestations and Stent Thrombosis. Cardiol Rev 2023; Publish Ahead of Print:e000535. [PMID: 36825903 DOI: 10.1097/crd.0000000000000535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Stent thrombosis (ST) has significant morbidity and mortality following percutaneous coronary intervention (PCI). ST is uncommon making the identification of nonprocedural predictors challenging. Numerous case reports of ST in both benign and malignant hematological conditions exist. Given ST could be a Herald event of an undiagnosed condition and condition-specific treatment may be available, it is important to consider specialist testing in an unexplained ST. This review included a case presentation of ST in previously undiagnosed paroxysmal nocturnal hemoglobinuria (PNH) and a literature review of ST in other acquired thrombophilias including myeloproliferative disorders (MPNs), antiphospholipid syndrome, hematological malignancies, and heparin-induced thrombocytopenia (HIT). Inherited thrombophilias and common pitfalls in thrombophilia and coagulation testing are also discussed. The cardiac-hematology landscape is becoming increasingly complex and there is a paucity of how to best manage ST in these patients. There is clear variability in practice and the use of multidisciplinary input between cardiologists and hematologists is essential.
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Affiliation(s)
- Rachael Biggart
- From the Bristol Haematology & Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, England
| | - Claire Davies
- Great Western Hospitals NHS Foundation Trust, Bristol, England
| | - Nikhil Joshi
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust 22 Horfield Rd, Bristol BS2 8ED, Bristol, England
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13
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Ng TL, Tsui DCC, Wang S, Usari T, Patil T, Wilner K, Camidge DR. Association of anticoagulant use with clinical outcomes from crizotinib in ALK- and ROS1-rearranged advanced non-small cell lung cancers: A retrospective analysis of PROFILE 1001. Cancer Med 2022; 11:4422-4429. [PMID: 35510711 PMCID: PMC9741966 DOI: 10.1002/cam4.4789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 04/11/2022] [Accepted: 04/17/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND ROS1- and ALK-rearranged advanced NSCLCs are associated with increased thromboembolic risk. We hypothesized that a prothrombotic phenotype offers an evolutionary advantage to subsets of these cancers. The impact of this phenotype could alter outcomes from targeted therapy. METHODS In a retrospective analysis of ROS1- and ALK-rearranged NSCLCs treated with crizotinib in a phase 1 trial, we compared progression-free survival (PFS) and objective response rate (ORR) based on the history of anticoagulation use (a possible surrogate of thromboembolism) at baseline (within 90 days before study enrollment) or within 90 days of study treatment. RESULTS Twelve out of 53 (22.6%) ROS1- and 39 out of 153 (25.5%) ALK-rearranged NSCLCs received anticoagulation before or during the trial. Most ROS1 and ALK patients on anticoagulation received low-molecular-weight heparin (75% and 64.1%, respectively). In the ROS1-rearranged group, the median PFS (95% CI) values were 5.1 (4.4-14.4) and 29.0 (16.5-48.8) months, and the ORR values were 41.7% (95% CI: 15.2 to 72.3) and 80.5% (95% CI: 65.1 to 91.2) among those with and without anticoagulation treatment, respectively. In the ALK-rearranged group, the median PFS (95% CI) was 7.1 (5.4-7.7) and 12.0 (9.4-18.3) months, and the ORR was 41% (95% CI: 25.6 to 57.9) and 74.3% (95% CI: 65.3 to 82.1) among those with and without anticoagulation, respectively. CONCLUSIONS Anticoagulation (as a potential surrogate of a prothrombotic subset) in ROS1- and ALK-rearranged NSCLCs may be associated with a lower PFS and ORR to crizotinib. CLINICALTRIAL gov: NCT00585195.
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Affiliation(s)
- Terry L. Ng
- Division of Medical Oncology, Department of MedicineUniversity of OttawaOttawaCanada
| | - David C. C. Tsui
- Division of Medical Oncology, Department of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | | | | | - Tejas Patil
- Division of Medical Oncology, Department of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | | | - David R. Camidge
- Division of Medical Oncology, Department of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
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14
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Paxton AB, Micieli JA. Diagnosis of Acute Promyelocytic Leukemia After Presentation to Neuro-Ophthalmology. J Neuroophthalmol 2022; 42:e181-e186. [PMID: 34483332 DOI: 10.1097/wno.0000000000001259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute promyelocytic leukemia (APML) is a medical emergency that can initially present with neuro-ophthalmologic signs. Early recognition is crucial, and immediate treatment with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) can be life-saving. The goal of this study was to describe patients who first presented to neuro-ophthalmology and were subsequently diagnosed with APML. METHODS We retrospectively reviewed consecutive patients seen at a tertiary neuro-ophthalmology centre. Patients with an unknown diagnosis of APML at presentation who subsequently went on to receive this diagnosis were included. Clinical characteristics, neuro-ophthalmologic findings, and outcome were retrieved. RESULTS A total of 3 patients (2 women and 1 men) with a mean age of 30.7 (range 24-33) years were included in the study. Neuro-ophthalmologic diagnoses at presentation were severe hemorrhagic papilledema related to dural venous sinus thrombosis, hemorrhagic bilateral optic disc edema, and left homonymous hemianopia related to an occipital lobe hemorrhage. At diagnosis, the average hemoglobin was 83.7g/L (range 78-104), and the platelet count was 39.3 × 109/L (range 15-77). All patients were treated with ATRA and ATO. One patient developed papilledema and sixth nerve palsies related to this treatment, which resolved with acetazolamide. Clinical follow-up ranged from 6 to 12 months, and all patients were in clinical remission about systemic APML. CONCLUSION Neuro-ophthalmologic symptoms may be the first manifestations of APML, and a complete blood count is an essential test in patients presenting with optic disc edema, especially if hemorrhagic.
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Affiliation(s)
- Andrew B Paxton
- Faculty of Medicine (ABP), University of Toronto, Toronto, Canada ; Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada ; Kensington Vision and Research Centre (JAM), Toronto, Canada ; and Division of Neurology (JAM), Department of Medicine, University of Toronto, Toronto, Canada
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15
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Xiao M, Zhou P, Liu Y, Wei S, Li D, Li W, Niu X, Niu J, Zhang Y, Cao W, Liu B, Wang X, Bai Y, Sun K. Predictive factors for differentiating thrombohemorrhagic disorders in high-risk acute promyelocytic leukemia. Thromb Res 2021; 210:33-41. [PMID: 34998209 DOI: 10.1016/j.thromres.2021.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/22/2021] [Accepted: 12/17/2021] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Acute promyelocytic leukemia (APL) is often accompanied by potentially fatal coagulopathy, especially in high-risk APL. Bleeding, particularly severe bleeding is the leading cause of early death (ED). Meanwhile, thrombosis, the other major coagulopathic complication, is being increasingly recognized. However, predictors of thrombohemorrhagic disorders are still not well investigated. MATERIALS AND METHODS In this study, we retrospectively studied 83 patients with high-risk APL and categorized them into severe bleeding, thrombosis and no evident events groups. RESULTS Severe bleeding was observed in 15 patients, nearly half of whom died of hemorrhage, while thrombosis was observed in 12 patients. Risk factor analysis showed that high WBC (>58.76 × 109/L) (p = 0.001) and prolonged PT (>17.7 s) (p = 0.015) could be independent predictors for severe bleeding, while high WBC/D-dimer>5.12 (p = 0.002) and low D-dimer/FIB<5.14 (p = 0.03) could be independent predictors for thrombosis in high-risk APL patients. Moreover, there are significant differences in WBC/D-dimer and D-dimer/FIB between DIC and Non-DIC groups (p < 0.001). Notably, we found that the WBC/D-dimer was dramatically higher in the thrombotic group than in the other two groups at the time of admission or during the first week of induction therapy. CONCLUSIONS High WBC and prolonged PT could predict severe bleeding in high-risk APL patients, while high WBC/D-dimer and low D-dimer/FIB could be independent predictors for thrombosis. For high-risk APL, WBC/D-dimer and D-dimer/FIB are also beneficial in the diagnosis of DIC. WBC/D-dimer might help early identification of thrombosis at the time of admission or during the first week of induction therapy.
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Affiliation(s)
- Mengyu Xiao
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Pan Zhou
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Yanhui Liu
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Shengjie Wei
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Dan Li
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Weiya Li
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Xiaona Niu
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Junwei Niu
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Yinyin Zhang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Henan, People's Republic of China
| | - Weijie Cao
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Henan, People's Republic of China
| | - Bing Liu
- Department of Clinical Laboratory, Henan Cancer Hospital, The Affiliated Cancer Hospital of Zhengzhou University, Henan, People's Republic of China
| | - Xiaojiao Wang
- Department of Central Laboratory, Henan Cancer Hospital, The Affiliated Cancer Hospital of Zhengzhou University, Henan, People's Republic of China
| | - Yanliang Bai
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Kai Sun
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China.
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16
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Hambley BC, Tomuleasa C, Ghiaur G. Coagulopathy in Acute Promyelocytic Leukemia: Can We Go Beyond Supportive Care? Front Med (Lausanne) 2021; 8:722614. [PMID: 34485349 PMCID: PMC8415964 DOI: 10.3389/fmed.2021.722614] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is characterized by frequent complications due to a distinct coagulopathy. While advances in treatments have improved long-term survival, hemorrhagic and thrombotic complications remain the most common causes of death and morbidity. Improved understanding of the mechanisms of the coagulopathy associated with APL may lead to therapeutic interventions to mitigate the risk of hemorrhage and thrombosis.
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Affiliation(s)
- Bryan C Hambley
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania.,Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Gabriel Ghiaur
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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17
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Zhang X, Guo X. Risk factors of thrombosis in Chinese subjects with acute promyelocytic leukemia. Thromb J 2021; 19:42. [PMID: 34130694 PMCID: PMC8207825 DOI: 10.1186/s12959-021-00294-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute promyelocytic leukemia (APL) is a special type of acute myeloid leukemia Thrombosis is at increased risk complication in patients with this disease. However, the risk factors of thrombosis related to Chinese APL patients are not fully understood. METHODS In this study, clinical and laboratory data of 44 consecutively Chinese APL patients were collected and analyzed. RESULTS One arterial and 6 venous thrombosis occurred in 44 patients, including 22 males and 22 females, with a median age of 44 years (range from 18 to 74 years). The ratio of male and female gender, age, white blood cell count, hemoglobin, platelets, disease risk stratification, CD2, Khorana score, differentiation syndrome (DS) and gene mutation related to prognosis of APL, including DNMT3A, TET2, IDH1, IDH2, NRAS and ASXL1 in the two groups with and without thrombosis were not statistically significant. The detection rate of PAI-1 genotype 4G4G was 71.4% (5/7) in 7 patients with thrombosis, while the detection rate of PAI-1 genotype 4G4G in 37 patients without thrombosis was 8.1% (3/37). The differences between the two groups in WT-1 (P = 0.01), PAI-1 4G4G (P = 0.0009), bcr3 (P = 0.027), CD15 (P = 0.005), and FLT3-ITD mutation (P = 0.0008) were statistically significant. Using multivariate analysis, the risk factors of venous thrombosis in APL were CD15 (P = 0.043), PAI-1 4G4G (P = 0.009), WT-1 (P = 0.043) and FLT3/ITD (P = 0.013), respectively. CONCLUSION Our results suggested the PAI-1 gene 4G4G type, CD15, WT-1 and FLT3-ITD mutations excluding DNMT3A, TET2, IDH1/2, NRAS and ASXL1 are risk factors of thrombotic events in Chinese APL patients.
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Affiliation(s)
- Xueya Zhang
- Department of Hematology, the Second Affiliated Hospital of Fujian Medical University, 34 Zhongshan North Road, Quanzhou, 362000, Fujian Province, China.
| | - Xizhe Guo
- Department of Hematology, the Second Affiliated Hospital of Fujian Medical University, 34 Zhongshan North Road, Quanzhou, 362000, Fujian Province, China
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18
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Cohen O, Caiano LM, Tufano A, Ageno W. Cancer-Associated Splanchnic Vein Thrombosis. Semin Thromb Hemost 2021; 47:931-941. [PMID: 34116580 DOI: 10.1055/s-0040-1722607] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Splanchnic vein thrombosis (SVT), which includes portal, mesenteric, and splenic vein thrombosis and the Budd-Chiari syndrome, is an infrequent manifestation of venous thromboembolism (VTE). Like typical site VTE, SVT is also frequently associated with cancer, particularly intra-abdominal solid malignancies and myeloproliferative neoplasms (MPNs). The clinical presentation of SVT is nonspecific. Symptoms may be related to the underlying malignancy, and thrombosis is incidentally diagnosed by imaging studies for cancer staging or follow-up in a substantial proportion of cases. The occurrence of SVT predicts worse prognosis in patients with liver or pancreatic cancer and, not uncommonly, SVT may precede the diagnosis of cancer. Therefore, the occurrence of an apparently unprovoked SVT should prompt careful patient evaluation for the presence of an underlying malignancy or MPN. Cancer patients carry a high risk of VTE extension and recurrence and long-term anticoagulant treatment is suggested in the absence of high risk of bleeding. Either LMWH or direct oral anticoagulants (DOACs) are suggested for the treatment of patients with cancer-related SVT, although limited experience is available on the use of DOACs in these settings. Vitamin K antagonists (VKAs) are suggested for the short and long-term treatment of SVT associated with MPN. This review outlines the epidemiological aspects, pathogenesis, risk factors, and diagnosis of cancer-associated SVT, and addresses questions regarding the management of this challenging condition.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lucia Maria Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Antonella Tufano
- Regional Reference Centre for Coagulation Disorders, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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19
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Maini K, Afzal F, Giurgiutiu DV, Rahimi SY, Shah M, Switzer JA, Vale FL, Garcia KA. Concomitant central venous sinus thrombosis and subdural hematoma in acute promyelocytic leukemia: middle meningeal artery embolization enables safe anticoagulation. Illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2021; 1:CASE2080. [PMID: 36046512 PMCID: PMC9394697 DOI: 10.3171/case2080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/14/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Acute promyelocytic leukemia (APL) has long been associated with coagulation disorders. The proposed mechanism is a combination of fibrinolysis, proteolysis, platelet dysfunction, thrombocytopenia, and possibly disseminated intravascular coagulation. Hemorrhagic complications are prominent. OBSERVATIONS In this case, a 25-year-old female with newly diagnosed APL developed extensive cerebral venous thrombosis (CVT) and was initiated on a protocol with idarubicin and all-trans retinoic acid. The general recommendation for treating CVT is anticoagulation to stabilize the existing thrombus and prevent propagation. The patient was initiated on a heparin drip, but her clinical course was complicated by subdural hemorrhage (SDH) and epidural hemorrhage in the setting of thrombocytopenia. Anticoagulation was held, and her CVT propagated on follow-up imaging. To restart anticoagulation for CVT with a limited risk of SDH, the authors pursued middle meningeal artery (MMA) embolization. The patient was transitioned to apixaban and discharged to home. LESSONS MMA embolization enables safe anticoagulation in patients with concomitant CVT and SDH. The authors report the complex clinical course and effective management of this rare clinical scenario.
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20
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Haghighat S, Rezvani A, Mokhtari M. Successful treatment of acute promyelocytic leukemia in a patient with prosthetic heart valves: a case report and review of the literature. J Med Case Rep 2021; 15:260. [PMID: 33941263 PMCID: PMC8094532 DOI: 10.1186/s13256-021-02825-2] [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: 08/20/2020] [Accepted: 03/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although life-threatening hemorrhage is a usual manifestation of acute promyelocytic leukemia (APL), thrombotic events seem to be more common in APL compared to other subtypes of acute leukemia. The treatment and prophylaxis of thrombosis are controversial due to the high risk of bleeding caused by disseminated intravascular coagulation (DIC) and thrombocytopenia. To the best of our knowledge we report the first case of APL in a patient with prosthetic heart valves successfully treated with a combination of all-trans-retinoic acid (ATRA) and arsenic trioxide (ATO). We hope this case report helps clinicians to manage different spectra of coagulopathy in APL successfully. CASE PRESENTATION A 38-year-old Asian man presented with diagnosis of APL confirmed by bone marrow biopsy. He was on warfarin due to prosthetic mitral and aortic valves. He was at risk of both hemorrhagic events due to DIC and life-threatening valve thrombosis. Our management regimen included unfractionated heparin adjusted according to the platelet count to prevent both valve thrombosis and bleeding events. The patient tolerated treatment well without any hemorrhagic or thrombotic events, and complete molecular remission was achieved by ATRA and ATO without the need for chemotherapeutic agents. CONCLUSION Although this case is exceptional, a precise evaluation may be needed to select the appropriate dose and type of anticoagulant to treat a patient with APL.
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Affiliation(s)
- Shirin Haghighat
- Department of Hematology and Medical Oncology, Shiraz University of Medical Sciences-Namazi Hospital, Zand Avenue, Shiraz, Iran.
| | - Alireza Rezvani
- Department of Hematology and Medical Oncology, Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maral Mokhtari
- Faghihi Hospital-Shiraz University of Medical Sciences, Shiraz, Iran
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21
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Liang H, Ba M, Li C, Li H, Guo Z, He P, Lin C. A case of acute myelogenous leukemia characterized by arterial and venous thrombosis. Cardiovasc Diagn Ther 2020; 10:1332-1340. [PMID: 33224757 DOI: 10.21037/cdt-20-486] [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] [Indexed: 11/06/2022]
Abstract
Acute myelogenous leukemia (AML) is a malignant disease of the hematopoietic system, characterized by features of bone marrow insufficiency and organ infiltration by leukemic cells. Venous thrombosis in AML patients is uncommon, compared to bleeding; therefore in patients with AML, simultaneous occurrence of venous and arterial thrombosis is a rather rare presentation. We reported an unusual case of anti-phospholipid antibody syndrome secondary to AML characterized by venous and arterial thrombosis. A 70-year-old man with deep venous thrombosis (DVT) of the left leg confirmed by Doppler was seen in our clinic. During treatment with a Vitamin K antagonist (3 mg daily of Warfarin) and a low molecular weight heparin (LMWH), he developed an acute pulmonary embolism and an acute inferior wall ST elevation myocardial infarction (STEMI), a result of right coronary artery embolism. His full blood count showed leukocytosis and thrombocytopenia. Lupus anticoagulant and anti-cardiolipin antibodies were positive. A bone marrow aspirate test showed results consistent with AML (FAB class M1). A diagnosis of antiphospholipid antibody syndrome secondary to AML characterized by coronary artery embolism, pulmonary embolism and left leg DVT was eventually established. He received anticoagulation with a low dose of warfarin after refusing chemotherapy. He however died of cerebral hemorrhage despite the fact that the INR was in the normal therapeutic range. It is challenging to anticoagulated AML patients complicated by multiple vascular thromboses and thrombocytopenia.
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Affiliation(s)
- Huasheng Liang
- Department of Cardiology, Guangdong Provincial People's Hospital's Nanhai Hospital, Foshan, China
| | - Mingchuan Ba
- Department of Cardiology, Guangdong Provincial People's Hospital's Nanhai Hospital, Foshan, China
| | - Chen Li
- Department of Cardiology, Guangdong Provincial People's Hospital's Nanhai Hospital, Foshan, China
| | - Haoping Li
- Department of Cardiology, Guangdong Provincial People's Hospital's Nanhai Hospital, Foshan, China
| | - Zhiqiang Guo
- Department of Cardiology, Guangdong Provincial People's Hospital's Nanhai Hospital, Foshan, China
| | - Pengcheng He
- Department of Cardiology, Guangdong Provincial People's Hospital's Nanhai Hospital, Foshan, China.,Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chunying Lin
- Department of Cardiology, Guangdong Provincial People's Hospital's Nanhai Hospital, Foshan, China
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22
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de Albuquerque Antunes A, Breviglieri CNM, Celeste DM, Garanito MP, Cristofani LM, Carneiro JDA. Prevalence and outcomes of thrombotic and hemorrhagic complications in pediatric acute promyelocytic leukemia in a tertiary Brazilian center. Hematol Transfus Cell Ther 2020; 43:309-312. [PMID: 32912837 PMCID: PMC8446233 DOI: 10.1016/j.htct.2020.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/02/2020] [Accepted: 06/08/2020] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Little attention is given to thrombosis associated with pediatric acute promyelocytic leukemia (APL). This study describes the thrombotic and hemorrhagic manifestations of APL in pediatric patients and evaluates their hemostasis, based on coagulation tests. METHODS Inclusion criteria were age 0-18 years and APL diagnosis between April 2005 and November 2017. Patients who had received blood transfusion prior to coagulation tests were excluded. Baseline coagulation tests, hematologic counts, and hemorrhagic/thrombotic manifestations were evaluated. RESULTS Median age was 10.7 years (1-15 years). The initial coagulation tests revealed a median Hgb of 8.3 g/dL (4.7-12.9 g/dL), median leucocyte count of 10.9 × 10⁹/L (1.1-95.8 × 10⁹/L), median platelet count of 31.8 × 10⁹/L (2.0-109.0 × 10⁹/L), median activated partial thromboplastin time (aPTT) of 31.7 s (23.0-50.4 s), median aPTT ratio of 1.0 (0.78-1.6), median thromboplastin time (PT) of 17.5 s (13.8-27.7 s), median PT activity of 62% (25-95 %), and median fibrinogen of 157.7 mg/dL (60.0-281.0 mg/dL). Three patients (13%) had thrombosis. At diagnosis, 21 patients (91.3%) had bruising, one patient (4.3%) had splenic vein and artery thrombosis and one patient (4.3%) presented without thrombohemorrhagic manifestations. During treatment, two patients (8.6%) had thrombosis. CONCLUSION Knowledge of thrombosis in pediatric APL is important to determine its risk factors and the best way to treat and prevent this complication.
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Affiliation(s)
- Alexandre de Albuquerque Antunes
- Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil.
| | | | - Daniele Martins Celeste
- Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Marlene Pereira Garanito
- Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Lilian Maria Cristofani
- Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Jorge David Aivazoglou Carneiro
- Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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23
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Chavez MA, Heidari B, Thacker S, Samuel LL, Ogbonna M. Acute Promyelocytic Leukemia Presenting as Bilateral Acute Limb Ischemia and ST Elevation Myocardial Infarction: A Case Report. Cureus 2020; 12:e8495. [PMID: 32656013 PMCID: PMC7343312 DOI: 10.7759/cureus.8495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Acute myelogenous leukemia (AML) is one of the most common hematologic malignancies. Among them, acute promyelocytic leukemia (APL) is well known for its coagulopathies. Bleeding secondary to disseminated intravascular coagulation, is a common initial presentation and carries a high risk for mortality if left untreated. Thrombotic complications are uncommon and can be related to treatment with chemotherapeutic agents. Large artery thrombosis is very rare, and standardized management remains elusive given the classic revascularization techniques carry a significant risk of re-thrombosis, as well as high risk for mortality given the multiple surgical and percutaneous interventions that are attempted. A multidisciplinary approach is necessary in these cases to carefully weigh the risk and benefits as the classical approach to revascularization and acute arterial thrombosis could potentially cause harm.
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Affiliation(s)
| | - Behnam Heidari
- Internal Medicine, Houston Methodist Hospital, Houston, USA
| | - Sameer Thacker
- Internal Medicine, Houston Methodist Hospital, Houston, USA
| | - Leena L Samuel
- Internal Medicine, Houston Methodist Hospital, Houston, USA
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24
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Jandial A, Mishra K, Lad D, Naseem S, Malhotra P. Deluging Thrombosis: An Unusual Presentation of Acute Promyelocytic Leukemia. Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_227_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AbstractAcute promyelocytic leukemia (APML) patients are prone to thrombosis. However, thrombosis at presentation is rare in APML. Our patient presented with thrombosis and cytopenia, and the clinical diagnosis was of paroxysmal nocturnal hemoglobinuria. However, subsequent peripheral blood smear and bone marrow study confirmed the diagnosis of APML. The patient was successfully managed with anticoagulation, arsenic trioxide, and all-trans retinoic acid.
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Affiliation(s)
- Aditya Jandial
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kundan Mishra
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepesh Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shano Naseem
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Mirza AS, Yun S, Ali NA, Shin H, O’Neil JL, Elharake M, Schwartz D, Robinson K, Nowell E, Engle G, Badat I, Brimer T, Kuc A, Sequeira A, Mirza S, Sikaria D, Vera JD, Hackney N, Abusrur S, Jesurajan J, Kuang J, Patel S, Khalil S, Bhaskar S, Beard A, Abuelenen T, Ratnasamy K, Visweshwar N, Komrokji R, Jaglal M. Validation of the Khorana score in acute myeloid leukemia patients: a single-institution experience. Thromb J 2019; 17:13. [PMID: 31303864 PMCID: PMC6604148 DOI: 10.1186/s12959-019-0202-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 05/27/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Although patients with acute myeloid leukemia (AML) were shown to have an increased risk of thrombosis, no thrombosis risk assessment scoring system has been developed for AML patients. The Khorana Risk Score (KRS), which has been widely used for thrombosis risk assessment in the clinical setting, was developed on the basis of solid tumor data and has not been validated among AML patients. This study aims to validate the use of the KRS as a thrombosis risk-scoring system among patients with AML. METHODS Using data from H. Lee Moffitt Cancer Center and Research Institution's Total Cancer Care Research Study, we retrospectively identified patients who were histologically confirmed with AML from 2000 to 2018. Clinical and laboratory variables at the time of AML diagnosis were characterized and analyzed. The thrombotic event rate was estimated with the Kaplan-Meier method and compared using the log-rank test. RESULTS A total of 867 AML patients were included in the analysis. The median age at AML diagnosis was 75 years (range, 51-96), and the majority were male (65%, n = 565). A total of 22% (n = 191), 51% (n = 445), 24% (n = 207), and 3% (n = 24) of patients had a KRS of 0, 1, 2, and 3, respectively. A total of 42 thrombotic events (3% [n = 6/191] with a KRS of 1; 5% [n = 23/445] with a KRS of 2; 6.3% [n = 13/207] with a KRS of 3) were observed, with a median follow-up of 3 months (range, 0.1-307). There was no statistical difference in the risk of thrombosis between these groups (P = .1949). CONCLUSIONS Although there was an increased risk of thrombosis associated with a higher KRS among AML patients with a KRS of 1 to 3, the difference was not statistically significant. Furthermore, only a few patients were found to have a KRS > 3, and this was largely due to pancytopenia, which is commonly associated with AML. These results indicate the need for a better thrombotic risk-scoring system for AML patients.
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Affiliation(s)
- Abu-Sayeef Mirza
- Department of Internal Medicine, H. Lee Moffitt Cancer Center and Research Institution, University of South Florida, 17 Davis Blvd., Suite 308, Tampa, FL 33606 USA
| | - Seongseok Yun
- Department of Internal Medicine, H. Lee Moffitt Cancer Center and Research Institution, University of South Florida, 17 Davis Blvd., Suite 308, Tampa, FL 33606 USA
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institution, Tampa, FL USA
| | - Najla Al Ali
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institution, Tampa, FL USA
| | - Hannah Shin
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | | | - Maher Elharake
- Department of Internal Medicine, H. Lee Moffitt Cancer Center and Research Institution, University of South Florida, 17 Davis Blvd., Suite 308, Tampa, FL 33606 USA
| | - Daniel Schwartz
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Katherine Robinson
- Department of Internal Medicine, H. Lee Moffitt Cancer Center and Research Institution, University of South Florida, 17 Davis Blvd., Suite 308, Tampa, FL 33606 USA
| | - Ethan Nowell
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Grace Engle
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Ibraahim Badat
- College of Arts and Sciences, University of South Florida, Tampa, FL USA
| | - Thomas Brimer
- Department of Internal Medicine, H. Lee Moffitt Cancer Center and Research Institution, University of South Florida, 17 Davis Blvd., Suite 308, Tampa, FL 33606 USA
| | - Amra Kuc
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Ashton Sequeira
- Department of Internal Medicine, H. Lee Moffitt Cancer Center and Research Institution, University of South Florida, 17 Davis Blvd., Suite 308, Tampa, FL 33606 USA
| | - Sabbir Mirza
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Dhiraj Sikaria
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Jesus Diaz Vera
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Noah Hackney
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Sammy Abusrur
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Jose Jesurajan
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Jameson Kuang
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Shreyans Patel
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Sabrina Khalil
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Sonya Bhaskar
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Alexander Beard
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Toaa Abuelenen
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Kevin Ratnasamy
- Morsani College of Medicine, University of South Florida, Tampa, FL USA
| | - Nathan Visweshwar
- Department of Internal Medicine, H. Lee Moffitt Cancer Center and Research Institution, University of South Florida, 17 Davis Blvd., Suite 308, Tampa, FL 33606 USA
| | - Rami Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institution, Tampa, FL USA
| | - Michael Jaglal
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institution, Tampa, FL USA
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Wang J, Chen R, Lin X, Wang Y, Wang JH, Wu Y. New perspectives on treatment strategies for patient with acute myeloid leukemia and complex karyotype abnormalities after percutaneous coronary intervention: A case report. Medicine (Baltimore) 2019; 98:e16586. [PMID: 31348297 PMCID: PMC6709177 DOI: 10.1097/md.0000000000016586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Acute myeloid leukemia (AML), in patients with coronary heart disease (CHD) and treated percutaneous coronary intervention (PCI), is rarely seen in clinic. There are few similar cases reported, and there are no evidence-based medicine guidelines for the treatment. PATIENT CONCERNS A 52-year-old man was diagnosed with coronary atherosclerotic heart disease in November 2011, and received a stent placement in the left anterior descending coronary artery 1 year later. One day after the surgery, his laboratory tests showed pancytopenia. DIAGNOSES Based on precise diagnosis of leukemia, namely cell morphology, immunology, cytogenetics, and molecular biological typing, the patient was diagnosed with AML-M2. INTERVENTIONS The patient received idarubicin with cytarabine in 1st cycles, and single cytarabine regimen was used in 2nd and 3rd cycles for the accumulative toxicity of idarubicin in postinduction chemotherapy. Meanwhile, staged-treatment strategy was implemented by using antiplatelet drugs during different chemotherapy phases, and personalized pharmaceutical care on the basis of the recognition of potential adverse effects of chemotherapy regimen. OUTCOMES Until now, the disease-free survival in the patient has been over 6 years, and he is still followed up in clinic. LESSONS Although leukemia accompanied with coronary heart disease, even after receiving the coronary stenting therapy is rarely seen in clinic, the treatment with antiplatelet drugs for post chemotherapy patients with coronary disease is necessary. Clinical pharmacists are supposed to be more proficient in developing personalized drug treatment strategies, especially maintaining the balance between the effect and the risk in difficult and complex cases.
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Affiliation(s)
| | | | | | | | | | - Yun Wu
- Department of General Medicine, First Affiliated Hospital of Xinjiang Medical University, Urumqi, People's Republic of China
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27
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Blast Cell Arterial Embolus in Acute Myelogenous Leukemia. Ann Vasc Surg 2019; 56:351.e9-351.e11. [DOI: 10.1016/j.avsg.2018.07.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 07/16/2018] [Indexed: 11/20/2022]
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Visweshwar N, Jaglal M, Sokol L, Djulbegovic B. Hematological Malignancies and Arterial Thromboembolism. Indian J Hematol Blood Transfus 2019; 35:611-624. [PMID: 31741612 PMCID: PMC6825093 DOI: 10.1007/s12288-019-01085-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 01/21/2019] [Indexed: 01/10/2023] Open
Abstract
Established guidelines exist for prevention and treatment of venous thromboembolism in hematological malignancies, but none for arterial thromboembolism. However, arterial and venous thromboembolism share the same provoking features—including altered procoagulant factors and defective fibrinolytic system. The morbidity for arterial thromboembolism is increasing in hematological malignancies, with the advent of immunomodulatory and targeted therapy. However, survival rate for hematological malignancy is improving. Consequently, as patients with hematological malignancies live longer, comorbidities including diabetes, hypertension and dyslipidemia, may accentuate arterial thrombosis. Thus far, the scientific literature on prophylaxis and treatment for arterial thromboembolism in hematological malignancies is limited. This review highlights the pathogenesis, incidence and clinical features of arterial thromboembolism in hematological malignancies.
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Affiliation(s)
- Nathan Visweshwar
- 1Division of Hematology, University of South Florida, Tampa, FL 33612 USA
| | - Michael Jaglal
- 2Division of Medical Oncology, Moffitt Cancer Center, Tampa, FL 35316 USA
| | - Lubomir Sokol
- 2Division of Medical Oncology, Moffitt Cancer Center, Tampa, FL 35316 USA
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29
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Aronson D, Brenner B. Arterial thrombosis and cancer. Thromb Res 2018; 164 Suppl 1:S23-S28. [PMID: 29703480 DOI: 10.1016/j.thromres.2018.01.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/17/2017] [Accepted: 01/02/2018] [Indexed: 12/21/2022]
Abstract
Cancer-associated arterial thrombotic events (ATEs) are increasingly recognized in specific malignancies and in association with the expanding armamentarium of novel chemotherapeutic agents. The improved cancer survival led to cardiovascular complications becoming clinically relevant many years after cancer diagnosis. The pathobiology of ATEs in cancer is complex and the individual patient risk for an ATE entails a multifactorial interaction between the traditional cardiovascular risk factors and comorbidities, the specific malignancy and selected therapy. Treatment with several specific chemotherapeutic agents, immunomodulatory drugs, vascular endothelial growth factor pathway inhibitors, tyrosine kinase inhibitors, and radiotherapy, impart increased risk for ATEs that result from specific therapy-related mechanisms, often involving endothelial injury. Cancer cell-specific prothrombotic properties are important players in the pathogenesis of cancer-associated hypercoagulability. There are distinct biological and molecular processes preferentially activated in specific cancer cells which can trigger ATEs, including platelet activation, increased expression of procoagulants and suppression of fibrinolytic activity. ATEs portend adverse prognosis in cancer patients. Prevention and treatment of cancer-associated ATEs may be improved by greater awareness and careful monitoring for vascular toxicity, aggressive effort to optimize conventional cardiovascular risk factors, and use of antiplatelet and antithrombotic agents in selected patients. These issues are targets for future studies aimed to reduce ATEs in patients with cancer.
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Affiliation(s)
- Doron Aronson
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel; The Ruth & Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; The Ruth & Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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30
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Transcriptomic landscape of acute promyelocytic leukemia reveals aberrant surface expression of the platelet aggregation agonist Podoplanin. Leukemia 2018; 32:1349-1357. [PMID: 29550835 DOI: 10.1038/s41375-018-0069-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 12/21/2017] [Accepted: 01/25/2018] [Indexed: 12/15/2022]
Abstract
Acute promyelocytic leukemia (APL) is a medical emergency because of associated lethal early bleeding, a condition preventable by prompt diagnosis and therapeutic intervention. The mechanisms underlying the hemostatic anomalies of APL are not completely elucidated. RNA-sequencing-based characterization of APL (n = 30) was performed and compared to that of other acute myeloid leukemia (n = 400) samples and normal promyelocytes. Perturbations in the transcriptome of coagulation and fibrinolysis-related genes in APL extend beyond known culprits and now include Thrombin, Factor X and Urokinase Receptor. Most intriguingly, the Podoplanin (PDPN) gene, involved in platelet aggregation, is aberrantly expressed in APL promyelocytes and is the most distinctive transcript for this disease. Using an antibody panel optimized for AML diagnosis by flow cytometry, we also found that PDPN was the most specific surface marker for APL, and that all-trans retinoic acid therapy rapidly decreases its expression. Functional studies showed that engineered overexpression of this gene in human leukemic cells causes aberrant platelet binding, activation and aggregation. PDPN-expressing primary APL cells, but not PDPN-negative primary leukemias, specifically induce platelet binding, activation and aggregation. Finally, PDPN expression on leukemia cells in a xenograft model was associated with thrombocytopenia and prolonged bleeding time in vivo. Together our results suggest that PDPN may contribute to the hemostatic perturbations found in APL.
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31
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Lad D, Jain A, Varma S. Complications and management of coagulation disorders in leukemia patients. Blood Lymphat Cancer 2017; 7:61-72. [PMID: 31360085 PMCID: PMC6467343 DOI: 10.2147/blctt.s125121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patients with leukemia are predisposed to various coagulation abnormalities. Thrombosis and bleeding continue to be a major cause of morbidity and mortality in leukemias. The pathophysiology of these disorders is unique, and not only the disease but also the treatment and other factors play a role. There has been an increase in the understanding of these disorders in leukemias. However, it is still difficult to predict when and which patients will have these complications. The evidence for the management of coagulation abnormalities in leukemias is still evolving and not as established as in solid malignancies. The management of these disorders is complex, and making clinical decisions is often challenging. In the era of specialization, where there are different hematologists looking after benign- and malignant-hematology patients, opinions of thrombosis experts are often sought by leukemia specialists. This review aims to bridge the gap in the knowledge of these disorders between these specialists.
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Affiliation(s)
- Deepesh Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Arihant Jain
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
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32
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Abstract
Acute promyelocytic leukaemia (APML) is a subtype of leukaemia arising from a distinct reciprocal translocation involving chromosomes 15 and 17, which results in the PML-RARA fusion gene. Over the past three decades, APML has been transformed from a highly fatal disease to a highly curable one. This drastic improvement is because of the introduction of a new treatment strategy with all-trans retinoic acid and, more recently, arsenic trioxide. The revolutionary treatment of APML has also paved the way for a new cancer treatment, which is genetically targeted therapy. In this review, we look into this amazing journey of transformation and provide recent advances in the management of APML.
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Affiliation(s)
- Chin-Hin Ng
- National University Cancer Institute, Singapore, Singapore
| | - Wee-Joo Chng
- National University Cancer Institute, Singapore, Singapore
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33
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D'Angelo P, Taormina C, Mosa C, Di Marco F, Valentino F, Trizzino A, Guadagna P, Talarico F. Severe Lower Limb Ischemia by Massive Arterial Thrombosis Revealing an Acute Myeloid Leukemia Needing for Leg Amputation: Clinical and Emotional Aspects Related to the Communication with the Patient and His Family. Pediatr Rep 2016; 8:6885. [PMID: 28058104 PMCID: PMC5178846 DOI: 10.4081/pr.2016.6885] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 10/02/2016] [Accepted: 10/08/2016] [Indexed: 11/23/2022] Open
Abstract
Large vessel thrombosis is a very rare clinical presentation of acute leukemia, generally associated with coagulopathy, usually characteristic of acute promyelocytic leukemia. A 13- year-old boy with a previously undiagnosed acute myeloid leukemia was referred to our hospital with acute ischemia of the right lower limb due to occlusion of the right external iliac artery, treated with emergency double surgical thromboembolectomy and chemotherapy. The thrombotic complication resulted in leg amputation. Now the boy is well in complete remission, with a good social integration and quality of life, 30 months after completing treatment. The report highlights the crucial role of early diagnosis and subsequent chemotherapy in avoiding amputation. We particularly focused critical and emotional aspects related to the communication about the leg amputation with the patient and his family.
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Affiliation(s)
| | | | - Clara Mosa
- Pediatric Hematology and Oncology Department
| | | | - Fabrizio Valentino
- Vascular Surgery Department, A.R.N.A.S Civico, Di Cristina e Benfratelli Hospitals , Palermo, Italy
| | | | | | - Francesco Talarico
- Vascular Surgery Department, A.R.N.A.S Civico, Di Cristina e Benfratelli Hospitals , Palermo, Italy
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34
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Chotai PN, Kasangana K, Chandra AB, Rao AS. Recurrent Arterial Thrombosis as a Presenting Feature of a Variant M3-Acute Promyelocytic Leukemia. Vasc Specialist Int 2016; 32:65-71. [PMID: 27386455 PMCID: PMC4928607 DOI: 10.5758/vsi.2016.32.2.65] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/15/2016] [Accepted: 03/28/2016] [Indexed: 11/20/2022] Open
Abstract
Acute limb ischemia (ALI) is a common vascular emergency. Hematologic malignancies are commonly associated with derangement of normal hemostasis and thrombo-hemorrhagic symptoms during the course of the disease are common. However, ALI as an initial presenting feature of acute leukemia is rare. Due to the rarity of this presentation, there is a scarcity of prospective randomized data to optimally guide the management of these patients. Current knowledge is mainly based on isolated cases. We report our experience managing a patient who presented with ALI and was found to have occult leukemia. A review of all cases with ALI as a presenting feature of acute leukemia is also presented.
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Affiliation(s)
- Pranit N Chotai
- Division of Vascular Surgery, Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA; Division of Pediatric Surgery, Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kalenda Kasangana
- Division of Vascular Surgery, Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Abhinav B Chandra
- Division of Hematology and Oncology, Department of Internal Medicine, Maimonides Medical Center, Brooklyn, NY, USA; Division of Hematology and Oncology, Yuma Regional Cancer Center, Yuma, AZ, USA
| | - Atul S Rao
- Division of Vascular Surgery, Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
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35
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Massive Pulmonary Embolism at the Onset of Acute Promyelocytic Leukemia. Mediterr J Hematol Infect Dis 2016; 8:e2016027. [PMID: 27413520 PMCID: PMC4928521 DOI: 10.4084/mjhid.2016.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 05/15/2016] [Indexed: 11/10/2022] Open
Abstract
Life-threatening bleeding is a major and early complication of acute promyelocytic leukemia (APL), but in the last years there is a growing evidence of thromboses in APL. We report the first case of a young woman with dyspnea as the first symptom of APL due to massive pulmonary embolism (PE) successfully treated with thrombolysis for PE and heparin. APL has been processed with a combination of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) obtaining complete remission.
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36
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Liu L, Yuan X. Transient ischemic attack as an unusual initial manifestation of acute promyelocytic leukemia. Int J Hematol 2016; 104:134-8. [PMID: 26984593 DOI: 10.1007/s12185-016-1982-6] [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: 10/21/2015] [Revised: 03/04/2016] [Accepted: 03/07/2016] [Indexed: 11/25/2022]
Abstract
Patients with acute promyelocytic leukemia (APL) are prone to both bleeding and thrombosis. Both of these have a significant impact on the morbidity and mortality of patients with this disease. Here we report a case of a 41-year-old male, who presented with transient ischemic attack (TIA) and early neurological deterioration (END) as initial manifestations prior to an ultimate diagnosis of APL. This patient had no cerebrovascular risk factors or familial cerebrovascular disease. The patient experienced an acute ischemic stroke, verified by magnetic resonance imaging (MRI), in less than 24 h after his second hospital admission. Some APL patients suffer from cerebral ischemia as an initial manifestation or during induction therapy, and patients presenting this condition may continue to deteriorate until their death during hospitalization. Thus, APL should be considered as a possible underlying disease in patients with TIA without cerebrovascular risk factors. Delayed diagnosis and treatment of APL can be fatal.
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Affiliation(s)
- Lifeng Liu
- Department of Neurology, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, Liaocheng, Shandong Province, 252000, China.
| | - Xiaoling Yuan
- Department of Neurology, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, Liaocheng, Shandong Province, 252000, China
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37
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Kutiyal AS, Dharmshaktu P, Kataria B, Garg A. A Rare Occurrence of Simultaneous Venous and Arterial Thromboembolic Events - Lower Limb Deep Venous Thrombosis and Pulmonary Thromboembolism as Initial Presentation in Acute Promyelocytic Leukemia. Clin Med Insights Oncol 2016; 10:1-4. [PMID: 26949347 PMCID: PMC4768938 DOI: 10.4137/cmo.s37866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 12/29/2015] [Accepted: 12/31/2015] [Indexed: 11/12/2022] Open
Abstract
The development of acute myeloid leukemia has been attributed to various factors, including hereditary, radiation, drugs, and certain occupational exposures. The association between malignancy and venous thromboembolism events is well established. Here, we present a case of a 70-year-old Indian man who had presented with arterial and venous thrombosis, and the patient was later diagnosed with acute promyelocytic leukemia (APL). In our case, the patient presented with right lower limb deep venous thrombosis and pulmonary thromboembolism four months prior to the diagnosis of APL. Although thromboembolic event subsequent to the diagnosis of malignancy, and especially during the chemotherapy has been widely reported, this prior presentation with simultaneous occurrence of both venous and arterial thromboembolism has rarely been reported. We take this opportunity to state the significance of a complete medical evaluation in cases of recurrent or unusual thrombotic events.
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Affiliation(s)
- Aditya S Kutiyal
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Pramila Dharmshaktu
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Babita Kataria
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Abhilasha Garg
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
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39
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Vaid AK, Batra S, Karanth SS, Gupta S. Acute promyelocytic leukemia presenting as pulmonary thromboembolism: Not all APLs bleed. Avicenna J Med 2015; 5:131-3. [PMID: 26629469 PMCID: PMC4637951 DOI: 10.4103/2231-0770.165125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We present a rare case of acute promyelocytic leukemia (APL) presenting as pulmonary thromboembolism being misdiagnosed as community-acquired pneumonia. Thrombotic phenomenon in APL are poorly understood and grossly underreported. In our case, following no response to standard antibiotic treatment, the patient was further investigated and detected to have an acute pulmonary thromboembolism following right lower limb deep vein thrombosis (DVT). Though, complete blood picture revealed only mild hyperleukocytosis, bone marrow biopsy and aspiration revealed 60% blasts and a positive t (15,17)(q22,12) and PML retinoic acid receptor alpha (RARA) fusion protein on molecular cytogenetics. He was diagnosed as APL and received treatment with all-transretinoic acid (ATRA) and arsenic trioxide (ATO) and therapeutic anticoagulation
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Affiliation(s)
- Ashok K Vaid
- Department of Medical Oncology, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Sandeep Batra
- Department of Medical Oncology, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Suman S Karanth
- Department of Medical Oncology, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Sachin Gupta
- Department of Medical Oncology, Max Superspeciality Hospital, Mohali, Punjab, India
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40
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Abstract
All-trans retinoic acid (ATRA) and Idarubicin are part of the AIDA protocol employed for the treatment of Acute promyelocytic leaukaemia (APML) and has been associated with marked improvement in the prognosis. However, it is known to worsen the haematological picture during the course of induction of therapy. Herein, we present a case of an APML patient who developed a rare documented incidence of cerebral sinus thrombosis, first noticed as an ophthalmology referral. This 22 year old lady, a known APML patient was then started on chemotherapy based on AIDA protocol but 17 days into the initiation of therapy, she began to complain of blurred vision on the right eye. Anterior segments were normal but both fundi showed papilloedema with peripapillary haemorrhages. A contrast MRI that was then ordered showed multiple filling defects in numerous venous sinuses. She was started on anticoagulant treatment and the findings resolved. Though a rare case of its side-effects, ATRA usage in APML has a multitude of presentations since its primary pathology lies in the inherent pro-coagulant potential.
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41
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Mitrovic M, Suvajdzic N, Elezovic I, Bogdanovic A, Djordjevic V, Miljic P, Djunic I, Gvozdenov M, Colovic N, Virijevic M, Lekovic D, Vidovic A, Tomin D. Thrombotic events in acute promyelocytic leukemia. Thromb Res 2014; 135:588-93. [PMID: 25528069 DOI: 10.1016/j.thromres.2014.11.026] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 10/24/2014] [Accepted: 11/30/2014] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Thrombotic events (TE) appear to be more common in acute promyelocytic leukemia (APL) than in other acute leukemias, with reported prevalence ranging from 2 to 10-15%. MATERIALS AND METHODS We retrospectively analyzed the data on TE appearance in 63 APL patients. RESULTS TE occured in 13 (20.6%) cases, four arterial (6.3%) and nine venous (14.3%). TE were more frequently diagnosed after initiation of weekly D-dimer monitoring (7 TE during 20 months vs 6 during 76 months, P=0.032). Patients with and without venous thrombosis were significantly different regarding female/male ratio (P=0.046), PT (P=0.022), aPTT (P=0.044), ISTH DIC score (P=0.001), bcr3 (P=0.02) and FLT3-ITD (P=0.028) mutation. The most significant risk factor for venous TE occurrence in multivariate analysis was FLT3-ITD mutation (P=0.034). PAI-1 4G/4G polymorphism was five times more frequent in patients with venous TE than without it (P=0.05). Regarding risk factors for arterial TE we failed to identify any. CONCLUSIONS We have demonstrated that APL-related TE rate is higher than previously reported and that weekly D-dimer monitoring might help to identify patients with silent thrombosis. Moreover, our study suggests a possible relationship between venous TE occurrence and several laboratory findings (PT, aPTT, ISTH DIC score, bcr3 isoform, FLT3-ITD mutation and PAI 4G/4G). Prophylactic use of heparin might be considered in patients with ISTH DIC score<5, bcr3 isoform, FLT3-ITD mutation and PAI 4G/4G.
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Affiliation(s)
| | - Nada Suvajdzic
- Clinic of Hematology CCS, Belgrade, Koste Todorovica 2 Serbia; Faculty of Medicine, University of Belgrade, Dr Subotica 8 Belgrade, Serbia
| | - Ivo Elezovic
- Clinic of Hematology CCS, Belgrade, Koste Todorovica 2 Serbia; Faculty of Medicine, University of Belgrade, Dr Subotica 8 Belgrade, Serbia
| | - Andrija Bogdanovic
- Clinic of Hematology CCS, Belgrade, Koste Todorovica 2 Serbia; Faculty of Medicine, University of Belgrade, Dr Subotica 8 Belgrade, Serbia
| | - Valentina Djordjevic
- Institute of Molecular Genetics and Genetic Engineering, University of Belgrade, Vojvode Stepe 444aBelgrade, Serbia
| | - Predrag Miljic
- Clinic of Hematology CCS, Belgrade, Koste Todorovica 2 Serbia; Faculty of Medicine, University of Belgrade, Dr Subotica 8 Belgrade, Serbia
| | - Irena Djunic
- Clinic of Hematology CCS, Belgrade, Koste Todorovica 2 Serbia
| | - Maja Gvozdenov
- Institute of Molecular Genetics and Genetic Engineering, University of Belgrade, Vojvode Stepe 444aBelgrade, Serbia
| | - Natasa Colovic
- Clinic of Hematology CCS, Belgrade, Koste Todorovica 2 Serbia; Faculty of Medicine, University of Belgrade, Dr Subotica 8 Belgrade, Serbia
| | | | | | - Ana Vidovic
- Clinic of Hematology CCS, Belgrade, Koste Todorovica 2 Serbia; Faculty of Medicine, University of Belgrade, Dr Subotica 8 Belgrade, Serbia
| | - Dragica Tomin
- Clinic of Hematology CCS, Belgrade, Koste Todorovica 2 Serbia; Faculty of Medicine, University of Belgrade, Dr Subotica 8 Belgrade, Serbia
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Trottier-Tellier F, Durand M, Kolan C, Wistaff R, Nguyen PV, Laskine M. Recurrent arterial and venous thromboemboli as initial presentation of acute promyelocytic leukemia. J Clin Med Res 2014; 6:388-91. [PMID: 25110545 PMCID: PMC4125336 DOI: 10.14740/jocmr1864w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2014] [Indexed: 11/21/2022] Open
Abstract
We report a case of a 52-year-old Caucasian woman diagnosed with a synchronic arterial and venous thrombosis as an initial presentation of an acute promyelocytic leukemia (APL). After the diagnosis, the patient was treated with all trans-retinoic acid and arsenic chemotherapy concomitant to systemic anticoagulation. This treatment regimen led to a complete remission and absence of relapse of the thrombosis or APL during the follow-up. To our knowledge, this presentation is the second case in the literature. We use this opportunity to emphasize the importance of performing a complete medical evaluation in cases of unusual thromboembolic events.
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Affiliation(s)
| | - Madeleine Durand
- Department of Medicine, Hopital Hotel-Dieu, CRCHUM, Montreal, Canada
| | - Christophe Kolan
- Department of Medicine, Hopital Hotel-Dieu, CHUM, Montreal, Canada
| | - Robert Wistaff
- Department of Medicine, Hopital Hotel-Dieu, CHUM, Montreal, Canada
| | - Paul Van Nguyen
- Department of Medicine, Hopital Hotel-Dieu, CHUM, Montreal, Canada
| | - Mikhael Laskine
- Department of Medicine, Hopital Hotel-Dieu, CRCHUM, Montreal, Canada
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