Complications and management of coagulation disorders in leukemia patients

Massive Spontaneous Right Hemothorax Revealing Acute Myeloid Leukemia: A Case Report and Literature Review

Acute myeloid leukemia (AML) is a malignant hematologic disorder characterized by bone marrow failure and an increased risk of hemorrhagic complications due to thrombocytopenia, coagulopathy, and hyperfibrinolysis. While AML is associated with bleeding tendencies, massive spontaneous hemothorax (SH) is an exceedingly rare and often fatal manifestation. We report the case of a patient who presented with acute chest pain, dyspnea, and hemodynamic instability, ultimately diagnosed with AML-associated hemothorax. Imaging confirmed a large pleural effusion, and pleural fluid analysis revealed a hematocrit consistent with hemothorax. Bone marrow biopsy established a diagnosis of acute myelomonocytic leukemia (AML M4, FAB classification) with myelodysplasia-related changes (WHO classification). Management included urgent tube thoracostomy, correction of coagulopathy, and fluid resuscitation, with surgical intervention considered based on bleeding progression. Despite supportive measures, the prognosis in AML-associated hemothorax remains poor due to the underlying malignancy and hemorrhagic complications. During disease progression, the development of spontaneous hemopericardium further worsened the prognosis, leading to severe hemodynamic deterioration and increased mortality risk. This case underscores the importance of early recognition, rapid diagnosis via ultrasound and CT imaging, and a multidisciplinary treatment approach involving hematologists, intensivists, and thoracic specialists. Given the rarity of this complication and the absence of standardized guidelines, further studies are needed to refine diagnostic and therapeutic strategies for AML-related hemothorax.

Important Considerations in the Intensive Care Management of Acute Leukemias

In the realm of hematologic disorders, acute leukemia is approached as an emergent disease given the multitude of complications and challenges that present both as a result of inherent disease pathology and adverse events associated with antineoplastic therapies and interventions. The heavy burden of leukemic cells may lead to complications including tumor lysis syndrome, hyperleukocytosis, leukostasis, and differentiation syndrome, and the initiation of treatment can further exacerbate these effects. Capillary leak syndrome is observed as a result of antineoplastic agents used in acute leukemia, and L-asparaginase, a bacterial-derived enzyme, has a unique side effect profile including association with thrombosis. Thrombohemorrhagic syndrome and malignancy-associated thrombosis are also commonly observed complications due to direct disequilibrium in coagulant and anticoagulant factors. Due to inherent effects on the white blood cell milieu, leukemia patients are inherently immunocompromised and vulnerable to life-threatening sepsis. Lastly, the advents of newer therapies such as chimeric antigen receptor (CAR) T-cells have clinicians facing the management of related toxicities on unfamiliar territory. This review aims to discuss these acute leukemia-associated complications, their pathology, and management recommendations.

Hematological malignancies: Prevalence and hematological characteristics in a single center in southern Saudi Arabia

OBJECTIVES

To determine the prevalence of leukemia in the Aseer region of Saudi Arabia and the importance of hematological, biochemical and coagulation profiles for leukemic patients in the context of disease management.

METHODS

This retrospective study comprised 210 patients between 2012 and 2022 who had been diagnosed with leukemia at different ages. The multiple unpaired t-test was used to compare leukemic patients with control samples, which consisted of healthy individuals, and p<0.05 was taken as significant. The data was compiled from Aseer Central Hospital in the Aseer region and collected through peripheral blood smear and bone marrow biopsy (2012-2017) or by flow cytometry (2018-2022), according to the hospital information system and registry data.

RESULTS

Of the total 210 leukemic patients (61.4% males and 38.6% females), 104 cases (2012-2017) were diagnosed based on peripheral blood smear and bone marrow biopsy, and 106 cases (2018-2022) based on flow cytometry. Fifteen subtypes of leukemia were identified, with chronic myeloid leukemia being the most common (34.2%), followed by acute myeloid leukemia (17.6%), chronic lymphoblastic leukemia (11.9%), and B-cell acute lymphoid leukemia (9.5%). Other rare cases were also found.

CONCLUSION

Of the 210 leukemia cases diagnosed in the Aseer region between 2012-2022, the most common subtype was chronic myeloid leukemia, followed by acute myeloid leukemia. In all leukemia subtypes, distinctive significant changes were observed in hematological parameters, biochemical parameters, and coagulation profiles.

A potential area of use for immune checkpoint inhibitors: Targeting bone marrow microenvironment in acute myeloid leukemia

Acute myeloid leukemia (AML) arises from the cells of myeloid lineage and is the most frequent leukemia type in adulthood accounting for about 80% of all cases. The most common treatment strategy for the treatment of AML includes chemotherapy, in rare cases radiotherapy and stem cell and bone marrow transplantation are considered. Immune checkpoint proteins involve in the negative regulation of immune cells, leading to an escape from immune surveillance, in turn, causing failure of tumor cell elimination. Immune checkpoint inhibitors (ICIs) target the negative regulation of the immune cells and support the immune system in terms of anti-tumor immunity. Bone marrow microenvironment (BMM) bears various blood cell lineages and the interactions between these lineages and the noncellular components of BMM are considered important for AML development and progression. Administration of ICIs for the AML treatment may be a promising option by regulating BMM. In this review, we summarize the current treatment options in AML treatment and discuss the possible application of ICIs in AML treatment from the perspective of the regulation of BMM.

Disseminated intravascular coagulation in a cohort of adult acute leukemia patients: a single center experience

OBJECTIVES

We aimed to detect the incidence of disseminated intravascular coagulation (DIC) in patients with acute leukemia (AL) and find out its association with types of AL and patients' clinical and pathological parameters.

METHODS

In this prospective study, 59 newly diagnosed adults with AL were clinically examined and screened for DIC presentation time. Coagulation tests, including prothrombin time, activated partial thromboplastin time, fibrinogen level, D-dimer, antithrombin, and protein C and protein S levels were all assessed. The International Society for Thrombosis and Hemostasis scoring system was adopted to diagnose overt DIC.

RESULTS

The age of the studied patients ranged from 15 to 81 years with a median of 41 years; male to female ratio was 1.1:1. acute myeloid leukemia (AML) constituted 64.4% of the total cases (38 patients). DIC was detected in 28 patients (47.5%); its incidence was higher in AML than in acute lymphoblastic leukemia (ALL) (52.6% vs. 38.1%). Overt DIC was significantly associated with bleeding manifestations, duration of symptoms, and leukocytosis ( P -values = 0.050, 0.044, and 0.003, respectively). Bleeding events were encountered in 50.8% of patients (25 AML and 5 ALL patients). Bleeding was associated significantly with leukocytosis, thrombocytopenia, and low fibrinogen level. Thrombosis was found in two patients (3.4%) at presentation.

CONCLUSIONS

Overt DIC was common in patients with AL at presentation, mostly in AML. Routine testing for coagulopathy in newly diagnosed AL patients will possibly aid in improving the overall patients' survival.

Hyperleukocytosis and Leukostasis in Acute Myeloid Leukemia: Can a Better Understanding of the Underlying Molecular Pathophysiology Lead to Novel Treatments?

Up to 18% of patients with acute myeloid leukemia (AML) present with a white blood cell (WBC) count of greater than 100,000/µL, a condition that is frequently referred to as hyperleukocytosis. Hyperleukocytosis has been associated with an adverse prognosis and a higher incidence of life-threatening complications such as leukostasis, disseminated intravascular coagulation (DIC), and tumor lysis syndrome (TLS). The molecular processes underlying hyperleukocytosis have not been fully elucidated yet. However, the interactions between leukemic blasts and endothelial cells leading to leukostasis and DIC as well as the processes in the bone marrow microenvironment leading to the massive entry of leukemic blasts into the peripheral blood are becoming increasingly understood. Leukemic blasts interact with endothelial cells via cell adhesion molecules such as various members of the selectin family which are upregulated via inflammatory cytokines released by leukemic blasts. Besides their role in the development of leukostasis, cell adhesion molecules have also been implicated in leukemic stem cell survival and chemotherapy resistance and can be therapeutically targeted with specific inhibitors such as plerixafor or GMI-1271 (uproleselan). However, in the absence of approved targeted therapies supportive treatment with the uric acid lowering agents allopurinol and rasburicase as well as aggressive intravenous fluid hydration for the treatment and prophylaxis of TLS, transfusion of blood products for the management of DIC, and cytoreduction with intensive chemotherapy, leukapheresis, or hydroxyurea remain the mainstay of therapy for AML patients with hyperleukocytosis.

Drug Review: Ibrutinib

Ibrutinib is an irreversible BTK inhibitor, characterized by high selectivity and potency. It has revolutionized the therapy of B-cell lymphomas, especially chronic lymphocytic leukemia (CLL) and mantle cell lymphoma. Importantly, it has expanded the armamentarium for those patients who are refractory to conventional chemoimmunotherapy. This small-molecule inhibitor has shown efficacy in this difficult-to-treat subset – those with del(17p)/TP53-mutated CLL. Its immunomodulatory properties make it an excellent choice for combining with other immunotherapeutic agents such as venetoclax. The drug is not without drawbacks. The need for indefinite therapy and the presence of adverse effects such as infection, bleeding, hypertension, and arrhythmia temper our enthusiasm for this versatile drug. But overall, ibrutinib's favorable risk profile and lack of myelosuppression make it an ideal therapy for the elderly and those with multiple comorbidities.

Benzoxazole Derivative K313 Induces Cell Cycle Arrest, Apoptosis and Autophagy Blockage and Suppresses mTOR/p70S6K Pathway in Nalm-6 and Daudi Cells

Benzoxazole derivative K313 has previously been reported to possess anti-inflammatory effects in lipopolysaccharide-induced RAW264.7 macrophages. To date, there have been no related reports on the anticancer effects of K313. In this study, we found that K313 reduced the viability of human B-cell leukemia (Nalm-6) and lymphoma (Daudi) cells in a dose-dependent manner without affecting healthy peripheral blood mononuclear cells (PBMCs) and induced moderate cell cycle arrest at the G0/G1 phase. Meanwhile, K313 mediated cell apoptosis, which was accompanied by the activation of caspase-9, caspase-3, and poly ADP-ribose polymerase (PARP). Furthermore, cells treated with K313 showed a significant decrease in mitochondrial membrane potential (MMP), which may have been caused by the caspase-8-mediated cleavage of Bid, as detected by Western blot analysis. We also found that K313 led to the downregulation of p-p70S6K protein, which plays an important role in cell survival and cell cycle progression. In addition, treatment of these cells with K313 blocked autophagic flux, as reflected in the accumulation of LC3-II and p62 protein levels in a dose- and time-dependent manner. In conclusion, K313 decreases cell viability without affecting normal healthy PBMCs, induces cell cycle arrest and apoptosis, reduces p-p70S6K protein levels, and mediates strong autophagy inhibition. Therefore, K313 and its derivatives could be developed as potential anticancer drugs or autophagy blockers in the future.