Heme-Malignancy

Conference
11/23/2015

Case-3
36-year-old Male
4/2014-Visual field defects as well as an orange color that
proved ultimately to be a retinal hemorrhage.
PMH: Plantar fasciitis and seasonal allergies
SOCIAL HISTORY: He grew up in Minnesota, but works in Alaska
for an oil pipeline. He went to school in Hutchinson and is
studying nondestructive testing, which basically inspects metals
ranging from bridges to pipelines. He has 2 children with his
wife, Michelle, ages 10 and 9. He has no siblings. He does smoke
less than a pack a day. He does not use alcohol. He has had a
long history of exposure to hydrocarbons, gas, oil and radiation
Family History: none significant

 Unity Hospital ;WBC 341,000, Hb 9.3

and Plt of 131,000.
Bone Marrow biopsy 4/2014
FISH

Bone Marrow results 4/2014

It was 100% cellular with granulocytic
hyperplasia, 3% blasts, consistent with chronic
phase CML. There were 2%-3% circulating cells.
There was some question on the bone marrow of
increased fibrosis with some increase in mast
cells. The fibrosis appeared to be an MF1, one of
3, with some areas of moderate MF2 fibrosis.
Philadelphia chromosome by FISH and by
cytogenetics; 445 out of 500 cells by FISH had
evidence of a BCR-ABL fusion gene. It was shown
that he had a p210 major breakpoint translocation

 Chronic myelogenous leukemia. He

had about 2.5% blasts. He was
treated with leukapheresis,
hydroxyurea and imatinib.

 He was started on imatinib and

actually did fairly well on the
imatinib.
-His counts came down and following
his FISH, by August he had only 2.2%
of his cells with BCR-ABL. He never
went to zero. In November 2014 he
had only 16 of 500 cells that were
positive for BCR-ABL.

 February 2015, he developed fatigue,

some sweats as well as low-grade
fever. He was found to have an
elevated white count of 78,000,
hemoglobin of 7.6 and platelet count
of 81,000.
He was started on dasatinib 140 mg.
He had issues with pancytopenia
requiring blood transfusions due to
dasatinib.

 Bone Marrow 4/21/2015

 May 2015 he was changed to

Nilotinib. He continued to have some
cytopenias but was maintained fairly
well on 150 mg bid alternating with
150 mg daily.

8/2015- Proptosis
Worsening of diffuse,
symmetric enlargement
of the
bilateral extraocular
musculature with stable
moderate associated
proptosis bilaterally.
Likely infiltration in
the setting of
CML.Bilateral optic
neuropathy and proptosis
secondary to CML

 Presented with decreased vision,eye

pain and photophobia,with headache
and nausea
He underwent radiation to orbits10
fractions(9/10-9/24) at that time. His
vision improved and nilotinib was
continued.

 He returned for follow up and his

WBC was elevated with increased
blasts.
9/28/15:Hb:9.5, WBC:28.3,Plt:58,
Blasts 32%- 44%
9/29/15: Bone Marrow biopsy

 He was admitted for induction

chemotherapy Idarubicin and
Cytarabine 7+3 (Day 1 = 9/30/2015).
Tolerated well
Day 14 Bone marrow biopsy
Day 30 Bone Marrow biopsy

 His Day 14 marrow from 10/13

showed. hypocellular marrow with 1%
blasts. He was discharged from the
hospital on 10/26.
A follow up BMBX was performed on
10/29-showed 61% blasts by
morphology.

 (11/2/15) for re-induction with MEC

As per protocol Cytarabine to be
started after ANC>1500
11/8/15: Acute Myopericarditis
managed with colchicine
11/15/15:Peripheral blood
5%11/17-16% blasts
11/17/15: D+16 Bone Marrow biopsy

 Current Treatment Nilotinib 200 mg

PO BID

Summary
Visual symptoms
4/2014 BM- CML
Imatinib
2/2015- Dasatinib
Cytopenias
4/21/2015- BM- CML
Nilotinib
ProptosisRT
9/29/15- BM- Blasts AML
9/30/2015-7+3
Day+14 BM- hypocellular
10/29/15-Day +30 BM- 61%Blasts
11/2/2015- Re-Induction with MEC
11/17/15- BM -56% blasts
Nilotinib