Extramedullary sudden blast crisis in chronic-phase chronic myeloid leukemia during first-line treatment with nilotinib

Angelopoulou, Maria K.; Asimakopoulos, John; Galani, Zacharoula; Levidou, Georgia; Roumelioti, Maria; Vassilakopoulos, T.; Korkolopoulou, Penelope; Panayiotidis, P.

doi:10.1038/bcj.2016.66

Cited by 6 publications

(5 citation statements)

References 14 publications

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“…The presence of immature myeloid cells is observed almost exclusively in patients with malignant myeloid neoplasms as observed in our case. The presence of numerous or sheets of myeloblasts should raise the possibility of myeloid sarcoma . We could not demonstrate any blast cells on morphology or immunohistochemistry in the FNA smears.…”

Section: Discussionmentioning

confidence: 99%

Cytology of extramedullary haematopoiesis—A rare unanticipated finding in the lymph node of an undiagnosed chronic myeloid leukaemia case

et al. 2019

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Extramedullary haematopoiesis (EMH) is a compensatory mechanism that occurs when there is deficient bone marrow haematopoiesis secondary to either peripheral red cell destruction or marrow replacement. 1 EMH is the appearance of haematopoietic tissue outside of the bone marrow, which may be composed of two or three haematopoietic cell lineages. 2 In routine cytology practice, it is unusual to encounter extramedullary proliferations of bone marrow elements. EMH is a rare complication of chronic myeloid leukaemia (CML) which can be encountered in the liver, spleen and, rarely, in the lymph nodes. The development of EMH in CML does not usually affect the prognosis of patients; however, the presence of a marrow proliferation in a lymph node would indicate an immediate search for an underlying bone marrow neoplasm and prompt a haematological evaluation, including review of haemogram, peripheral blood smear, and possibly a bone marrow aspiration and biopsy. 3 Here, we report a case of EMH in the axillary lymph node of 67-year-old man with CML in chronic phase which was diagnosed on cytology based on the identification of all the three lineages of haematopoietic cells with a background of reactive lymphoid cells. | C A S E REP ORTA 67-year-old man presented to medicine outpatient department with easy fatigability, early satiety, dyspnoea on exertion and weight loss for 2 months. He had no complaints of fever and bleeding manifestations or any history of hospitalisation. On physical examination, he had pallor, left axillary lymphadenopathy and splenomegaly.The axillary lymph node which measured 2 × 2 cm was firm, mobile and non-tender. The patient was subjected to fine needle aspiration (FNA) cytology from the axillary node with a clinical possibility of tuberculosis. May-Grünwald Giemsa-and Papanicolaou stained smears revealed a polymorphous population of reactive lymphoid cells admixed with few neutrophils, eosinophils, occasional basophils and tingible body macrophages. In addition, there were scattered large giant cells with lobulated nuclei and some giant cells with large round nuclei, simulating the morphology of large and small megakaryocytes, respectively. Furthermore, we could appreciate a few precursor forms of myeloid and erythroid lineage cells. There was no granuloma or malignancy. Hence, we reported the smears as suggestive of extramedullary haematopoiesis with a note for detailed haematological evaluation (Figures 1A-D and 2A).On haematological evaluation, he was found to have a total leucocyte count of 369.57 × 10 9 /L, haemoglobin 55 g/L and platelets 161 × 10 9 /L. A peripheral blood smear showed hyper-leucocytosis with myeloid bulge and blast accounting for less than 2% with basophilia ( Figure 2B). The haematological diagnosis was CML-chronic phase (BCR-ABL1 positive proven on peripheral blood). Later, bone marrow examination revealed 100% cellularity and myeloid hyperplasia with a full range of maturation. The blast cells constituted <5% on morphology as well as on immunohistochemistry for CD34 and C...

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Section: Discussionmentioning

confidence: 99%

Cytology of extramedullary haematopoiesis—A rare unanticipated finding in the lymph node of an undiagnosed chronic myeloid leukaemia case

et al. 2019

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“…However, even in patients with optimal responses to TKIs, sudden blast crises have been reported 2,3 . Several reports have shown that patients can develop an extramedullary crisis after TKI treatment with imatinib 4 or dasatinib, 5 or even during TKI treatment 6–9 . After initiating bosutinib, our patient achieved MMR within four months and remained so for more than four years.…”

Section: Figurementioning

confidence: 69%

“…Generally, extramedullary crisis cases show a dismal prognosis even with intensive therapy. Angelopoulou et al 8 . reported a CML patient who developed an extramedullary crisis while MMR by nilotinib.…”

Section: Figurementioning

confidence: 99%

Extramedullary blast crisis in a chronic myeloid leukaemia patient after achieving a major molecular response with bosutinib

et al. 2021

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“…In the era of TKIs, the development of blast crisis after an optimal response is an uncommon feature but nevertheless a probability. Reports of blast crisis transformation following therapy with imatinib [ 17 , 18 ], dasatinib [ 20 ], nilotinib [ 21 , 22 ] show us that there are underlying hidden clinical and biological factors that influence this unfavorable outcome. Ph-positive/Ph-negative mosaicism [ 17 ], clonal evolution [ 18 ], mutations such as T315l [ 22 ] among others are some of the findings observed when the patients transformed into blast phase.…”

Section: Discussionmentioning

confidence: 99%

“…Reports of blast crisis transformation following therapy with imatinib [ 17 , 18 ], dasatinib [ 20 ], nilotinib [ 21 , 22 ] show us that there are underlying hidden clinical and biological factors that influence this unfavorable outcome. Ph-positive/Ph-negative mosaicism [ 17 ], clonal evolution [ 18 ], mutations such as T315l [ 22 ] among others are some of the findings observed when the patients transformed into blast phase. It has also been implied that sometimes treatment with TKIs itself provides an opportunity for more indolent and resistant cells to develop.…”

Section: Discussionmentioning

confidence: 99%

Sudden Blast Crisis After Excellent Initial Response in Chronic Myeloid Leukemia

Prakash¹,

Sivakolundu

Savage

et al. 2021

Cureus

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Sudden blast crisis is an uncommon phenomenon in chronic myeloid leukemia (CML) patients who are being treated with tyrosine kinase inhibitors (TKIs). Despite well-defined guidelines to treat and monitor the disease, it is difficult to predict the occurrence of a sudden blast crisis. Research directed towards improving guidelines in choosing the appropriate TKIs and better monitoring protocols could help prevent such unfortunate outcomes. We present a case of a 46-year-old man diagnosed with CML who responded well to imatinib as evidenced by a downtrend in quantitative BCR-ABL mutation to less than 1. He quickly transformed into a blast crisis phase after five months of therapy with imatinib regardless of achieving an excellent initial optimal response. In conclusion, it is possible to transform into a blast phase despite achieving an initial optimal response. Therefore, attention should be focused on the selection of proper tyrosine kinase inhibitors and careful monitoring to allow the early detection of sudden blast crisis.

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Extramedullary sudden blast crisis in chronic-phase chronic myeloid leukemia during first-line treatment with nilotinib

Cited by 6 publications

References 14 publications

Cytology of extramedullary haematopoiesis—A rare unanticipated finding in the lymph node of an undiagnosed chronic myeloid leukaemia case

Cytology of extramedullary haematopoiesis—A rare unanticipated finding in the lymph node of an undiagnosed chronic myeloid leukaemia case

Extramedullary blast crisis in a chronic myeloid leukaemia patient after achieving a major molecular response with bosutinib

Sudden Blast Crisis After Excellent Initial Response in Chronic Myeloid Leukemia

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