Management of chronic myeloid leukemia in the setting of pregnancy: when is leukocytapheresis appropriate? A case report and review of the literature

Abstract

BACKGROUND: Chronic myeloid leukemia (CML) is a common hematologic malignancy; however, its occurrence during pregnancy is unusual due to its low prevalence in females of childbearing age. There are conflicting reports of how to best manage CML in pregnancy, particularly in the setting of leukocytosis. CASE REPORT: A 30-year-old female was diagnosed with CML at 18 weeks’ estimated gestational age. On initial presentation she reported fatigue, night sweats, and early satiety, and was found to have a white blood cell (WBC) count of 69.3 × 109/L and platelet count of 366 × 109/L. Her disease was managed during pregnancy using interferon-α alone despite persistent leukocytosis. CONCLUSION: CML may be effectively managed during pregnancy, even in the setting of leukocytosis, without the application of leukocytapheresis. Management relies not only upon the coordination of drug therapy and fetal monitoring, but requires close communication between multiple medical disciplines. Leukocytapheresis has been safely performed during pregnancy and may be a suitable adjunct management strategy in pregnant patients diagnosed with CML with specific clinical presentations, such as hyperleukocytosis (WBC count > 150 × 109/L) and/or symptomatic leukostasis.

Chronic Myeloid Leukemia, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology

“…253 Leukapheresis can be used for a rising white blood cell (WBC) count, although there are no data that recommend at what level of white blood cell count leukapheresis should be initiated. 249,[254][255][256] Low-dose aspirin or low-molecular-weight heparin can be considered for patients with thrombocytosis. 257,258 Monthly monitoring with qPCR and initiating treatment if the BCR-ABL1 IS increases to .1.0% is recommended.…”

Additive genotoxic effects in cord blood cells upon indirect exposure to chemotherapeutic compounds crossing an in vitro placental barrier

“…Though cyclophosphamide and epirubicin are part of standard cancer treatment regimens for pregnant cancer patients[26-28], placenta toxicity following prenatal administration to these drugs is largely unexplored. The sparse studies investigating this topic showed that exposed to cyclophosphamide and epirubicine presented higher levels of apoptosis and in ammatory lesions [18,33,34]. Likewise, it is also largely unknown whether and how such placental toxicity would adversely affect the fetus.…”

Leukapheresis and Hyperleukocytosis, Past and Future

“… 39 Multiple case reports proposed leukapheresis for management of hyperleukocytosis in pregnant as leukapheresis had no adverse effect on the mother and fetus. 40 , 41 Therefore, leukapheresis was safe and also could be used for the treatment of children (excluding acute promyelocytic leukemia) and pregnant women with hyperleukocytic leukemia.…”