Clustered incidence of acute promyelocytic leukemia during gefitinib treatment for non-small-cell lung cancer: experience at a single institution

Case report: Identification of acute promyelocytic leukemia during osimertinib resistance followed by granulocyte colony-stimulating factor and pembrolizumab

Background

The occurrence of acute promyelocytic leukemia (APL) during the management of lung cancer is rare and life-threatening. It was mainly reported to be secondary to chemoradiotherapy. A few studies reported an increased incidence of therapy-related acute promyelocytic leukemia (t-APL) after gefitinib became available.

Case presentation

We reported a patient who developed thrombocytopenia after receiving oral osimertinib in combination with intensity-modulated radiotherapy (IMRT). For half a year, she had an unrecoverable low platelet count, which progressed to concomitant leukopenia and the transient appearance of orthochromatic normoblasts in the peripheral blood test, indicating a dormant myeloid disorder. Due to simultaneous resistance to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKI), pembrolizumab and granulocyte colony-stimulating factor (G-CSF) were administered, revealing prominent signs of hematological malignancy in a peripheral blood test that was later identified as t-APL.

Conclusion

In general, patients undergoing EGFR-TKI combined with local radiotherapy should be concerned about their hematological assessment. If patients exhibit unrecoverable abnormalities in routine blood tests, a secondary nonsolid malignancy other than myelosuppression should be considered, and further lung cancer treatment should be discontinued.

Clinicopathological features, risk and survival in lung cancer survivors with therapy-related acute myeloid leukaemia

BACKGROUND

A secondary malignancy is the most serious complication in lung cancer (LC) survivors. This study aimed to evaluate the clinicopathological features, predictable risk factors and survival of patients with LC who developed therapy-related acute myeloid leukaemia (t-AML).

METHODS

Patients from the Surveillance, Epidemiology, and End Results (SEER) database diagnosed with t-AML after LC between 1975 and 2015 were included. Standardized incidence ratios (SIRs) were used to perform multiple primary analyses. The risk of t-AML development among LC patients was assessed using a logistic regression model. Kaplan-Meier analysis was used to construct overall survival (OS) curves. Cox regression was used to assess the influence of various prognostic factors.

RESULTS

A total of 104 patients with t-AML after LC-targeting chemotherapy were included. The median latency period to the development of t-AML was 35.5 months. The calculated SIR of t-AML was 4.00. Chemoradiotherapy, small cell lung cancer (SCLC), or localized/regional-stage LC was a risk factor for the development of t-AML. The median OS was only 1 month, and those younger than 65 years were predicted to have a better OS time.

CONCLUSIONS

t-AML is a rare but serious late complication in LC patients and is associated with a poor prognosis. It is necessary to carry out long-term follow-up and screen for t-AML in LC patients, especially among those undergoing both radiotherapy and chemotherapy, with SCLC or with localized/regional-stage LC.

Leukemoid reaction in a patient with adenocarcinoma of the lung: a case report

Introduction

Lung cancers are characterized by high incidence, prevalence and mortality. They may be associated with numerous paraneoplastic syndromes. Mild leukocytosis is not rare. The case described here, however, is of a female patient with adenocarcinoma of the lung who developed extreme leukocytosis at over 140,000 cells/μL. Descriptions of such leukemic forms of lung cancer are few and far between in the literature. In our case, the complete hematological diagnostic investigation, which included cytological, immunocytological, cytogenetic, histological and molecular genetic tests of the bone marrow (mutation analyses of BCR-ABL and JAK2), was accompanied for the first time by a molecular genetic workup of the primary tumor for epidermal growth factor receptor and K-RAS gene mutations.

Case presentation

We present the medical case of a 51-year-old female Caucasian patient, who was diagnosed with a poorly differentiated stage IV (International Union Against Cancer staging) adenocarcinoma of the lung. While undergoing treatment, our patient developed extreme leukocytosis, for which, despite extensive diagnostic tests, no infection-related or hematological cause could be identified. The tumor proved to be highly resistant to treatment. Our patient died only five months after the initial diagnosis.

Conclusion

A leukemoid course can most likely be interpreted as the paraneoplastic production of hematopoietic growth factors. Despite the absence of a verified primary hematological origin, this possibility should always be investigated in all patients in a comparable situation.

Phase II study of gefitinib in combination with paclitaxel (P) and carboplatin (C) as second-line therapy for ovarian, tubal or peritoneal adenocarcinoma (1839IL/0074)

OBJECTIVE

This phase II investigated efficacy and tolerability of gefitinib in combination with paclitaxel (P) and carboplatin (C) for second-line treatment of patients (pts) with ovarian, tubal or peritoneal adenocarcinoma.

PATIENTS AND METHODS

Women (>18 years) with platinum-resistant/refractory (relapsed<6 months), or platinum-sensitive (relapsed >6 months) disease after first-line platinum-based and P chemotherapy. Pts received 6-8 cycles of gefitinib (500 mg/day), P (175 mg/m(2) 3 h infusion) and C (AUC 5) every 3 weeks, followed by gefitinib alone. The primary endpoint was objective response rate (ORR) (RECIST or Rustin criteria).

RESULTS

Sixty-eight patients (26 resistant/refractory and 42 sensitive) were enrolled (median age: 57 years). ORR and disease control rates were 19.2% and 69.2% for resistant/refractory, and 61.9% and 81.0%, for sensitive disease. Median time to progression and overall median survivals were 6.1 and 16.9 months for resistant/refractory and 9.2 and 25.7 months for sensitive disease. Grade 3/4 toxicities (in > or = 10% patients) were neutropenia (59%), diarrhea (25%), leukopenia (22%), anemia (13%), and acne (13%). Two secondary myelodysplastic syndromes (MDS) and one secondary acute leukemia occurred during treatment, and one MDS 34 months after treatment discontinuation.

CONCLUSION

Gefitinib, administered in combination with paclitaxel and carboplatin, provides a good clinical response but associated with an increased risk of hematologic disorders.

Molecular mechanisms of ZD1839 (Iressa)-induced apoptosis in human leukemic U937 cells

AIM

To investigate the molecular mechanisms of ZD1839-induced apoptosis in human leukemic U937 cells.

METHODS

The inhibition of human leukemic U937 cell growth was assessed by 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphnyl-2H-tetrazolim bromide (MTT) assays, lactate dehydrogenase (LDH) release, and cell cycle distribution. The expression of anti- and pro-apoptotic proteins was detected by Western blot analysis.

RESULTS

This study demonstrated that ZD1839 induced apoptosis in leukemic U937 cells by the downregulation of Bcl-2, caspase activation and subsequent apoptotic features. Cotreatment with ZD1839 and the caspase-3 inhibitor z-DEVD-fmk blocked apoptosis, indicating that caspase-3 activation is at least partially responsible for ZD1839-induced apoptosis. The ectopic expression of Bcl-2 attenuated caspase-3 activation, PARP cleavage, and subsequent indicators of apoptosis, including sub-G1 DNA content and LDH release. These results indicate that the downregulation of Bcl-2 plays a major role in the initiation of ZD1839-induced apoptosis, and that the activation of a caspase cascade is involved in the execution of apoptosis. Furthermore, ZD1839 treatment triggered the activation of p38 mitogen-activated protein kinase (MAPK) and the down-regulation of c-Jun-N-terminal kinase (JNK), extracellular signal-regulated kinase (ERK) and phosphatidyl inositol 3-kinase (PI3K)/Akt. The inhibition of the ERK and PI3K/Akt pathways also significantly increased cellular death.

CONCLUSION

ZD1839 activated caspase-3 and the inhibited Bcl-2 in human leukemic U937 cells through the downregulation of the ERK and PI3K/Akt pathways.