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Sharma N, Hassoun H, Hatem J, Kouides P. Cardiac ALL: Most Unusual Occurrence of Lenalidomide-associated Acute Lymphoblastic Leukemia with Subsequent Cardiac Involvement. Cureus 2019; 11:e6009. [PMID: 31815073 PMCID: PMC6881078 DOI: 10.7759/cureus.6009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Leukemic infiltration of the myocardium is an extremely rare complication and requires high clinical suspicion, as <5% pf patients are symptomatic. Commonly encountered cardiovascular complications are secondary to anemia, infections, and chemotherapy. We present an unusual case of biopsy-proven myocardial B-cell acute lymphoblastic leukemia (ALL) in an elderly male on chronic maintenance therapy with lenalidomide, with a previous history of multiple myeloma (MM) and subsequent ALL. Lenalidomide is a Category 1 recommendation for primary and maintenance therapy of MM, but there is growing evidence of secondary primary malignancies (SPMs). Despite this increase in SPM, the overall survival (OS) benefit associated with the use of maintenance immunomodulatory (IMID) therapy in multiple myeloma outweighs the risk of SPMs. Only age-appropriate screening methods are recommended. This case report serves as an important reminder of a rare manifestation of leukemia and presents as anecdotal evidence of response to the monoclonal antibody inotuzumab for visceral involvement of ALL, which has not been reported to our knowledge and requires further exploration.
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Affiliation(s)
- Naman Sharma
- Internal Medicine, Rochester General Hospital, Rochester, USA
| | - Hani Hassoun
- Hematology / Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Joseph Hatem
- Pathology, Rochester General Hospital, Rochester, USA
| | - Peter Kouides
- Hematology / Oncology, Rochester General Hospital, Rochester, USA
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Li G, Zhou Z, Yang W, Yang H, Fan X, Yin Y, Luo L, Zhang J, Wu N, Liang Z, Ke J, Chen J. Long-term cardiac-specific mortality among 44,292 acute myeloid leukemia patients treated with chemotherapy: a population-based analysis. J Cancer 2019; 10:6161-6169. [PMID: 31762826 PMCID: PMC6856578 DOI: 10.7150/jca.36948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 08/21/2019] [Indexed: 02/01/2023] Open
Abstract
Background: Acute myeloid leukemia (AML) is a common hematological malignancy treated with regimens containing anthracycline, an agent with cardiotoxicity. However, the cardiac-specific mortality in AML patients receiving chemotherapy remains unknown. Methods: In this population-based study, patients diagnosed with AML between 1973 and 2015 were identified in the Surveillance, Epidemiology, and End Results database. Cumulative mortality by cause of death was calculated. To quantify the excessive cardiac-specific death compared with the general population, standardized mortality ratios (SMRs) were calculated. Multivariate Cox regression analyses were performed to identify risk factors associated with cardiac-specific death and AML-specific death. Results: A total of 64,679 AML patients were identified between 1973 and 2015; 68.48% of patients (44,292) received chemotherapy. Among all possible competing causes of death, AML was associated with the highest cumulative mortality. The AML patients who received chemotherapy showed excessive cardiac-specific mortality compared with the general population, with an SMR of 6.35 (95% CI: 5.89-6.82). Age, year of diagnosis, sex, and marital status were independently associated with patient prognosis. Conclusion: Cardiac-specific mortality in AML patients receiving chemotherapy is higher than that in the general population.
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Affiliation(s)
- Guangli Li
- Department of Cardiology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China
| | - Zhijuan Zhou
- Department of Cardiology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China.,Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China
| | - Wencong Yang
- Department of Cardiology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen 518017, Guangdong, China
| | - Hao Yang
- Department of Cardiology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China
| | - Xiuwu Fan
- Department of Cardiology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China
| | - Yuelan Yin
- Department of Cardiology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China.,Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China
| | - Liyun Luo
- Department of Cardiology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China.,Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China
| | - Jinyou Zhang
- Department of Cardiology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China
| | - Niujian Wu
- Department of Cardiology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China
| | - Zibin Liang
- Department of Thoracic Oncology, The Cancer Center of The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Jianting Ke
- Department of Nephrology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China
| | - Jian Chen
- Department of Cardiology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China.,Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China.,Guangdong Provincial Key Laboratory of Biomedical Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai 519000, China
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Assuncao BMBL, Handschumacher MD, Brunner AM, Yucel E, Bartko PE, Cheng KH, Campos O, Fathi AT, Tan TC, Scherrer-Crosbie M. Acute Leukemia is Associated with Cardiac Alterations before Chemotherapy. J Am Soc Echocardiogr 2017; 30:1111-1118. [PMID: 28927558 DOI: 10.1016/j.echo.2017.07.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patients with acute leukemia (AL) have a higher rate of congestive heart failure than patients with other cancers. AL may predispose to cardiac dysfunction before chemotherapy because of high cytokine release or direct leukemic myocardial infiltration. The aims of this study were to evaluate whether AL is associated with abnormalities of myocardial structure and function before chemotherapy and to identify possible risk factors associated with these myocardial changes. METHODS Using an echocardiographic database, 76 patients with AL and 76 patients without cancer matched for age, gender, hypertension, and the presence of diabetes were retrospectively selected. Subsequently, to assess the effect of a nonhematologic malignancy, 28 women in each group were matched with women with breast cancer. Left ventricular (LV) mass, volumes, ejection fraction, and global longitudinal strain (GLS) were measured before chemotherapy. RESULTS The patients were predominantly male (63%), with a median age of 51 years, and had low prevalence of cardiovascular risk factors. Despite similar LV ejection fractions, patients with AL had higher LV mass and volumes and lower GLS (-19.3 ± 2.7% vs -20.9 ± 1.9%, P < .001) than patients without cancer. Similarly, GLS was lower in women with AL compared with women with breast cancer or without cancer. Among patients with AL, high body mass index, low LV ejection fraction, and a small number of circulating lymphocytes were all independently associated with low GLS. CONCLUSIONS Patients with AL had higher LV volumes and lower GLS than patients without cancer and lower GLS than patients with breast cancer, suggesting that AL by itself may be associated with these cardiac alterations.
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Affiliation(s)
- Bruna Morhy Borges Leal Assuncao
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Department of Internal Medicine, Federal University of Sao Paulo, Paulista School of Medicine, Sao Paulo, Brazil
| | - Mark D Handschumacher
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew M Brunner
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Evin Yucel
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Philipp E Bartko
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kai-Hung Cheng
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Orlando Campos
- Division of Cardiology, Department of Internal Medicine, Federal University of Sao Paulo, Paulista School of Medicine, Sao Paulo, Brazil
| | - Amir T Fathi
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy C Tan
- Blacktown Clinical School, Department of Cardiology, Faculty of Medicine, University of Western Sydney, and School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Marielle Scherrer-Crosbie
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Cardiac Ultrasound Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania.
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Intramuscular leukemic relapse: clinical signs and imaging findings. A multicentric analysis. Skeletal Radiol 2015; 44:491-6. [PMID: 25256752 DOI: 10.1007/s00256-014-2009-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 09/08/2014] [Accepted: 09/11/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Leukemia is a group of malignant diseases involving peripheral blood and bone marrow. Extramedullary tumor manifestation in leukemia can also occur. They more often involve lymph nodes, skin, and bones. Intramuscular leukemic relapse (ILR) is very unusual. The aim of this analysis was to summarize the reported data regarding clinical signs and radiological features of ILR. MATERIAL AND METHODS The PubMed database was searched for publications related to ILR. After an analysis of all identified articles, 20 publications matched the inclusion criteria. The authors of the 20 publications were contacted and provided imaging of their cases for review. The following were recorded: age, gender, primary diagnosis, clinical signs, pattern, localization and size of the intramuscular leukemic relapse. Images of 16 patients were provided [8 computer tomographic (CT) images and 15 magnetic resonance images, MRI]. Furthermore, one patient with ILR was identified in our institutional database. Therefore, images of 17 patients were available for further analysis. RESULTS Overall, 32 cases with ILR were included in the analysis. In most cases acute myeloid leukemia was diagnosed. Most ILRs were localized in the extremities (44 %) and in the extraocular muscles (44 %). Clinically, ILR manifested as local pain, swelling and muscle weakness. Radiologically, ILR presented most frequently with diffuse muscle infiltration. On postcontrast CT/MRI, most lesions demonstrated homogeneous enhancement. ILRs were hypo-/isointense on T1w and hyperintense on T2w images. CONCLUSION ILR manifests commonly as focal pain, swelling and muscle weakness. ILR predominantly involved the extraocular musculature and the extremities. Radiologically, diffuse muscle infiltration was the most common imaging finding.
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Tsubokura M, Miura Y, Itokawa T, Murata K, Takei N, Higaki T, Murashige N, Kami M, Komatsu T. Fatal Dysrhythmia Following Initiation of Lansoprazole During a Long-Term Course of Voriconazole. J Clin Pharmacol 2013; 51:1488-90. [DOI: 10.1177/0091270010384483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Krehbiel K, Matshes E. Endocardial Involvement in Acute Leukemia. Acad Forensic Pathol 2013. [DOI: 10.23907/2013.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Kacy Krehbiel
- University of New Mexico, Department of Pathology, Albuquerque, NM
| | - Evan Matshes
- Office of the Medical Investigator, Albuquerque NM
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McGregor A, Hurst E, Lord S, Jones G. Bradycardia following retinoic acid differentiation syndrome in a patient with acute promyelocytic leukaemia. BMJ Case Rep 2012; 2012:bcr.02.2012.5848. [PMID: 22778455 DOI: 10.1136/bcr.02.2012.5848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The authors describe a 28-year-old woman with newly diagnosed acute promyelocytic leukaemia (APL), who developed junctional bradycardia after receiving the molecular-targeted therapy all-trans retinoic acid (ATRA) and the anthracycline-based chemotherapeutic agent idarubicin following sepsis and the APL differentiation syndrome. The patient was asymptomatic of the bradycardia. Electrolytes and cardiac imaging were unremarkable. No other cases have been reported in this context and the mechanisms of the sinus node dysfunction are unclear. The patient achieved normal sinus rhythm after ATRA was withheld. The patient recovered and went on to achieve complete remission after re-starting ATRA and idarubicin.
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Affiliation(s)
- Andrew McGregor
- Specialist Haematology Services, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK.
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Acute myeloid leukemia with the t(8;21) translocation: clinical consequences and biological implications. J Biomed Biotechnol 2011; 2011:104631. [PMID: 21629739 PMCID: PMC3100545 DOI: 10.1155/2011/104631] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 01/31/2011] [Accepted: 02/22/2011] [Indexed: 12/20/2022] Open
Abstract
The t(8;21) abnormality occurs in a minority of acute myeloid leukemia (AML) patients. The translocation results in an in-frame fusion of two genes, resulting in a fusion protein of one N-terminal domain from the AML1 gene and four C-terminal domains from the ETO gene. This protein has multiple effects on the regulation of the proliferation, the differentiation, and the viability of leukemic cells. The translocation can be detected as the only genetic abnormality or as part of more complex abnormalities. If t(8;21) is detected in a patient with bone marrow pathology, the diagnosis AML can be made based on this abnormality alone. t(8;21) is usually associated with a good prognosis. Whether the detection of the fusion gene can be used for evaluation of minimal residual disease and risk of leukemia relapse remains to be clarified. To conclude, detection of t(8;21) is essential for optimal handling of these patients as it has both diagnostic, prognostic, and therapeutic implications.
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Taizi M, Deutsch VR, Leitner A, Ohana A, Goldstein RS. A novel and rapid in vivo system for testing therapeutics on human leukemias. Exp Hematol 2006; 34:1698-708. [PMID: 17157167 DOI: 10.1016/j.exphem.2006.07.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2006] [Revised: 07/12/2006] [Accepted: 07/13/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To develop a novel in vivo system for rapid assessment of leukemia growth and treatment of human blood cell malignancies. MATERIALS AND METHODS Cell lines derived from several human hematologic malignancies were introduced into chick embryos using four different methods. RESULTS K562 cells engraft in 100% of embryos following intravascular or intra-amniotic injection. The engraftment is rapid, appearing as soon as 7 days after injection, in striking contrast to the 4 weeks and more required for engrafting severe combined immunodeficient mice with human leukemia by systemic injection. The engraftment is easily visualized in vivo as tumor nodules in the chicken chorioallantoic membrane (CAM). In addition, leukemia is consistently detected in the embryos' hematopoietic organs by polymerase chain reaction amplification of human-specific DNA sequences. Consistent engraftment was also obtained using another leukemia cell line (DAMI). Finally, we demonstrate proof of principle that this system can be used for testing the efficacy of chemotherapy agents. Dramatic and consistent regression of tumors in the CAM was induced by a single intravenous dose of doxorubicin administered to K562-engrafted embryos. CONCLUSION This in vivo system provides a new platform for studying human blood cell malignancies at much lower cost than other animal models and has the potential to provide rapid chemotherapy assays, which could significantly reduce drug development time and expense.
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Affiliation(s)
- Moran Taizi
- Mina & Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat-Gan, Israel
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Mateen FJ, Harding SR, Saxena A. Extensive myocardial infiltration by hemopoietic precursors in a patient with myelodysplastic syndrome. BMC HEMATOLOGY 2006; 6:4. [PMID: 16953890 PMCID: PMC1569821 DOI: 10.1186/1471-2326-6-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2006] [Accepted: 09/05/2006] [Indexed: 02/05/2023]
Abstract
Background Although myocardial infiltration with leukemic blasts is a known finding in patients with acute leukemia, this phenomenon in myelodysplasia is not reported in the literature. Cardiac symptoms in patients with myelodysplasia are often due to anemia and may be due to iron overload and side effects of therapy. Case presentation Herein we report the first case of neoplastic infiltration of the heart with associated myocardial necrosis in a patient with myelodysplasia. It was associated with unicellular and multifocal geographic areas of necrosis in the left ventricle and the interventricular septum. It is likely that cardiac compromise in our patient was due to a combination of restrictive cardiomyopathy due to leukemic infiltration, concomitant anemia, cardiac dilatation, conduction blocks and myocardial necrosis. Myocardial necrosis was most likely due to a combination of ischemic damage secondary to anemia and prolonged hypotension and extensive leukemic infiltration. Markedly rapid decrease in ejection fraction from 66% to 33% also suggests the role of ischemia, since leukemic infiltration is not expected to cause this degree of systolic dysfunction over a 24-hour period. The diagnosis was not suspected during life due to concomitant signs and symptoms of anemia, pulmonary infections, and pericardial and pleural effusions. The patient succumbed to cardiac failure. Conclusion Hemopoietic cell infiltration was not considered in the differential diagnosis and contributed to this patient's morbidity and mortality. This case highlights the clinical importance of considering myocardial infiltration in patients with myelodysplasia and cardiac symptoms.
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Affiliation(s)
| | - Sheila R Harding
- Departments of Pathology and Internal Medicine, University of Saskatchewan and Saskatoon Health Region, Saskatoon, Canada
- Department of Pathology, University of Saskatchewan and Saskatoon Health Region, Saskatoon, Canada
| | - Anurag Saxena
- Departments of Pathology and Internal Medicine, University of Saskatchewan and Saskatoon Health Region, Saskatoon, Canada
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