Gastrointestinal manifestations of leukemia

Neutropenic Enterocolitis: An Uncommon, but Fearsome Complication of Leukemia

Neutropenic enterocolitis (NEC) is a life-threatening condition occurring in severely neutropenic patients, following intensive chemotherapy for leukemia. Its pathogenesis is not entirely understood and believed to be multifactorial, including mucosal injury as a result of cytotoxic drugs, profound neutropenia, impaired host defense and possibly microbiota changes. Establishing an early diagnosis is key. The management of NEC remains undefined due to lack of high-quality clinical data. With a better understanding of the disease, a more conservative approach is preferred over surgical intervention. The involvement of a multi-disciplinary team, consisting of the oncologist, infectious diseases specialists and surgeons is highly recommended. This review aims to delineate insights into the pathophysiology and clinical presentation of NEC and to emphasize the diagnostic and therapeutic approach to this condition.

Chronic Lymphocytic Leukemia Causing Gastric Ulcer Perforation: A Case Presentation and Literature Review

Chronic lymphocytic leukemia (CLL) is a malignancy characterized by the progressive accumulation of lymphocytes in the bone marrow and lymphoid organs. Gastrointestinal manifestations are rare in all types of leukemia. Generally, this occurs during relapsing disease or in acute leukemias; however, recent advancements in treatment have reduced these complications. Most commonly, lesions in the stomach are hemorrhagic, and lesions in the lower gastrointestinal tract present as peritonitis or colitis. Our patient was unique because she had a perforated, rather than bleeding, peptic ulcer caused by infiltrative chronic lymphocytic leukemia after starting ibrutinib. Although this medication can impair wound healing and/or cause bleeding, there are no reports of perforation of existing ulcers. Additionally, chronic lymphocytic leukemia causing perforated peptic ulcer disease (PUD) is rare, and this is, to our knowledge, the first case of this phenomenon.

Gut and liver involvement in pediatric hematolymphoid malignancies

Hematolymphoid malignancies are common neoplasms in childhood. The involvement of the gastrointestinal (GI) tract, liver, biliary system, pancreas, and peritoneum are closely interlinked and commonly encountered. In leukemias, lymphomas, and Langerhans cell histiocytosis (LCH), the manifestations result from infiltration, compression, overwhelmed immune system, and chemotherapy-induced drug toxicities. In acute leukemias, major manifestations are infiltrative hepatitis, drug induced gastritis, neutropenic typhlitis and chemotherapy related pancreatitis. Chronic leukemias are rare. Additional presentation in lymphomas is cholestasis due to infiltration or biliary obstruction by lymph nodal masses. Presence of ascites needs a thorough workup for the underlying pathophysiology that may modify the therapy and affect the outcome. Uncommon hematolymphoid malignancies are primary hepatic, hepatosplenic, and GI lymphomas which have strict definitions. In advanced diseases with extensive spread, it may be impossible to distinguish these diseases from the primary site of origin. LCH produces biliary strictures that mimic as sclerosing cholangitis. Liver infiltration is associated with poor liver recovery even after chemotherapy. The heterogeneity of gut and liver manifestations in hematolymphoid malignancies has a clinical impact on their management. Though chemotherapy is the mainstay of therapy in all hematolymphoid malignancies, debulking surgery and radiotherapy have an adjuvant role in specific clinical scenarios. Rare situations presenting as liver failure or end-stage liver disease require liver transplantation. At their initial presentation to a primary care physician, given the ambiguity in clinical manifestations and the prognostic difference with time-bound management, it is vital to recognize them early for optimal outcomes. Pooled data from robust registries across the world is required for better understanding of these complications.

Extramedullary involvement of the ascending colon in relapsing acute lymphocytic leukemia: A case report

Acute lymphoblastic leukemia (ALL) accounts for <1% of adult cancers. Extramedullary relapse of ALL has been primarily reported in pediatric patients or hematopoietic stem cell transplant recipients, and the gastrointestinal (GI) tract is a less frequently reported site of extramedullary relapse. Here, we report a case of a 30-year-old male who was a known case of ALL with multiple relapses and allogenic stem cell transplantations. The patient presented with acute lower GI bleeding and was confirmed to have an extramedullary relapse of ALL in the ascending colon. As the patient already had early relapses after two hematopoietic stem cell transplants in the past, he was managed with palliative chemotherapy, consisting of vincristine, dexamethasone, and rituximab, following which the patient achieved complete remission. This case highlights the importance of recognizing uncommon presentations of ALL such as those involving the GI tract.

Lymphoepithelioma-Like Gastric Carcinoma and Gastric Involvement of Chronic Lymphocytic Leukemia: Two Rare Identities Coexisting in One Patient

Lymphoepithelioma-like gastric carcinoma (LELGC) constitutes 1-4% of all gastric carcinomas and gastrointestinal involvement in leukemia can be present in up to 25%, being more common in acute than chronic leukemia, affecting most frequently the stomach, ileum, and proximal colon. LELGC is usually associated with a better prognosis than other gastric carcinomas, generally presenting with low T and N stages. The reports of chronic lymphocytic leukemia (CLL) involving infiltration of the gastrointestinal tract are relatively rare in the literature, and the estimated incidence ranges from 5.7% to 25%. We present the case of a 77-year-old female, on surveillance by a known CLL that was diagnosed with gastric carcinoma on an esophagogastroduodenoscopy (EGD) performed for epigastric pain. A subtotal gastrectomy was performed and the surgical specimen revealed simultaneous involvement of the stomach by LELGC and CLL. To the best of our knowledge, this is the first reported case of a LELGC and CLL simultaneously involving the stomach.

Acute appendicitis revealing a diagnosis of chronic myelogenous leukemia

Gastrointestinal manifestations of leukemias have been well recognized. Typically, acute leukemias cause typhlitis or appendicitis more commonly than chronic leukemias. Our case points to appendicitis as possible manifestation of chronic myelogenous leukemia.

De novo adult acute myeloid leukemia with two new mutations in juxtatransmembrane domain of the FLT3 gene: a case report

Background

Approximately 30% of adult acute myeloid leukemia (AML) acquire within fms-like tyrosine kinase 3 gene (FLT3) internal tandem duplications (FLT3/ITDs) in their juxtamembrane domain (JMD). FLT3/ITDs range in size from three to hundreds of nucleotides, and confer an adverse prognosis. Studies on a possible relationship between of FLT3/ITDs length and clinical outcomes in those AML patients were inconclusive, yet.

Case presentation

Here we report a 54-year-old Arab male diagnosed with AML who had two FLT3-ITD mutations in addition to NPM1 mutation. Cytogenetic approaches (banding cytogenetics) and fluorescence in situ hybridization (FISH) using specific probes to detect translocations t(8;21), t(15;17), t(16;16), t(12;21), and deletion del(13q)) were applied to exclude chromosomal abnormalities. Molecular genetic approaches (polymerase chain reaction (PCR) and the Sanger sequencing) identified a yet unreported combination of two new mutations in FLT3-ITDs. The first mutation induced a frameshift in JMD, and the second led to a homozygous substitution of c.1836T>A (p.F612L) also in JMD. Additionally a NPM1 type A mutation was detected. The first chemotherapeutic treatment was successful, but 1 month after the initial diagnosis, the patient experienced a relapse and unfortunately died.

Conclusions

To the best of our knowledge, a combination of two FLT3-ITD mutations in JMD together with an NPM1 type A mutation were not previously reported in adult AML. Further studies are necessary to prove or rule out whether the size of these FLT3-ITDs mutations and potential other double mutations in FLT3-ITD are correlated with the observed adverse outcome.

Intussusception caused by typhlitis: a rare complication in a patient with acute lymphoblastic leukemia after chemotherapy

INTRODUCTION

Intussusception, which is common in pediatric patients but rare in adults with leukemia, usually presents with an intralumenal lesion as a lead point in adults.

CASE REPORT

We herein report the case of a 38-year-old female who developed right lower quadrant abdominal pain and fever on day 16 of chemotherapy. Abdominal computed tomography showed ileocecal intussusception. The patient underwent surgery, and the definitive pathological diagnosis was typhlitis leading to intussusception. Albeit very rare in adults, typhlitis-induced intussusception should be suspected in those with leukemia presenting with abdominal pain.

Colonic Wall Thickening as the First Indicator of Relapse of Acute Lymphoblastic Leukemia

The gastrointestinal (GI) tract is a rarely reported site of extramedullary relapse of acute lymphoblastic leukemia (ALL). We report a patient being effectively treated with immunotherapy for relapsed ALL who was incidentally noted to have colonic wall thickening on imaging that was subsequently pathologically confirmed to be the result of disease infiltration of colonic tissue. Primary ALL involvement of the GI tract should be considered in the evaluation of GI complaints in patients with ALL, particularly those with relapsed disease otherwise effectively treated with immunotherapy.

The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia

Introduction

Liver involvement is common in hematological malignancies, but the incidence and pattern of liver injury vary among the different types. The aims of our study were to determine the incidence and clinical course of acute hepatitis and the important factors for its development in patients with leukemia after chemotherapy.

Materials and methods

All patients with the diagnosis of leukemia who were treated at the Department of Hematology between January 2008 and January 2013 were included in the study. A detailed medical history, clinical and laboratory findings, treatment modalities, complications, and clinical course were recorded retrospectively.

Results

A total of 124 patients (64 females) with the diagnosis of leukemia were included in the study. The mean age was 45.2 years (16-89 years) and mean follow-up time was 29.7 months (0.25-192 months). A total of 43 (34.6%) patients had acute hepatitis after chemotherapy. Pattern of liver injury was hepatocellular in 31 patients, cholestasis in 2, and mix in 10 patients. Age (p = 0.001), hepatitis B surface antigen (HBsAg, p = 0.007), acute leukemia (p < 0.001), positive blood culture (p = 0.004), the amount of transfused red blood cell (p = 0.001), and amount of transfused platelets (p = 0.002) were significantly different under univariate analysis between the acute hepatitis group and the nonacute hepatitis group. Under multivariate analysis, only acute lymphoblastic leukemia (ALL) was identified as independent predictive factor for development of acute hepatitis after starting chemotherapy.

Conclusion

Acute and self-limited hepatitis develops in the substantial proportion of patients with leukemia. The most important factor for development of acute hepatitis is the type of leukemia.

How to cite this article: Kaya M, Akdogan R, Uçmak F, Ayyildiz MO, Karakus A, Kaplan MA. The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia. Euroasian J Hepato-Gastroenterol 2018;8(1):31-37.

Ileocolic Intussusception in a Leukemic Adult Patient: A Case Report and Review of the Literature

We present a rare case of intussusception in a 41-year-old man with acute myeloid leukemia without an evidence of leukemic infiltration of the bowel. The patient presented to the emergency room with right lower quadrant pain. Initially he was diagnosed with typhlitis. CT scan was done and showed ileocolic intussusception without a definitive lead point identified. Patient underwent hemicolectomy and histopathological study of the specimen did not show any leukemic infiltrate. High suspicion of intussusception should be kept in mind with leukemic patients presenting with abdominal pain.

Phase I study of evofosfamide, an investigational hypoxia-activated prodrug, in patients with advanced leukemia

Tumor hypoxia causes resistance to radiation and chemotherapy. Evofosfamide (TH-302) has exhibited specific hypoxia-dependent cytotoxicity against primary acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) samples in vitro. Based on these findings, a Phase I study of evofosfamide was designed for patients with relapsed/refractory leukemia (NCT01149915). In this open-label study, patients were treated with evofosfamide as a 30-60 min/day infusion on Days 1-5 of a 21-day cycle (Arm A, n = 38) or as a continuous infusion over 120 hr over Days 1-5 of a 21-day cycle (Arm B, n = 11). Forty-nine patients were treated including 39 (80%) with AML and 9 (18%) with ALL. Patients had received a median of five prior therapies. In Arm A, the dose-limiting toxicities (DLTs) were grade 3 esophagitis, observed at a dose of 550 mg/m(2) . The maximum tolerated dose (MTD) was a daily dose of 460 mg/m(2) . In Arm B, the DLTs were grade 3 stomatitis and hyperbilirubinemia, observed at a daily dose of 460 mg/m(2) . The continuous infusion MTD was a daily dose of 330 mg/m(2) . Hypoxia markers HIF-1α and CAIX were highly expressed in leukemic bone marrow and were significantly reduced after evofosfamide therapy. The combined overall response rate in Arms A and B was 6% (2 CR/CRi and 1 PR), with all responses seen in Arm A. Evofosfamide has shown limited activity in heavily pretreated leukemia patients. Further evaluation investigating evofosfamide in combination with cytotoxic or demethylating agents is warranted. Am. J. Hematol. 91:800-805, 2016. © 2016 Wiley Periodicals, Inc.

Abdominal surgical emergencies in patients with advanced cancer

Abdominal emergency in an advanced oncologic setting is defined as an acute life-threatening abdominal pathology in a patient with incurable cancer. These include bowel obstruction, infections and, more rarely, hemorrhage. To benefit the patient, surgery should both increase the survival and improve the quality of life. These two goals are of equal importance and must be achieved together. This is difficult because these patients are frail, often malnourished and have a poor performance status. They also have a high risk of post-operative morbidity and mortality, a major risk of symptom recurrence and a limited life expectancy. For patients near the end-of-life, a therapeutic decision for surgical intervention must respect ethical and legal standards. This review reports the surgical outcomes and median survival of these patients, specifies rules that must be known and respected, and presents non-operative interventional alternatives.

Multiple Targetoid Lesions in the Spleen

Chronic lymphocytic leukemia (CLL) is the most prevalent hematologic malignancy of adults in the western hemisphere. Involvement of the spleen is not uncommon, often presenting as diffuse enlargement due to infiltration of neoplastic cells. A case is presented of an 81-year-old woman with a past medical history of CLL who was incidentally found to have multiple, focal splenic infiltrates on sonography. The patient had a normal sized spleen, which is a less common occurrence with splenic invasion by CLL. As current CLL guidelines discourage imaging but rely on evidence of organ involvement, this finding was critical in staging the patient properly. The sonographic appearance of this rare condition is described, and the advantages of sonography in its evaluation are discussed.

Phase I/II study of the hypoxia-activated prodrug PR104 in refractory/relapsed acute myeloid leukemia and acute lymphoblastic leukemia

We previously demonstrated vast expansion of hypoxic areas in the leukemic microenvironment and provided a rationale for using hypoxia-activated prodrugs. PR104 is a phosphate ester that is rapidly hydrolyzed in vivo to the corresponding alcohol PR-104A and further reduced to the amine and hydroxyl-amine nitrogen mustards that induce DNA cross-linking in hypoxic cells under low oxygen concentrations. In this phase I/II study, patients with relapsed/refractory acute myeloid leukemia (n=40) after 1 or 2 prior treatments or acute lymphoblastic leukemia (n=10) after any number of prior treatments received PR104; dose ranged from 1.1 to 4 g/m(2). The most common treatment-related grade 3/4 adverse events were myelosuppression (anemia 62%, neutropenia 50%, thrombocytopenia 46%), febrile neutropenia (40%), infection (24%), and enterocolitis (14%). Ten of 31 patients with acute myeloid leukemia (32%) and 2 of 10 patients with acute lymphoblastic leukemia (20%) who received 3 g/m(2) or 4 g/m(2) had a response (complete response, n=1; complete response without platelet recovery, n=5; morphological leukemia-free state, n=6). The extent of hypoxia was evaluated by the hypoxia tracer pimonidazole administered prior to a bone marrow biopsy and by immunohistochemical assessments of hypoxia-inducible factor alpha and carbonic anhydrase IX. A high fraction of leukemic cells expressed these markers, and PR104 administration resulted in measurable decrease of the proportions of hypoxic cells. These findings indicate that hypoxia is a prevalent feature of the leukemic microenvironment and that targeting hypoxia with hypoxia-activated prodrugs warrants further evaluation in acute leukemia. The trial is registered at clinicaltrials.gov identifier: 01037556.

Acute leukemia

Although great progress has been made in the understanding and treatment of acute leukemia, this disease has not been conquered. For emergency providers (EPs), the presentation of these patients to an emergency department presents a host of challenges. A patient may present with a new diagnosis of leukemia or with complications of the disease process or associated chemotherapy. It is incumbent on EPs to be familiar with the manifestations of leukemia in its various stages and maintain some suspicion for this diagnosis, given the nebulous and insidious manner in which leukemia can present.

Management of Acute Myeloid Leukemia in the Intensive Care Setting

Patients with acute myeloid leukemia (AML) who are newly diagnosed or relapsed and those who are receiving cytotoxic chemotherapy are predisposed to conditions such as sepsis due to bacterial and fungal infections, coagulopathies, hemorrhage, metabolic abnormalities, and respiratory and renal failure. These conditions are common reasons for patients with AML to be managed in the intensive care unit (ICU). For patients with AML in the ICU, providers need to be aware of common problems and how to manage them. Understanding the pathophysiology of complications and the recent advances in risk stratification as well as newer therapy for AML are relevant to the critical care provider.

Abdominal complications following neutropenia and haematopoietic stem cell transplantation: CT findings

In haematology units, acute abdominal symptoms are common and often challenging for the clinician in charge. Two haematological conditions that may induce specific diagnoses are of particular concern: neutropenia and haematopoietic stem cell transplantation. Clinical and biological manifestations, including abdominal pain, fever, diarrhoea, hepatic cytolysis, or cholestasis are often non-specific. Computed tomography is often the primary imaging screening technique performed in such patients, as it is widely available, performs well for this indication, and may demonstrate evocative findings. The aim of this review is to provide the spectrum of specific diagnoses encountered and the corresponding key CT features in patients presenting with acute abdominal disorders following neutropenia and/or haematopoietic stem cell transplantation.