Acute promyelocytic leukemia with marrow fibrosis at initial presentation: possible involvement of transforming growth factor-beta(1)

Gangrenous Ischemic Colitis Due to Acute Promyelocytic Leukaemia, and Myelofibrosis in a 62-year-old Man Suffering from ESRD; Case Report

Introduction and importance

Ischemic colitis, also rare, is the most common ischemic pathology of the digestive system. It usually affects the ageing population and those suffering from end-stage renal disease (ESRD), hypertension, and heart failure. Its incidence varies from 4.5 to 44 cases per 100,000 annually.

Case presentation

We have reported a case of gangrenous colitis in a 62-year-old man suffering from acute promyelocytic leukaemia (APL) and myelofibrosis. He had hypertension and ESRD due to obstructive uropathy from seven years ago in his past medical history. His recurrent constitutional symptoms and persistent leukocytosis of more than 20,000 in μL was always treated as catheter-related infection or sepsis until acute abdomen emerged. The surgical team encountered a vast gangrenous right hemicolon. The leukocytosis did not resolve. Thus, the haematological investigations proved APL with myelofibrosis. The affected colon was free of leukemic infiltration.

Clinical discussion

Hypoperfusion due to ESRD and hemodialysis accompanied with malignancy induced hypercoagulative state provided a context in which small vessels of the bowel were obstructed.

Conclusion

Malignancies are associated with thrombophilia, and colonic involvement is not always related to lymphatic infiltration in leukaemia patients.

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Ischemic colitis, also rare, is the most common ischemic pathology of the digestive system.

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Not every leukocytosis should be viewed as sepsis.

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Although rare, acute promyelocytic leukaemia can be accompanied by myelofibrosis.

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Ischemic colitis may be a result of a hypercoagulable state caused by leukaemias, not necessarily leukaemic invasion.

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The cecum is within a watershed of the colon in which incomplete anastomoses of the marginal arteries make its blood supply poor and vulnerable to ischemia.

Acute promyelocytic leukemia with myelofibrosis: A case report and literature review

RATIONALE

Acute promyelocytic leukemia (APL) with myelofibrosis (MF) is rare, and only 14 cases have been reported in the literature to date.

PATIENT CONCERNS

A 42-year-old woman was admitted to the hospital with easy bruising and excessive bleeding. With the remission of the primary disease during treatment, the degree of fibrosis did not decrease, but worsened progressively.

DIAGNOSIS

The woman was diagnosed with acute promyelocytic leukemia with secondary myelofibrosis.

INTERVENTIONS

All-trans retinoic acid (ATRA) was discontinued after 6 months of complete remission of APL. Arsenic trioxide (ATO) was discontinued because of supraventricular tachycardia 9 months after complete remission of APL.

OUTCOMES

After withdrawal of ATRA for 2 months, the degree of fibrosis was significantly alleviated, and after withdrawal of ATRA for 8 months and ATO for 5 months, bone marrow biopsy showed no reticular fiber deposition.

LESSONS

In this case report and review of an additional 14 cases of APL with MF, we highlighted the importance of the degree of MF to be evaluated by bone marrow biopsy at the time of bone marrow aspiration when APL is suspected. If MF is present, the type of MF should be determined in a timely manner, and appropriate intervention measures should be taken accordingly.

Prolonged Myelosuppression due to Progressive Bone Marrow Fibrosis in a Patient with Acute Promyelocytic Leukemia. Case Rep Hematol. 2019;2019:1616237. [PMID: 31885950 PMCID: PMC6900957 DOI: 10.1155/2019/1616237]

A 34-year-old woman was diagnosed with acute promyelocytic leukemia. Chemotherapy was administered following the JALSG APL204 protocol. Induction therapy with all-trans retinoic acid resulted in complete remission on day 49. She developed coccygeal pain from day 18, which spread to the spine and cheekbones and lasted 5 weeks. She had similar bone pain on days 7–10 of the first consolidation therapy and on days 4–12 of the second consolidation therapy. Oral loxoprofen was prescribed for pain relief. On day 33 of the third consolidation, white blood cell and neutrophil counts were 320/μL and 20/μL, respectively. After she developed epigastralgia and hematemesis, she developed septic shock. Gastroendoscopy revealed markedly thickened folds and diffusely damaged mucosa with blood oozing. Computed tomography revealed thickened walls of the antrum and the pylorus. Despite emergency treatments, she died. Bacterial culture of the gastric fluid yielded Enterobacter cloacae and enterococci growth. Collectively, she was diagnosed with phlegmonous gastritis. Retrospective examination of serial bone marrow biopsy specimens demonstrated progressive bone marrow fibrosis, which may have caused prolonged myelosuppression. Thus, evaluation of bone marrow fibrosis by bone marrow biopsy after each treatment cycle might serve as a predictor of persistent myelosuppression induced by chemotherapy.

Acute promyelocytic leukemia with increased bone marrow reticulin fibrosis: Description of three cases and review of the literature

Pathologic increase in bone marrow reticulin fibrosis can be present in many malignant hematopoietic diseases. In acute leukemia, one-third of patients have some degree of marrow reticulin fibrosis at presentation, which is thought to be related to cytokine release from blasts. Marrow fibrosis is particularly common in acute megakaryoblastic leukemia, while this change is rarely seen in acute promyelocytic leukemia. Six case reports of acute promyelocytic leukemia with marrow reticulin fibrosis have been described so far in the literature. Herein, we present three cases of classical acute promyelocytic leukemia with increased marrow reticulin fibrosis encountered in our institution, summarizing their clinicopathologic features, treatment, and outcome to date. Awareness of the features of acute promyelocytic leukemia with marrow reticulin fibrosis is important as it may guide treatment options.

Unusual massive bone marrow fibrosis in acute promyelocytic leukemia following arsenic trioxide therapy

Bone marrow fibrosis has been associated with different types of non-neoplastic conditions like granulomatous and autoimmune diseases and a variety of neoplastic disorders such as acute megakaryoblastic leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma and myeloproliferative neoplsms. Therapy induced fibrosis is a rare phenomenon. Here we report a case of an incidentally diagnosed acute promyelocytic leukemia (APL) with t(11;17) which was treated with arsenic trioxide (ATO) for 45 days. However, the patient did not go into remission and developed massive fibrosis of bone marrow. Literature search does not reveal such documented marrow fibrosis following therapy with ATO in a case of APL.

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During pre-op evaluation for hysterectomy in a 44 year old, a high TLC was noted.

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APL with 45X,−X, t(11;17)(q23;q21) was diagnosed on bone marrow examination.

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Treated with ATO, day+45 bone marrow biopsy revealed diffuse fibrosis.

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Case is reported for this unusual feature of ATO-induced bone marrow fibrosis.

Acute Promyelocytic Leukemia Presenting with Severe Marrow Fibrosis

We report a case of acute promyelocytic leukemia (APL) presenting with severely fibrotic marrow. There are four other reports of similar cases in the literature. Our patient was treated with All-Transretinoic Acid- (ATRA-) containing induction chemotherapy, followed by consolidation and maintenance therapy. He achieved a complete morphologic remission with adequate count recovery in a timely fashion, and later a molecular remission was documented. The patient remains in molecular remission and demonstrates normal blood counts now more than 4 years after induction. Since the morphological appearance may not be typical and the bone marrow may not yield an aspirate for cytogenetic analysis, awareness of such entity is important to make a correct diagnosis of this potentially curable disease.

Phosphoinositide-specific phospholipase C (PI-PLC) β1 and nuclear lipid-dependent signaling

Over the last years, evidence has suggested that phosphoinositides, which are involved in the regulation of a large variety of cellular processes both in the cytoplasm and in the plasma membrane, are present also within the nucleus. A number of advances has resulted in the discovery that phosphoinositide-specific phospholipase C signalling in the nucleus is involved in cell growth and differentiation. Remarkably, the nuclear inositide metabolism is regulated independently from that present elsewhere in the cell. Even though nuclear inositol lipids hydrolysis generates second messengers such as diacylglycerol and inositol 1,4,5-trisphosphate, it is becoming increasingly clear that in the nucleus polyphosphoinositides may act by themselves to influence pre-mRNA splicing and chromatin structure. Among phosphoinositide-specific phospholipase C, the beta(1) isoform appears to be one of the key players of the nuclear lipid signaling. This review aims at highlighting the most significant and up-dated findings about phosphoinositide-specific phospholipase C beta(1) in the nucleus.

Deregulated TGF-beta signaling in leukemogenesis

Cellular homeostasis is tightly controlled by the various pathways that regulate cell proliferation and cell death. Breaking this balance is often associated with cancer development. The transforming growth factor-beta (TGF-beta) pathway plays an important role in cellular homeostasis by regulating cell growth inhibition, cellular senescence, differentiation and apoptosis. Deregulated TGF-beta signaling is known to be involved in a variety of human cancers, including those of the colon, pancreas, breast and prostate. While TGF-beta is a potent negative regulator of hematopoiesis, the role of aberrant TGF-beta signaling in leukemogenesis remains largely unknown. Recently, evidence demonstrating deregulated TGF-beta signaling in leukemogenesis, particularly in acute promyelocytic leukemia (APL), has started to emerge. In this review, we summarize the current progress towards the understanding of the molecular mechanisms by which aberrant TGF-beta signaling may participate in leukemogenesis.

bcr/abl-negative, classic myeloproliferative disorders: diagnosis and treatment

Essential thrombocythemia, polycythemia vera, and myelofibrosis with myeloid metaplasia constitute the "classic" bcr/abl-negative myeloproliferative disorders (MPDs). Each of these MPDs represents a stem cell-derived clonal myeloproliferation with the respective features of thrombocytosis, erythrocytosis, and bone marrow fibrosis. Unlike with cases of chronic myeloid leukemia, in which the bcr/abl mutation is invariably detected, current diagnosis of essential thrombocythemia, polycythemia vera, and myelofibrosis with myeloid metaplasia is based on a consensus-driven set of clinical and laboratory criteria that have undergone substantial modification in recent times. The recent discovery of a recurrent activating Janus tyrosine kinase (JAK2) mutation (JAK2VG17F) in all 3 classic MPDs offers another opportunity for refining current diagnoses and disease classifications. In this article, we outline contemporary diagnostic algorithms for each of these disorders and provide an evidence-based approach to management.

A variant form of acute promyelocytic leukemia with marked myelofibrosis

We describe a variant form, French-American-British (FAB) M3v, of acute promyelocytic leukemia (APL; FAB M3) with atypical morphocytochemical features, immature antigens (CD34 and HLA-DR) and marked myelofibrosis (MF). Usual APL cells do not express CD34 or HLA-DR antigens. MF may be more frequently observed in patients with M3v expressing CD34 and HLA-DR antigens than in patients with M3 lacking these antigens. Despite marked MF, recovery from the hypoplastic phase in the case we described was not delayed after remission induction chemotherapy consisting of enocitabine, 200 mg/mi2 intravenously; 6-mercaptopurine, 70 mg/m2 orally for 10 days; daunorubicin 40 mg/m2 intravenously for 4 days; and all-trans retinoic acid 45 mg/M2 orally between days 20 and 33. The promyelocytic leukemia-retinoic-acid receptor (PML-RAR) alpha fusion transcript, according to reverse transcriptase-polymerase chain reaction (RT-PCR), became negative in the bone marrow after the first course of consolidation chemotherapy. Autologous peripheral blood stem cell transplantation (autoPBSCT) was carried out after 3 courses of consolidation chemotherapy. There were no specific complications based on MF throughout the clinical course, including engraftment in autoPBSCT. The patient has been without MF and in molecular remission, defined as disappearance of the PML-RAR alpha fusion transcript according to RT-PCR, for 21 months. Longer follow-up will clarify the effects of autoPBSCT on prognosis in APL with MF.