Question

A 48 year old woman with Hypertension, Atrial Fibrillation, Obesity with Dyslipidimia on ARBS, Diuretics, Warfarin, and Atorvastatin.

Initially diagnosed with Myleopthisic syndrome Chronic Myelogenous Leukemia, started on Imatinib. She is presently having Pneumonia, treated with Azithromycin and Piperacilin Tazobactam. Pleural effusion grows hyphal elements showing a fungal pneumonia hence started on Itraconazole.

Later progressed into Acute Myelogenous Leukemia (AML), after being successfully treated for breast cancer four years ago, receiving six cycles of Doxorubicin and Cyclophosphamide. Then with an Estrogen Porgesterone (ER) positive, thus, started with Tamoxifen for five years. She had symptoms of hot flushes, vaginal dryness and breakthrough bleeding. Ultrasound showed a thickened endometrium.

Her total dose of doxorubicin is 360 mg/m2, and the oncologist will begin with induction chemotherapy for her AML with the goal of achieving remission. After high dose induction, she develops arrhythmia and cardiotoxicity, with hepatic induced bilirubinemia. Hence, given Dexrazoxane. Chemo meds shifted to Daunorubicin with Vincristine, plus oral Dexamethasone, after one cycle develops Peripheral neuropathy, ileus and constipation.

Abnormal uterine bleeding ensues, with a palpable abdominopelvic mass where the biopsy revealed Epithelial Adenocarcinoma of the Ovaries, thus, a new three cycle of

Cisplatin and Paclitaxel started. After the first cycle, she develops numbness of feet, persistent nausea and vomiting, severe neutropenia with ANC of 300, and renal dysfunction of 2.0 mg/dl. To address the concern, she was hydrated with IV Dextrose, and Mesna was started and IV Chemo drug shifted to Ifosfamide and Etoposide.

Further deterioration with renal dysfunction, chemo drug again shifted to Carboplatin and Paclitaxel, however, had anaphylactoid reactions manifested as dyspnea, bronchospasm, angioedema, hypotension and urticarial skin reactions. The oncologist, gave pretreatment with Dexamethasone, Diphenydramine and Ranitidine.

Later on, an oral antimetabolite Methotrexate was started, along with NSAIDS to address her pain on movement. Her neutropenia got worst and started on high dose Penicillin drugs. But on review noted some contraindications and further myelosupression, thus, shifting penicillin to Meropenem.

Her AML relapse after a brief remission on high dose Cytarabine and Daunorubicin, what is your alternative drug class in this case?

Later on a compatible stem cell bone marrow transplant was done, she was started on immunosuppressive drugs such as cyslosperine, mycophenolate mofetil, prednisone. Then after two weeks, there is an acute rejection. What will be the treatment for the acute stem cell bone marrow rejection?

Your diagnosis is

Cancer of Unknown Primary with Hematologic Malignancy

Acute Myelogenous Leukemia, Chronic Myleogenous Leukemia with adverse drug reactions

Abdominoplevic mass secondary to Stage 3 Epithelial Adenocarcinoma

Breast Cancer stage 2, ER Positive, S/P Chemotreatment, cytoreduction Hypertension, Atrial Fibrillation, Obesity with Dyslipidimia

What will be your Treatment of choice given the above findings. ?

Answer 1

1,she was at the blast phase of chronic myelogenic leukemia. she was suggested for under go stem cell bone marrow transplantation. in chronic stage, most patinet never responds to medication. thatswhy, she developed AML relapse after brief remission on high induction of daunorubicin and cytarabine.

her HML was relapse after a brief remission on high dose cytarabine and daunorubicin, she may be  treated with alternative therapy with vincrinstine, predinosine, and doxarubicin along with imitinib. but she cannot be treated with this because of adverse reaction and previous usuage. next option is methotrexate can be used. or newer  drugs such as dasatinib,nilotinib

2. she had  rejection of graft versus host disease after 2 weeks of bone transplantation under immusuppresssive therapy such as cyclosporine,mycophenolate moftil and predinosine . graft versus host disease can be treated with intravenous glucocorticoids.

if she develops again graft versus host disease, there is no point giving immunosuppressive agents

glucocorticoids are antithymocyte globulin, denileukin diftitox, infliximab

most patients in the blast cannot be cured because of adverse reaction to medication, secondary stages and third stage of breast cancer and epithelial adenocarcinoma respectively