Challenging Cases

Micheal C. Wiemann, MD President, Clinical

St. John Providence Physician Network Detroit, Michigan

T-Cell Lymphoblastic Leukemia/Lymphoma • 30 yo with PMH Wilms tumor, s/p chemo and

nephrectomy, presents with SOB/cough and a 4cm left axillary adenopathy.

• CXR: Large bilateral pleural effusions and mediastinal adenopathy (positive cytology)

• Lymph node biopsy: T cell Lymphoblastic lymphoma. BM and LP negative.

Case presented by Dr. Luke Akard, Pathology: Dr. David Wilson

H and E Ki-67 CD3

T-Cell Lymphoblastic Leukemia/Lymphoma • Induction therapy: CALGB C10403 AYA Regimen:

2 year EFS 66% and OS 79% – REGIMEN: daunomycin, vincristine, prednisone,

asparaginase, and intrathecal prophylaxis with methotrexate and cytarabine.

– No response • Second Induction: Etoposide and Cytarabine: No

response • She died of refractory disease less than 5 months

after presentation. • Treatment options: Induction, biologic therapy,

lymphoma inspired therapy, emerging therapies ?

Chronic Myelogenous Leukemia • 42 yo presents with 6 mos of night sweats, weight loss, abdominal

distension, with massive splenomegaly. • WBC 475.5K, Hemoglobin 7.4, Platelets 363. Differential: 89%

neutrophils, 1% lymphocytes, 8% monocytes, 2% eosinophils, ANC 422K, ALC 6200, monocytes 38.8K Eosinophils 8500, basophils 100.

• BM biopsy/aspirate: Chronic Phase CML. Cytogenetics: t 9:22, PCR p210 • Sokal Score: 1.19 (INT), Hasford (Euro) score: 923 (INT), EUTOS score:80

(low) • EUTOS probability of no CCgR at 18 months: 21%

Case presentation: Dr. Ruemu Birhiray, Pathology Dr. David Wilson

BM aspirate BM Biopsy Peripheral blood smear

Chronic Myelogenous Leukemia • Initial Treatment

options: Imatinib vs. later generation TKIs

Acute Myelogenous Leukemia • 57 yo with h/o Stage III, locally advanced, triple

negative Breast Cancer, diagnosed 1 yr prior, s/p dose dense chemo with doxorubicin, cyclophosphamide and paclitaxel, achieving a CR.

• Presents with pancytopenia, resulting in a BM biopsy. • Diagnosis: Acute myeloid leukemia with monoblastic

features, therapy-related. • Cytogenetics: 49,XX,+8,+8,+8,t(9;11)(p22;q23)[20] • WHO classification: Acute myeloid leukemia with

t(9;11)(p22;q23); MLLT3-MLL (KMT2A). • HLA typing: Haplo-indentical brother, 2 children, 8/10

MUD

Acute myeloid leukemia with t(9;11)(p22;q23); MLLT3-MLL (KMT2A)

• Treatment options: – Induction – Consolidation – ? Targeted Therapy – Hematopoietic Allogeneic Transplantation

Case presentation: Dr. Ruemu Birhiray, Pathology: Dr. David Wilson