Author: Wang Zhe
Unit: The First Hospital of Baoding City, Hebei Province
The patient, a 15-year-old student on loan from outside the province, who was in good health before, had no obvious trigger for drowsiness, fatigue and weakness half a month ago, and was treated at the local hospital, and the results of the blood routine were shown in the following figure:
Imaging suggests splenomegaly; hematologic disorders are clinically considered. A bone marrow imaging test is followed by a rapid AML of chronic myelogenous leukemia. The bone marrow is like the following figure:
Molecular Biology: Positive for characteristic BCR-ABL fusion genes, as shown in the figure below:
Cytogenetics: CML-associated clonal Philadelphia chromosomes are visible, as shown in the figure below:
The diagnosis is clear, and the clinical treatment plan is proposed for the progression of chronic myeloid leukemia to acute myeloid leukemia. The next day, the patient's relatives brought bone marrow and peripheral blood smears to the author's consultation. The bone marrow smear is shown in the figure below:
Bone marrow elephant
Bone marrow hyperplasia is extremely active, of which granules account for 86.5%, reds account for 7.50%, and grains: red = 11.53: 1. Granules: 4.50% of the original granulocytes, 3.0% of basophils; erythroids: the proportion is reduced, a few middle and late young red blood cells can be seen, and some red blood cells vary in size. Lymphocytes account for 5.50%, and the morphology is generally normal. The total count of megakaryocytes is 56, and 50 cells are classified, including naïve macrosmillo: 4/50, granular macrosmuff: 12/50, plate-producing macrosomia: 8/50, bare nuclei: 26/50, and more platelets, which are distributed in clusters.
Hemogram
The total number of white blood cells is abnormally increased, 3.0% of the original granulocytes, some red blood cells vary in size, nucleated red blood cells can be seen, and platelets are distributed in clusters.
After reading the film, the author considered: the patient has not been treated with chemotherapy, and the original granulocytes of the bone marrow and peripheral blood have not yet reached the proportion standard of 20% of the cmL blast phase of chronic myelogenous leukemia, and are now in the chronic stage of the disease, so the diagnosis: CML (CML-CP), it is recommended to improve the relevant hematological tests. Bone marrow image reports are shown in the figure below:
Suggests that the patient's relatives are still in the CML-CP (chronic phase), and oral therapy targeting TKI (tyrosine kinase inhibitor) should be preferred, and continuous intensive therapy regimen for acute myeloid leukemia should be avoided for the time being;
TKI (tyrosine kinase inhibitor) is clinically recognized as the first-line drug for the treatment of chronic myelogenous leukemia, the application of TKI has made the status of allogeneic bone marrow transplantation treatment chronic phase CML down to the second-line choice, the so-called "incurable disease" chronic myelogenous leukemia for a chronic disease that can be controlled by targeted drug therapy, TKI can be said to be the gospel of CML patients, changing the traditional concept of CML treatment, improving the quality of life of patients, and effectively prolonging survival.
The patient's relatives cried with joy and went to the Department of Hematology of Peking Union Medical College Hospital for re-consultation two days later, and cmL-CP (chronic phase) was still diagnosed. At present, the patient is standardized at home with second-generation TKI oral therapy, symptoms are alleviated, spleen is retracted, peripheral blood returns to normal, and he has returned to school and is now being followed up regularly.
The following figure shows the patient's oral second-generation TKI for about 1 month, and the blood routine data of the test:
In hematologic diseases, the diagnosis of CML in chronic myelogenous leukemia is not difficult; the clinical staging of this disease is directly related to the prognosis, survival assessment, and choice of treatment regimen. The proportion of blastocytes in the bone marrow and peripheral blood is an important basis for the clinical staging of CML, and the occurrence of misdiagnosis and mistreatment can be avoided as much as possible by strictly grasping the morphological characteristics and diagnostic criteria of cells, and combining molecular biology, cytogenetics, immunology, etc.
Edited by: Yeah Reviewer: Xiao Ran