SUMMARY

Daniil Valerievich VELICHKO, born January 15, 2001

Address: ul. Krupskoi 19-29, Yalta, Crimea, Ukraine

Clinical diagnosis: 1. Retroperitoneal neuroblastoma stage 3 (2002). 2. Secondary acute myeloid leukemia (M₁ – FAB), early-stage differentiation with monosomy 7 (June 12, 2007).

Consequences of the removal of neuroblastoma (extra-, intraventricular, and extradural localization) at the level of Th12-L2 with slight paresis of legs and minor functional pelvic disorder.

Chronic viral hepatitis C of minimum activity.

Blood group B(III) Rh(pos)

Diagnostic summary:

The child received treatment for retroperitoneal neuroblastoma since 2002. The chemotherapy was completed on March 3, 2004. Remission, regular monitoring. Changes in the CBC were revealed during a check-up on June 12, 2007. According to the results of the bone marrow examination and immunophenotypic study of blast cells, the child was diagnosed with acute biphenotypic leukemia. Consulted by Dr. S.B. Donskaya, Chief Child Hematologist of Ukraine. Decision: the only radical treatment method possible in this case is unrelated marrow transplantation somewhere outside Ukraine.

The child was admitted to the Center for Child Oncology and Hematology on July 5, 2007, in grave but stable condition. No fever. Hemorrhagic rash on the trunk and limbs. Slight mucositis. Lymph nodes of all groups enlarged up to 1.5 cm. Enteral uptake. Stable hemodynamics. Lungs without alterations. Liver +3.0 cm, spleen +2.0 cm.

CBC on admission: Hb 103 g/L, RBC 3.31 x 10¹²/L, PLT 56 x 10³, WBC 22.4 x 10³/L, blasts 10%, juven 2%, bands 5%, segm 18%, lym 25%, mon 40%.

Blood biochemistry test on admission: within normal ranges for the boy’s age.

Bone marrow examination No. 930/07 of July 6, 2007: blast cells 32.5%, M₁ – FAB, myelokaryocytes 250, megakaryocytes 0.012. Bone marrow punctate rich in cellular elements. Low content of megakaryocytes; some are functioning. Low content of platelets.

Cytochemical study of blast cells: peroxidase reaction positive for 7% blasts, lipid reaction positive for 12% blasts, glycogen (in diffuse and fine-granular forms) reaction positive for 14% blasts.

Immunophenotypic assay of blast cells: early myeloid leukemia with CD 22+ and CD 10+ coexpression.

Cytogenetic study of blast cells: 45 XY, -7 (minus 7^th chromosome)

Molecular biology of blast cells: no prognostically significant rearrangements found.

CSF test on admission: no pathological signs found.

Heart ultrasound on admission: LV cavity somewhat dilated. Valve functioning normal. Total contractility of LV myocardium satisfactory. LV 39 mm, RV 12 mm, heart rate 83 bpm, SF 35%, EF 65%, CO 3.5 L/min.

Abdominal ultrasound on admission: Liver (+3 cm) and spleen (+3.5 cm) enlarged. Diffuse alterations of liver and kidney. Multiple lymph nodes near the hepatic porta and in the projection of the pancreas up to 14 mm. Ultrasound evidence for gallbladder hypotonia.

Chest X-ray No. 4040 of July 9, 2007: No pathological alterations.

Blood test of July 5, 2007: HBsAg negative, a/HCV positive.

Blood test for HCV RNA of July 9, 2007: observed amount 2.55x10⁵ IU/mL.

Blood test of July 18, 2007: CMV IgM negative, CMV IgG positive, HSV IgM negative, EBV IgM positive.

Blood test of July 9, 2007: Ag Aspergillus negative, At Aspergillus IgM negative, At Aspergillus IgA/G positive.

Treatment according to AML-MM-2003 protocol since July 10, 2007. Total doses of cytostatics:

From July 10 to 16, 2007, ADE.

Early toxicity 3-4 (WHO). Complete infusion, supplementary, transfusion, antibacterial, antifungal, antiviral therapy. Complications: cytopenic syndrome, toxic keratitis. Consulted by an ophthalmologist; therapy as recommended.

July 26 to 27, 2007: the second part of HAM induction (in view of toxic keratitis in the anamnesis, Cytosar produced by another company was used).

For further treatment, in view of deep cytopenic syndrome, the child was transferred to the Department of Marrow Transplantation by agreement with Yu.S. Strongin, Head of Department.

Treatment at the Department of Marrow Transplantation from July 27 to August 23, 2007.

Cytopenia July 20 to August 19, 2007 (31 days).

Treatment: decontamination, Augmentin IV, Fungizone IV, Heptral IV, Ursosan per os, Neuromedin per os, Immunoglobulin IV, Etamsylate IV, replacement therapy with blood components according to indications (last transfusion of leukocyte- and platelet-depleted RBCs B(III)Rh(pos) on August 17, 2007; last platelet transfusion on August 20, 2007).

Discharged from hospital in compensated condition.

·        CBC of August 23, 2007: Hb 84 g/L, RBC 3.3x10⁹/mL, PLT 55x10³/L, WBC 1x10³/L.

·        Blood  biochemistry test of August 23, 2007: CRP < 0.5 mg/mL, ALT 122 MU/L, AST 53 MU/L, GGT 38.8 MU/L

Received treatment on day-patient basis on August 24 to 27, 2007

Next admission to the Department of Marrow Transplantation on August 27, 2007

Presently the child is at the Department of Marrow Transplantation in stable condition. No fever. Child is active. Skin and mucous membranes are pale pink, with moderate hemorrhagic syndrome. Pulm without pathological alterations. Stable hemodynamics. Liver +1.5–2 cm; spleen +0.5 cm.

·        Bone marrow test No. 1172/07 of August 28, 2007: blasts 30%, myelokaryocytes 93x10³/L, megakaryocytes 0.006x10³/L, erythrokaryocytes 19.5%, neutrophils 20%, eosinophils 0.5%, lymphocytes 24.25%, monocytes 5.5%, plasma cells 0.25%. Bone marrow punctate rich in cellular elements. Low content of megakaryocytes; functioning ones not found. Low content of platelets.

·        MTT test of August 31, 2007: under processing.

·        CBC of August 30, 2007: Hb 91 g/L, RBC 3.34x10⁹/mL, PLT 24x10³/L, WBC 1.1x10³/L, eos 2%, segm 12%, lym 40%, mon 46%.

The child’s condition and treatment have been discussed with Prof. O.V. Aleinikova, Director of Center. Considering the diagnosis (AML with early-stage differentiation and monosomy 7) and the absence of remission after the induction therapy (ADE-HAM cycle), the tactics of further therapy will be determined according to the results of the MTT test.

August 31, 2007

Physycian                                                                                           Yu.E. Mareiko

Head of the Department of Marrow Transplantation                            Yu.S. Strongin

Deputy Director of Hospital                                                                O.N. Romanova