Kyiv Center of Bone Marrow Transplantation
Extract from a patient's history No 286
Reichel Anna Bogdanovna, date of birth - 07.11.01 (6 years old).
Place of residence: 5 Revutskogo Str., ap. 311, Kyiv
Date of admission: 26.08.08
Blood group: A(II) Ph positive, HIV antibodies – not detected (21.08.08), RW – negative (21.08.08), HBsAg – negative (21.08.08), anti-HCV – negative (21.08.08), CMV IgG - positive (21.08.08), HSV-1 IgG – negative (21.08.08), HSV-2 IgG – negative (21.08.08). PCR analysis of HBV and HCV is being performed.
Diagnosis: acute lymphoblastic leucosis, FAB L-1. The second acute period. Superearly isolated CNS-relapse. S2 therapeutic group.
The disease has manifested itself in February 2007 through lymphadenopathy appearance. Complete blood count has revealed hyperleukocytosis and blastema. The disease has been diagnosed in hematological department of “OHMATDYT” Ukrainian Pediatric Specialized Hospital on the basis of myelogram data of 09.02.07. Conclusion: acute lymphoblastic leucosis, FAB variant L-1, common-ALL, CNS (-). Cytogenetic analysis of the patient’s bone marrow, conducted on 27.02.08, has revealed the following 2 clones: 1-2 metaphases contained 49 chromosomes (determination of additional chromosomes was impossible), and 2-5 metaphases were normal.
The patient was treated according to ALL-BFM-2000 program from 10.02.07 till 28.09.07. The treatment complications included febrile neutropenia, enteropathy, and fungal mucositis. The total dose of anthracyclines administered to the patient during therapy of the first ALL acute period was 182 mg (240 mg/m2).
General brain neurological symptoms emerged and started accumulating in March 2008. On 12.03.08, isolated CNS-relapse of ALL was diagnosed in “OHMATDYT” hematological department. Since 13.03.08, the patient was treated according to ALL-REZ-BFM-02 protocol. The treatment course was complicated with febrile neutropenia and necrosis of left vulvar lip section. Total anthracycline dose administered during therapy of the second acute period was 105 mg/m2. The results of bone marrow molecular-genetic examination, dated 02.04.08, have revealed no chimeric transcripts BCR-ABL and MLL/AF4.
According to the criteria of the selected therapeutic program (ALL-REZ-BFM-02), the patient was recommended high dose chemotherapy (HDCT) with maintaining autotransplantation of peripheral blood stem cells and consultation in Kyiv Center of Bone Marrow Transplantation (KCBMT).
On 18.08.08, following the 7-th block of maintenance chemotherapy and granulocytic colony-stimulating factor stimulation, peripheral blood stem cell collection was performed in KCBMT.
Pre-HDCT examination has revealed 4-fold increase of transaminase level compared to normal values with following negative dynamics during biochemical blood count dated 27.08.08, which rendered HDCT conduction inexpedient in the existing clinical situation.
The patient was discharged from the department on 28.08.08 in satisfactory condition. The patient had no contacts with patients suffering from infectious diseases.
Results of the analyses conducted before the discharge:
Complete blood count, 28.08.08: leucocytes - 2.0*109 /l, neutrophils – 42%, hemoglobin – 84 g/l, erythrocytes – 2.65*1012 /l, platelets – 266*109 /l, erythrocyte sedimentation rate – 24 mm/hour.
Biochemical blood count, 27.08.08: total protein – 41.9 g/l, bilirubin – 7.2 µmol/l, glucose – 4.7 mmol/l, urea – 2.3 mmol/l, alanine aminotransferase – 121 U/l (N up to 32), aspartate aminotransferase – 55 U/l (N up to 31), creatinine – 37.9 µmol/l, albumins – 33.5 g/l.
Biochemical blood count, 28.08.08: total protein – 65.5 g/l, bilirubin – 7.4 µmol/l, alanine aminotransferase – 143 U/l, aspartate aminotransferase – 57 U/l, alkaline phosphatase – 307 U/l.
Urinalysis, 27.08.08: sugar – not found, protein – not found, pH – 6.0, leucocytes – 0-1 in visual field, squamous epithelium – single cells in visual field.
Recommendations:
- observation of hematologist and infectiologist (?) at the patient’s place of residence;
- continuance of standard chemotherapy and radiotherapy of central nervous system.
Contact phone numbers: 452-34-91, 451-22-20
[Seal]
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Physician
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[Signature]
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Koren’kova I.S.
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The department head
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[Signature]
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Karamanesht E.E.
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Head doctor
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[Signature]
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Homenko V.I.
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Ministry of Health of Ukraine
“OHMATDYT” Ukrainian Pediatric Specialized Hospital
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28/1 Chornovola Str, 01135, Kyiv
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Tel.: 236-6942
Fax: 236-6165
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On No ______
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EXTRACT
from the case history of Reichel Anna, date of birth - 07.11.2001.
The patient was admitted to oncohematology department on 09.02.2007, where the following was diagnoses on the basis of bone marrow and liquor examination: acute lymphoblastic leucosis, CNS-negative, standard risk group, 1-st acute period, common.
Chemotherapy was carried out from 09.02 till 02.11.2007 according to Protocol ALL BFM 2002 (m). In March 2008, during maintenance therapy, the patient started complaining about headaches. Diagnostic punctures – bone-marrow and spinal – were carried out. Liquor cytosis of 2800/µl due to blast cells was detected (common immunological variant) with bone marrow remission preservation. The analyses performed allowed diagnosing the following: acute lymphoblastic leucosis, superearly isolated CNS-relapse, 2-nd acute period, S2 therapeutic group.
From 12.03 till 15.12.2008, chemotherapy was carried out according to Protocol ALL REZ BFM 2002, including radiotherapy in the dose of 18 gray.
The child’s parents rejected bone marrow autotransplantation.
On 17.02.2008 spinal puncture was realized: liquor cytosis comprised 2000/µl and was represented by cells of common immunophenotype. Bone marrow puncture was performed on 18.02, and revealed 2% of blasts.
Diagnosis: acute lymphoblastic leucosis, III acute period, FAB-L1, common, II superearly isolated CNS-relapse.
The patient is being treated with dexazone, lanvis, and intrathecal cytostatics in the department.
In order to determine the following therapeutic tactics, a consultation of doctors, including the head of Center of Pediatric Hematology and Bone Marrow Transplantation Donskaya S.B., the head of the department of bone marrow transplantation of Center of Pediatric Hematology and Bone Marrow Transplantation Pyzhak O.A., and the head of oncohematology department Kubalya N.A. was carried out on 20.02.09.
Conclusion: the patient is going through the 2-nd superearly isolated CNS-relapse. Bone marrow autotransplantation is contraindicated at the moment. Following the remission achievement, allogenic bone marrow transplantation from an alternative donor may be carried out as experimental therapy.
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Acting head of Center of Pediatric Hematology and Bone Marrow Transplantation
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[Signature]
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Pyzhak O.A.
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Head of oncohematology department
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[Signature]
[Seal]:
Ministry of Health of Ukraine
Kyiv
“Ohmatdyt” National Pediatric Specialized Hospital
Identification code 01994089
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Kubalya N.A.
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MINISTRY OF HEALTH OF UKRAINE
UKRAINIAN SPECIALIZED CHILDREN HOSPITAL
“OHMATDIT”
01131, the city of Kiev tel. 236-6942
Chornovola st 28/1 fax 236-6165
Discharge summary from the case report
of Raihel Anna, born on November 7, 2001
The patient was admitted to the Department of Oncohematology on February 9, 2007 for the first time. There she was diagnosed with acute lymphoblastic leukaemia, central nervous system negative, the group of the standard risk, 1 acute period, common. The diagnosis was based on the results of the bone marrow and liquor examination.
The patient received chemotherapy from February 9 till November 2, 2007 according to ALL-BFM-2002 (m) protocol. In March 2008 during the maintenance therapy the patient started complaining on headaches. Exploratory punctures were made - marrow and spinal punctures. Keeping the status of marrow remission the patient has liquor cytosis of 2800/μl due to blast cells, immunological variant is common. According to the examinations performed the patient was diagnosed with acute lymphoblastic leukaemia, ultraearly isolated central nervous system recurrence, 2 acute period, therapy group is S2.
The patient received chemotherapy from March 12 till December 15, 2008 according to ALL REZ BFM 2002 protocol including radiation therapy with the dose of 18 Grey.
The child’s parents refused autologous marrow transplantation.
On February 17, 2008 the spinal puncture was done: liquor cytosis was 2000/μl, it was represented with the cells of common immunophenotype.
On February 18, 2008 the marrow puncture was done – blasts are 2%.
Diagnosis: acute lymphoblastic leukaemia, III acute period. FAB – L1, common. II ultraearly isolated central nervous system recurrence.
The patient received therapy at the Department including dexason, lanvis, intrathecal introduction of the cytostatics.
The consultation with doctors was carried out on February 20, 2009 to define the tactics of the further therapy. Head of the Center of Children Oncohematology and Bone Marrow Transplantation S.B. Donskaya, Head of the Department of Marrow Transplantation of the Center of Children Oncohematology and Bone Marrow Transplantation O.A.Ryzhak and Head of the Department of Oncohematology N.A. Kubalya took part in the consultation.
Conclusion: The patient has II ultraearly isolated central nervous system recurrence. At the present moment autologous marrow transplantation is not recommended. When the remission is achieved the marrow allografting could be performed from the alternative donor as an experimental therapy.
Acting Head of the Center of Children Oncohematology and Marrow Bone Marrow Transplantation,
Ryzhak O.A.
Head of the Department of Oncohematology Kubalya N.A.
[Seal: MINISTRY OF HEALTH OF UKRAINE
THE CITY OF KIEV
NATIONAL SPECIALIZED CHILDREN HOSPITAL
“OHMATDIT” ID code 01994089}
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