Open Journal of Bloo d Di seases, 2011, 1, 1-2
doi:10.4236/ojbd.2011.11001 Published Online September 2011 (
Copyright © 2011 SciRes. OJBD
Diagnosis of Chronic Myeloid Leukemia Early in
Fabio Stagno*, Paolo Vigneri*, Massimo Poidomani, Stefania Stella, Alessandra Cupri,
Michele Massimino, Livia Manzella, Francesco Di Raimondo
Department of Clinical and Molecular Bio-Medicine, Sections of Hematology, Oncology and Clinical Pathology, University of
Catania, Catania, Italy.
Received July 28th, 2011; revised August 28th, 2011; accepted September 6th, 2011.
Imatinib therapy has revolutionized the clinical course of Chronic Myeloid Leukemia. The unexpected prolonged sur-
vival raised several issues on the quality of life and on the possibility to parent childs.
Keywords: Chronic Myeloid Leukemia, Pregnancy, Therapy, BCR-ABL
1. Introduction
The introduc tion of the tyrosine kinase inhibitor Imatinib
Mesylate (IM) for the treatment of Chronic Myeloid
Leukemia (CML) in chronic phase (CP) resulted in high
rates of hematologic, cytogenetic and molecular responses
[1]. Furthermore, clinical long term follow up has shown
an estimated 8-year overall survival of 85% for patients
receiving IM on an intention to treat basis [2]. These
spectacular results led CML patients not only to a pro-
longed survival but also to drive relatively normal lives.
In this view, several issues on the quality of life and,
among them, on fertility and pregn ancy have b een raised .
Here we report the case of a female patient who was in-
cidentally diagnosed with CML while early in pregnancy
and who wanted to get gestation to term.
2. Case Report
A 41 year-old female was referred to our Institution be-
cause of severe leukocytosis. She was at the 10th week of
gestation and at physical examination presented only a
mild splenomegaly (1 cm below costal margin) without
any lymph nodes enlargement. Laboratory exams re-
vealed a white blood cell (WBC) cou nt of 146.3 × 109/L,
a platelet cell count of 820.0 × 109/L, a hemoglobin con-
centration of 10.1 g/dL and lactic acid dehydrogenase of
1440 UI/L. The differential WBC showed the presence of
immature myeloid circulating cells (metamyelocytes
11%, myelocytes 13%, promyelocites 3% and blasts 2%),
while bone marrow cytogenetic showed the presence of
the Philadelphia (Ph)-positive chromosome in all the ex-
amined methaphases with no further abnormalities. The
patient was then diagnosed as having CP-CML, interme-
diate Sokal risk with a e13a2 BCR-ABL-transcript and a
BCR-ABL/ABL % ratio of 107.62 on the International
Standardized Scale (IS). Since the patient wanted to carry
pregnancy to term, she started cytoreduction, with five
weekly leukapheresis, and thrombosis prophylaxis with
low dose low molecular weight heparin (Clivarin 1750 U)
every 12 hours. From the 23 rd week of gestation she begu n
α-interferon-treatment (α-IFN; 5MUI daily), obtaining
soon a complete hemato logical remission (CHR). α-IFN-
therapy was interrupted at the 37th week of gestation
since a cesarean delivery was scheduled at the 38th week,
when the patient gave birth to a healthy baby. After fif-
teen days from delivery and while still in CHR, she
started conventional IM-therapy (400 mg daily). BCR-
ABL/ABL transcript levels were 46.52IS at that time and
decreased to 10.26IS at the third month of therapy. She is
presently alive and well on standard IM treatment.
3. Conclusions
The radical improvements in the long-term survival of
CML patients now pose novel medical challenges.
Treating physicians will have to manage IM long-term
side effects [3] as well as simultaneous chronic illnesses
in an aging CML population. Moreover, the higher rates
of molecular remission coupled with a relatively normal
quality of life raised in some CML patients the issue on
the ability to parent children. On this address a recent
cumulative experience has been published on CML pa-
*The indicated authors e
contributed to this wor
Diagnosis of Chronic Myeloid Leukemia Early in Pregnancy
tients conceiving while taking IM [4]. Nevertheless the
CML management during pregnancy remains still a
clinical challenge and no systematic clinical studies are
described. Here we report a pregnant woman whose
CP-CML disease was incidentally diagnosed while early
in gestation and who wanted to carry her pregnancy to
term. A similar clinical case has been reported by Cole S.
and collegues [5] whereas Bjorkholm M. et al. described
a CML patient presenting late in pregnancy [6]. However
our patient had an intermediate Sokal risk, a high
BCR-ABL/ABL transcript at diagnosis (both representa-
tive of aggressive leukemic burden) and an increasing
WBC-count: these two relevant clinical events prompted
us to consider a proper therapeutical intervention.
Since the use of both hydroxyurea and IM is not rec-
ommended during gestation, we started cytoreduction
with leukapheresis and introduced α-IFN therapy, which
reduced BCR-ABL/ABL transcript levels from 107.62IS to
46.52IS Therefore, on th e basis o f our clinical experience,
we believe that α-IFN-treatment might be a useful tool in
the management of early pregnancy during CML. How-
ever, when a CML female patient wants to conceive, the
best choice could be to start IM-therapy, to achieve a
major molecular response, or better a complete molecular
response, and then to stop treatment attempting to con-
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