New perspectives on treatment strategies for patient with acute myeloid leukemia and complex karyotype abnormalities after percutaneous coronary intervention: A case report

Abstract

Rationale: Acute myeloid leukemia (AML), in patients with coronary heart disease (CHD) and treated percutaneous coronary intervention (PCI), is rarely seen in clinic. There are few similar cases reported, and there are no evidence-based medicine guidelines for the treatment.

Patient concerns: A 52-year-old man was diagnosed with coronary atherosclerotic heart disease in November 2011, and received a stent placement in the left anterior descending coronary artery 1 year later. One day after the surgery, his laboratory tests showed pancytopenia.

Diagnoses: Based on precise diagnosis of leukemia, namely cell morphology, immunology, cytogenetics, and molecular biological typing, the patient was diagnosed with AML-M2.

Interventions: The patient received idarubicin with cytarabine in 1st cycles, and single cytarabine regimen was used in 2nd and 3rd cycles for the accumulative toxicity of idarubicin in postinduction chemotherapy. Meanwhile, staged-treatment strategy was implemented by using antiplatelet drugs during different chemotherapy phases, and personalized pharmaceutical care on the basis of the recognition of potential adverse effects of chemotherapy regimen.

Outcomes: Until now, the disease-free survival in the patient has been over 6 years, and he is still followed up in clinic.

Lessons: Although leukemia accompanied with coronary heart disease, even after receiving the coronary stenting therapy is rarely seen in clinic, the treatment with antiplatelet drugs for post chemotherapy patients with coronary disease is necessary. Clinical pharmacists are supposed to be more proficient in developing personalized drug treatment strategies, especially maintaining the balance between the effect and the risk in difficult and complex cases.

Figure 1

Initial coronary angiogram showed that left anterior descending coronary artery (LAD) and left circumflex branch (LCX) has mild stenosis. In November 2011, initial coronary angiography examination showed that both the left anterior descending coronary artery (LAD) and left circumflex branch (LCX) had 30% to 40% stenosis in the middle portion.

Figure 2

A year later, the coronary angiography examination showed stenosis degree aggravating than earlier. In November 2012, because of chest pain and the other symptoms significantly worse than before, so the patient underwent coronary angiography examination again, the results showed that the 75% localized stenosis was seen in the middle proption of the LAD, and 60% localized stenosis was seen in the middle proption of the LCX.

Figure 3

The final coronary angiogram showed a successfully implanted stent at the LAD. The pathological changes were quickly resolved by percutaneous transluminal coronary angioplasty and placement of 1 drug-eluting stents in the LAD.

Figure 4

The results of bone marrow examination when the patient had unknown pancytopenia and suspected with hematological diseases. Bone marrow aspiration revealed abundant, immature myeloid cells with coalescent granules, and histochemical staining showed peroxidase staining positive rate approximate 83% and alkaline phosphatase staining rate approximate 2%.

Figure 5

The results of chromosome karyotype analysis and immunophenotype. Conventional cytogenetic analysis was carried out on direct preparations, and immunophenotype was performed on isolated bone marrow mononuclear cells by flow cytometry after collection according to standard procedure. Cytogenetic karyotypes revealed 88∼9,XX,YY,2 × t(8;21)(q22;q22)[20], and immunophenotype suggested myeloid expression with HLA-DR, CD13, CD15, CD19, CD33, CD34, CD38, CD56, CD64, CD117, CD123, MPO.

Figure 6

The results of bone marrow and peripheral examination after chemotherapy. Bone marrow morphology that revealed no clusters or collections of blast cells, and peripheral blood smear could not observe bone marrow blast cell.

Figure 7

The results of cytogenetic karyotypes and minimal residual disease (MRD) during the patient followed up in clinic. Cytogenetic karyotypes and MRD was detected during the patient followed up in clinic, and the sesults showed continuous complete remission after chemotherapy.