A 57-year-old man comes to the physician because of fatigue, abdominal discomfort, and poor appetite. He denies changes in his bowel function or urinary habits. He has lost approximately 10 lbs (4.5 kg) in the past month. Family history is not significant.
His blood pressure is 133/70 mm Hg and pulse is 76/min. Examination shows intact skin on the extremities. Breath sounds are normal. His liver is palpable 3 cm below the costal margin. There is moderate splenomegaly. There is no lymphadenopathy.
Laboratory results are as follows:

The peripheral smear shows predominantly myelocytes and polymorphonuclear neutrophils. A bone marrow biopsy shows a hypercellular marrow with 7% blasts.
This patient is most likely to benefit from which of the following?

Question

A 57-year-old man comes to the physician because of fatigue, abdominal discomfort, and poor appetite.  He denies changes in his bowel function or urinary habits.  He has lost approximately 10 lbs (4.5 kg) in the past month.  Family history is not significant.
His blood pressure is 133/70 mm Hg and pulse is 76/min.  Examination shows intact skin on the extremities.  Breath sounds are normal.  His liver is palpable 3 cm below the costal margin.  There is moderate splenomegaly.  There is no lymphadenopathy.
Laboratory results are as follows:

The peripheral smear shows predominantly myelocytes and polymorphonuclear neutrophils.  A bone marrow biopsy shows a hypercellular marrow with 7% blasts.
This patient is most likely to benefit from which of the following?

Quizplus · Accepted Answer

11ec193a_9834_13e9_853d_636728a49ca2_MD0002_00 This patient's presentation is consistent with chronic myeloid leukemia (CML), which is a clonal hematologic malignancy associated with a specific translocation between chromosomes 9 and 22 (Philadelphia chromosome). It can appear in all age groups with median onset at age 67, and it accounts for approximately 15% of adult leukemias. Patients usually present with fatigue, weight loss, bone aches, and abdominal discomfort from splenomegaly. The peripheral blood typically reveals anemia, thrombocytosis, and leukocytosis. The bone marrow is almost always hypercellular. Chronic myeloid leukemia can present in different phases (see table). Diagnosis is confirmed by identifying the Philadelphia chromosome, BCR-ABL1 fusion gene, or the BCR-ABL1 fusion mRNA. Tyrosine kinase inhibitors (e.g., imatinib) are used as first line targeted therapy. Depending on the response to medication and existing comorbidities, some patients may be candidates for a bone marrow transplant. (Choice A) All-trans retinoic acid plus anthracycline-based chemotherapy is used in acute promyelocytic leukemia. In acute myeloid leukemias, the bone marrow typically shows > 20% blasts. However, the blast count in APML is usually low, but on the peripheral smear and bone marrow biopsy one would expect to see hypergranular promyelocytes. (Choice B) Fludarabine-based chemotherapy is indicated for patients with chronic lymphocytic leukemia but not for CML. (Choice C) Lenalidomide is an immunomodulator and antiangiogenic agent. It is currently indicated for the treatment of multiple myeloma and MDS with 5q- syndrome. It is not indicated for the treatment of CML. (Choice D) Anti-CD20 antibodies (i.e., rituximab) are not indicated in the treatment of CML. They are indicated in CD20 positive B cell lymphomas, rheumatoid arthritis, and microscopic polyangiitis. Educational objective: Chronic myeloid leukemia (CML) may present in phases (chronic stable, accelerated, or blast phase) with nonspecific systemic symptoms, leukocytosis, anemia, and thrombocytosis. Diagnosis is confirmed by identifying the Philadelphia chromosome, BCR-ABL1 fusion gene, or BCR-ABL1 fusion mRNA. Tyrosine kinase inhibitors (e.g., imatinib) are first line agents for the treatment of CML. __________ References: How I treat chronic myeloid leukemia in the imatinib era. (http://www.ncbi.nlm.nih.gov/pubmed/17626839) Current and emerging treatment options in chronic myeloid leukemia. (http://www.ncbi.nlm.nih.gov/pubmed/17431887)

A 57-Year-Old Man Comes to the Physician Because of Fatigue