|
|
|
|
|
In July 1994, a 31-year-old man was admitted
for investigation of pancytopenia (hemoglobin level, 11 g/L; white blood
cell count, 8,8x109/L; and platelet count, 88x109/L).
Bone marrow examination findings showed AML (French-American-British classification,
M4Eo subtype), and a cytogenetic analysis demonstrated the typical abnormality
found in AML of inversion of chromosome 16.
The patient stated on admission that he was a Jehova’s Witness and would not accept any blood products. The diagnosis of AML was explained to him and he made the decision to be treated without blood products in an attempt to achieve a remission. The therapy selected consisted of daunorubicin hydrochloride, 50 mg/m2, for days 1 through 3 and cytarabine hydrochloride, 100 mg/m2, for days 1 through 7 as a continuous infusion (a 7-3 regimen). This regimen was thought to offer a reasonable chance of remission without prolonged pancytopenia. No blood products were used during the course of the patient’s induction therapy and blood tests were restricted to not more than twice per week. Other than these modifications, the patient was treated according to the standard protocols of the hematology unit. |
|
|
The documented nadirs of his hemoglobin level, white blood cell count,
and platelet count were 23 g/L, 0,4x109/L and 1,0x109/L,
respectively. During the course of his induction therapy, the patient developed
severe hypoxia manifested by air hunger and confusion, both of wich were
relieved with administration of 50% oxygen. He was treated with antibiotics
for an episode of neutropenic sepsis and received tranexamic acid, 1g 4
times per day, to prevent bleeding. On day 14, treatment with erythropoietin
was initiated at a dosage of 4000 U 3 times per week by subcutaneous injection.
this treatment was begun because of obvious severe anemia and a recognition
that his low hemoglobin level represented the most immediate life-threatening
problem. On day 25, the patient’s white blood cell count began to show
signs of recovery and he was discharged on day 31. Findings of a bone marrow
examination performed on day 30 showed him to be in remission. results
of a cytogenetic analysis showed persistence of the inversion of chromosome
16 in 30% of metaphases.
|
| Periferal
blood stem cell
autograft |
Consolidation therapy was the administred, wich consisted of 2 courses
of cytarabine hydrochloride, 100 mg/m2, and daunorubicin
hydrochloride, 50 mg/m2, in a 5-2 regimen. Both courses
were well tolerated withouth any complications. Peripheral blood stem cells
were harvested on his recovery from the second consolidation course: 17,9x104/Kg
colony-forming unit-granulocyte macrophages were obtained. Bone marrow
sampling showed continuing remission, but aberrant chromosome 16 persisted
throughout.
Bone marrow was harvested from the patient 3 months after the second consolidation course. Unfortunately, the patient experienced a relapse within 4 weeks of the bone marrow harvest. A decision was made to proceed with a periferal blood stem cell autograft instead of a bone marrow transplantation using the harvested bone marrow because of its obvious leukemic contamination. Myeloablative chemotherapy with busulfan, 4 mg/kg per day, was administred for 4 days, followed by treatment with cyclophosphamide, 60 mg/kg per day, for 2 days. The stem cells were infused after a single day of rest. There were no significant complications from this therapy and the patient's bone marrow function recovered by the 15th day following the start of myeloablative chemotherapy. The nadirs of his hemoglobin level, white blood cell count, and platelet count were 74 d/L on day 18, 0,5x109/L on day 11, and 3,0x109/L on day 18 respectively. There was a secondary decrease in his platelet count to 24x109/L, but there were no bleeding broblems during this time. |
|
|
Four months after the autotransplantation the patient experienced another relapse, and this time he opted for no further therapy. He died 5 weeks later....Our experience with this patient demonstrates that an attempt at curative therapy for AML should not be precluded by the refusal to accept blood products on religious grounds. |