Type: Research Essays
Sample donated: Ramona Graham
Last updated: October 2, 2019
Chronic myeloid leukemia or CML is a variety of myeloproliferative malady regarded as the amplified and unfettered progression of myeloid cells in the bone marrow and its amassment in the blood (Zafar, 2017).
It is the pristine neoplasm in individuals concomitant with a distinct, explicit, assimilated genetic condition and is also one of the widely identified myeloproliferative ailments at the molecular tier (Bagg, 2007). Specifically, CML is the upshot of a communalalteration of genes 9 and 22, also identified as the Philadelphia (Ph) chromosome (Guilhot et al., 2014). This Phchromosome consorts to the countenance of BCR-ABL1 tyrosine kinase, an oncogenic commixture protein BCR-ABL(Guilhot et al., 2014). The frequency of CML upsurgessluggishly with age up until the mid-forties when it commences to escalate more briskly, consequential to its identification at intermediary age of sixty (Kaur et al.
, 2012).The medication of CML with the BCR-ABL1 tyrosine kinase inhibitor (TKI) imatinib has modernized the ministration of the ailment (Guilhot et al., 2014). Recently, results amplified to append molecular assessment which is regarded as initialgauges of retort and prognosticators of malady relapse(Radich, 2012). Molecular ascertainment is stereotypicallyimplemented via chronological real-time quantifiablepolymerase series of blood tasters (Guilhot et al.
, 2014). Procedures asseverate that blood and bone marrow mockupsshould not be amalgamated due to unalike assessment of responsiveness to the categories of samples (Guilhot et al., 2014).
Case Studies:A recent case study performed by Zafar (2017) in Lahore Cantt. Pakistan involved a 58 year old Asian lady, weighing 68 kg who was experiencing comprehensive body feebleness, pallor, pain in her left abdomen and a speedy loss of weight within three weeks. Numerous tests concerning her blood count, liver function, blood urea nitrogen, serum uric acid and other important examinations came out to be notably abnormal.
She was diagnosed with myeloid-proliferative condition and upon recommendation she undergone bone marrow aspirate and BCR-ABL1 fusion gene analysis by fluorescent in situ hybridization (FISH) technic. These tests led to the diagnosis of CML to the patient. The ailment was assumed to be managed at an early period, however the case became problematic due to the overlooked pathological circumstances of the patient. Thus, Zafar pointed out the importance of good clinical assessment vital in order not to impede treatment of the patient. Another case study performed by Verma, et al., (2014)included a 74 year-old female diagnosed previously with anemia, thrombocytopenia and leukocytosis with complete monocytosis.
She has a history of surgeries including hysterectomy and mastectomy and had undergone numerous therapies including chemotherapy and radiation therapy. She had complete blood count and was diagnosed with chronic myelomomonotic leukemia, however she only received interlude observational supervision. Consequently in October 2011, the patient developed progressive leukocytosis, anemia and thrombocytopenia. Again, she underwent CBC and bone marrow investigation where a hypercellular marrow with atypical megakaryotic hyperplasia and dysgranulopoiesis has been disclosed. Conventional cytogenetic studies showed a complex karyotype including t(9:22).
FISH readings exhibitedBCR-ABL1 reorganization and as a result, she was diagnosed with CML, BCR-ABL1 positive. Her management included imatinib and her case had positive results due to notable leukodeclination although no comprehensive hematologic reaction and she persist to have anemia, thrombocytopenia, and monocytosis. In 2012 the patient underwent reexamination. FISH results expressed BCR-ABL1 reorderingand superfluous duplicates of the BCR-ABL1 fusion indicator. Verma, et al., reported that notwithstanding the cytogenetic discoveries, a BCR-ABL1 merging transcription was not revealed by real-time polymerase causal nexus. IngrainedPCR investigation for the BCR-ABL1 transcription exposed an alternate 166-bp BCR-ABL1 transcription, which Sanger syncing validated to be a B2A3 BCR-ABL1 blending printwith fractional obliteration of exon 3 of ABL1 at the mergingintersection. An alteration in codon 12 of NRAS (NM_002524: c.
34G>Cp.G12R) was also single-outed. The patient continued to take maintenance treatment with decitabine and at the same time she was being monitored for her anemia and thrombocytopenia.
This instance according to Verma, et al., underscores the impact and usage of multimodal molecular genetic analysis in the achievement of proper diagnosis, prognosis and management. Another case reported by Young Jae Byun, et al., (2014)included a 21 year old female who had pain in her lower abdomen. Prior to her appearance, she had fissured corpus luteal cyst identified via CT scan. She had a typical medical history and no family history of hematologic ailments or genetic maladies. Aside from her minor lower abdomen soreness, there were no distinct findings in her physical investigation. The patient then underwent series of tests including CBC, WBC and serum biochemistry among others.
An outlying blood smudge exhibited thrombocytosis. CT in her abdomen and pelvis revealed a trivial quantity of hemoperitoneum resultant from the previous rupturing of herovarian cyst. Bone marrow examination and biopsy exposed a great amount of megakaryocytes, but absence of cells undertaking nasty alteration. Cytogenetic aberration was discovered with the karyotype 46,XX,t(9;22)(q34;q11.2) on her bone marrow. Byun, et al., also detecteda BCR/ABL movement in the bone marrow via oppositetranscriptase PCR, these likewise exposed enlarged producesfrom the b3a2 mRNA omission in the chief BCR gene.
Outcomes were in the negative concerning the JAK2 V617F transformation. Due to the patient’s sequesteredthrombocytosis (3,294×109/L), she was uncertainly identifiedwith ET prior to the outcomes of the cytogenetic and molecular readings were obtainable, even if outcomes for the JAK2 V617F transmutation were unidentified. Hydroxyurea was directed to the patient for 14 days to lessenher platelet count. A sequel CBC presented tenaciousthrombocytosis, platelet counts of 2,206×109/L, and leukocytopenia (1.1×109/L).
Hydroxyurea was stopped and discovered rearrangement in her Ph chromosome and bcr/abl ,but no JAK2 V617F alteration. At this stage the patient was diagnosed with chronic-phase CML, consequently, the patient took imatinib. After six days of taking imatinib, the patient obtained normal platelet count. After three months of medication, chief molecular reaction was detected.Conclusion:The aforementioned case reports depicts the importance of molecular techniques which incorporates various facets of laboratory analysis vital to the complete assessment of patients with CML and underwrites to the identification and valuation of the effectiveness of their medical treatment.
The clinical perspective of the patient and the precise handlingmodality regulate the definite investigations that are appositeto set rules in order to effectually and parsimoniously guide the laboratory findings and monitoring. These algorithms applicably integrate different approaches including cytogenicand FISH analysis adding to molecular techniques which areto be expected to advance via continuous research in the development of technology and treatment plans.