Chronic myeloid leukemia after living donor liver transplantation.

A 51-year-old Taiwanese man was a known hepatitis B virus carrier with cirrhosis and bilobar hepatocellular carcinoma (HCC). He underwent four episodes of transarterial embolization for the HCC. On follow-up, he had HCC recurrences and was advised liver transplantation. He underwent routine pretransplant workup and subsequently underwent right lobe living donor liver transplantation. The perioperative course was uneventful. The immunosuppression used tacrolimus, mycophenolate mofetil, and prednisone. Posttransplant, he underwent 10 cycles of doxorubicin-based chemotherapy due to tumor invasion to the hilar soft tissue and microscopic portal vein tumor thrombosis. He did well postchemotherapy and had no episodes of graft rejection or HCC recurrence. At 6 months posttransplant, he developed nonspecific leukocytosis. At 13 months posttransplant, his white blood cell count (WBC) was 46.2 10. At 14 months posttransplant, the leukocytosis increased to 63 10 (segmenters 49, bands 17, lymphocytes 7.5, monocytes 3.5, eosinophils 1.5, basophils 4, blasts 1, promyeloblast 1, myeloblast 2.5) with no apparent focus of infection (Supplemental Table 1). The C-reactive protein was 3.14. He was advised chromosomal studies and bone marrow biopsy. Leukemia was entertained. Cytogenetic analyses done on Geimsa banded chromosomes from cultured bone marrow cells showed 46, XY, t(9; 22)(q34;q11), 100% (Supplemental Fig. 1). A genetic study from peripheral blood sample in the nested polymerase chain reaction assay showed b2a2 BCRABL. Bone marrow biopsy revealed hypercellular marrow with myeloid and megakaryocytic hyperplasia, eosinophilia, and basophilia consistent with myeloid leukemia, chronic phase (Supplemental Table 2; Supplemental Fig. 2). Cytoreduction with hydroxyurea was started. Complete hematologic remission (CHR) was reached in 2 months, and continuous CHR thereafter. The WBC count decreased from 95.1 10 to 4.3 10 within 7 months treatment with hydroxyurea. Imatinib was started after 9 months of hydroxyurea treatment. Continuous CHR was also noted with imatinib; and genetic study done from peripheral blood samples at 3 months and 6 months after imatinib treatment showed continuous major molecular remission (Supplemental Table 3). At 40 months posttransplant to present date, the patient is alive with no HCC recurrence, and no episode of graft rejection. He remains on CHR 25 months after the diagnosis of leukemia. His current medications include low-dose tacrolimus, mycophenolate, and imatinib. Myeloproliferative disorder is a lifethreatening condition that can present after the use of immunosuppression in order to prevent rejection in transplantation. However, acute leukemias are rare after solid organ transplantation with an incidence of 0.2–2.5% in reported series (1). There are approximately 13 cases of acute leukemia after solid organ transplant reportedintheEnglishmedical literature(1– 6). Chronic myeloid leukemia (CML) has not been reported after liver transplantation. There were no molecular data of the BCR-ABL at the time of transplantation. However, serial pretransplant hematologic data showed that all hematologic parameters were within acceptable limits. In the early chronic phase of CML, the most common presentation is leukocytosis or thrombocytosis only. Leukocytosis, which was noted for about 6 months before the diagnosis of CML was made, may have been suppressed by doxorubicin (Table 1). Doxorubicin may have suppressed hematopoiesis whereby the patient presented with leu-