Blood consult Blood consult: Therapeutic strategy and complications in the adolescent and young adult with acute lymphoblastic leukemia

A 21-year-old woman was diagnosed with B lineage acute lymphoblastic leukemia (ALL) after presenting to a community-based medical oncologist with fatigue, fevers, and pancytopenia (white blood cell count 2.3 103/ L, hemoglobin 8 g/dL, platelets 42 103/L). She was transferred to a regional children’s hospital to institute therapy. Cytogenetics showed 55, XX, 4, 6, 10, 14, 17, 18, 21, 21[8]/46, XX[7]. Fluorescence in situ hybridization confirmed the presence of trisomies of chromosomes 4, 10, and 17 and was negative for ETV6RUNX1 [t(12;21)] or BCR-ABL1 [t(9;22)(q34;q11)] fusion. A lumbar puncture performed before therapy showed no malignant cells. She began 4-drug induction therapy (vincristine, prednisone, daunorubicin, PEG-asparaginase) and intrathecal chemotherapy following the Children’s Oncology Group (COG) protocol AALL0232.1 She was discharged home after day 8 chemotherapy, with plans to continue treatment with her community medical oncologist in consultation with the pediatric oncology team. During subsequent outpatient visits, she reported severe fatigue and weakness, making it difficult for her to return to her third-floor walk-up apartment, and she became dependent on her parents to carry out activities of daily living. She demonstrated hyperglycemia requiring insulin therapy throughout induction and progressive hyperbilirubinemia (chemotherapy doses were modified appropriately). In the final week of induction, she presented with severe nausea, sharp right-upper-quadrant abdominal pain, total bilirubin 6.1 mg/dL (direct bilirubin 4.2 mg/dL), and sequential labs demonstrated rising lipase. With a broad differential, including asparaginase-induced hepatotoxicity and/or pancreatitis, steroid-induced fatty liver disease, gallstones, and cholangitis, she was admitted to receive supportive care for the remainder of induction therapy. Bone marrow evaluation at end induction showed remission with no blasts by morphology; flow cytometry minimal residual disease testing showed 0.012% leukemia cells. Still facing difficulties with mobility, fatigue, and malnutrition, she was discharged home to start consolidation therapy as an outpatient. To date, she has completed consolidation, interim maintenance with high-dose methotrexate, and delayed intensification treatment, during which she again experienced significant hyperglycemia.1 Most treatment has been administered by her communitybased medical oncologist in collaboration with the pediatric oncology team. Discussion