Management of B-ALL in older adults

Management of B-ALL in older adults

CME 49408

Case presentation

75M w hx indolent chronic ITP, prostate Ca (s/p XRT+ADT early 2010s), CAD, AVR 2015, HFrEF (LVEF 30% 2022), presented with several months of dyspnea on exertion, sore throat, and extreme fatigue.

Plts had been high 80s-low 100s since mid 2015 (s/p steroids, rituximab).

2014 BMBx variably cellular <10% to 30-40% with mild erythroid atypia and karyotype 4 of 20 cells with -Y.

Notable labs on presentation:

• WBC 1.46, ANC 580
• Hgb 9.1 (wnl a few months earlier)
• plt 35 -> 16 on recheck two weeks later (97 a few months earlier)
• T bili 3.89 (D bili 2.38), ALK 368, ALT 183, AST 75

ferritin 516.89, folate >20, Fe 205, TIBC 323.85, transferrin 255, TSH 8.1506, fT4 0.93, Cr 1.42; HbA1c 6.5; PSA <0.100

Case presentation continued

Exam notable for jaundice (1wk per wife), no edema, JVP wnl

BMBx

• >90% blasts
• positive [CD34, HLA-DR, CD38, TdT, moderate CD58, moderate cytoplasmic CD22, and moderate cytoplasmic CD79a]
• heterogeneous [CD19, CD38, dim CD10, CD20, cytoplasmic CD19]
• negative [CD33, CD11b, CD15, CD16, CD14, CD64, CD2, CD56, cytoCD3, CD117, and myeloperoxidase.]
• negative for BCR-ABL including breakapart
• Ph-like pending
• complex karyotype (specifics not available)