The following will serve as a clinical summary of what has happened thus far: On Tuesday, September 13, 2011, Jennifer was seen in primary care clinic at Vanderbilt Internal Medicine regarding some leg swelling, shortness of breath, and skin/soft tissue issues she was having. Routine blood work returned from the clinic visit later that afternoon when Jennifer was at work that indicated she had acute leukemia. She was severely anemic in addition. I called Jennifer at approximately 5pm that afternoon once I became aware of the lab abnormalities and asked her to leave work to present to the ER for a much needed blood transfusion.
Upon arrival to the ED, she was promptly seen in the ER by hematology who made us aware that she had acute leukemia but were not sure exactly which type. At this point, Jennifer was placed in a room on the 8th floor where she stayed for the rest of the night.
The following day, Wednesday, September 14, 2011, she underwent a bone marrow biopsy to help determine the type of leukemia she had as well as get specifics about the cells that would help determine the best course of treatment. Intravenous fluids and allopurinol (a medicine to assist with clearing away cellular breakdown products as they react with chemo) were started. She also underwent a breast biopsy of a mass that was discovered earlier in the week. Finally, she was transferred to the bone marrow unit on the 11th floor.
On Friday, September 16, 2011, the final results from the bone marrow biopsy had returned with the diagnosis of biphenotypic leukemia as her specific type of acute leukemia (in previous posts referred to as mixed lineage leukemia, but more accurately referred to as biphenotypic). This is a rare type of acute leukemia (less than 5% of all acute leukemia) and the specific subtype of biphenotypic leukemia that she has (T myeloid) makes it even more rare. The biphenotypic portion of the name simply refers to her leukemia as being a combination of both ALL and AML within the same malignant cell. All of this taken together means that there are not any clinical trials or research that might inform our physicians' decisions. That is not to say, however, that they are unsure of what to do for her. As one of the more senior physicians put it, “she’s got leukemia, we can treat that.”
Later that day, she began on a regimen of cytarabine, idarubacin, prednisone, and vincristine to begin treating her leukemia - this represents day 0 of treatment. This is part of the induction phase of chemotherapy. The way leukemia is typically treated is first giving induction chemotherapy to knock the malignant cells down low enough in the bone marrow such that our tests are no longer able to detect them. We know, based on medicine’s long history of treating this illness, that if no therapy is offered beyond induction chemotherapy, the leukemia would return. This is because malignant cells remain in the marrow despite our tests not being able to find them, i.e. they are below the test’s limit of detection.
After induction chemotherapy, depending on the type of leukemia, either a day 14 bone marrow biopsy is performed (for AML) or a day 30 marrow is performed (for ALL). If no cells are seen, the patient is determined to be in clinical remission and the next phase of therapy, which is consolidation chemotherapy, may begin. This consists of 2 to 5 sessions of chemo intended to drive the malignant cells count even lower in the marrow (and possibly even kill it for good depending on the specific type of leukemia).
After beginning induction chemotherapy on Friday, September 16, 2011, she was ready for her day 14 bone marrow biopsy on Friday, September 30, 2011. This biopsy was rather controversial amongst the hematologists as there has been no research to show that this is the correct day to assess whether or not chemotherapy has been effective given her specific type of acute leukemia (biphenotypic). Remeber, we check a day 14 marrow for AML and a day 30 marrow for ALL to check to make sure the chemo has been effective, but in Jennifer’s case, she has a combination of the two types and so no one was really sure when was the appropriate time to check.
Despite this area of controversy, a day 14 marrow (14 days are the beginning of induction chemo) was done which showed very few cells of any type within the marrow which is what one expects in the setting of chemo. There were, however, still malignant cells present within the marrow. Specifically, 7.5% of the cells seen in the marrow were cancerous at day 14, whereas on day 0 they had been at 95%. We can therefore say that Jennifer has responded to the chemo that had already been given but were not sure if we should have expected there to be no cancer there or anything in between. We were ecstatic about the results, despite the uncertainty.
Given that Jennifer’s bone marrow wasn’t totally free of cancer, her doctors decided to give a little more induction chemotherapy by adding on a different medication called PEG asparaginase with plans to reassess her chemo response with a day 30 bone marrow biopsy (roughly, could be anywhere from day 30 to 40). This would mean that her next bone marrow biopsy would be scheduled for anywhere from Monday, October 17 to Wednesday, October 26. We are in dire need of prayers that her marrow will be free of cancer at this point and she will be determined to be in a state of remission, so that we may begin consolidation chemotherapy.
On Monday, October 3, 2011, our hematologists met and determined that once Jennifer achieves a remission, she would need to undergo a bone marrow transplant. We also need prayers that there will be a donor for Jennifer and that this procedure goes well. The previous Saturday, October 1, 2011, we found out that neither Lauren nor Lindsey were matches for Jennifer’s bone marrow.
Jennifer has had two fevers during this hospitalization which have no doubt been related to her suppressed immune symptoms and bacterial infection of her IV line. She has been treated with antibiotics since her first fever, and thankfully, these have resolved for now.
So as of today, October 10, 2011, day 24, Jennifer has received all of her induction chemotherapy and her immune system is starting to return. The major cell of the immune system that we monitor is called the neutraphil. We want her neutraphil count to be at least 500 prior to her discharge. It had been 0 for the past 4 weeks as a results of chemo and her cancer. Today it is 60. Please pray that her counts continue to rise and that we don’t see a return of her malignant cells in her blood stream. We are anxiously awaiting her day 30 bone marrow biopsy so that we can determine when she can begin consolidation chemo.