Antineoplastics

Abstract

Pancytopenia and lack of efficacy: case report A 17-year-old girl developed pancytopenia during treatment with carboplatin, cyclophosphamide, cytarabine, doxorubicin, etoposide, ifosfamide, methotrexate, obinutuzumab, prednisone, rituximab and vincristine for post-transplant lymphoproliferative disorders (PTLD). Additionally, she exhibited lack of efficacy with cyclophosphamide, cytarabine, doxorubicin, etoposide, methotrexate, prednisone, rituximab and vincristine while being treated for PTLD, and she exhibited lack of efficacy with ketamine while being treated for headaches [routes and dosages not stated]. The girl underwent an orthotopic heart transplant that included complex systemic venous anastomotic reconstruction. She received maintenance immunosuppression including tacrolimus, mycophenolate mofetil and prednisone. She presented to the hospital 4 months after the transplantation. Subsequently, she was diagnosed with EBV + monomorphic PTLD. Her goal tacrolimus levels were decreased and mycophenolate was stopped. She received two cycles of R-COP regimen consisting of rituximab, cyclophosphamide, vincristine, and prednisone. But, PET/CT following completion of the second cycle showed an interval increase in the right axillary, right and left iliac, and right inguinal regions concerning for progression of disease. She then received two cycles of R-COPADM consisting of rituximab, cyclophosphamide, vincristine, prednisone, doxorubicin and high dose methotrexate and two cycles of R-CYVE consisting of rituximab, cytarabine and etoposide; however, the follow-up PET/CT revealed noteworthy growth of the mass in the right axilla, in addition to elevated lymphadenopathy in the right axillary and right supraclavicular regions. Thereafter, she received two cycles of O-ICE regimen consisting of obinutuzumab, ifosfamide, carboplatin and etoposide and the subsequent PET/CT showed a decrease in size of the right axillary mass but increased activity and size of the right supraclavicular and right femoral lymph nodes, in addition to spread to a right distal external iliac node. She had progressively worse marrow recovery after cycles of chemotherapy indicating an inability to tolerate more cytotoxic chemotherapy. CAR T therapy was then recommended. Subsequently, she underwent preparation for CAR T-cell therapy and her immunosuppressive regimen was reduced to prednisone and a tacrolimus. She then tolerated CAR T-cell infusion well with no severe adverse effects. Subsequently, she also reported headaches which developed gradually and became persistent and severe on day +41 and were refractory to nearly all interventions involving a ketamine drip at hospital. Thereafter, headache responded to verapamil. Consequently, she received various other medications. Her course continued to be complicated by pancytopenia that had initially developed following her cytotoxic chemotherapy [durations of treatments to reaction onset not stated] six months following CAR T-cell therapy. She was managed with eltrombopag, and platelet and packed red blood cell transfusions.