A previously healthy 65-year-old man presented to an outside hospital with fatigue, folliculitis, easy bruising, vision changes, and decreased hearing. He had a normal coagulation screen; however, he was found to have cytopenias with a white blood cell count of 5.5 K/microL that included approximately 50% blast forms, hemoglobin of 10.0 g/dL, and platelet count of 78 K/microL. Marrow showed 70-80% blasts positive for CD34, terminal deoxynucleotidyl transferase (TdT), CD3, myeloperoxidase (MPO), and CD5, and negative for PAX-5 and c-Kit (Figure 1). Flow cytometry (FC) demonstrated the blasts to express markers specific for myeloid (cytoplasmic MPO) and T-lymphoid (cytoplasmic CD3) lineages. Blasts were also positive for CD5, CD7, CD10, CD34, CD11b, CD33, and TdT on FC. Cytogenetics were normal, and no abnormalities were identified on 200 interphase cells examined by fluorescence in-situ hybridization: specifically, analysis showed no evidence of 3q21.3q26.2 translocation or inversion, deletion 5q31, monosomy 7, deletion 7q31, RUNX1T1-RUNX1 translocation, KMT2A rearrangement, CBFB rearrangement, or PML/RARA translocation. Next generation sequencing identified the following mutations: DNMT3A c.2206C > T (variant allele frequency (VAF) 43.9%); DNMT3A c.1755dup (VAF 36.5%); IDH1 c.394C > T (VAF 44.0%); CBL c.1227 + 2T > C (VAF 51.6%); and NOTCH 1 c.5023_5025del (VAF 13.9%). Together, findings established the diagnosis of T/myeloid MPAL. Cerebrospinal fluid was negative by cytology and FC.
Induction treatment was given with 3 half cycles (1A, 1B, and 2A) of cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with methotrexate and cytarabine (hyper-CVAD) and intrathecal (IT) prophylaxis. This achieved a complete remission (CR), with bone marrow biopsy after cycle 1A, showing no evidence of disease by morphology or FC and no circulating blasts in the peripheral blood. He was transferred to our facility for consideration of consolidation stem cell transplantation. A repeat bone marrow exam was performed and demonstrated continued remission. The patient proceeded to a matched related donor allogeneic stem cell transplantation (allo-SCT) from his brother with reduced intensity conditioning (RIC) (fludarabine 30 mg/m2 daily for 3 consecutive days (Flu) and 200 cGy total body irradiation (TBI)) with tacrolimus and mycophenolate mofetil graft versus host disease (GvHD) prophylaxis. Marrow on day 28 posttransplant showed morphologic remission with 0.06% blasts by FC. Markers used to detect MRD by FC included CD45, CD34, CD38, CD48, CD56, CD71, CD117, CD123, CD5, CD7, CD33, cCD3, sCD3, CD4, CD8, CD13, CD14, CD15, CD16, CD19, CD64, and HLA-DR. A repeat marrow one week later showed an increase in blasts to 0.1% by FC, and chimerism analysis showed donor CD3 of 40%, CD33 of 85%, and CD56 of 71%. His immunosuppression was tapered and completely discontinued on day 47, and he received donor-lymphocyte infusion with pentostatin on day 50 posttransplant. At day 18 post DLI blasts had increased to 6% by FC; by morphology, a population of 5% TDT + CD34+ blasts were shown. The patient was next treated with one cycle of intensive reinduction using cladribine, cytarabine, filgrastim, and mitoxantrone (CLAG-M) plus vincristine and dexamethasone. This was complicated by neutropenic sepsis requiring prolonged intensive care, but the patient made a full recovery, and restaging bone marrow biopsy showed a CR by morphology and FC. A second allogeneic stem cell transplant was planned, but shortly beforehand, the patient developed grade 2 GvHD of the skin and was treated successfully with oral corticosteroids. Given that he was still in CR by FC and hoping the GvHD would correspond to increased graft versus leukemia, the 2nd transplant was postponed. Unfortunately, repeat bone marrow exam approximately 3 months later confirmed low-level relapse detectable by FC. Reinduction with 2 cycles of CLAG-M plus vincristine and dexamethasone (with mitoxantrone omitted from the 2nd cycle) was again administered but associated with substantially increased toxicity to the patient's functional status and a prolonged length of recovery. CR by morphology and FC was briefly achieved before disease was identified at a level of 0.9% by FC on day 441 posttransplant.
At this juncture, the patient was >1-year post-allo-SCT with relapsed T/myeloid MPAL despite several rounds of high-intensity chemotherapy. He was reasonably fit, evidenced by his regular exercise bicycling regimen, but had shown declining tolerance of successive cytotoxic chemotherapy regimens. He had no clinically active GvHD. Given the paucity of published data to inform this clinical scenario, we presented 3 options for management that included (1) directly pursuing a 2nd allo-SCT using a different donor; (2) additional conventional multiagent chemotherapy; or (3) venetoclax plus HMA. He began venetoclax 400 mg by mouth daily and decitabine 20 mg/m2 intravenous daily on days 1-5 in 28 day cycles. No dose ramp-up of venetoclax was given in the setting of low disease burden. Because of grade 4 neutropenia and grade 4 thrombocytopenia, venetoclax was stopped on day 25. Both cell lines recovered by day 35, and a bone marrow exam at that time showed CR by morphology and FC. A 2nd cycle was given, with venetoclax dose-reduced to 100 mg daily. A full 28 days of venetoclax was administered with recovery of neutrophils and platelets on day 37. Other than cytopenias, the regimen was well tolerated. He proceeded to a 2nd SCT from a matched unrelated donor allograft with Flu/TBI RIC and cyclosporine, mycophenolate mofetil, and sirolimus GvHD prophylaxis. Engraftment of neutrophils occurred on day 19 after transplantation, and no grade >1 GvHD has been observed to date. At his most recent follow-up 1 year after his 2nd allo-SCT he remains in CR by morphology and FC with CD3, CD33, and CD56 compartments entirely of donor origin.