PMC9041600_01
PMC9041600_02
PMC9041600_03
PMC9041600_04
Molecular biology clearance.
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During the gilteritinib therapy with a reduced dose, the patient experienced a progressive clinical improvement and was transfusion-free; the neutrophils count progressive recovered according to the progressive reduction blasts count, as well as quantitative PCR for FLT3-ITD and NPM1B mutation on bone marrow with consensual near complete chimerism recovery (Figure 1).
Haematological recovery.
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After 3.5 months of gilteritinib therapy (October 2020), the patient was in good clinical condition, neutropenia was solved (neutrophils 3700/microL) and noteworthy she achieved the second haematological complete remission with minimal molecular disease positivity for FLT3-ITD e NPM1B mutation and a near complete chimerism (Figure 2).
PMC9041600_05
Consolidating pneumonia before starting gilteritinib.
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The patient was therefore a candidate for gilteritinib monotherapy, but she developed hypotension, fever and bilateral consolidating pneumonia (Figure 3) with respiratory failure prior to start the drug.
Evolution of the skin rash during the differentiation syndrome (A-F).
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After 7 days of gilteritinib treatment, the patient developed a severe differentiation syndrome, with a rapidly progressing non-itchy maculo-papular skin rash (Figure 4A and B) associated with fever, weight gain and increase of transaminase values. A steroid therapy with dexamethasone 10 mg bid was initiated without discontinuing gilteritinib therapy, resulting in a gradual resolution of the skin rash (Figure 4C-F).
PMC9041600_06
CT scans of submandibular and laterocervical sarcoma.
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Despite an initial cytoreductive treatment with hydroxycarbamide, he developed a rapid and massive progression of submandibular and laterocervical sarcoma resulting in rapidly progressive inspiratory dyspnea and dysphagia (Figure 5).
Evolution of the cutaneous sarcoma in a submandibular abscess.
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The treatment was complicated by the evolution of cutaneous sarcoma in a submandibular abscess (Figure 6) caused by methicillin-sensitive Staphylococcus aureus; oral midostaurin was not initiated due to severe dysphagia.
Evolution of the myeloid sarcoma during the treatment with gilteritinib.
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After 6 months from the start of gilteritinib therapy, the patient was still alive with full recovery of performance status and complete regression of the sarcomatous lesions (Figure 7).
PMC9041600_07
PMC9041600_08
NPM1/FLT3-ITD assays.
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AR mutations (Figure 8). No acute graft versus host disease were observed after transplant and the chimerism detected on day 30 on peripheral blood and bone marrow aspirate was of full-donor origin. After the discharge (day + 32), the patient did not show hepatic, renal and cardiac toxicity.