CML-357 Jumping Out of the Frying Pan, Into the Fire: Case Report of Secondary Non-Hodgkin Lymphoma (NHL) in a Case of Chronic Myeloid Leukemia (CML)

Context: The introduction of TKIs at the start of the second millennium has dramatically changed CML treatment. Now, two decades later, we are observing and trying to assess the long-term side effects of prolonged TKI use. Objective: To report a secondary malignancy in a CML patient on TKI and its impact on her CML course. Design: This is a case report of a chronic-phase CML patient who developed NHL. Setting: OCMU is an academic institutional practice acting as a referral center that provides multidisciplinary tertiary care for hematology patients in the Egyptian delta region. Patients or Other Participants: A 58-year-old female resident of Damietta was referred to OCMU in January 2020 after discovering leukocytosis. She was diagnosed as CML based on blood film, bone marrow aspiration, and biopsy results and was confirmed by the detection of Philadelphia chromosome P210 in 46% of cells. The patient was started on 100 mg dasatinib, but she developed a diffuse skin rash with recurring anemia requiring transfusion and dasatinib interruptions. She was shifted to nilotinib with the absence of the previous toxicities and QPCR reduction. Interventions: She was referred back to us in November 2021 with left submandibular swelling measuring 3.8×3.5 cm, with submandibular LNs as large as 1.8×1.1 cm with faint hilum. QPCR was undetectable, but bone marrow aspiration and both free-hand and tru-cut biopsies revealed DLBCNHL positive for CD20 and negative for CD3 and CD23, with Ki67 detected in 85%. CD34, CD117, and TdT were negative, excluding chloroma. PET-CT showed active uptake only in the submandibular mass (4 × 3 cm; SUV=7). She started the R-CHOP regimen and continued nilotinib. Main Outcome Measures: The response was assessed by PET-CT and QPCR. Results: PET- CT was negative after four cycles, and QPCR remained undetectable. Therefore, the patient is continuing nilotinib with regular monthly follow-up for lymph node ultrasonography. Conclusions: Secondary malignancies with CML are increasingly common, but the literature reports contradictory data, with NHL ranked as the fourth most common secondary malignancy. The roles of TKIs in disease evolution and increased life expectancy require more research to assess the genetic bases and incidences of secondary malignancies.