MINISTRY OF HEALTH OF UKRAINE
UKRAINIAN CHILDREN SPECIALIZED HOSPITAL
“OHMATDIT”
01131, the city of Kiev tel. 236-6942
Chornovola st 28/1 fax 236-6165
Discharge summary from the case report #252
of Kovalchuk Nazar, born in 1991,
living in Kiev, Beretti st 14 ap. 11
Stamp:
01131, the city of Kiev Chornovola st 28/1
NATIONAL SPECIALIZED CHILDREN HOSPITAL
“OHMATDIT”
MINISTRY OF HEALTH OF UKRAINE
The patient has been undergoing the inpatient treatment in the Department of Oncohematology from February 29, 2008 up to the present moment with the diagnose Acute Lymphoblastic Leukaemia (C 91.0), initial central nervous system affection, 1st acute period, the group of the high risk.
It is known from the medical history that mediastinal neoplasm was revealed in November 2007 for the first time at the planned examination according to the data of chest X-ray. In the Research Institute of Oncology the patient was diagnosed with malignant thymoma. The malignant disease is progressive against chemotherapy performed, there are hyperleukocytosis and blasts in the peripheral blood.
The patient was diagnosed with T-cell acute lymphoblastic leukaemia, according to the data of overall examination of the bone marrow dated February 29, 2008.
The patient received chemotherapy from February 29 till March 24, 2008 according to ALL-BFM-2000 protocol. The complications: cytostatic neutropenia, vincristine neuropathy, dynamic bowel obstruction developed against the complications.
On March 30, 2008 the patient had a surgery because of the peritonitis development resulting from multiple perforations of the large intestine. A resection of the large intestine segment was performed with stoma exteriorization onto anteroventral wall. Histological examination revealed mycosis of the intestinal wall. According to CT of the abdominal cavity and retroperitoneal space dated April 24, 2008 the patient was also diagnosed the mycosis of the liver and both kidneys. The patient received a prolonged course of the combined fungicide therapy (cansidas+vfend, fungison (amphotericinum b)+ vfend). Stabilization of the clinical condition was achieved against the therapy with the resolution of the fungous focuses in the parenchymal organs.
Because of the above mentioned complications there was a forced pause in the therapy of the underlying disease. The chemotherapy was resumed May 29, 2008. At the present moment remission of the acute lymphoblastic leukaemia is observed.
Virus B hepatitis was diagnosed on July 21, 2008. The antiviral therapy consisted of intron A subcutaneous in every day regiment #14, then 3 times per week during 6 weeks, following with peg-intron A once per week (up to the present moment), zeffix per os (up to the present moment).
According to the criteria of EBMT therapeutic program the patient needs marrow allografting in the first remission. As for the data of HLA matching of the family there is no identical relative donor for the allografting.
On September 03, 2008 the reparative operation was done to close stoma and to restore the bowels. There were no complications.
From November 04 till November 24, 2008 bilateral cranial irradiation was done with the therapeutic purpose, the cumulative dose was 18 Gy.
Echocardiogram on December 23, 2008: heart cavities are not enlarged, ejection fraction 70%, fractional shortening 41%, myocardial contractility is good, the valves are not changed, the walls are not thickened.
Ultrasound of the abdominal cavity organs on January 13, 2009: the liver is insignificantly enlarged, A-P diameter of the right lobe of liver is 145 mm, parenchyma, vascular pattern are retained. Pancreas is not enlarged, parenchyma is without echo-structural changes. The kidneys are located typically, they are of the age-related sizes, without visible echo-structural changes, cavitary system is not extended. There is no free fluid in the abdominal cavity.
Chest radiography on December 20, 2008: there are no focal-infiltrative shadows, the roots are structural, the heart shadow is not extended, pleural recesses are free.
Complete blood count on January 13, 2009: WBC – 4.9x109/l (neutrophils 46% (NEUT), lymphocytes 23% (LYMP), monocytes 28% (MONO), eosinophils 3% (EOS)).
Biochemical blood assay on January 12, 2009: glucose 4.3 mmol/l, bilirubin 7.2 μmol/l, GPT 73 UIL, GOT 30 UIL, K 4.5, Ca 1.1 mmol/l, creatinine 0.078 mmol/l.
At the present moment the patient is receiving the course of chemotherapy according to protocol COALL – 05 – 92 HIGH RISK (Reinduktion), upon its completion it is planned to perform supporting chemotherapy outpatiently.
Taking into consideration the high aggression of the malignant process, absence of HLA-identical relative donor we think it reasonable to consider the unrelated marrow allografting.
The case record is given to outpatient department of the place of residence to settle the question of disability extension according to the order of Ministry of Health of Ukraine #454/471/516 dated November 08, 2001.
January 13, 2009
Head of the Center of Children Oncohematology and Marrow Allografting
Donskaya S.B.
Head of the Department of Chemotherapy of oncohematological diseases with intensive therapy course
Kubalya N.A.
Attending medical doctor Peresada L.A.
Seal:
MINISTRY OF HEALTH OF UKRAINE
THE CITY OF KIEV
NATIONAL SPECIALIZED CHILDREN HOSPITAL
“OHMATDIT”
ID code 01994089
CONCLUSION # _____ dated ____
on the necessity of the patient referral for the treatment to be taken overseas
The child: Kovalchuk Nazariy Maximovich
Year of birth: 1991
Address: Kiev, Beretti st 14 ap 11
Diagnose: T-cell Acute Lymphoblastic Leukemia, the group of the high risk
- The reason of the necessity of the patient referral for the treatment to be taken overseas: transplantation of the bone marrow from unrelated donor (impossible in Ukraine).
- Recommended countries, medical centers overseas:
- Estimated cost of the treatment:
- Currency support (financing) of the referral for the treatment for the patient and accompanying person:
a) against the set quota with the country on the patients exchange:
b) free treatment (at the expense of the receiving health care facility):
c) at the expense of the patient funds:
d) at the expense of the currency funds which are allocated by the departments, organizations, facilities: Ministry of Health of Ukraine.
e) the other sources:
Note: medical information should be printed in 4 copies and be translated into the country language.
Main specialist of the children hematology of the Ministry of Health of Ukraine [illegible]
MINISTRY OF HEALTH OF UKRAINE
UKRAINIAN SPECIALIZED CHILDREN HOSPITAL
“OHMATDIT”
01131, the city of Kiev tel. 236-6942
Chornovola st 28/1 fax 236-6165
Discharge summary from the case report #252
of Kovalchuk Nazar, born in 1991,
living in Kiev, Beretti st 14 ap. 11
The patient underwent the inpatient treatment in the Department of Oncohematology from February 29, 2008 till February 16, 2009 with the diagnose acute lymphoblastic leukaemia (C 91.0), initial central nervous system affection, 1st acute period, the group of the high risk.
It is known from the medical history that mediastinal neoplasm was revealed in November 2007 for the first time at the planned examination according to the data of chest X-ray. In the Research Institute of Oncology the patient was diagnosed with malignant thymoma. The malignant disease is progressive against chemotherapy performed, there are hyperleukocytosis and blasts in the peripheral blood.
The patient was diagnosed with acute lymphoblastic leukaemia, T-cell according to the data of overall examination of the bone marrow dated February 29, 2008.
The patient received chemotherapy from February 29 till March 24, 2008 according to ALL-BFM-2000 protocol. The patient was assigned to the group of high risk because the blast cell level in blood was more than 1000/microliter on the 8th day.
The complications of the chemotherapy are cytostatic neutropenia, vincristine neuropathy, dynamic bowel obstruction developed against the complications.
On March 30, 2008 the patient had a surgery because of the fecal peritonitis development resulting from multiple perforations of the large intestine. A resection of the large intestine segment was performed with stoma exteriorization onto anteroventral wall. Mycosis of the intestinal wall was revealed according to the data of the histological examination. Postoperative period was severe due to septic condition. According to CT of the abdominal cavity and retroperitoneal space dated April 24, 2008 the patient was also diagnosed with the mycosis of the liver and both kidneys. The patient received a prolonged course of the combined fungicide therapy (considas+vfend, fungizon (amphotericinum b)+ vfend). Stabilization of the clinical condition was achieved against the therapy with the resolution of the fungous focuses in the parenchymal organs.
Because of the above mentioned complications there was a necessary pause in the therapy of the underlying disease from Mach 24 till May 07, 2008.
Chemotherapy (purinethol in the regiment of the supporting chemotherapy) was resumed on May 07, 2008 with the connection of infectious status stabilization against complete remission of the underlying disease and continuing antimycotic therapy.
Taking into consideration the biology of the underlying disease, assignment to the high risk group, the duration of the pause in the intensive stage of chemotherapy and also the availability of the intestinal stoma and unresolved focus of infection in the liver (most likely of fungous genesis), on May 28, 2008 the board of doctors took a decision of chemotherapy modification – to continue the treatment according to COALL-05-92 protocol for the patients of the high risk group.
Virus B hepatitis was diagnosed on July 21, 2008. The antiviral therapy consisted of intron A subcutaneous in every day regiment #14, then 3 times per week during 6 weeks, then peg-intron A once per week (up to the present moment), zeffix per os (up to the present moment).
According to the criteria of EBMT therapeutic program the patient needs marrow allografting in the first remission. As for the data of HLA matching of the family there is no identical relative donor for the allografting.
On September 03, 2008 the reparative operation was done to close stoma and to restore the bowels. There were no complications.
From November 04 till November 24, 2008 bilateral cranial irradiation was done with the therapeutic purpose, the cumulative dose was 18 Gy .
Echocardiogram on December 23, 2008: heart cavities are not enlarged, ejection fraction 70%, fractional shortening 41%, myocardial contractility is good, the valves are not changed, the walls are not thickened.
Ultrasound of the abdominal cavity organs on January 13, 2009: the liver is insignificantly enlarged, A-P diameter of the right lobe of liver is 145 mm, parenchyma, vascular pattern are retained. Pancreas is not enlarged, parenchyma is without echo-structural changes. The kidneys are located typically, they are of the age-related sizes, without visible echo-structural changes, cavitary system is not extended. There is no free fluid in the abdominal cavity.
Chest radiography on December 20, 2008: there are no focal-infiltrative shadows, the roots are structural, the heart shadow is not extended, pleural recesses are free.
Chest, abdominal and pelvic CT on January 27, 2009: no pathological changes in internals and body bones were revealed.
Taking into consideration the recurring prolonged episodes of IV stage myelosuppression due to associated receiving of the cytostatic agents and peg-intron, the condition of recurrent febrile agranulocytosis, transfusion dependence and also taking into account the total duration of the intensive stage of chemotherapy (from February 29, 2008 till January 26, 2009) a decision was taken on February 02, 2009 to stop the intensive reinduction phase of the therapy (without two courses of average dose cytosar and cyclophosphamide).
RECOMMENDATIONS:
1) hematologist supervision,
2) monitoring of the complete blood count once per week, of the biochemical blood assay once per month,
3) to start supporting chemotherapy on February 16, 2009: purinethol in the everyday regiment, methotrexatum – once per week (dose correction as per white blood cell level – the instruction is enclosed),
4) to continue of the combined antiviral therapy (zeffix 100 mg/24 hours every day + peg-intron 60 μg subcutaneous once per week) up to July 20, 2009.
Head of the Center of Children Oncohematology and Bone Marrow Transplantation
Donskaya S.B.
Head of the Department of Chemotherapy of oncohematological diseases with intensive therapy course
Kubalya N.A.
Attending medical doctor Peresada L.A.
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