Experts from West China Hospital and a U.S. Ivy League Medical Center Conduct Joint Video Consultation for a Complex Patient with Many Comorbidities.
In March 2020, Medebound Health was asked to help Mr. Zhang, a leukemia patient with a T-cell large, granular lymphocyte.
Because the global epidemic was raging at that time, many hospitals in the United States were already in the overloaded operation stage. To get treatment recommendations in the shortest time possible, we contacted experts from top north hospitals both in the United States and In China A 45-minute video consultation from three locations was planned to jointly make the next treatment recommendations for the patient.
Due to the rising need to consult a US-based cancer specialist, Medebound HEALTH have been actively engaged in fulfilling these requests for the last years. A doctor from New York Presbyterian-Columbia University Medical Center’s department of oncology, an expert from the Department of Hematology from the West China Hospital of Sichuan University ( which have been ranked consistently as the 2nd best hospital in China) conducted the joint video consultation
Mr. Zhang (a pseudonym), 58 years old, was found to have abnormal lymphocytes three years ago. As he did not have any symptoms, he did not have a clear diagnosis and special treatment plan.
Near the end of 2019, Mr. Zhang was diagnosed with T-cell large granular lymphocytic leukemia with pure red aplastic anemia and severe anemia.
T cell large granular lymphocytic leukemia
There are two types of large granular lymphocytes (LGL) in peripheral blood: T-cell large granular lymphocytes (T-LGL) and natural killer cell large granular lymphocytes (NK-LGL). T-cell large granular lymphocyte leukemia is the clonal reproduction of T-cell large-granular lymphocytes, which usually manifests as the unexplained increase in LGL for more than six months, which is the nature of malignant tumors.
In addition to T-cell large granular lymphocytic leukemia, Mr. Zhang also suffers from a variety of other diseases, including sperm cirrhosis with drug-induced liver injury, double lateral pneumonia, anemic heart disease, right kidney cancer surgery (clear cell renal cell carcinoma: Fuhrman grade:I), type 2 diabetes, high triglycerides, hyperemia, and hypertension.
Mr. Zhang is affected by so many comorbidities, which combined have a negative impact on the treatment of T-cell large granular lymphocytic leukemia. In order to get a comprehensive treatment plan and advice about a more effective approach for the later period, Mr. Zhang contacted Medebound HEALTH.
Therefore, Mr. Zhang decided to consult a US-based cancer doctor for a second diagnosis and treatment opinion.
After receiving Mr. Zhang’s request, we immediately started the collection, sorting, and translation process of his records.
The professor from the US:
The Professor of Columbia University Medical Center involved in the call
specializes in the treatment of blood diseases, and has devoted himself to the study of molecular genetics of hemoglobin and the study of chronic myeloid leukemia in the early stage. In the past 25 years, this doctor has focused on the diagnosis and treatment of blood diseases, especially leukemia, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, and multiple myeloma. He is currently conducting clinical research on Hodgkins and non-Hodgkin's lymphoma, and has been repeatedly rated as the top doctor in the United States by the Castle Connolly Top Doctors and Newsweek.
New York-Presbyterian Hospital
The New York-Presbyterian Hospital is the largest hospital in New York. It is also the home to two famous Ivy League teaching hospitals of Cornell University and Columbia University. It is also one of the top medical systems in the United States. The medical center is world-renowned for its various research results. It is also a hospital where dignitaries such as the Clintons and the Royal Family of the Middle East have been treated In the US News & World Report's ranking of nearly 5,000 hospitals in the United States, the New York-Presbyterian Hospital ranked first among the best hospitals in the tri-state area of New York.
The professor from China:
The hematology specialist and chief physician of West China Hospital of Sichuan University specializes in Leukemia, Lymphoma, Myeloma Treatment. He graduated from West China Medical College of Sichuan University with a bachelor's degree, and then stayed at school to work on blood system diseases. He has been responsible for two provincial-level topics, two GCP topics, and published numerous articles, including SCI indexed ones. He has extensive experience in the diagnosis and treatment of blood system diseases such as leukemia, lymphoma, myeloma, anemia, and bleeding diseases.
On March 21, 2020 , these two doctors and Mr. Zhang conducted a 45-minute video consultation across the Pacific Ocean. Chinese and American professors discussed the case together, developed an actionable treatment plan, and answered all the related questions from Mr. Zhang.
Screenshots of the joint video consultation with U.S. and Chinese experts
Summary of Answers to the Professors' Questions in China and the United States
Q
Please evaluate the patient's current condition. Does he need other tests? Do you need to do genetic testing, such as mutation analysis?
The main clinical problem of T-cell large granular lymphocytic leukemia (T-LGL) stems from cytopenias, especially the reduction of neutrophils which can easily cause infection. And the patient is accompanied by pure red blood cell aplastic anemia (PRCA), the bone marrow hematopoietic function is impaired, and it is easy to cause fatigue and shortness of breath. Cyclosporine is very helpful in the treatment of PRCA, but it may take up to several months of treatment to see the effect.
Regarding the patient’s chest CT scan, the lesion has changed very little compared with the previous chest CT, and it is more inclined to inflammatory nodules. If you want to clarify the nature, you may need to contact the respiratory department for a lung nodule biopsy. However, the risk of puncture biopsy of lung nodules in patients is high, and the changes of lung nodules can be continuously monitored by reexamination of chest CT scans. If there is a significant tendency to increase, you can contact the respiratory department or thoracic surgery for further examination.
Regarding next-generation gene sequencing and gene mutation detection, it can guide the treatment of some relapsed and refractory lymphomas. However, there are many feasible first-line treatment options for this patient, so this patient does not currently need second-generation sequencing.
Q
What is the best treatment plan for patients with T-cell large granular lymphocytic leukemia with aplastic anemia and multiple comorbidities? Are there other drugs suitable for him, such as Alemtuzumab?
Regarding treatment, because the patient has liver cirrhosis, his choice of treatment options is limited. For example, the two recognized first-line drugs, methotrexate and cyclophosphamide, require good liver function and metabolic function. In situations where patients have liver cirrhosis, it is difficult to use these drugs for treatment. Regarding Alemtuzumab, because of its obvious liver toxicity, it is not suitable for this patient.
Regarding the patient's treatment plan, consider:
Immunotherapy, such as intravenous immunoglobulin (IVIG), has a good effect on the treatment of PRCA;
Low-dose chemotherapy drugs, such as bendamustine (15mg is a safe dose), have relatively low liver toxicity;
T-cell treatment options.
At present, the best treatment for the patient is cyclosporine because his hemoglobin rises significantly, reticulocytes increase, and the interval between blood transfusions is lengthening, indicating that the effect is good. The drug dose can be reduced according to the treatment situation in the later stage. If the patient does not respond to cyclosporine, bendamustine can be substituted later.
Staff Physician's Note:
Intravenous immunoglobulin (IVIG) is an immune preparation prepared by mixing hundreds of normal human immunoglobulins to improve patient immunity and help treat some complications caused by T-cell dysfunction.
Bendamustine: It is a bifunctional nitrogen mustard derivative with both alkylating and anti-metabolism effects. It acts on cells in quiescent and dividing phases and is effective for the treatment of some lymphomas.
Alemtuzumab: A humanized monoclonal antibody that targets CD52, binds to CD52 on the surface of T lymphocytes and B lymphocytes, through complement-dependent cytotoxicity (CDC) and antibody-dependent cytotoxicity ADCC kills tumor cells, but has many side effects.
Q
Are there new drugs or clinical trials applicable to patients with this type of leukemia, such as NK therapy and stem cell therapy?
Regarding CAR-T, NK cell therapy and stem cells are mainly used to treat some refractory lymphomas and leukemias. The patient does not need to consider these drugs because he already has many first-line drugs that can be chosen to treat T-LGL.
Many new drugs are currently undergoing clinical trials and have not yet been commercialized, but because the patient has liver cirrhosis, he is unlikely to be a candidate for the drug trial.
Q
How should he monitor the progress of his disease? Any suggestions for his diet, habits, and exercise to help him cope with this disease?
Since the current cyclosporine treatment effect on the patient is good, the blood routine can be reviewed regularly to monitor the therapeutic effect, and the blood routine and bone marrow can be reviewed after three months.
The patient is currently experiencing a malignant clone of bone marrow T cells, and lifestyle management is very important for the patient. Because any malignant clone will be affected by the surrounding environment, we can make some adaptations to his lifestyle that are conducive to the cloning of bone marrow cells. These changes could include weight control, a low carbohydrate diet, regular aerobic exercise, and stress reduction exercise, including meditation, breathing training, and physical and mental exercises such as yoga, Tai Chi, and Qigong, and a comprehensive lifestyle to suppress the vicious cloning progress.
After this consultation, the patients spoke highly of our service quality, and process details.
The global epidemic is raging, and the epidemic is ruthless. Although many hospitals in the United States are already at the stage of overloading, we still contacted the professors of a prestigious American medical center within a short time.
After collecting the medical records, making an appointment, and coordinating the details, the video conference officially started in less than five days, which is shorter than the registration time in a tertiary hospital in the US or in China. The 45-minute video consultation in the three locations allows patients to fully appreciate that they can access the world without leaving their homes. When we saw the patient's heartfelt praise for us, we had no overtime work, and once again felt the existence of our value and the motivation to continue working hard. I wish Teacher Zhang an early recovery to health!
The process began on March 17, 2020, according to customer needs.
On March 17th, 20th, and 21st, 2020, we coordinated the time between the Chinese and American professors, and the final video time was confirmed at 9 a.m. Beijing time on March 21st, 2020.
At about 10 a.m. on March 18, 2020, our team started to assist customers in downloading video software, and then completed the video test with the customer’s assistant at about 15:30 p.m. This testing included the customer self-test and the test with colleagues in our customer service department.
At 15:30 p.m. on March 20, 2020, the customer completed the last lung CT data transmission, and all medical records were complete.
From 10 p.m. to 12 p.m., we worked tirelessly and finalized the date March 21, 2020, for the video meeting.
Learn more about Medebound HEALTH Global Telehealth Services, visit：https://www.medeboundHEALTH.com
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