What is the proper treatment for extreme leukocytosis and leukemoid reaction? - 1274614

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al314
What is the proper treatment for extreme leukocytosis and leukemoid reaction? - 1274614

My wife was on Tarceva until we started to notice her white blood cell count was elevated. CT confirmed that her cancer has progressed with multiple tumors/nodules in her lung and enlarged lymph nodes. Her white blood cell count was 12 K on April 4. It was 33 K on June 17, before she was given the first infusion of Keytruda. She was tested PD-L1 positive (80%, intensity 3) and was prescribed pembrolizumab 2 mg/kg every 3 weeks. Her white blood cell count was 56 K yesterday on July 6, before she received her second infusion. About 70% of her white blood cells are neutrophil. Only 5% are Lymphocyte. What worries me the most is the speed her white cell count increases. It increases 7 K in one day, from 49 K on July 5 to 56 K on July 6.

She was put on antibiotics for 10 days in June. It did not change the trajectory of the white cell counts. My understanding is that white blood cell count over 50 K is termed as paraneoplastic leukemoid reaction. I was hoping that Keytruda could stabilize the white blood cell count and her cancer. Three weeks after one infusion, the WBC count continues to increase at a rapid rate. Our oncologist had never seen this kind of cases before, as I read that they are not very common. I would like to know if any physicians or patients had similar experience and/or know the proper course of action/treatment.

As a side note, I planned, three month ago, a 10-day family vacation in Europe, including a 7-day cruise. We were about to start the trip tomorrow. Given my wife's condition, do you think we should cancel the trip?

Thank you so much!

catdander
Hi al314,

Hi al314,

I'm sorry but we can't say what one should or shouldn't do, it's very much up to your doctors to help with that.
Oncologists are specialists in blood disorders so even if should be able to lead you in the right direction. I can only imagine that your wife would have a pretty the biggest say on the trip.

I will ask an oncologist to comment about the counts but note that he/she can't respond about travel.

Let us know what y'all decide.

Janine

I wanted to add this link that seems to show rising white counts play a big part of malignancies. http://www.sciencedirect.com/science/article/pii/S2213089615000109

al314
Thank you, Janine, for the

Thank you, Janine, for the response. We saw her doctor today. The doctor ordered a blood culture, a urine test, and CT to see if there is any infection. He will call us today to let us know if he see infection. If infection is found, we will definitely cancel the trip. Otherwise, he encouraged us to continue with the trip. He also prescribed Metronidazole and Levofloxacin (two antibiotics) for us to carry on the trip. My wife seems to be doing ok. She does have shortness of breath and on-and-off low grade fever. We figure that if the high WBC is caused by cancer progression, instead of infection, there is not much we can do in the next two weeks (am I wrong?). I will try to login and check emails during the trip to see if we can come up with a better treatment plan. We will travel with our two college-age boys, which will bring her joy.

catdander
Barring infection it doesn't

Barring infection it doesn't sound as though there's anyplace better than a good trip with you and the boys then. I hope all goes well.

There's a chance it could be from the immunotherapy itself. It's been seen in at least in one study of those with sclc. On another note there have been people who have what is called a pseudo progression directly after beginning immunotherapy for nsclc, though now found to be fairly rare. So please know that if there's no infection and you go on the trip that it's very possible to come home to a better or stable scan. AND HAVE FUN 8-)