Case based discussion
Pankaj Malhotra
PGIMER, Chandigarh, India
Case History
• A 43-year old gentleman presented with
weakness and fatigability x 3 months
• Hb 13.4 gm/dl, WBC 220,000 ce...
Case History
• A 43-year old gentleman presented with
weakness and fatigability x 3 months
• Hb 13.4 gm/dl, WBC 220,000 ce...
Choice of first line therapy Feb 2013
1. Imatinib 400 mg OD
2. Imatinib 800 mg OD
3. Dasatinib 100 mg OD
4. Nilotinib 300 ...
Choice of first line therapy Feb 2013
1. Imatinib 400 mg OD
2. Imatinib 800 mg OD
3. Dasatinib 100 mg OD
4. Nilotinib 300 ...
Case History
• A 43-year old gentleman presented with
weakness and fatigability x 3 months
• Hb 13.4 gm/dl, WBC 220,000 ce...
Choice of first line therapy Feb 2013
1. Imatinib 400 mg OD
2. Imatinib 800 mg OD
3. Dasatinib 100 mg OD
4. Nilotinib 300 ...
Case History
• A 43-year old gentleman presented with
weakness and fatigability x 3 months
• Hb 13.4 gm/dl, WBC 220,000 ce...
Choice of first line therapy Feb 2013
1. Imatinib 400 mg OD
2. Imatinib 800 mg OD
3. Dasatinib 100 mg OD
4. Nilotinib 300 ...
Choice of first line therapy depends upon
1. Available finances/Full insurance
2. Side effect profile of the drugs
3. Co-m...
Choice of first line therapy depends upon
1. Available finances/Full insurance
2. Side effect profile of the drugs
3. Co-m...
Comparison of TKI
Favour Imatinib
• Cheaper
• Long-term experience
• Known side effect profile
• CCyR 70% at 1 year
• Less...
The patient was started on Imatinib
400 mg/day
Progress
• Achieved CHR by 2 months
• RQ PCR for BCR-ABL at 3 months 22% IS
What are the long-term chances of PFS of this
...
Progress
• Achieved CHR by 2 months
• RQ PCR for BCR-ABL at 3 months 12% IS
What are the long-term chances of PFS of this
...
The patient was started on Dasatinib
100 mg/day
Progress
• Achieved CHR by 2 months
• RQ PCR for BCR-ABL at 3 months 12% IS
What are the long-term chances of PFS of this
...
Thus with 2nd G TKI, you expect more
rapid response, may be CCyR at 3
months/BCR ABL <2% at 3months
Assessment at 6 -months
• Glivec 400 mg/day continued
• Hb 10.0 gm/dl MCV 102 WBC 3500 cells/mm3
Plat 100,000 cells/mm3
• ...
Current role of Allo HSCT
Conclusions
• Rapid advancement taking place in the field of
CML
• Availability of many drugs have made life easy
as well ...
CML-CASE BASED DISCUSSION
CML-CASE BASED DISCUSSION
CML-CASE BASED DISCUSSION
CML-CASE BASED DISCUSSION
CML-CASE BASED DISCUSSION
CML-CASE BASED DISCUSSION
CML-CASE BASED DISCUSSION
CML-CASE BASED DISCUSSION
CML-CASE BASED DISCUSSION
CML-CASE BASED DISCUSSION
CML-CASE BASED DISCUSSION
CML-CASE BASED DISCUSSION
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CML-CASE BASED DISCUSSION

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CML-CASE BASED DISCUSSION

  1. 1. Case based discussion Pankaj Malhotra PGIMER, Chandigarh, India
  2. 2. Case History • A 43-year old gentleman presented with weakness and fatigability x 3 months • Hb 13.4 gm/dl, WBC 220,000 cells/mm3, Plat 679000 cells/mm3 • Spleen 10 cm • BM: Hypercellular, 8% blasts, Ph 20/20 positive, Q RT PCR for BCR ABL mRNA 80% • Sokal High-risk
  3. 3. Case History • A 43-year old gentleman presented with weakness and fatigability x 3 months • Hb 13.4 gm/dl, WBC 220,000 cells/mm3, Plat 679000 cells/mm3 • Spleen 10 cm • BM: Hypercellular, 8% blasts, Ph 20/20 positive, Q RT PCR for BCR ABL mRNA 80% • Sokal High-risk • Availability of Imatinib/Dasatinib/Nilotinib
  4. 4. Choice of first line therapy Feb 2013 1. Imatinib 400 mg OD 2. Imatinib 800 mg OD 3. Dasatinib 100 mg OD 4. Nilotinib 300 mg BD 5. Nilotinib 400 mg BD 6. Bosutinib 500 mg OD Would Sokal high-risk score have impact on the choice of first line therapy?
  5. 5. Choice of first line therapy Feb 2013 1. Imatinib 400 mg OD 2. Imatinib 800 mg OD 3. Dasatinib 100 mg OD 4. Nilotinib 300 mg BD 5. Nilotinib 400 mg BD 6. Bosutinib 500 mg OD Does enough finances/insurance coverage impact on choice of first line therapy
  6. 6. Case History • A 43-year old gentleman presented with weakness and fatigability x 3 months • Hb 13.4 gm/dl, WBC 220,000 cells/mm3, Plat 679000 cells/mm3 • Spleen 10 cm • BM: Hypercellular, 8% blasts, Ph 20/20 positive, Q RT PCR for BCR ABL mRNA 80% • Sokal High-risk • Active coronary artery disease and AF
  7. 7. Choice of first line therapy Feb 2013 1. Imatinib 400 mg OD 2. Imatinib 800 mg OD 3. Dasatinib 100 mg OD 4. Nilotinib 300 mg BD 5. Nilotinib 400 mg BD 6. Bosutinib 500 mg OD Would active coronary artery disease & AF impacts your decision making?
  8. 8. Case History • A 43-year old gentleman presented with weakness and fatigability x 3 months • Hb 13.4 gm/dl, WBC 220,000 cells/mm3, Plat 679000 cells/mm3 • Spleen 10 cm • BM: Hypercellular, 8% blasts, Ph 20/20 positive, Q RT PCR for BCR ABL mRNA 80% • Sokal High-risk • Past history of pulmonary tuberculosis
  9. 9. Choice of first line therapy Feb 2013 1. Imatinib 400 mg OD 2. Imatinib 800 mg OD 3. Dasatinib 100 mg OD 4. Nilotinib 300 mg BD 5. Nilotinib 400 mg BD 6. Bosutinib 500 mg OD Would a past history of lung infection impacts your decision making?
  10. 10. Choice of first line therapy depends upon 1. Available finances/Full insurance 2. Side effect profile of the drugs 3. Co-morbid conditions of the patient 4. Phase of the disease(Acc or BC) 5. Sokal score (?)
  11. 11. Choice of first line therapy depends upon 1. Available finances/Full insurance 2. Side effect profile of the drugs 3. Co-morbid conditions of the patient 4. Phase of the disease(Acc or BC) 5. Sokal score (?) 6. Physician preference/Patient preference (?)
  12. 12. Comparison of TKI Favour Imatinib • Cheaper • Long-term experience • Known side effect profile • CCyR 70% at 1 year • Less effective • More than 100 mutations Favour 2nd G TKI • More effective • CCyR 80-85% • Fewer mutations (<10) • Costly • Post marketing surveillance suggest some unusual side effect • Fewer options if disease progress
  13. 13. The patient was started on Imatinib 400 mg/day
  14. 14. Progress • Achieved CHR by 2 months • RQ PCR for BCR-ABL at 3 months 22% IS What are the long-term chances of PFS of this gentleman? ( RQ PCR >10% at 3 months)? 1. High 2. Low
  15. 15. Progress • Achieved CHR by 2 months • RQ PCR for BCR-ABL at 3 months 12% IS What are the long-term chances of PFS of this gentleman? ( RQ PCR >10% at 3 months)? 1. High 2. Low
  16. 16. The patient was started on Dasatinib 100 mg/day
  17. 17. Progress • Achieved CHR by 2 months • RQ PCR for BCR-ABL at 3 months 12% IS What are the long-term chances of PFS of this gentleman? ( RQ PCR >10% at 3 months)? 1. High 2. Low
  18. 18. Thus with 2nd G TKI, you expect more rapid response, may be CCyR at 3 months/BCR ABL <2% at 3months
  19. 19. Assessment at 6 -months • Glivec 400 mg/day continued • Hb 10.0 gm/dl MCV 102 WBC 3500 cells/mm3 Plat 100,000 cells/mm3 • BM: Mild hypocellular • Cytogenetics 2/20 = MCyR • Q PCR 1% IS What is your assessment and would you consider change in your strategy?
  20. 20. Current role of Allo HSCT
  21. 21. Conclusions • Rapid advancement taking place in the field of CML • Availability of many drugs have made life easy as well as difficult both for the physician as well as the patient • Need to continue update our knowledge on CML on the basis of continuously emerging data
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