Clinical Case Discussion Forum
To share and enhance best practice management of CML, experts and interested clinicians can discuss difficult or interesting CML cases here. Physicians submit a brief history of the patient and the case for discussion using this forum.
Challenging case
Male 20 yrs old, was on gleevec 600mg od, wcc57.94, hb14, plts 338 2019. Same dose follow up till June 2021, wcc 4.14 n2.42 hb 13 plts 149 gleevec decreased to 200mg od. Aug 2021wcc 3.32 n 1.97 hb11.6 plts 92, continues on gleevec 200mg od. On 17.09.2021, plts 32, no gleevec was transfused with plts. 08.10.2021 wcc 36.7 n56% hb9.1 plts 58, BMA done showed CML In blast crisis, blasts 40%. Received 1 dose of cytarabine 100mg. On 22.10.2021 wcc 15.24 ig17.8 hb10.1 plts 21, was transfused with plts. Stuck with way forward for this patient. Please advise.
We do not know if this blast crisis is lymphoid or myeloid. To know this as well as to search for mutations is essential to know which chemo and which TKI has to be used in combination (certainly not imatinib). If the mutation analysis cannot be performed Ponatinib 45mg a day is the best solution, to be associated with dexamethasone (at a dose of 20 mg per day)-If there is a persistent MRD positivity (measurable) I would consider Blinatumomab to reach at least MR4 or MR4.5, but allo SCT is always needed. If the BC is myeloid I would associated the ponatinib or at least dasatinib to the AML chemocycle that you use in AML. The goal in anycase is to reach a good remission (at least MMR, but deeper is always better) and then to move the patient to an allo transplant. More details are needed. and if you want you can write me directly.
If you do not have facilities to perform this kind of therapies, as Mauritius according to my knowledge is an extra European territory of France, the best option is to move the patient to France.