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.
Dasatinib induced severe thrombocytopenia
I would appreciate your expert opinion regarding a 24-year-old patient with high-risk Sokal CML in the chronic phase. The patient was diagnosed in June 2026, with WBC 413, Hb 6.7 g/dL, platelets 607–870, massive splenomegaly (7 fingerbreadths below the costal margin), and BCR-ABL1 p210 of 55%. Dasatinib was initiated on 16/06/2026.
On 27/07/2026, the patient developed grade 4 pancytopenia (platelets 11, ANC 0.3), which resolved within 3 weeks after discontinuation. Dasatinib was restarted at 50 mg on 16/08/2026 (platelets 545, Hb 10.6, WBC 5.3) and increased to 100 mg on 23/08/2026. On 17/09/2026, platelets dropped to 84, so the dose was reduced to 50 mg. Treatment was stopped on 27/09/2026 when platelets further declined to 38.
Additional available information:
- Bone marrow histology: The initial bone marrow biopsy showed no fibrosis. A repeat bone marrow biopsy was performed during the episode of severe thrombocytopenia and revealed a hypocellular marrow with no significant fibrosis.
- Cytogenetics: Conventional cytogenetic analysis was not performed at diagnosis due to limited local resources.
- BCR::ABL1 transcript: The available report indicates BCR::ABL1 positivity 51% however, the exact transcript subtype was not specified.
The patient remains off treatment, with persistent severe thrombocytopenia. Latest CBC Hb 12.5 g/dL, WBC 4.6 /L, ANC 2.8 and platelets 17. There is no palpable splenomegaly currently. Smear showed severe thrombocytopenia bone marrow biopsy showed marked hypocellularity however, the specimen was small, and no megakaryocytes were identified.
I would appreciate your opinion regarding this isolate severe thrombocytopenia and the safest subsequent CML treatment strategy.