I would like to ask a few questions here:

1. Do we have baseline cardiac evaluation of the patient prior to start of Imatinib mesylate?

2. Why was the evaluation of cardiac functions done in 2006?

3. What are the other risk factors for cardiac dysfunction (e.g. Obesity, Abnormal lipids, Smoking etc.)

4. How was coronaries evaluated (by angiography or any other method)

5. What is cardiologist opinion regarding decrease in ejection fraction (is there any other explanation)?

6. Is decrease in cardiac ejection fraction documented by Echocardiography or by MUGA scan?

7. Unless a clear link is establised between Imatinib mesylate and ongoing cardiac dysfunction, stopping imatinib mesylate is experimetal and should be done with clear discussion with patient.

8. Since we are talking of experimental approaches, what is the role of maintenance IFN after stopping IFN?
(Burchert A et al. Sustained Molecular Response With Interferon Alfa Maintenance After Induction Therapy With Imatinib Plus Interferon Alfa in Patients With Chronic Myeloid Leukemia. JCO 2010; 28:1429-35)

Thanks and kind regards

I agree with Michele Baccarani and Tim. After a long period as the patient got it is feasible to stop Imatinib starting a close molecular monitoring as FISH as: anyway in may experience if the patient relapses, after such his long story, the response to imatinib will be prompt.
Best wishes

Hi Kerry,

I think the link between imaitnib and cardiac dysfunction is not so convincing given the large scale case reviews conducted over the past few years so I am not sure the deterioration is likely to be due to imatinib, but I agree it is possible. I presume he has been in complete molecular response for several years rather than MMR. If so you do have the option of stopping with very close PCR monitoring. Unfortunately only about 40% can stop and remain in CMR but you probably don't lose anything by trying. If he had a high Sokal score at diagnosis his chances of remaining in CMR off-therapy seem to be quite low based on the French study (recent Lancet Oncology paper) so his Sokal score may influence your decision.

The other consideration is switching to another TKI but if cardiac dysfunction is driven by ABL blockade this might actually lead to greater dysfunction. I am not sure there have been any animal studies or long term clinical studies to look at this question.

Regards
Tim

YES, I’d discontinue ther treatment, monitoring the BCR-ABL transcripts level monthly for 6 months, then every three months for another 12 months, then every 6 months, recommending to use peripheral blood, and to sample 20 ml of blood for each test.

Thank you, best regards, Michele Baccarani

would be interested in your opinion about the following case:

I have a patient, aged 54, with mild cardiomyopathy (fall in EF from 56% in 2006 to 45-50%, recent SVT and unremarkable coronary a’s) who has been on Glivec for 9 years (since 2001) and in molecular remission for most of the last 6 years. The patient has only had one positive molecular test in that time . This occurred in late 2008.

For other reasons (long-term skin issues) I had been contemplating cessation of Glivec and close molecular monitoring.

Would you stop the treatment and observe with freq. molecular monitoring

Many thanks for your consideration.