Peer to peer: how the iCMLf Case Discussion Forum helps clinicians manage the toughest CML cases
Some CML cases do not follow the textbook. A patient presents with features that do not quite fit, a response that does not develop as expected, or a picture that raises more questions than answers. In these situations, having access to the collective experience of the global CML expert community can make a real difference to clinical decisions.
This is exactly what the iCMLf Clinical Case Discussion Forum is designed to offer. It gives clinicians anywhere in the world a place to share a difficult or unusual case and receive input from CML experts and peers within days. A recent discussion illustrates just how valuable this exchange can be.
A challenging case from Brazil
Dr Jacqueline Holanda de Souza shared the case of a 39 year old man diagnosed with chronic phase CML in mid 2025. Alongside the expected findings, his presentation included features that were unusual for CML alone: massive hepatosplenomegaly, ascites, marked peripheral oedema, and grade III myelofibrosis on marrow biopsy. His course was further complicated by intolerance to second generation TKIs, and allogeneic transplant had been deemed not feasible by the transplant team. Dr de Souza brought the case to the forum seeking expert advice on management.
A rapid, global expert response
Within hours, the case drew responses from clinicians across the world, including David Yeung (Australia), Delphine Réa (France), Jeff Lipton (Canada), Beppe Saglio (Italy), Katarina Slezakova (Slovakia), Akhil Ranjon Biswas (Bangladesh), Carolina Pavlovsky (Argentina), Nicholas Othieno-Abinya (Kenya) and Henry Ddungu (Uganda).
Despite their different settings, a clear consensus emerged. Several experts noted that massive hepatomegaly with ascites is highly unusual for CML alone, and that a second, independent process was likely at play. The discussion moved quickly from broad impressions to concrete, practical suggestions: confirm CML status with quantitative BCR::ABL1 monitoring; test for CALR and MPL mutations and consider NGS MPN testing to characterise the myelofibrosis; repeat imaging and marrow biopsy; and involve hepatology to investigate portal hypertension and possible primary liver disease. Colleagues also weighed in on the feasibility of transplant, the role of combination approaches, and access to later generation TKIs.
Just as importantly, the exchange was genuinely two way. Dr de Souza responded to questions, shared updated results and reported the evolving plan, including the decision to investigate an abdominal mass identified on imaging. The forum became a working conversation rather than a one-off answer.
The value of shared expertise
Cases like this show what the forum does best. It brings together a breadth of expertise that is rarely available in a major academic centre and it does so quickly, without cost, and regardless of where the treating physician is based. For clinicians in settings with limited access to subspecialist colleagues, this connection to the wider CML community is especially valuable. And for the experts who contribute, it is an opportunity to share knowledge that directly informs patient management.
How to get involved
The Clinical Case Discussion Forum is open to any clinician managing CML. You can submit a case for discussion, contribute your perspective to an existing case, or simply follow the conversations to learn from real world scenarios. Every case shared adds to a growing resource for the whole community.
We encourage you to take part. Your next difficult case could benefit from the insight of colleagues around the world and your experience could help another clinician facing a similar challenge.