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Case based discussion

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 cells/mm3, Plat 679000 cells/mm3 Spleen 10 cm

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Case based discussion

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  1. Case based discussion PankajMalhotra PGIMER, Chandigarh, India

  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. 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. Choice of first line therapy Feb 2013 • Imatinib 400 mg OD • Imatinib 800 mg OD • Dasatinib 100 mg OD • Nilotinib 300 mg BD • Nilotinib 400 mg BD • Bosutinib 500 mg OD Would Sokal high-risk score have impact on the choice of first line therapy?

  5. Choice of first line therapy Feb 2013 • Imatinib 400 mg OD • Imatinib 800 mg OD • Dasatinib 100 mg OD • Nilotinib 300 mg BD • Nilotinib 400 mg BD • Bosutinib 500 mg OD Does enough finances/insurance coverage impact on choice of first line therapy

  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. Choice of first line therapy Feb 2013 • Imatinib 400 mg OD • Imatinib 800 mg OD • Dasatinib 100 mg OD • Nilotinib 300 mg BD • Nilotinib 400 mg BD • Bosutinib 500 mg OD Would active coronary artery disease & AF impacts your decision making?

  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. Choice of first line therapy Feb 2013 • Imatinib 400 mg OD • Imatinib 800 mg OD • Dasatinib 100 mg OD • Nilotinib 300 mg BD • Nilotinib 400 mg BD • Bosutinib 500 mg OD Would a past history of lung infection impacts your decision making?

  10. Choice of first line therapy depends upon • Available finances/Full insurance • Side effect profile of the drugs • Co-morbid conditions of the patient • Phase of the disease(Acc or BC) • Sokal score (?)

  11. Choice of first line therapy depends upon • Available finances/Full insurance • Side effect profile of the drugs • Co-morbid conditions of the patient • Phase of the disease(Acc or BC) • Sokal score (?) • Physician preference/Patient preference (?)

  12. Comparison of TKI FavourImatinib 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 • Cheaper • Long-term experience • Known side effect profile • CCyR 70% at 1 year • Less effective • More than 100 mutations

  13. The patient was started on Imatinib 400 mg/day

  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)? High Low

  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)? High Low

  16. The patient was started on Dasatinib 100 mg/day

  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)? High Low

  18. Thus with 2nd G TKI, you expect more rapid response, may be CCyR at 3 months/BCR ABL <2% at 3months

  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. Current role of Allo HSCT

  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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