1. Case based discussion
Pankaj Malhotra
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
1. Imatinib 400 mg OD
2. Imatinib 800 mg OD
3. Dasatinib 100 mg OD
4. Nilotinib 300 mg BD
5. Nilotinib 400 mg BD
6. 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
1. Imatinib 400 mg OD
2. Imatinib 800 mg OD
3. Dasatinib 100 mg OD
4. Nilotinib 300 mg BD
5. Nilotinib 400 mg BD
6. 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
1. Imatinib 400 mg OD
2. Imatinib 800 mg OD
3. Dasatinib 100 mg OD
4. Nilotinib 300 mg BD
5. Nilotinib 400 mg BD
6. 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
1. Imatinib 400 mg OD
2. Imatinib 800 mg OD
3. Dasatinib 100 mg OD
4. Nilotinib 300 mg BD
5. Nilotinib 400 mg BD
6. Bosutinib 500 mg OD
Would a past history of lung infection impacts your
decision making?

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

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

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

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

16. 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)?
1. High
2. Low

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)?
1. High
2. Low

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

21. 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)?
1. High
2. Low

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

28. 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?

31. Current role of Allo HSCT

33. 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