32 year old woman presents with high WBC and work up confirms CML chronic phase, int Sokal. She is 11 weeks pregnant and wishes to carry the baby to term. Patient is from China and is a hepatitis B carrier. Initial WBC is 147 with a standar chronic phase differential. Spleen is not palpable. After reviewing the options and the risks, she is start on leukopheresis as often as 4-5 times per week and over a period of about 2 months, WBC is brought down to between 10-15 and pheresis decreased to twice weekly. She requires red cell transfusions about 1-2 times per week initially. The patient is started on Pegasys 180mcg once weekly and leukopheresis is stopped for about a month, but is required about once every 2-3 weeks until abut month 7 when the blood counts stabilize in chronic phase. She delivers a healthy son and breast feeds for about 2 months, but her blood counts are unstable, but remain in chronic phase. Pegasys is increased to 360mcg weekly at about month 8. She realizes that the interferon is not generating even a hematologic remission and is started on dasatinib at 100mg daily and within 2 weeks is pancytopenic, but not transfusion dependent. Dasatinib is held now for about 4 weeks with blood counts slowly recovering. Plan is to restart at 50mg daily when they recover. First molecular assessment is pending. Nothing suggests disease progression.

Pass on your comments on management of CML during her pregnancy and post breast feeding. I expect that the prolonged cytopenia is because of the suppression of normal clonal hemopoiesis by CML and interferon. Bone marrow will be done if the pancytopenia persists.

... interesting and your comments are welcome.

I would guess that the pregnancy, the management of the pregnancy and the imperfect response to imatinib were quite unrelated. She must originally have had a poor reserve of Ph-negative stem cells. She may do well with judicious re-introduction of a TKI, preferably not dasatinib .