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Pregnancy and accelerated phase CML

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Francis Ssali
Topic Author

8 years 8 months ago #1090 by Francis Ssali

Pregnancy and accelerated phase CML was created by Francis Ssali

I have a patient who was in the accelerated phase at the onset of TKI therapy but subsequently became molecularly well controlled on glivec to <0.1%. She became pregnant and we stopped the TKI . She couldn’t afford the interferon therapy and had disease progression by BCR_ABL RT-PCR to 17% . She really wanted the pregnancy. She has had to go back to the TKI. How have others managed similar patients?

Jeff Lipton
Topic Author

8 years 8 months ago #1091 by Jeff Lipton

Replied by Jeff Lipton on topic Pregnancy and accelerated phase CML

I guess that I am fortunate to live in a system of socialized medicine where I can get coverage for the interferon so long as I have produced the necessary 5 km of paperwork. You do not specify when the recurrence happened during the pregnancy. There are individuals who believe that the TKI can be used during the third trimester and some even feel the second trimester. I must admit that I have a degree of discomfort with this, but it is an option. I cannot quote the risk if any, as the later stage of pregnancy develops. I have never had this situation. In a handful of cases where accidental pregnancy has occurred while on TKI, the patient has elected to terminate the pregnancy early and continue with the TKI. This is a case of AP CML an the risk of blast crisis is not trivial. I would favor termination of pregnancy if early and restarting TKI. If late in pregnancy, then add TKI and hope for no problems.

Ekaterina Chelysheva

8 years 8 months ago #1101 by Ekaterina Chelysheva

Replied by Ekaterina Chelysheva on topic Pregnancy and accelerated phase CML

We reinitiated TKIs starting from week 15th in cases when BCR-ABL was higher than 1%.
www.bloodjournal.org/content/126/23/5144

She has a significant chance to loose complete hematologic response in 3-4 months more as it was in some of our current cases. That woman should be informed very well about her risks.

ppanayi
Offline

8 years 7 months ago #1103 by ppanayi

Replied by ppanayi on topic Pregnancy and accelerated phase CML

Usually at diagnosis of CML in young ladies,we always start therapy with 2ed generation TKIs and we strongly advise them to wait for becoming pregnant ,only when MR4 has been obtained for at least 3 months. She can then conceive, (preferably assisted pregnancy/ in vitro fertilization of oocytes) and during that time and until delivery, we switch to aIFN 3 MU 3 times weekly sc, with monthly monitor of bcd-abl levels .
2) If the lady with CML is >40-45 yeas old and in chronic phase of the disease, we start IFNa and we urge her to start a program of in vitro fertilization of her oocytes and freezing of fertilized embryos. After that , we switch to 2ed generation TKI and wait for her programmed pregnancy until she has MR4 for minimum 3 months as previously

Panos Panagiotidis

jeff lipton
Topic Author

8 years 7 months ago #1104 by jeff lipton

Replied by jeff lipton on topic Pregnancy and accelerated phase CML

I may have missed the point of the last comment, but unless a woman is going to consider surrogate pregnancy, I do not see how assisted fertilization and oocyte preservation confers any advantage over normal pregnancy. It is important to remember that TKI therapy is not believed to be mutagenic, but rather teratogenic. Thus, regardless of the origin of the embryo, the woman needs to be off the TKI for a period of time not yet firmly established, while pregnant to prevent or reduce the possibility of spontaneous abortion or birth defect.

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