We have received the following case:
"I am a Haematologist at Peter MacCallum Cancer Centre, and would appreciate the iCMLf’s consideration of a difficult-to-treat, multiply resistant case of CML who is currently under my care. The case summary is as follows.
The patient has given her consent for this case to be put on the forum for discussion.
33 year old woman with CML diagnosed February 2009. Initial cytogenetics showed standard t(9;22), BCR-ABL 92%.
Imatinib was commenced at 400mg, poorly tolerated with fluid retention, nausea, weight gain, fatigue.
PCR after imatinib for 2 months was 23%.
PCR after imatinib for 7 months was 32%, with continuing poor tolerance.
Switched to Dasatinib on grounds of poor response to imatinib.
PCR after Dasatinib for 3 months was 16%.
PCR after Dasatinib for 5 months was 1.3%. Dasatinib intolerance with grade 4 somatic pain requiring narcotic analgesia.
Switched to Nilotinib.
PCR after Nilotinib for 3 months was 28%. Repeat at 3.5 months was 24%.
BMAT at this stage showed CML-chronic phase, Ph+ve in 41% cells, no clonal evolution. Negative for mutation testing.
Switched to Compassionate Access Bosutinib.
PCR after Bosutinib for 3 weeks was 12%. Severe intolerance with grade 3 nausea and grade 3-4 diarrhea despite maximum antinausea and antidiarrheals.
PCR after 7 weeks Bosutinib was 27%.
PCR after 11 weeks Bosutinib was 59% with rising white cell count to 30.9x10^9/L, no basophils, no splenomegaly.
BMAT at this stage confirms CML, likely early accelerated phase, cytogenetics pending.
Currently on hydroxyurea, white cell count now 17.0x10^9/L.
No sibling or matched unrelated donor available on national or international search. Patient is of Christian Lebanese origin.
A double cord unit has been identified however patient is reluctant to have cord blood transplant due to concerns regarding mortality and high risk of significant morbidity if she survives.
Her treating clinician is currently attempting to access compassionate use omacetaxine, awaiting in-vitro testing for ponatinib sensitivity which will take 3-4 weeks, and considering ponatinib study opening in 2-3 months time.
The questions for the forum include:
- - How hard to push for cord blood transplant.
- - Role of interferon in a young woman with history of poor tolerance to all available treatments so far.
- - Level of optimism regarding ponatinib response in the light of resistance to imatinib, nilotinib and bosutinib without a demonstrable mutation.
- - Level of optimism regarding omacetaxine.
- - Other options: arsenic trioxide? Induction chemotherapy?
Yours sincerely,
Dr Kirsten Herbert MD(Hons) BSci(Med) FRACP PhD
Haematologist, Peter MacCallum Cancer Centre
Locked Bag 1, A’Beckett St. Victoria 8006 AUSTRALIA"
Please find also attached the case which carries a table of previous diagnostics.
Attachment 2011_01_05_MD_Herbert___Case_presentation.pdf not found