ASH Highlights in Asia ECHO -Chronic Myelogenous Leukemia

Marjorie Bravo, MD

St. Luke’s Medical Center

• Michael J. Mauro, MD – Memorial Sloan Kettering Cancer Center

• Jorge Cortes, MD – MD Anderson Cancer Center

• Neil P. Shah, MD – University of California

Case 1

• 57 y/o M business executive referred : abnormal CBC – WBC 121k with 8% basophils, 3% eosinophils, 2%

blasts – Hgb 12, platelets 650k, spleen 4cm below the costal

margin– PMH : hypertension, hyperlipidemia, +FH CAD

– BM performed, 90% cellular, myeloid hyperplasia, megakaryocytic hyperplasia, 1-2 % blasts, minimal basophilia; Karyotype 100% t(9:22), no other abnormalities

– His younger brother is an HLA identical match

Case 1 choices

• He has researched extensively and asks your thoughts on which is the best first therapy?

– Nilotinib 300mg BID

– Imatinib 400mg OD

– Dasatinib 100mg OD

– Allografting dirrectly

– Bosutinib 400mg OD

– Imatinib 600mg OD

Case 1 continued

• You and he decide to pursue one of the three TKIs FDA approved for front line use at standard dose. Initial qPCR revealed a level of 178% on the International scale (IS)

• Hematologic response with minimal myelosuppresionoccurs in month one. He feels well and returns at 3 mos. PB qPCR is repeated, and : – His level of 15% is inadequate and he should change

therapy

– His level of 15% may be adequate and he should be reassessed at 6 mos

– He should have waited until 6 mo for qPCR as 3 mo is too early

Case 1 continued further

• Given the degree of 3 mo transcript reduction, initial therapy continues and MMR is noted at 12 mo

• After 2 years of treatment he is noted to have a deep molecular response (MR4.5) that is then sustained without significant change through the next 2 years

• He heard in a chat room for CML about treatment free remission trials and he wants to know more

• Also he heard about a newer drug something called “ABL001”, and wants to know anything you can tell him about these.

Take Home Message

• Dasatinib may be a valid option at first line • There is benefit of monitoring patients earlier

than 3 months in order to optimize therapy • TKIs MAY BE STOPPED! But for a select group

of patients. • There are new agents on the horizon, which

may help us achieve better responses and hopefully cure.

Thank You!