Managing Relapsed Chronic Myeloid Leukemia

Case: A Younger Patient With Relapsed CML

May 2013

• A 48-year-old female was diagnosed with CP-CML with a splenomegaly, 3.2 cm below the costal margin
• Laboratory values:
  • WBCs, 157,000/μL
  • HCT, 30% hematocrit
  • Platelets, 359,000/μL
  • Myeloblasts, 6%
• Bone marrow biopsy: Ph+ in 20/20 metaphases
• Q-PCR, showed a BCR-ABL1/ABL1 ratio of 176%
• The patient was started on dasatinib 100 mg; she achieved MMR after 6 months, and a deeper molecular remission (>MR4) after 12 months on therapy and remained in remission for 3 years

December 2016

• The patient complained of increasing fatigue and weight loss.
• Q-PCR showed a significant increase in BCR-ABL1 transcript ratio (to 50% IS)
• Bone marrow biopsy; 80% cellularity, 18/20 Ph+ metaphases
• Mutation testing showed the presence of T315I
• CBC WNL
• The patient was started on ponatinib 45 mg daily
• She developed grade 3 thrombocytopenia; the ponatinib dose was reduced to 30 mg daily

March 2017

• Cytogenetics, 3/20 Ph+ metaphases
• BCR-ABL1 transcript ratio, 5%

June 2017

• BCR-ABL1 transcript ratio, 0.75%.

October 2017

• BCR-ABL1 transcript ratio, 0.01% and no T315I mutation was detected