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Case #824
Chronic Myeloid Leukemia

A 72-year-old African American female with myeloid blast crisis CML

Release Date: October 30, 2009
Expiration Date: October 29, 2010

To Start Case:

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Chief Complaint

Fatigue, easy bruising, bleeding gums, fevers, night sweats, chills, and generalized bony aches

History of Present Illness

Mary returns for a follow-up visit to her hematologist with complaints of increased fatigue, easy bruising, fevers, night sweats, chills, and generalized body aches. Eighteen months ago, Philadelphia chromosome-positive (Ph[+]) bcr-abl-positive chronic myelogenous leukemia (CML) was diagnosed, and she was subsequently treated with imatinib, 400 mg/d, orally. She had failed to attain a complete cytogenetic response (CyR) at the 18-month follow-up and was deemed to have a primary resistance to imatinib. At that point, imatinib therapy was discontinued, and she received a nonmyeloablative allogenic transplant from her fully matched sister. She did well after the transplant and has not manifested signs of graft-versus-host disease (GVHD), but continued to have a persistently positive polymerase chain reaction (PCR) result for bcr-abl. Most recently, her transplant physician has suggested using imatinib. She presents to you for a follow-up visit.


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Disclosures and Important Information

Supported by an educational grant from Novartis Oncology.

Release Date: October 30, 2009

Expiration Date: October 29, 2010

Estimated time to complete this activity: 2.0 hours

Accreditation Statement

MedCases, LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education.

Credit Designation Statement

MedCases designates this educational activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Statement of Responsibility

MedCases takes responsibility for the content, quality, and scientific integrity of this CME activity.

Principal Faculty

Professor of Medicine
Deputy Chair, Department of Leukemia
University of Texas
MD Anderson Cancer Center
Houston, Texas

Independent Reviewer

Assistant Professor of Oncology and Medicine
Myeloma Program, Director
Sidney Kimmel Comprehensive Cancer Center
Johns Hopkins University
Baltimore, MD

Target Audience

This activity is intended for medical oncologists, hematologists, hematologist-oncologists, pathologists, and other allied healthcare professionals.

Prerequisites

There are no prerequisites.

Statement of Need

The treatment of chronic myelogenous leukemia (CML) continues to challenge healthcare providers and patients. Integration of recent therapeutic advances in CML management strategies requires careful consideration of patient-specific characteristics, physician expertise, clinician comfort with the newer therapies, and availability of health system resources. Potential barriers to optimizing CML therapy include rapid advancement in development of novel therapeutic agents, lack of physician awareness of the most recent clinical trial data, swiftly evolving treatment guidelines, reduced awareness of pharmacogenetics and the impact of new assays to monitor patients with CML, and concerns about management of potentially significant toxicities from the newer therapeutic agents. If optimal treatment of patients with CML is to be realized, these barriers must be overcome.

Objectives

After completing this activity, you should be able to:

Identify potential roles for second-generation bcr-abl tyrosine kinase inhibitors in patients with primary resistance to imatinib and coverting to blast phase (BP) CML
Explain the effects and implications of bcr-abl mutations and their effects on subsequent treatment approaches
Develop rational treatment strategies for patients who progress to blast phase (BP) CML

Method of Participation

This Internet-based activity takes approximately 2 hours to complete. You should review the objectives and cases, answer the multiple-choice posttest, and complete an evaluation form online. Once completed, you will be able to save your certificate to your own computer and print it on your own printer.

Disclosure Statement

As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is MedCases policy to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The following was reported:

Faculty
Jorge Cortes, MD	Grants/Research Support: Bristol-Myers Squibb Company, Novartis Pharmaceuticals, Wyeth

Independent Reviewer
Carol Ann Huff, MD	Advisory Board: Amgen Inc., Celgene Corporation Royalties: Syndax

Planning Committee

Dalia Mobarek, MD has indicated that she is on the Speakers' Bureau for Millenium Pharmaceuticals. Carolyn Darrow, MPH and Daryl Lynn Ehrentreu, RPh, MBA indicated that they have not received financial support for consultation, research, or, evaluation, or have a financial interest relevant to this online activity.

Notice of Off-Label Use Presentations

In accordance with US Food and Drug Administration (FDA) requirements regarding the disclosure of off-label, investigational, or unapproved recommendations for the use of drugs or devices, you are advised that content in this activity does not contain reference(s) to uses of drugs or devices that are off-label, investigational, or unapproved in the United States. The following information is provided for educational purposes and not to endorse off-label use.

Dasatinib followed by DLI is an off-label indication.

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Hardware/Software Requirements and Technical Assistance

This Web-based CME activity is best experienced using a current generation browser, such as Internet Explorer 5.5 or higher. This Web site requires that JavaScript and session cookies be enabled. In addition, you will require the Adobe Flash Player plugin to view the case simulation.

Detailed Requirements:

128 MB RAM
Windows 98 or newer
Adobe Flash Player 8 minimum needed
Audio playback with speakers for programs that have video content
Internet Explorer 5.5 or higher or Mozilla Firefox 1.0 or higher or Apple Safari
1024 x 768 resolution
Broadband connection highly recommended

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Confirmation

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