Chapter 15. Leukemias
DT is a 34-year-old man who presents to the hospital presenting with fatigue and splenomegaly. A CBC is drawn and reveals the following: WBC 100 × 109 /L (8% blasts), 82% segs; hemoglobin/hematocrit (HgB/HCT) 8.9 g/dL/27%; platelets 80 × 109 /L. Bone marrow biopsy results: BCR-ABL positive. Which are indicated for chronic phase CML (CP-CML) in patient DT? Select all that apply.
a. Bosutinib 400 mg PO every day
b. Dasatinib 100 mg PO every day
c. Nilotinib 300 mg PO BID
d. Omacetaxine mepesuccinate 1.25 mg SQ BID for 14 consecutive days
Answer a is correct. Bosutinib is FDA-approved for newly diagnosed CP-CML.
Answer b is correct. Dasatinib is FDA-approved for newly diagnosed CP-CML.
Answer c is correct. Nilotinib is FDA-approved for adult and pediatric patients of 1 year or older with newly diagnosed CP-CML.
Answer d is incorrect. Omacetaxine mepesuccinate is indicated for CP or AP-CML with resistance and/or intolerance to two or more TKIs. Omacetaxine mepesuccinate is associated with prolonged cytopenias and is not a recommended option in frontline setting.
TC is a 60-year-old woman who presents to her local ER complaining of dyspnea and fatigue. She reports a 2-week history of worsening symptoms. Her laboratory results reveal the following:
white blood cell (WBC) 80 × 109/L, hemoglobin (HgB) 8.3 g/dL, platelets 53 × 109/L
Other notable: Left ventricular ejection fraction (LVEF) 60%
Bone marrow biopsy: 20% blasts, cytogenetics t(6;11)
Molecular studies: WT-CEPBA and NPM1, FLT3-ITD mutation positive
She is admitted to the hospital to initiate induction chemotherapy for acute myeloid leukemia (AML). Which of the following regimens is recommended?
a. Gilteritinib 120 mg PO every day
b. Infusional cytarabine (days 1-7) and midostaurin 50 mg PO BID
c. Infusional cytarabine (days 1-7) and daunorubicin (days 1-3) plus gemtuzumab ozogamicin (days 1,4, and 7)
d. Infusional cytarabine (days 1-7) and daunorubicin (days 1-3) plus midostaurin (days 8-21)
Answer d is correct. Given TC has FLT3 positive AML, study data has demonstrated improved survival with the addition of midostaurin in combination with infusional cytarabine and daunorubicin (7+3 chemotherapy). Patient’s cardiac function is normal, the addition of an anthracycline (daunorubicin) is recommended.
Answer a is incorrect. Single-agent gilteritinib (FLT3 inhibitor) is FDA-approved in relapsed or refractory AML with FLT3 mutation. This single-agent strategy is not recommended as initial AML induction therapy.