You Make the Call
Each month in “ You Make the Call ,” we pick a challenging clinical question submitted through the Consult a Colleague program and post the expert ’ s response , but we also want to know what you would do . Send in your response to next month ’ s clinical dilemma and see how your answer matches up to the expert ’ s in the next print issue .
This month , Ayalew Tefferi , MD , discusses managing a pregnant patient with chronic-phase ( CP ) chronic myeloid leukemia ( CML ).
TRAINING and EDUCATION
Clinical Dilemma :
I am treating a 20-year-old pregnant woman at seven weeks gestation who was found to have CP-CML . Her white blood cell count is 300,000 /µ L with less than 5 percent blasts . The patient would like to keep the pregnancy and understands the risks . Leukapheresis did not provide much reduction in her counts . She remains asymptomatic with a relatively stable peripheral blood picture . Options that I have been considering include interferon now and hydroxyurea or imatinib starting in the second trimester .
Expert Opinion
Ayalew Tefferi , MD Professor of Hematology / Oncology Mayo Clinic Rochester , MN
Thanks to tyrosine kinase inhibitors ( TKIs ), most patients with CP-CML can now look forward to a near-normal life span . Obviously , no one wants to undercut this by unnecessarily deferring or discontinuing treatment with TKI . And yet , such is the challenge for this young woman who is pregnant and may also expect to breastfeed .
None of the approved TKIs for use in CML are considered safe for pregnant patients or for those intending to have children . A limited number of studies have shown relatively little effect on fertility from TKI use in prospective parents , men or women . On the other hand , their use during pregnancy is not advised because these drugs harbor off-target kinase inhibitory properties that could be harmful to fetal development and usually cross the placental barrier . Although CML itself can lead to complications during pregnancy , delaying TKI treatment in CP-CML , for a few weeks or months , has not been shown to compromise ultimate disease outcome . Therefore , it is reasonable to either simply monitor asymptomatic patients without treatment or use alternative , pregnancy-safe drugs , such as interferon , to control disease symptoms until a TKI can safely be instituted . If the situation mandates cytoreductive intervention other than interferon , I suggest therapeutic leukapheresis during the first trimester and hydroxyurea during the second or third trimester , considering the latter ’ s track record of safety , compared with TKIs .
Additional points :
• Incidental discovery of pregnancy while on TKI treatment does not necessarily mandate therapeutic abortion .
• Interferon therapy , while safe for use during pregnancy and lactation , might not be required in asymptomatic patients who can be monitored without drug intervention .
• There is no hard evidence to support specific TKI recommendations for partners .
• Although not recommended , the use of TKIs during the second or third trimester of pregnancy is not absolutely contraindicated and might be necessary in certain circumstances .
Consult a Colleague Through ASH
Consult a Colleague is a service for ASH members that helps facilitate the exchange of information between hematologists and their peers . ASH members can seek consultation on clinical cases from qualified experts in 11 categories :
• Anemias
• Hematopoietic cell transplantation
• Hemoglobinopathies
• Hemostasis / thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström macroglobulinemia
• Myeloproliferative disorders
• Myelodysplastic syndromes
• Thrombocytopenias
Assigned volunteers (“ colleagues ”) will respond to inquiries within two business days ( either by email or phone ).
Have a puzzling clinical dilemma ? Submit a question , and read more about Consult a Colleague volunteers at hematology . org / Clinicians / Consult . aspx or scan the QR code .
REFERENCE Apperley J . Issues of imatinib and pregnancy outcome . J Natl Compr Canc Netw . 2009 ; 7:1050-8 .
Next Month ’ s Clinical Dilemma :
A 19-year-old woman had iron studies performed by her primary care physician . The results showed ferritin in the 250 ng / mL range , transferrin saturation of 38 percent , and normal liver function . Family history is remarkable for a maternal aunt with hemochromatosis , and genetic testing shows that she is homozygous for the C282Y mutation . She is gravida 0 . She has no menses because of her oral contraceptive method and eats no red meat . Her most recent labs showed normal liver function ; however , her iron studies showed a serum iron of 208 mg / dL , total iron-binding capacity of 268 mcg / dL , transferrin saturation of 78 percent , and ferritin 301 ng / mL . Would you start phlebotomy ? And what would you use to decide on frequency of therapy ? One hematologist told me to use transferrin saturation below 50 percent as a goal in premenopausal women .
How would you respond ? Email us at ashclinicalnews @ hematology . org . ●
* If you have a request related to a hematologic disorder not listed here , please email your recommendation to ashconsult @ hematology . org so it can be considered for addition in the future .
DISCLAIMER : ASH does not recommend or endorse any specific tests , physicians , products , procedures , or opinions , and disclaims any representation , warranty , or guaranty as to the same . Reliance on any information provided in this article is solely at your own risk .
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