Chronic Myeloid Leukemia.doc

8/10/2019 Chronic Myeloid Leukemia.doc

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Chronic Myeloid Leukemia

Also called: Chronic granulocytic leukemia, Chronic myelogenous leukemia, CMLShare on facebook Share on twitterBookmark & SharePrinterfriendly !ersionSubscribe to

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Leukemiais cancer of the white blood cells# $hite blood cells hel% your body fight

infection# our blood cells form in your bone marrow# 'n leukemia, the bone marrow

%roduces abnormal white blood cells# (hese cells crowd out the healthy blood cells, makingit hard for blood to do its work# 'n chronic myeloid leukemia )CML*, there are too many

granulocytes, a ty%e of white blood cell#

Most %eo%le with CML ha!e a gene mutation )change* called the Philadel%hia

chromosome#

Sometimes CML does not cause any sym%toms# 'f you ha!e sym%toms, they may include:

+atigue

$eight loss

ight sweats

+e!er

Pain or a feeling of fullness below the ribs on the left side

(ests that e-amine the blood and bone marrow diagnose CML# (reatments include

chemothera%y, stem cell trans%lants, infusion of donated white blood cells following stemcell trans%lants, surgery to remo!e the s%leen, and biologic and targeted thera%ies# Biologic

thera%y boosts your body.s own ability to fight cancer# (argeted thera%y uses substancesthat attack cancer cells without harming normal cells#

'/: ational Cancer 'nstitute

0et Chronic Myeloid Leukemia u%dates by email

$hat.s this1

Start Hereo Chronic Myelogenous Leukemia )P23*: (reatment )ational Cancer

'nstitute*

o Also a!ailable in S%anish

o $hat 's Chronic Myeloid Leukemia1)American Cancer Society*
http://www.nlm.nih.gov/medlineplus/chronicmyeloidleukemia.htmlhttp://www.addthis.com/bookmark.php?pub=medlineplus&title=MedlinePlus%3A%20Trusted%20Health%20Information%20for%20Youhttp://www.nlm.nih.gov/medlineplus/chronicmyeloidleukemia.htmlhttp://www.nlm.nih.gov/medlineplus/feeds/topics/chronicmyeloidleukemia.xmlhttp://www.nlm.nih.gov/medlineplus/feeds/topics/chronicmyeloidleukemia.xmlhttp://www.nlm.nih.gov/medlineplus/leukemia.htmlhttp://www.nlm.nih.gov/medlineplus/listserv.htmlhttp://www.nlm.nih.gov/medlineplus/listserv.htmlhttp://www.cancer.gov/cancertopics/pdq/treatment/CML/patient/http://www.cancer.gov/espanol/pdq/tratamiento/leucemiamielogena/patienthttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-what-is-c-m-lhttp://www.nlm.nih.gov/medlineplus/chronicmyeloidleukemia.htmlhttp://www.nlm.nih.gov/medlineplus/chronicmyeloidleukemia.htmlhttp://www.addthis.com/bookmark.php?pub=medlineplus&title=MedlinePlus%3A%20Trusted%20Health%20Information%20for%20Youhttp://www.nlm.nih.gov/medlineplus/chronicmyeloidleukemia.htmlhttp://www.nlm.nih.gov/medlineplus/feeds/topics/chronicmyeloidleukemia.xmlhttp://www.nlm.nih.gov/medlineplus/feeds/topics/chronicmyeloidleukemia.xmlhttp://www.nlm.nih.gov/medlineplus/leukemia.htmlhttp://www.nlm.nih.gov/medlineplus/listserv.htmlhttp://www.cancer.gov/cancertopics/pdq/treatment/CML/patient/http://www.cancer.gov/espanol/pdq/tratamiento/leucemiamielogena/patienthttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-what-is-c-m-l


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o Also a!ailable in S%anish

Patient information: Chronic myeloid

leukemia (CML) in adults (Beyond theBasics)

Authors "obert S egrin,

M2 Charles A Schiffer, M2

Section 4ditor "ichard A

Larson, M2

2e%uty 4ditor "ebecca +

Connor, M2Ad by BlockTheAdApp.More Info |Hide These Ads

C/"5'C M4L5'2 L4674M'A 584"8'4$

Chronic myeloid leukemia )also called CML or chronic myelogenous leukemia* is a

chronic )longterm* disorder of the bone marrow# Bone marrow is the s%ongy, red tissuethat fills the large bones# All of the blood cells are %roduced in the bone marrow#

Peo%le with CML ha!e ac9uired an abnormality that causes a section of one chromosome

)a strand of genes* to break off and attach to another chromosome this results in an

abnormally short chromosome, known as the Philadel%hia chromosome# (his e-change ofgenetic information causes two genes, BC" and ABL, to fuse into one gene, called BC"

ABL#

(he BC"ABL gene causes bone marrow cells to %roduce an abnormal en;yme )the BC"

ABL tyrosine kinase* this en;yme stimulates white blood cells to grow out of control,

resulting in ele!ations of the white blood cell count and an increase in the si;e of thes%leen# 4!entually, the disease can transform into a more aggressi!e disease, called acute

leukemia#

Peo%le with acute leukemia ha!e an increased number of immature white blood cells)called blast cells*# (he o!ergrowth of blast cells leads to an inade9uate number of mature

white blood cells, which limits %roduction of other !ital blood cells, including red blood

cells and %latelets# /a!ing a decreased number of blood cells and %latelets can increase therisk of de!elo%ing infections or bleeding e-cessi!ely#

P/AS4S 5+ C/"5'C M4L5'2 L4674M'A

(here are three %hases of CML:

Chronic %hase < 'n the chronic %hase, there are less than = %ercent immature blast cells in

the bone marrow# A%%ro-imately >= %ercent of %eo%le are in the chronic %hase when theyare initially diagnosed# (his %hase generally lasts se!eral years and is readily controlled

with oral medications#
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Accelerated %hase < 2uring the accelerated %hase, maturation of white blood cells

becomes %rogressi!ely im%aired, and there are between ?@ and ? %ercent blast cells in theblood or bone marrow# (he number of abnormal cells in the body is more difficult to

control with medications, likely because of new mutations that de!elo% in the blast cells#

Blast %hase < 'n blast crisis )blast %hase*, there are more than @ to @ %ercent blast cellsin the blood or bone marrow# Before recent ad!ances in treatment, blast crisis ty%icallyoccurred within four to fi!e years after diagnosis and was often unres%onsi!e to treatment#

C/"5'C M4L5'2 L4674M'A ("4A(M4( 5P('5S

(reatment decisions for %eo%le with chronic myeloid leukemia )CML* are com%le- due to

the !ariety of a!ailable o%tions# Currently, the most fre9uently used treatment o%tions

include:

D2isease control with oral tyrosine kinase inhibitors )(7's* such as imatinib )brand name:

0lee!ec*, dasatinib )brand name: S%rycel*, or nilotinib )brand name: (asigna*

DPotential cure with hemato%oietic cell trans%lantation )also called bone marrow

trans%lantation*, usually after the disease sto%s res%onding or rela%ses during treatment witha (7'

D(reatment to reduce sym%toms with chemothera%y )hydro-yurea, busulfan, or interferon

al%ha with or without cytarabine*

(he choice of thera%y de%ends u%on the %hase of CML, the a!ailability of a stem celldonor, the %atient.s candidacy for stem cell trans%lantation, and the %atient.s %reference#

"es%onse to treatment < (he %rimary goal of treatment is to reduce or eliminate the cells

with the abnormal Philadel%hia chromosome# (his is measured as the cytogeneticresponse# Such treatment, if effecti!e, will also return the blood counts to normal# (his ismeasured as the hematologic response#

$hile achie!ing a hematologic res%onse will reduce the se!erity of sym%toms associated

with CML, %rogression to the accelerated or blast %hase will continue unless a cytogenetic

res%onse is achie!ed# Achie!ing a hematologic res%onse is im%ortant, but does not ensurethat the disease is ade9uately controlled#

Another way to determine how well the disease is controlled is to %erform sensiti!e

molecular testing# A %erson is said to ha!e a com%lete molecular responsewhen there is no

e!idence of the BC"ABL gene# (he goal of hemato%oietic cell trans%lantation is toachie!e this le!el of res%onse# A molecular res%onse is sometimes seen during longer term

follow u% of %eo%le treated with (7's# Chemothera%y rarely, if e!er, %roduces such a

res%onse#

("5S'4 7'AS4 '/'B'(5"S )(7's*


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(he Philadel%hia chromosome, characteristic of chronic myeloid leukemia )CML*, gi!es

rise to the formation of a uni9ue gene %roduct, an abnormal en;yme called the BC"ABLtyrosine kinase# "esearchers directed their efforts at de!elo%ing com%ounds that could

selecti!ely inhibit this abnormal en;yme, resulting in the de!elo%ment of a class of

medications known as tyrosine kinase inhibitors )(7's*# (7's slow or sto% the actions of

BC"ABL, which leads to the ra%id death of cells containing the abnormal Philadel%hiachromosome# ormal cells suffer fewer to-ic effects from (7's com%ared with traditional

chemothera%y treatments#

Although they ha!e not been %ro!en to cure the disease, (7's are able to achie!e longterm

control of CML in the maEority of %eo%le thus, they ha!e become the initial treatment ofchoice for almost all %eo%le who are newly diagnosed with CML# All of the a!ailable (7's

are able to induce hematologic and cytogenetic res%onses in all stages of the disease F?G#

As a result, a choice among these medications is usually based u%on the %atient.s medicalhistory and the %otential side effects of each medication )table ?*#

Many %rescri%tion and non%rescri%tion medications can interact with (7's, %otentiallymaking the treatment less effecti!e or dangerously increasing the amount of drug in the

bloodstream# (wo non%rescri%tion medications that should be a!oided are acetamino%hen)brand name: (ylenol* and St# Hohn.s wort )also called hy%ericum %erforatum*# 0ra%efruit

Euice should also be a!oided#

'matinib )brand name: 0lee!ec* < 'matinib mesylate is a (7' that can be used in %eo%le

with all %hases of CML# 't is %ro!en to ha!e significant benefits# 5ne study com%aringimatinib !ersus interferon %lus cytarabine )a form of chemothera%y* for %eo%le with newly

diagnosed, chronic %hase CML found that I %ercent of %eo%le who were gi!en imatinib

had a com%lete hematologic res%onse rate, and IJ %ercent achie!ed a com%lete cytogeneticres%onse F?G#

+urther followu% is needed to determine how long res%onses will last, although the rela%se

rate has been remarkably low in %eo%le followed for se!en or more years who achie!ed a

com%lete cytogenetic res%onse# At %resent, e-%erts recommend continuing imatinibtreatment indefinitely because the disease recurs, often within months, in the maEority of

%eo%le who sto% taking it# Progression to blast crisis can occur des%ite imatinib treatment in

%eo%le with accelerated %hase disease and in those who ac9uire new genetic mutations#

(he medication should be taken by mouth once daily, with a meal and a large glass ofwater#

't is e-tremely im%ortant to take e!ery single scheduled dose of your imatinib# Ski%%ing

%ills can seriously Eeo%ardi;e your chances of ha!ing a good res%onse# 5ne study showedthat you need to take o!er @ %ercent of your %ills to ha!e a chance of a sustained com%lete

res%onse FKG# )See (reatment of chronic myeloid leukemia in chronic %hase after failure of

initial thera%y, section on ."esistance.#*
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Side effects < 'matinib is generally !ery well tolerated most side effects are mild to

moderate and do not cause the %erson to sto% taking it# Less than = %ercent of %eo%le will beunable to tolerate longterm treatment with imatinib#

Common side effects include:

Dausea and !omiting, although this is not usually a %roblem when the drug is taken with

meals#

D2iarrhea is usually mild to moderate, but can be se!ere# 't generally res%onds to treatmentwith lo%eramide )brand name: 'modium*#

DMuscle cram%s are %erha%s the most bothersome longterm sym%tom associated with

imatinib, most commonly affecting the cal!es, feet, and hands# (here is no definiti!e

treatment, although some %eo%le benefit from treatment with calcium or magnesiumsu%%lements#

DSkin rash is uncommon# $hen it occurs, it is usually mild and often resol!es with

continued treatment#

DBreast enlargement )gynecomastia* may occur in a small number of men#

DMild anemia, which manifests as fatigue or listlessness, is not uncommon in %eo%le whouse imatinib for long %eriods#

DSome %atients note mild to moderate fatigue#

Pregnancy < $omen and men who take imatinib usually ha!e no increased difficultyachie!ing %regnancy# /owe!er, the risk of miscarriage and birth defects while taking

imatinib is uncertain# (hus, men and women who take imatinib are strongly ad!ised to usea birth control method during treatment#

$omen who take imatinib and become %regnant are left with a difficult choice:

DContinuing imatinib may result in damage to the de!elo%ing fetus#

DSto%%ing imatinib may allow CML to rela%se in the mother#

'n one series of women e-%osed to imatinib during %regnancy, =@ %ercent deli!ered ahealthy baby, > %ercent elected to ha!e a termination, ?K %ercent had a miscarriage, and

a%%ro-imately ?@ %ercent had a baby with a birth defect F=G# 'n addition, imatinib is %assed

into breast milk, and breastfeeding women are ad!ised to a!oid imatinib# $omen whobecome %regnant while taking imatinib should s%eak with their healthcare %ro!ider as soon

as %ossible#
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2asatinib )brand name: S%rycel* < 2asatinib is a second generation (7' that may be

recommended for treatment of CML after imatinib# 't can also be used as initial treatmentinstead of imatinib# 't is taken by mouth once or twice daily#

Side effects < 6% to = %ercent of %eo%le who take dasatinib for ad!anced %hase CML can

de!elo% a %leural effusion, a collection of fluid in s%ace between the lining of the lung )the%leura* and the chest wall# 'n some cases, this com%lication re9uires a reduction in the doseof dasatinib, a tem%orary break in treatment, or a %rocedure to drain the fluid# Pleural

effusions occur in a%%ro-imately ?@ %ercent of %atients treated with dasatinib in chronic

%hase and generally tend to be of less clinical se!erity than in %atients with ad!anced CML#

"arely, %atients ha!e de!elo%ed %ulmonary hy%ertensionhigh blood %ressure in the blood!essels that carry blood to the lungs# Pulmonary hy%ertension causes %eo%le to ha!e trouble

breathing and to feel !ery tired#

$omen who are %regnant or breastfeeding should not use dasatinib due to the %otential risk

of harm to the infant men and women are strongly encouraged to use a birth controlmethod during treatment#

ilotinib )brand name: (asigna* < ilotinib is another second generation (7' that may be

recommended for treatment of CML after imatinib# 't can also be used as initial treatment

instead of imatinib# 't should be taken by mouth on an em%ty stomach )one hour before ortwo hours after eating* e!ery ? hours taking the medication with food can lead to

e-cessi!e amounts of the drug in the bloodstream and is not recommended#

Side effects < (he most common side effects of nilotinib include rash, itching, nausea, and

consti%ation# An abnormal heart rhythm, known as 3( %rolongation, is a %otential sideeffect of both dasatinib and nilotinib# 3( %rolongation can %otentially cause sudden cardiac

death, although this com%lication is !ery rare# Peo%le who ha!e an electrolyte imbalance

)low blood le!el of %otassium or magnesium*, an abnormal heart rhythm, or who takemedication to regulate their heart rhythm should talk with their doctor about the need for

additional monitoring while taking dasatinib or nilotinib#

(here is a higher rate of cardio!ascular com%lications in %atients recei!ing nilotinib

com%ared with those recei!ing imatinib, %articularly in indi!iduals with cardio!ascular riskfactors )high blood %ressure, high blood cholesterol, diabetes , smokers*# (hese

com%lications include stroke, heart attacks, and sym%toms related to decreased blood flow

to the legs# (he latter is called %eri%heral artery disease and can cause leg %ain that getsworse with acti!ity# Muscle %ain that gets worse with acti!ity and im%ro!es with rest is

called claudication#

$omen who are %regnant or breastfeeding should not use nilotinib men and women are

strongly encouraged to use a birth control method during treatment#

Bosutinib )brand name: Bosulif* < Bosutinib is another (7' that may be recommended for

treatment of CML after failure of another (7'# 't should be taken daily by mouth with food#

MaEor side effects include diarrhea, abnormalities in li!er function tests, and nausea and
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!omiting# Some %atients ha!e fluid retention# +luid retention includes swelling in the legs

)called edema* and fluid around the lungs )called %leural effusion*# $omen who are%regnant or breastfeeding should not use bosutinib men and women are strongly

encouraged to use a birth control method during treatment#

Ponatinib )brand name: 'clusig* < Ponatinib is another (7' that may be recommended fortreatment of CML that has rela%sed or is unres%onsi!e to treatment with other (7's# 't isthe only (7' that is acti!e in CML with certain mutations )eg, (?='*# 2ue to concerns

regarding dangerous side effects, %onatinib is reser!ed for use in %atients who are not

candidates for other (7's# Potentially lifethreatening side effects include cardio!ascular

%roblems )stroke, heart attack, %eri%heral artery disease*, inflammation of the %ancreas)%ancreatitis*, and li!er failure# $omen who are %regnant or breastfeeding should not use

%onatinib men and women are strongly encouraged to use a birth control method during

treatment#

'f the tyrosine kinase inhibitor fails < Peo%le who cannot tolerate, fail to res%ond, or sto%

res%onding to an initial (7' are faced with the decision of what treatment to try ne-t# (heo%tions include:

DControl the disease with another (7', and then %roceed as soon as %ossible withhemato%oietic cell trans%lantation#

DControl the disease with another (7' with %lans to %roceed with trans%lantation if the

disease rela%ses a second time#

D'f the disease rela%ses des%ite treatment with another (7' and trans%lantation is not an

o%tion, treatment with interferon al%ha can hel% to reduce sym%toms and %rolong sur!i!al#)See .'nterferon al%ha.below#*

"ela%ses during treatment with a (7' are often due to the de!elo%ment of a new mutation

in the BC"ABL gene, which allows the disease to become resistant to treatment# (esting todetermine whether additional mutations ha!e de!elo%ed in the BC"ABL gene )called

mutation analysis* can be %erformed# Some mutations )eg, (?='* will not res%ond to

commonly a!ailable tyrosine kinase inhibitors )imatinib, dasatinib, or nilotinib* %eo%le

with these mutations are generally encouraged to consider trans%lantation# )See./emato%oietic cell trans%lantation.below#*

'f trans%lantation is not an o%tion, o%tions include treatment with omaceta-ine )brand

name: Synribo*, %onatinib, or enrollment on a clinical trial# 5maceta-ine is a chemothera%y

that can be gi!en as an inEection under the skin daily for two weeks and re%eated e!ery fourweeks for a ma-imum of si- cycles# Side effects include infection, diarrhea, nausea, fe!er,

and fatigue# )See .Ponatinib )brand name: 'clusig*.abo!e and .Clinical trials.below#*

A maEor cause of treatment failure is %oor com%liance with taking the medication,meaning the %atient has been ski%%ing doses or not taking the medication as directed#

(herefore, it is critical that the doctor be certain that the %atient was actually taking the (7'

treatment before switching thera%ies#
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/4MA(5P5'4('C C4LL ("ASPLA(A('5

'n hemato%oietic cell trans%lantation )%ronounced heemahtoh%oy4(ick*, also referred

to as bone marrow trans%lantation or stem cell trans%lantation, the %atient.s diseased bonemarrow )hemato%oietic* cells are re%laced with healthy ones from a donor# )SeePatient

information: Bone marrow trans%lantation )stem cell trans%lantation* )Beyond theBasics*#*

Choice of donor < (he donor is a %erson other than the %atient this is called an allogeneic

transplant# Allogeneic trans%lants can come from a relati!e )eg, sibling* or from an

unrelated donor# $ithin a family, the best chance for a match comes from siblings who

ha!e the same %arents as the %atient# 4ach sibling has a one in four chance of matching anindi!idual %atient# Since many %eo%le do not ha!e a sibling who matches, unrelated donors

may be used# "elated or unrelated donors who are fully /LAmatched are %referred# 6nder

some circumstances, %artially or halfmatched )ha%loidentical* donors can be used#

'n chronic myeloid leukemia )CML*, the chances of success with hemato%oietic celltrans%lantation are directly related to the %hase of disease at the time of the trans%lant# 'n

the %ast, trans%lantation of %eo%le in chronic %hase within the first year resulted in the best

outcomes# Se!eral studies ha!e suggested that treatment with a tyrosine kinase inhibitor)(7'* %rior to trans%lantation does not reduce the chance that trans%lantation will be

successful, although additional studies are needed to confirm this finding#

'f a matched sibling donor can be found, =@ to >= %ercent of %eo%le with CML trans%lanted

in the first or second chronic %hase of their disease achie!e longterm remissions# 2iseasefree sur!i!al falls to @ to K@ %ercent in %eo%le trans%lanted in the accelerated %hase, and to

?@ to @ %ercent in %eo%le trans%lanted in blast %hase#

A %atient.s age has a maEor influence on the outcome after trans%lantation with cells from a

sibling donor# 'n the subgrou% of %eo%le under age =@ who undergo this %rocedure duringthe first year of diagnosis, I@ to >= %ercent will be ali!e and free of disease fi!e years later#

/owe!er, %eo%le u% to J@ years of age ha!e successfully undergone allogeneic

trans%lantation with treatments that com%letely destroy the bone marrow )myeloablati!etreatment*# (he de!elo%ment of reduced intensity regimens, which ha!e reduced to-icity,

has %ermitted e!en older %eo%le to be successfully trans%lanted#

"ela%se after trans%lant < "ela%se or recurrence of CML may occur if cells containing the

Philadel%hia chromosome remain after the trans%lant %rocedure# /owe!er, finding residualdisease with sensiti!e molecular tests in the first si- months following trans%lantation is notassociated with e!entual rela%se because the antitumor effects of the graft may e!entually

%re!ail#

"ela%se can be treated with a (7' or with infusions of leukocytes from the original donor,with the ho%e of mounting a more effecti!e graft!ersustumor effect# 2onor leukocyte

infusions )2L's* can be e-tremely effecti!e, and remissions attained after 2L' a%%ear to be

9uite durable# /owe!er, graft!ersushost disease, and in some instances graft failure, maycom%licate 2L'#
http://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_link


9/24

24C'2'0 B4($44 ("ASPLA(A('5 A2 A ("5S'4 7'AS4

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'nitial treatment with a tyrosine kinase inhibitor )(7'* is welltolerated and effecti!e for atleast eight years in most %eo%le with chronic %hase chronic myeloid leukemia )CML*#

Successful allogeneic trans%lantation can %roduce longterm su%%ression of CML with a!ery low chance of rela%se because such %eo%le ha!e a molecular, cytogenetic, andhematologic res%onse#

/owe!er, trans%lantation has some %otentially serious risks, including graft!ersushost

disease and e!en death# $hile there ha!e not been any randomi;ed clinical trials directly

com%aring (7's with hemato%oietic cell trans%lantation in %eo%le newly diagnosed withchronic %hase disease, most e-%erts recommend initial treatment with a (7', reser!ing

trans%lantation for ifwhen the disease rela%ses#

(rans%lantation may be recommended as a %art of the initial treatment in %eo%le who are

diagnosed with accelerated or blast %hase disease# 0i!ing chemothera%y or a (7' %rior totrans%lantation )to achie!e chronic %hase* is %referable to trans%lanting during the blast

%hase the chance of a cure is greater when trans%lantation is done during the chronic %hase#

'(4"+4"5 ALP/A

'nterferon al%ha )'+a, brand name: Pegasys* was commonly used in the %ast for treatmentof chronic myeloid leukemia )CML*# 'n u% to @ %ercent of %eo%le, interferon can induce a

hematologic res%onse, im%ro!e sym%toms, and reduce or eliminate enlargement of the

s%leen )s%lenomegaly*# /owe!er, tyrosine kinase inhibitors )(7's* are clearly su%erior to

'+a in studies com%aring the two treatments#

As a result, interferon is considered to be a %alliati!e treatment for CML since it is not

curati!e and only rarely results in a %rolonged com%lete cytogenetic res%onse# A %atient

who cannot tolerate (7's might be offered '+a with or without another chemothera%ymedication, cytarabine#

Side effects < Side effects are a maEor %roblem with '+a, and include fe!er, chills, and

flulike sym%toms# (y%ically, the drug is started at a relati!ely low dose three days %er

week and then slowly increased# '+a must be inEected, and many %eo%le %refer to taketheir inEection at night along with acetamino%hen )brand name: (ylenol* and an

antihistamine such as di%henhydramine )brand name: Benadryl* to minimi;e the side

effects#

"4C5MM42A('5S +5" ("4A(M4( 5+ C/"5'C M4L5'2 L4674M'A

(he treatment of chronic myeloid leukemia )CML* is com%le-, and the o%timal treatment isa source of considerable debate# (herefore, consultation with a %hysician familiar with the

latest data is critical#


10/24

D(yrosine kinase inhibitors )(7's* are %referred by most healthcare %ro!iders and %eo%le,

and an e-%ert %anel has recommended their use as the initial treatment for %eo%le withnewly diagnosed chronic %hase CML#

DAllogeneic hemato%oietic cell trans%lantation remains the only treatment that is known to

cure CML# Peo%le who rela%se during treatment with a (7' should discuss this o%tion indetail with their %hysician# )See .'f the tyrosine kinase inhibitor fails.abo!e#*

DBecause rela%ses occur fre9uently in %eo%le with accelerated %hase CML and in !irtuallyall %eo%le with blast %hase CML who are treated with a (7', allogeneic trans%lantation

should be considered when %ossible, %referably after the %erson.s disease has res%onded to

the (7'#

CL''CAL ("'ALS

Many %eo%le with chronic myeloid leukemia )CML* will be asked about enrolling in a

clinical )research* trial# A clinical trial is a carefully controlled way to study theeffecti!eness of new treatments or new combinations of known thera%ies# Ask yourhealthcare %ro!ider for more information, or read about clinical trials at:

Dational Cancer 'nstitute

)www#cancer#go!clinicaltrials*

Dational Library of Medicine

)htt%:clinicaltrials#go!*

$/4"4 (5 04( M5"4 '+5"MA('5

our healthcare %ro!ider is the best source of information for 9uestions and concernsrelated to your medical %roblem#

(his article will be u%dated as needed on our website )www#u%todate#com%atients*#

"elated to%ics for %atients, as well as selected articles written for healthcare %rofessionals,

are also a!ailable# Some of the most rele!ant are listed below#

Patient le!el information < 6%(o2ate offers two ty%es of %atient education materials#

(he Basics < (he Basics %atient education %ieces answer the four or fi!e key 9uestions a

%atient might ha!e about a gi!en condition# (hese articles are best for %atients who want a

general o!er!iew and who %refer short, easytoread materials#

Patient information: Leukemia in adults )(he Basics*Patient information: Chronic myeloid leukemia )CML* )(he Basics*

Patient information: eutro%enia and fe!er in %eo%le being treated for cancer )(he Basics*
http://www.uptodate.com/contents/chronic-myeloid-leukemia-cml-in-adults-beyond-the-basics?view=print#H12http://www.cancer.gov/clinicaltrials/http://clinicaltrials.gov/http://www.uptodate.com/patientshttp://www.uptodate.com/contents/leukemia-in-adults-the-basics?source=see_linkhttp://www.uptodate.com/contents/chronic-myeloid-leukemia-cml-the-basics?source=see_linkhttp://www.uptodate.com/contents/neutropenia-and-fever-in-people-being-treated-for-cancer-the-basics?source=see_linkhttp://www.uptodate.com/contents/chronic-myeloid-leukemia-cml-in-adults-beyond-the-basics?view=print#H12http://www.cancer.gov/clinicaltrials/http://clinicaltrials.gov/http://www.uptodate.com/patientshttp://www.uptodate.com/contents/leukemia-in-adults-the-basics?source=see_linkhttp://www.uptodate.com/contents/chronic-myeloid-leukemia-cml-the-basics?source=see_linkhttp://www.uptodate.com/contents/neutropenia-and-fever-in-people-being-treated-for-cancer-the-basics?source=see_link


11/24

Beyond the Basics < Beyond the Basics %atient education %ieces are longer, more

so%histicated, and more detailed# (hese articles are best for %atients who want inde%thinformation and are comfortable with some medical Eargon#

Patient information: Bone marrow trans%lantation )stem cell trans%lantation* )Beyond the

Basics*

Professional le!el information < Professional le!el articles are designed to kee% doctors

and other health %rofessionals u%todate on the latest medical findings# (hese articles arethorough, long, and com%le-, and they contain multi%le references to the research on which

they are based# Professional le!el articles are best for %eo%le who are comfortable with a lot

of medical terminology and who want to read the same materials their doctors are reading#

Cellular and molecular biology of chronic myeloid leukemiaClinical manifestations and diagnosis of chronic myeloid leukemia

Clinical use of tyrosine kinase inhibitors for chronic myeloid leukemia

0enetic abnormalities in hematologic and lym%hoid malignancies/emato%oietic cell trans%lantation in chronic myeloid leukemia

'nitial treatment of chronic myeloid leukemia in chronic %hase

'nterferon al%ha for the treatment of chronic myeloid leukemiaMolecular genetics of chronic myeloid leukemia

5!er!iew of the myelo%roliferati!e neo%lasms

5!er!iew of the treatment of chronic myeloid leukemia

(reatment of chronic myeloid leukemia in accelerated %hase(reatment of chronic myeloid leukemia in blast crisis

(reatment of chronic myeloid leukemia in chronic %hase after failure of initial thera%y

(he following organi;ations also %ro!ide reliable health information#

Dational Library of Medicine

)www#nlm#nih#go!medline%lushealthto%ics#html*

Dational Cancer 'nstitute

)www#cancer#go!*

DAmerican Cancer Society

)www#cancer#org*

D(he Leukemia & Lym%homa Society

)www#leukemialym%homa#org*

Dational Marrow 2onor Program
http://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/cellular-and-molecular-biology-of-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/clinical-use-of-tyrosine-kinase-inhibitors-for-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/genetic-abnormalities-in-hematologic-and-lymphoid-malignancies?source=see_linkhttp://www.uptodate.com/contents/hematopoietic-cell-transplantation-in-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/initial-treatment-of-chronic-myeloid-leukemia-in-chronic-phase?source=see_linkhttp://www.uptodate.com/contents/interferon-alpha-for-the-treatment-of-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/molecular-genetics-of-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/overview-of-the-myeloproliferative-neoplasms?source=see_linkhttp://www.uptodate.com/contents/overview-of-the-treatment-of-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/treatment-of-chronic-myeloid-leukemia-in-accelerated-phase?source=see_linkhttp://www.uptodate.com/contents/treatment-of-chronic-myeloid-leukemia-in-blast-crisis?source=see_linkhttp://www.uptodate.com/contents/treatment-of-chronic-myeloid-leukemia-in-chronic-phase-after-failure-of-initial-therapy?source=see_linkhttp://www.nlm.nih.gov/medlineplus/healthtopics.htmlhttp://www.cancer.gov/http://www.cancer.org/http://www.leukemia-lymphoma.org/http://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/bone-marrow-transplantation-stem-cell-transplantation-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/cellular-and-molecular-biology-of-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/clinical-use-of-tyrosine-kinase-inhibitors-for-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/genetic-abnormalities-in-hematologic-and-lymphoid-malignancies?source=see_linkhttp://www.uptodate.com/contents/hematopoietic-cell-transplantation-in-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/initial-treatment-of-chronic-myeloid-leukemia-in-chronic-phase?source=see_linkhttp://www.uptodate.com/contents/interferon-alpha-for-the-treatment-of-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/molecular-genetics-of-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/overview-of-the-myeloproliferative-neoplasms?source=see_linkhttp://www.uptodate.com/contents/overview-of-the-treatment-of-chronic-myeloid-leukemia?source=see_linkhttp://www.uptodate.com/contents/treatment-of-chronic-myeloid-leukemia-in-accelerated-phase?source=see_linkhttp://www.uptodate.com/contents/treatment-of-chronic-myeloid-leukemia-in-blast-crisis?source=see_linkhttp://www.uptodate.com/contents/treatment-of-chronic-myeloid-leukemia-in-chronic-phase-after-failure-of-initial-therapy?source=see_linkhttp://www.nlm.nih.gov/medlineplus/healthtopics.htmlhttp://www.cancer.gov/http://www.cancer.org/http://www.leukemia-lymphoma.org/


12/24

)www#marrow#org*

DAmerican Society of Clinical 5ncology

)www#cancer#net%ortalsite%atient*

F?,JG

Literature re!iew current through: May @?K# N (his to%ic last u%dated: feb ?@, @?K#(he content on the 6%(o2ate website is not intended nor recommended as a substitute for

medical ad!ice, diagnosis, or treatment# Always seek the ad!ice of your own %hysician or

other 9ualified health care %rofessional regarding any medical 9uestions or conditions# (heuse of this website is go!erned by the 6%(o2ate (erms of 6seO@?K 6%(o2ate, 'nc#

"eferences

?# 5.Brien S0, 0uilhot +, Larson "A, et al# 'matinib com%ared with interferon andlowdose cytarabine for newly diagnosed chronic%hase chronic myeloid leukemia#

4ngl H Med @@ K>:K## 7antarEian /, Shah P, /ochhaus A, et al# 2asatinib !ersus imatinib in newlydiagnosed chronic%hase chronic myeloid leukemia# 4ngl H Med @?@ J:J@#

# Saglio 0, 7im 2$, 'ssaragrisil S, et al# ilotinib !ersus imatinib for newly

diagnosed chronic myeloid leukemia# 4ngl H Med @?@ J:=?#

K# Marin 2, Ba;eos A, Mahon +, et al# Adherence is the critical factor for achie!ingmolecular res%onses in %atients with chronic myeloid leukemia who achie!e

com%lete cytogenetic res%onses on imatinib# H Clin 5ncol @?@ >:>?#

=# Pye SM, Cortes H, Ault P, et al# (he effects of imatinib on %regnancy outcome#Blood @@> ???:==@=#

J# 5./are (, 4ide CA, 2eininger M$# BcrAbl kinase domain mutations, drug

resistance, and the road to a cure for chronic myeloid leukemia# Blood @@I??@:K#

I# 7antarEian /, 0iles +, $underle L, et al# ilotinib in imatinibresistant CML and

Philadel%hia chromosome%ositi!e ALL# 4ngl H Med @@J =K:=K#

># Schiffer CA# BC"ABL tyrosine kinase inhibitors for chronic myelogenousleukemia# 4ngl H Med @@I =I:=>#

# 7antarEian /, 5.Brien S, (al%a; M, et al# 5utcome of %atients with Philadel%hia

chromosome%ositi!e chronic myelogenous leukemia %ostimatinib mesylatefailure# Cancer @@I ?@:?==J#

G!PH"CS

Ad by BlockTheAdApp.More Info |Hide These Ads

Com%arison of tyrosine kinase inhibitors used for chronic myeloid leukemia

0eneric

name

6nited States

brand name/ow taken "isks and side effects 5ther

'matinib 0lee!ec 2aily )or twice

daily* with food Low blood counts

)increased infection*

Most long

term safety
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13/24

Swelling and fluid

retention

2iarrhea

"ash

+atigue

Muscle cram%s /eart damage

)uncommon*

Li!er damage

)uncommon*

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ilotinib (asigna(wice daily

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Low blood counts


"ash, itching

Abnormal heart rhythm

)called 3( %rolongation*

/eart attack, stroke, andrelated e!ents

4lectrolyte imbalance

Li!er damage

Pa

Com%arison of tyrosine kinase inhibitors used for chronic myeloid leukemia

0eneric

name

6nited

States

brandname

/ow taken "isks and side effects 5ther

'matinib 0lee!ec

2aily )or

twice daily*

with food

Low blood counts)increased infection*

Swelling and fluid retention

2iarrhea

"ash

+atigue

Muscle cram%s

/eart damage )uncommon*

Li!er damage )uncommon*

Most longterm

safety data

ilotinib (asigna (wice daily

without

food

Low blood counts


"ash, itching

Abnormal heart rhythm

)called 3( %rolongation*

/eart attack, stroke, and

related e!ents

4lectrolyte imbalance


14/24

Li!er damage

Pancreatitis )inflammation

of the %ancreas that can

cause stomach %ain*

2asatinib S%rycel

2aily with

or without

food

Low blood counts)increased infection and

fatigue*

Pleural or %ericardial

effusions )fluid around the

lung or heart*

Pulmonary hy%ertension

)high blood %ressure in the

blood !essels that carry

blood to the lungsuncommon*

Abnormal heart rhythm)called 3( %rolongation*

4asy bleeding and bruising

/eadache

Bosutinib Bosulif2aily with

food

Low blood counts

)increased infection and

fatigue*

+e!er, fatigue, headache

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)increased infection and

fatigue* Swelling and fluid retention

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of the %ancreas that can

cause stomach %ain* 4asy bleeding and bruising

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Least longterm

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15/24

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Previous Topic

Signs and symptoms of chronic myeloid leukemia

Next Topic

Ho* is chronic myeloid leukemia classified+

Ho* is chronic myeloid leukemia diagnosed+

Many %eo%le with CML do not ha!e sym%toms when it is diagnosed# (he leukemia is often found when theirdoctor orders blood tests for an unrelated health %roblem or during a routine checku%# 4!en when sym%toms

are %resent, they are often !ague and nons%ecific#

&ypes of samples used to test for chronic myeloid leukemia

'fsigns and sym%tomssuggest you may ha!e leukemia, the doctor will need to check sam%les )s%ecimens* of

blood and bone marrow to be certain of this diagnosis# 5ther tissue and cell sam%les may also be taken in

order to treat CML#

Blood samples

Blood sam%les for tests for CML are generally taken from a !ein in the arm#

Bone marrow samples

Bone marrow sam%les are taken from a bone marrow as%iration and bio%sy# (hese tests are usually done at

the same time# (he sam%les are taken from the back of the %el!ic )hi%* bone, although in some cases they may

be taken from the breastbone )sternum* or other bones#

+or a bone marrow aspiration, you lie on a table )either on your side or on your belly*# After the area is

cleaned, the skin o!er the hi% and the surface of the bone is numbed with local anesthetic, which may cause abrief stinging or burning sensation# A thin, hollow needle is then inserted into the bone and a syringe is used

to suck out a small amount )about ? teas%oon* of li9uid bone marrow# 4!en with the anesthetic, most %atients

still feel some brief %ain when the marrow is remo!ed#

A bone marrow biopsyis usually done Eust after the as%iration# A small %iece of bone and marrow )about ??J

inch in diameter and ? inch long* is remo!ed with a slightly larger needle that is twisted as it is %usheddown into the bone# (he bio%sy may also cause some brief %ain# 5nce the bio%sy is done, %ressure will be

a%%lied to the site to hel% %re!ent bleeding#

(hese sam%les are sent to a lab, and they are looked at under a microsco%e for leukemia cells# (hese tests may

also be done after treatment to see if the leukemia is res%onding to treatment#
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La, tests

5ne or more of the following lab tests may be used to diagnose CML or to hel% determine how ad!anced thedisease is#

Blood cell counts and blood cell exam

(he com%lete blood count )CBC*is a test that measures the le!els of different cells, like red blood cells, white

blood cells, and %latelets, in the blood# (he CBC often includes a differential )diff*, which is a count of the

different ty%es of white blood cells in the blood sam%le# 'n a blood smear, some of the blood is %ut on a slideto see how the cells look under the microsco%e# Most %atients with CML ha!e too many white blood cells

with many early )immature* cells# Sometimes CML %atients ha!e low numbers of red blood cells or blood

%latelets# 4!en though these findings may suggest leukemia, this diagnosis usually needs to be confirmed by

another blood test or a test of the bone marrow#

Blood chemistry tests

(hese tests measure the amount of certain chemicals in the blood, but they are not used to diagnose leukemia#

(hey can hel% find li!er or kidney %roblems caused by the s%read of leukemia cells or by the side effects ofcertain chemothera%y drugs# (hese tests also hel% determine if treatment is needed to correct low or high

blood le!els of certain minerals#

Routine exam under a microscope

(he sam%les of blood and bone marrow are looked at under a microsco%e by a %athologist )a doctor whos%eciali;es in diagnosing diseases with lab tests* and may be looked at by a hematologistoncologist )a doctor

s%eciali;ing in treating blood diseases and cancer* as well#

(he doctors will look at the si;e and sha%e of the cells in the sam%les and whether they contain granules

)small s%ots seen in some ty%es of white blood cells*#

An im%ortant factor is whether the cells look mature )like normal circulating blood cells* or immature)lacking features of normal circulating blood cells*# (he most immature cells are called myeloblasts)often

called blasts*#

An im%ortant feature of a bone marrow sam%le is how much of it is bloodforming cells# (his is known as

cellularity# ormal bone marrow contains both bloodforming cells and fat cells# $hen the bone marrow hasmore bloodforming cells than e-%ected, it is said to be hypercellular# 'f too few of these cells are found, the

marrow is called hypocellular# 'n %eo%le with CML, the bone marrow is often hy%ercellular because it is full

of leukemia cells#

Genetic tests

Some sort of gene testing will be done to look for the Philadel%hia chromosome andor theBCR-ABLgene#(his ty%e of test is used to confirm the diagnosis of CML#

Con-entional cytogenetics:(his test looks at chromosomes )%ieces of 2A* under a microsco%e to find any

changes# 't is also called karyotyping# Chromosomes in a cell can best be seen when the cell is di!iding# (hat

is why to do this test, a sam%le of blood or bone marrow has to be cultured )in the lab* so that the cells start to

grow and di!ide# (his takes time, and is not always successful# ormal human cells ha!e %airs ofchromosomes, each of which is a certain si;e# (he leukemia cells in many CML %atients contain an abnormal

chromosome known as thePhiladelphia chromosome, which looks like a short chromosome # 't is caused
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17/24

by swa%%ing %ieces )translocation* between chromosomes and )see the section, 2o we know what

causes chronic myeloid leukemia1*# +inding a Philadel%hia chromosome is hel%ful in diagnosing CML# 4!en

when the Philadel%hia chromosome can.t be seen, other tests can often find theBCR-ABLgene#

.luorescent in situ hy,ridi/ation:+luorescent in situ hybridi;ation )+'S/* is another way to look atchromosomes# (his test uses s%ecial fluorescent dyes that only attach to s%ecific %arts of genes or

chromosomes# +'S/ can be used to look for s%ecific %ieces of theBCR-ABLgene on chromosomes# 't can beused on regular blood or bone marrow sam%les without culturing the cells first, so the results can come back

9uicker than with con!entional cytogenetics#

Polymerase chain reaction (PC):(his is a su%ersensiti!e test that can be used to look for theBCR-ABLoncogene in leukemia cells# 't can be done on blood or bone marrow sam%les and can detect !ery small

amounts ofBCR-ABL, e!en when doctors can.t find the Philadel%hia chromosome in bone marrow cells with

cytogenetic testing# PC" can be used to hel% diagnose CML and is also useful after treatment to see if co%ies

of theBCR-ABLgene are still there# 'f co%ies of this gene are still %resent it means that the leukemia is still%resent, e!en when the cells aren.t !isible under the microsco%e#

"maging tests

'maging tests %roduce %ictures of the inside of the body# (here are se!eral imaging tests that might be done in%eo%le with leukemia# Leukemia does not usually form !isible tumors, so imaging tests are not often hel%ful

in making the diagnosis but they may be done to hel% find the e-tent of the disease#

Computed tomography scan

(his test can hel% tell if any lym%h nodes or organs in your body are enlarged# 't isnRt usually needed to

diagnose CML, but it may be done if your doctor sus%ects the leukemia is growing in an organ, like yours%leen#

(he com%uted tomogra%hy )C(* scan is a ty%e of -ray test that %roduces detailed, crosssectional images of

your body# 6nlike a regular -ray, C( scans can show the detail in soft tissues )such as internal organs*# A C(

scanner has been described as a large donut, with a narrow table in the middle o%ening# ou will need to liestill on the table while the scan is being done# C( scans take longer than regular -rays, and you might feel a

bit confined by the ring while the %ictures are being taken#

'nstead of taking one %icture like a regular -ray, a C( scanner takes many %ictures as it rotates around you# A

com%uter then combines these %ictures into detailed images of the %art of your body that is being studied#

5ften before the test, you may be asked to drink a contrast solution that hel%s better outline abnormal areas in

the body# (his hel%s outline abnormal areas more clearly# ou may also recei!e an '8 )intra!enous* linethrough which a different contrast dye )'8 contrast* is inEected# (his also hel%s outline abnormal areas#

(he '8 inEection of contrast dye can cause some flushing )redness and a feeling of warmth in the face or

elsewhere*# Some %eo%le are allergic to the dye and get hi!es# "arely, more serious reactions like trouble

breathing and low blood %ressure can occur# Be sure to tell the doctor if you ha!e e!er had a reaction to anycontrast material used for -rays#

'n some cases, a C( can be used to guide a bio%sy needle %recisely into a sus%ected abnormality, such as an

abscess# +or this %rocedure, called a CT-guided needle biopsy, you remain on the C( scanning table while a

radiologist mo!es a bio%sy needle through the skin and toward the location of the mass# C( scans are re%eated

until the needle is within the mass# A sam%le is then remo!ed to be looked at under a microsco%e# (his israrely needed in CML#
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Magnetic resonance imaging scan

Magnetic resonance imaging )M"'* scans are !ery hel%ful in looking at the brain and s%inal cord# (hese scans

can also be used to look at other areas of the body# M"' scans use radio wa!es and strong magnets instead of

-rays# (he energy from the radio wa!es is absorbed by the body and then released in a %attern formed by thety%e of body tissue and by certain diseases# A com%uter translates the %attern into a !ery detailed image of

%arts of the body# ot only does this create images of crosssectional slices of the body like a C( scanner, itcan also %roduce images of slices that are %arallel with the length of your body#

A contrast material might be inEected, Eust as with C( scans, but this is done less often# (his will be a different

contrast from that used for C( scans, so being allergic to one doesnRt mean you are allergic to the other#

M"' scans take longer than C( scans, often u% to an hour# ou might ha!e to lie inside a narrow tube, which

is confining and can u%set %eo%le with a fear of enclosed s%aces# S%ecial, o%en M"' machines may hel%

with this %roblem# (he M"' machine makes loud bu;;ing noises that you may find disturbing# Some %laces

gi!e you head%hones or ear%lugs to hel% block this noise out#

Ultrasound

6ltrasound uses sound wa!es and their echoes to make a %icture of internal organs or masses# Most often forthis test a small, micro%honelike instrument called a transduceris %laced on the skin )which is first

lubricated with a gel*# 't gi!es off sound wa!es and %icks u% the echoes as they bounce off the organs# (he

echoes are con!erted by a com%uter into an image that is shown on a com%uter screen#

6ltrasound can be used to look at lym%h nodes near the surface of the body or to look for enlarged organsinside your abdomen such as the kidneys, li!er, and s%leen#

(his is an easy test to ha!e, and it doesn.t use radiation# +or most scans you sim%ly lie on a table, and a

technician mo!es the transducer o!er the %art of your body being looked at#

Chest xray

A %lain -ray of your chest can be done in most out%atient settings# 'n %atients with CML, it isn.t needed for a

diagnosis, but an -ray may be used to see if you ha!e normal lungs or if you ha!e an infection#

Last Medical "e!iew: @@?

Last "e!ised: @?@@?K

Back to to% Q

0uide (o%ics

o $hat 's Leukemia Chronic Myeloid )CML*1

o Causes, "isk +actors, and Pre!ention

o 4arly 2etection, 2iagnosis, and Stagingo (reating Leukemia Chronic Myeloid )CML*

o (alking $ith our 2octor

o After (reatment

o $hats ew in Leukemia Chronic Myeloid )CML* "esearch1

o 5ther "esources and "eferences

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Site Ma%

Pri!acy

Accessibility

&%!&"G L%12%M"! 3 CH'"C M#%L'"$ (CML) &'P"CS

2ocument (o%ics

05 Q

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Previous Topic

Complementary and alternati-e therapies for chronic myeloid leukemia

Next Topic

More treatment information for chronic myeloid leukemia

&reating chronic myeloid leukemia ,y phase

(reatment o%tions for %eo%le with chronic myeloid leukemia )CML* de%end on the %hase of their disease)chronic, accelerated, or blast %hase*, their age, other %rognostic factors, and the a!ailability of a stem cell

donor with matching tissue ty%e#

'f youRd like more information on a drug used in your treatment or a s%ecific drug mentioned in this section,

see our0uide to Cancer 2rugs, or call us with the names of the medicines youRre taking#

Chronic phase

(he standard treatment for chronic %hase CML is a tyrosine kinase inhibitor )(7'* such as imatinib )0lee!ec*,nilotinib )(asigna*, or dasatinib )S%rycel*# +or imatinib, the usual starting dose is K@@ mg %er day# 'f the first

drug sto%s working )or it ne!er really worked well at all* the dose may be increased or the %atient may be

switched to one of the other (7's )including bosutinib*# Ponatanib is an o%tion after all of the other (7's ha!e

been tried#

Switching to another (7' is also an o%tion if the %atient can.t take the first drug because of side effects#

Some %eo%le in chronic %hase may be treated with an allogeneic stem cell trans%lant )SC(*# (his treatment

was discussed in detail in the section, Stem cell trans%lant for chronic myeloid leukemia#

Monitoring treatment results

Monitoring the %atient to see how they res%ond to treatment is !ery im%ortant# Blood counts are checked, and

the blood may also be checked with a %olymerase chain reaction )PC"* test to measure the amount of the

BCR-ABLgene# (he bone marrow may also be checked to see if the Philadel%hia chromosome is there# Bloodcounts may be checked more often, but tests for theBCR-ABLgene or the Philadel%hia chromosome are

usually done about months after treatment with a (7' is started# 'f the results show that treatment is
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working well, the %atient may not need further testing for a few months# 'f the treatment isnRt working well,

treatment may be changed#

2octors look for different kinds of res%onses to treatment:

Hematologic response)usually ha%%ens within the first months of treatment*

$hen blood cell counts return to normal, there are no immature cells seen in the blood, and the

s%leen has returned to normal si;e it is called a complete hematologic response)or C/"*#

Apartial hematologic responseis similar to this, but not all of the abo!e conditions are met#

Cytogenetic response)may take se!eral months or longer*

A complete cytogenetic response)CCy"* occurs when no cells with the Philadel%hia chromosome

can be found in the blood or bone marrow#

Apartial cytogenetic response)PCy"* occurs when less than =U of cells still ha!e the Philadel%hia

chromosome#

A major cytogenetic response)MCy"* includes both com%lete and %artial res%onses

A minor cytogenetic responseoccurs when =U to @U of cells still ha!e the Philadel%hiachromosome#

Molecular response)this is based on the results of the PC" test*

A complete molecular response)CM"* means that the PC" test does not find theBCR-ABLgene in

the %atient.s blood#

A major molecular response)MM"* means that the amount ofBCR-ABLgene in the blood is !ery

low#

6% to about I@U of %eo%le ha!e a CCy" within ? year of starting imatinib, and the rate of CCy" is e!en

higher with the other (7's )nilotinib and dasatanib*# After a year, e!en more %atients will ha!e had a CCy"#

Many of these %atients also ha!e a CM"#

But e!en if theBCR-ABLgene isnRt found, these %eo%le are %robably not cured# +or now, doctors recommend

that %eo%le stay on the drug indefinitely#

"f the first treatmentdoesn4t *ork

'f the CML is res%onding well to treatment, at months the %atient should ha!e a C/" and either some ty%e

of cytogenetic res%onse or certain le!el ofBCR-ABLon the PC" test# At J months, the %atient should ha!e atleast a PCy", and a CC" at ? and ?> months# (he %atient should also ha!e a MM" at ?> months#

'f this doesn.t ha%%en, or if the leukemia gets worse, there are se!eral o%tions#

'ncreasing the dose of the drug# (his hel%s some %eo%le, although the higher dose often has worse

side effects#

Switching to another (7', for e-am%le from imatinib to dasatinib, nilotinib, bosutinib, or %onatanib#

(he doctor may check the CML cells for genetic changes )mutations* to hel% decide what drug

would be best#

'nterferon or chemothera%y )chemo* may be tried for those who can.t take these drugs or those for

whom they are not working,

Stem cell trans%lant may be an o%tion, es%ecially for younger %eo%le who ha!e a donor with a

matching tissue ty%e#


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&reating CML after a stem cell transplant

Some %eo%le who ha!e a stem cell trans%lant may not get a com%lete res%onse# 'f they do notha!e graft

!ersushost disease )08/2*, doctors may try to get their new immune system to fight the leukemia# 5ne way

to do this is by slowly lowering the doses or sto%%ing the immune su%%ressing drugs they are taking# (his isdone !ery carefully in order to ha!e an antileukemia effect without getting too much 08/2# Patients are

watched closely during this time# Another a%%roach that hel%s some %atients is an infusion of lym%hocytestaken from the %erson who donated the stem cells for the trans%lant# (his can induce an immune reaction

against the leukemia# 'nterferon may also be hel%ful#

'n %atients who doha!e 08/2 after a stem cell trans%lant, boosting the immune system further is not likelyto hel%# (hese %atients are often treated with a (7' like imatinib#

!ccelerated phase

$hen CML is in accelerated %hase, leukemia cells begin to build u% in the body more 9uickly, causing

sym%toms# (he leukemia cells often ac9uire new gene mutations, which hel% them grow and might make

treatments less effecti!e#

(he treatment o%tions for accelerated %hase CML de%end on what treatments the %atient has already had# 'ngeneral, the o%tions are similar to those for %atients with chronic %hase CML, but %atients with accelerated

%hase CML are less likely to ha!e a longterm res%onse to any treatment#

'f the %atient hasnRt had any treatment, a (7' will be used# 'matinib )often at higher doses than used for

chronic %hase CML* is one o%tion for most %eo%le# Most %atients in this %hase can res%ond to treatment withimatinib, but the res%onses do not seem to last as long as they do in %atients in the chronic %hase# Still, about

half these %atients are still ali!e after K years# (he newer drugs like dasatinib and nilotinib are often used in

this %hase, and other drugs are under study#

'f the %atient is already getting imatinib, the dose may be increased# Another o%tion is to switch to one of the

other (7's )dasatinib, nilotinib, or bosutinib*# Sometimes the CML cells are tested to see if they ha!e genetic

changes )mutations* that may mean that a certain (7' is more or less likely to work )see the section VCMLwith the (?=' mutationW*# 'n CML without that mutation, %onatanib is an o%tion after all of the other (7's

ha!e been tried#

'nterferon is another o%tion, but it is also much less effecti!e in this %hase than in the chronic %hase# About

@U of %atients ha!e some res%onse to chemo, but these res%onses are usually shorter than J months#

An allogeneic stem cell trans%lantmay be the best o%tion for most %atients who are young enough to be

eligible# About @U to K@U of %atients with accelerated %hase CML are ali!e se!eral years after a stem cell

trans%lant# Most doctors %refer that the leukemia be controlled, %referably in remission, before beginning the

trans%lant %rocedure# (o achie!e this, chemowill often be used#

'n some cases, an autologous SC( may be an o%tion to try to get the CML back into the chronic %hase, but it.s

!ery unlikely to result in a cure#

Blast phase

'n the blast %hase of CML, the leukemia cells become more abnormal# (he disease acts like an acute

leukemia, with blood counts getting higher and sym%toms a%%earing or becoming more se!ere#

+or %eo%le with blast %hase CML who ha!en.t been treated before, highdose imatinib may be hel%ful,

although it works in a smaller number of %eo%le and for shorter lengths of time than when used earlier in the
http://www.cancer.org/ssLINK/http://www.cancer.org/ssLINK/http://www.cancer.org/ssLINK/http://www.cancer.org/ssLINK/


23/24

course of the disease# (he newer agents, dasatinib and nilotinib, seem to be better in this %hase, %articularly if

they hadn.t been used earlier# Bosutinib is also an o%tion for %atients who had %re!iously been taking another

(7'# Ponatanib may be used, but only after all of the other (7's ha!e been tried# Patients who res%ond to

these drugs may still want to consider ha!ing a stem cell trans%lant, if %ossible#

Most often, the leukemia cells in this %hase act like cells of acute myeloid leukemia )AML*, but they are often

resistant to the chemo drugs normally used to treat AML# Standard chemo for AML )see our document,Leukemia: Acute Myeloid Myelogenous!* will bring about a remission in about ? out of = %atients, but this is

usually shortli!ed# 'f this does occur, it may be a chance to consider some ty%e of stem cell trans%lant#

A smaller number of %atients ha!e blast cells that act like cells of acute lym%hoblastic leukemia )ALL*# (hesecells are more sensiti!e to chemo drugs# "emissions can be induced in about half of these %atients with drugs

such as !incristine, %rednisone,and do-orubicin, along with imatinib, if that hasn.t been gi!en yet# Like

%atients with ALL, these %atients are at risk for ha!ing leukemia cells in the fluid that surrounds the brain and

s%inal cord, so they often get chemo )cytarabine or methotre-ate* infused directly into that fluid )like during as%inal ta%*# "adiation thera%y to the brain is another o%tion but is used less often# +or more information, see

our document,Leukemia: Acute Lymphocytic#

Allogeneic SC( is less successful for blast %hase CML than for earlier %hases, and the longterm sur!i!al rate

is less than ?@U# Still, it is the only known o%tion that may cure the disease# 't is more likely to be effecti!e ifthe CML can be brought back to the chronic %hase before the trans%lant#

Because most %atients with blast %hase CML can.t be cured,%alliati!e treatment)intended to relie!e

sym%toms rather than cure the disease* is im%ortant# "adiation thera%y can hel% shrink an enlarged s%leen or

reduce %ain from areas of bone damaged by leukemia#Chemo)usually with drugs such as hydro-yurea* may

relie!e some sym%toms for a time#

Clinical trials of new combinations of chemo, targeted agents, and biologic thera%ies are im%ortant o%tions#

CM" with the T#$%& mutation

As was mentioned in the section about targeted thera%y,in some %atients on (7' treatment, the cancer cellsde!elo% a gene change called the T"#$% mutationthat kee%s most of the (7's from working# 'f your CML

sto%s res%onding to treatment with a (7', another one may be tried# our doctor may also check to see if the

cancer cells ha!e de!elo%ed the (?=' mutation# 'f they ha!e, you may be switched to %onatinib, which is theonly (7' that works against CML with this mutation# 'f this doesnRt work or you canRt take it because of side

effects, you may be started on chemothera%y )chemo*# 5maceta-ine )Synribo* is a newer chemo drug that has

been shown to hel% sometimes in this situation, but other chemo drugs may hel% as well#

Last Medical "e!iew: @@?Last "e!ised: @?@@?K

Back to to% Q

0uide (o%icso $hat 's Leukemia Chronic Myeloid )CML*1

o Causes, "isk +actors, and Pre!ention

o 4arly 2etection, 2iagnosis, and Staging

o (reating Leukemia Chronic Myeloid )CML*

o (alking $ith our 2octor

o After (reatment

o $hats ew in Leukemia Chronic Myeloid )CML* "esearch1
http://www.cancer.org/ssLINK/leukemia-acute-myeloid-aml-detailed-guide-tochttp://www.cancer.org/ssLINK/leukemia-acute-lymphocytic-all-detailed-guide-tochttp://www.cancer.org/ssLINK/leukemia-acute-lymphocytic-all-detailed-guide-tochttp://www.cancer.org/ssLINK/palliative-carehttp://www.cancer.org/ssLINK/leukemia-chronic-myeloid-myelogenous-treating-chemotherapyhttp://www.cancer.org/ssLINK/leukemia-chronic-myeloid-myelogenous-treating-chemotherapyhttp://www.cancer.org/ssLINK/leukemia-chronic-myeloid-myelogenous-treating-chemotherapyhttp://www.cancer.org/ssLINK/leukemia-chronic-myeloid-myelogenous-treating-targeted-therapieshttp://www.cancer.org/ssLINK/leukemia-chronic-myeloid-myelogenous-treating-targeted-therapieshttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-treating-treating-by-phase#tophttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-what-is-cancerhttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-risk-factorshttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-detectionhttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-treating-general-infohttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-talking-with-doctorhttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-after-follow-uphttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-new-researchhttp://www.cancer.org/ssLINK/leukemia-acute-myeloid-aml-detailed-guide-tochttp://www.cancer.org/ssLINK/leukemia-acute-lymphocytic-all-detailed-guide-tochttp://www.cancer.org/ssLINK/palliative-carehttp://www.cancer.org/ssLINK/leukemia-chronic-myeloid-myelogenous-treating-chemotherapyhttp://www.cancer.org/ssLINK/leukemia-chronic-myeloid-myelogenous-treating-targeted-therapieshttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-treating-treating-by-phase#tophttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-what-is-cancerhttp://www.cancer.org/cancer/leukemia-chronicmyeloidcml/detailedguide/leukemia-chronic-myeloid-myelogenous-risk-factorshttp://www

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Chronic Myeloid Leukemia.doc