Chapter 104. Acute and Chronic Myeloid Leukemia (Part 13) Chronic Myelogenous Leukemia: Treatment The therapy of CML is changing rapidly because we have a proven curative treatment (allogeneic transplantation) that has significant toxicity and a new targeted treatment (imatinib) with excellent outcome based on 5-year follow-up data. Therefore, physician experience and patient preference must be factored into the treatment selection process. Discussion of both treatment options with a patient is indicated. The decision should focus on the outcomes, risks, and toxicities of the various approaches. At present, the goal of therapy in CML is to achieve prolonged, durable, nonneoplastic, nonclonal hematopoiesis, which entails the eradication of any residual cells containing the BCR/ABL transcript. Hence the goal is complete molecular remission and cure. A proposed imatinib treatment algorithm for the newly diagnosed CML patient is presented in Table 104-4. Table 104-4 Imatinib Treatment Milestones for Newly Diag nosed CML Patients Proposed Course of Action a Transplantation from an HLA- compatible (related or unrelated) donor, dasatinib, new drugs Continue same b or increase dose c Time, months Milestones 3 No complete hematologic remission Complete hematologic remission b,d 6 No cytogenetic remission Any cytogenetic remission c 12 Minor e or no cytogenetic remission Complete b,f or partial c,g cytogenetic remission 18 Partial, minor, or no cytogenetic remission Complete cytogenetic remission b Anytime Loss of previously achieved hematologic, cytogenetic, or molecular remission a Nutritional Comprehensive Cancer Network, Chronic myelogenous leukemia. b Denotes that at the indicated milestones, patients should stay on the same dose. c Denotes that at the indicated milestones, for patients on 400 mg/d, one can either continue the same or increase the dose to a maximum of 600– 800 mg, as tolerated. d Complete hematologic remission, WBC <10,000/µL, normal blood morphology, hemoglobin and platelet counts, and disappearance of splenomegaly. e Minor cytogenetic remission, 36– 85% bone marrow metaphases with t(9;22). f Complete cytogenetic remission, no bone marrow metaphases with t(9;22). g Partial cytogenetic remission, 1- 35% bone marrow metaphases with t(9;22). Abbreviations: HLA, human leukocyte antigen; WBC, white blood cell count. Allogeneic SCT Allogeneic SCT is complicated by early mortality owing to the transplant procedure. Outcome of SCT depends on multiple factors including: (1) the patient (e.g., age and phase of disease); (2) the type of donor [e.g., syngeneic (monozygotic twins) or HLA-compatible allogeneic, related or unrelated]; (3) the preparative regimen (myeloblative or reduced intensity); (4) GVHD; and (5) posttransplantation treatment. . Chapter 104. Acute and Chronic Myeloid Leukemia (Part 13) Chronic Myelogenous Leukemia: Treatment The therapy of CML is changing rapidly. is complete molecular remission and cure. A proposed imatinib treatment algorithm for the newly diagnosed CML patient is presented in Table 104- 4. Table 104- 4 Imatinib Treatment Milestones. transplantation) that has significant toxicity and a new targeted treatment (imatinib) with excellent outcome based on 5-year follow-up data. Therefore, physician experience and patient preference must be