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Tang K, Lipton JH. Stem cell allografting for chronic Myeloid leukemia in the tyrosine kinase era - forgotten but not gone. Leuk Lymphoma 2024; 65:705-714. [PMID: 38335007 DOI: 10.1080/10428194.2024.2313626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/29/2024] [Indexed: 02/10/2024]
Abstract
Due to the remarkable success of tyrosine kinase inhibitors (TKI) in chronic myeloid leukemia (CML), allogeneic stem cell transplantation (alloSCT) is not first-line treatment for delivering durable, long-term survival. Consequently, alloSCT is reserved for patients with TKI-resistant or TKI-intolerant chronic phase CML (CP-CML) and advanced phase CML (AP-CML). Advances in transplant technology, such as high-resolution HLA typing, introduction of reduced intensity conditioning and increased alternative donor availability, coupled with improved supportive care, have significantly reduced transplant-related mortality and expanded the pool of transplant-eligible patients. Refinement of conditioning regimens, innovative use of post-transplant cellular and pharmacological therapies, and judicious post-transplant monitoring are important strategies for reducing risk of relapse. Given its potential to cure, alloSCT will invariably remain a key part of the treatment algorithm. This article reviews the data underpinning the role and outcomes of alloSCT and provides an update on current recommendations.
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Affiliation(s)
- Kenny Tang
- Division of Medical Oncology and Hematology, University Health Network - Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Haematology, Blacktown Hospital, New South Wales, Australia
| | - Jeffrey H Lipton
- Division of Medical Oncology and Hematology, University Health Network - Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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2
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Elmakaty I, Saglio G, Al-Khabori M, Elsayed A, Elsayed B, Elmarasi M, Elsabagh AA, Alshurafa A, Ali E, Yassin M. The Contemporary Role of Hematopoietic Stem Cell Transplantation in the Management of Chronic Myeloid Leukemia: Is It the Same in All Settings? Cancers (Basel) 2024; 16:754. [PMID: 38398145 PMCID: PMC10886670 DOI: 10.3390/cancers16040754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 02/25/2024] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) for chronic myeloid leukemia (CML) patients has transitioned from the standard of care to a treatment option limited to those with unsatisfactory tyrosine kinase inhibitor (TKI) responses and advanced disease stages. In recent years, the threshold for undergoing HSCT has increased. Most CML patients now have life expectancies comparable to the general population, and therefore, the goal of therapy is shifting toward achieving treatment-free remission (TFR). While TKI discontinuation trials in CML show potential for achieving TFR, relapse risk is high, affirming allogeneic HSCT as the sole curative treatment. HSCT should be incorporated into treatment algorithms from the time of diagnosis and, in some patients, evaluated as soon as possible. In this review, we will look at some of the recent advances in HSCT, as well as its indication in the era of aiming for TFR in the presence of TKIs in CML.
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Affiliation(s)
- Ibrahim Elmakaty
- College of Medicine, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
| | - Giuseppe Saglio
- Department of Clinical and Biological Sciences, University of Turin, 10124 Turin, Italy
| | | | | | - Basant Elsayed
- College of Medicine, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
| | - Mohamed Elmarasi
- College of Medicine, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
| | | | - Awni Alshurafa
- Hematology Section, Medical Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation (HMC), Doha P.O. Box 3050, Qatar
| | - Elrazi Ali
- Interfaith Medical Center, Brooklyn, NY 11213, USA
| | - Mohamed Yassin
- College of Medicine, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
- Hematology Section, Medical Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation (HMC), Doha P.O. Box 3050, Qatar
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3
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Short NJ, Senapati J, Jabbour E. An Update on the Management of Advanced Phase Chronic Myeloid Leukemia. Curr Hematol Malig Rep 2023; 18:234-242. [PMID: 37651057 DOI: 10.1007/s11899-023-00709-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE OF REVIEW While most patients with chronic myeloid leukemia (CML) present in a chronic phase and are expected to have a normal life expectancy, some patients present with or progress to a more aggressive accelerated phase (AP) or blast phase (BP) of CML. Herein, we discuss the diagnostic considerations of advanced phase CML and review its contemporary management. RECENT FINDINGS Later-generation, more potent BCR::ABL1 tyrosine kinase inhibitors (TKIs) such as ponatinib may result in superior outcomes in patients with advanced phase CML. For CML-BP, combination approaches directed against the blast immunophenotype appear superior to TKI monotherapy. The role of allogeneic stem cell transplantation is controversial in CML-AP but has consistently been shown to improve outcomes for patients with CML-BP. Advanced phase CML, particularly CML-BP, remains a poor risk subtype of CML. However, novel combination approaches using later-generation TKIs are being explored in clinical trials and may lead to improved outcomes.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
| | - Jayastu Senapati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
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Kantarjian HM, Tefferi A. Classification of accelerated phase chronic myeloid leukemia in the era of the BCR::ABL1 tyrosine kinase inhibitors: A work in progress. Am J Hematol 2023; 98:1350-1353. [PMID: 37357837 DOI: 10.1002/ajh.27007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/27/2023]
Affiliation(s)
- Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ayalew Tefferi
- The Department of Leukemia, Mayo Clinic, Rochester, Minnesota, USA
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5
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Balsat M, Alcazer V, Etienne G, Huguet F, Berger M, Cayssials E, Charbonnier A, Escoffre-Barbe M, Johnson-Ansah H, Legros L, Roy L, Delmer A, Ianotto JC, Orvain C, Larosa F, Meunier M, Amé S, Andreoli A, Cony-Makhoul P, Morisset S, Tigaud I, Rea D, Nicolini FE. First-line second generation tyrosine kinase inhibitors in patients with newly diagnosed accelerated phase chronic myeloid leukemia. Leuk Res 2023; 130:107308. [PMID: 37230027 DOI: 10.1016/j.leukres.2023.107308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 05/27/2023]
Abstract
Accelerated phase (AP) CML at onset and have poorer prognosis than CP-CML. We hypothesize that off-license use of second generation TKI (TKI2) as front-line therapy might counterbalance this poor prognosis, with limited toxicity. In "real-life" conditions, newly diagnosed patients meeting the ELN cytological criteria for AP-CML or harboring ACA and treated with first-line TKI2 were included in this retrospective multicenter observational study. We enrolled 69 patients [69.5 % male, median age 49.5 years, median follow-up 43.5 months], segregated into hematologic AP [HEM-AP (n = 32)] and cytogenetically defined AP [ACA-AP (n = 37)]. Hematologic parameters were worse in HEM-AP [spleen size (p = 0.014), PB basophils (p < .001), PB blasts (p < .001), PB blasts+promyelocytes (p < .001), low hemoglobin levels (p < .001)]. Dasatinib was initiated in 56 % patients in HEM-AP and in 27 % in ACA-AP, nilotinib in 44 % and 73 % respectively. Response and survival do not differ, regardless of the TKI2: 81 % vs 84.3 % patients achieved CHR, 88 % vs 84 % CCyR, 73 % vs 75 % MMR respectively. The estimated 5-year PFS 91.5 % (95%CI: 84.51-99.06 %) and 5-year OS 96.84 % (95%CI: 92.61-100 %). Only BM blasts (p < 0.001) and BM blasts+promyelocytes (p < 0.001) at diagnosis negatively influenced OS. TKI2 as front-line therapy in newly diagnosed AP-CML induce excellent responses and survival, and counterbalance the negative impact of advanced disease phase.
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Affiliation(s)
- Marie Balsat
- Hematology Department, Centre Hospitalier Lyon Sud, Pierre Bénite, France; French Group of CML (Fi-LMC), Lyon, France
| | - Vincent Alcazer
- Hematology Department, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Gabriel Etienne
- Hematology Department, Institut Bergonié, Bordeaux, France; French Group of CML (Fi-LMC), Lyon, France
| | - Françoise Huguet
- Hematology Department, Institut Universitaire du Cancer, Toulouse, France; French Group of CML (Fi-LMC), Lyon, France
| | - Marc Berger
- Hematology Department, CHU Estaing, Clermont-Ferrand, France; French Group of CML (Fi-LMC), Lyon, France
| | - Emilie Cayssials
- Hematology Department, Hôpital Jean Bernard, Poitiers, France; French Group of CML (Fi-LMC), Lyon, France
| | - Aude Charbonnier
- Hematology Department, Institut Paoli Calmettes, Marseilles, France; French Group of CML (Fi-LMC), Lyon, France
| | - Martine Escoffre-Barbe
- Hematology Department, Hôpital de Pontchaillou, Rennes, France; French Group of CML (Fi-LMC), Lyon, France
| | - Hyacinthe Johnson-Ansah
- Hematology Department, Hôpital Clémenceau, Caën, France; French Group of CML (Fi-LMC), Lyon, France
| | - Laurence Legros
- Hematology Department, Hôpital Paul Brousse, Villejuif, France; French Group of CML (Fi-LMC), Lyon, France
| | - Lydia Roy
- Hematology department, Hôpital Universitaire Henri Mondor - AP-HP & Faculté de Santé - UPEC, Créteil, France; French Group of CML (Fi-LMC), Lyon, France
| | | | - Jean-Christophe Ianotto
- Hematology Department, Hôpital Morvan, Brest, France; French Group of CML (Fi-LMC), Lyon, France
| | - Corentin Orvain
- Hematology Department, Hôpital universitaire, Angers, France; French Group of CML (Fi-LMC), Lyon, France
| | - Fabrice Larosa
- Gerontology Department, Hôpital du Bocage, Dijon, France; French Group of CML (Fi-LMC), Lyon, France
| | - Mathieu Meunier
- Hematology Department, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France; French Group of CML (Fi-LMC), Lyon, France
| | - Shanti Amé
- Hematology Department, Institut de Cancérologie Strasbourg Europe, Strasbourg, France; French Group of CML (Fi-LMC), Lyon, France
| | - Annalisa Andreoli
- Hematology Department, CH d'Argenteuil, Argenteuil, France; French Group of CML (Fi-LMC), Lyon, France
| | - Pascale Cony-Makhoul
- Hematology Department, Centre Hospitalier Annecy Genevois, Pringy, France; French Group of CML (Fi-LMC), Lyon, France
| | | | - Isabelle Tigaud
- Laboratory for Cytogenetics, Centre Hospitalier Lyon Sud, Pierre Bénite, France; French Group of CML (Fi-LMC), Lyon, France
| | - Delphine Rea
- Hematology Department, Hôpital Saint Louis, Paris, France; French Group of CML (Fi-LMC), Lyon, France
| | - Franck Emmanuel Nicolini
- Hematology Department, Centre Léon Bérard, Lyon, France; INSERM U1052, CRCL, Lyon, France; French Group of CML (Fi-LMC), Lyon, France.
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Senapati J, Jabbour E, Kantarjian H, Short NJ. Pathogenesis and management of accelerated and blast phases of chronic myeloid leukemia. Leukemia 2023; 37:5-17. [PMID: 36309558 DOI: 10.1038/s41375-022-01736-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 02/01/2023]
Abstract
The treatment of chronic myeloid leukemia (CML) with tyrosine kinase inhibitors (TKIs) has been a model for cancer therapy development. Though most patients with CML have a normal quality and duration of life with TKI therapy, some patients progress to accelerated phase (AP) and blast phase (BP), both of which have a relatively poor prognosis. The rates of progression have reduced significantly from over >20% in the pre-TKI era to <5% now, largely due to refinements in CML therapy and response monitoring. Significant insights have been gained into the mechanisms of disease transformation including the role of additional cytogenetic abnormalities, somatic mutations, and other genomic alterations present at diagnosis or evolving on therapy. This knowledge is helping to optimize TKI therapy, improve prognostication and inform the development of novel combination regimens in these patients. While patients with de novo CML-AP have outcomes almost similar to CML in chronic phase (CP), those transformed from previously treated CML-CP should receive second- or third- generation TKIs and be strongly considered for allogeneic stem cell transplantation (allo-SCT). Similarly, patients with transformed CML-BP have particularly dismal outcomes with a median survival usually less than one year. Combination regimens with a potent TKI such as ponatinib followed by allo-SCT can achieve long-term survival in some transformed BP patients. Regimens including venetoclax in myeloid BP or inotuzumab ozogamicin or blinatumomab in lymphoid BP might lead to deeper and longer responses, facilitating potentially curative allo-SCT for patients with CML-BP once CP is achieved. Newer agents and novel combination therapies are further expanding the therapeutic arsenal in advanced phase CML.
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Affiliation(s)
- Jayastu Senapati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Ortí G, García-Gutiérrez V, Bautista G, Ferrer-Marín F, Vallansot R, Xicoy B, Sánchez À, Simon I, Triguero A, Sierra M, Casado LF. Tyrosine kinase inhibitor dose reduction during the management of accelerated phase chronic myeloid leukemia. Leuk Res 2022; 121:106923. [PMID: 35933910 DOI: 10.1016/j.leukres.2022.106923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/12/2022] [Accepted: 07/31/2022] [Indexed: 10/16/2022]
Affiliation(s)
- Guillermo Ortí
- Department of Hematology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain; Grupo Español de Leucemia Mieloide Crónica, Spain.
| | - Valentín García-Gutiérrez
- Department of Hematology, Hospital Ramon y Cajal. Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; Grupo Español de Leucemia Mieloide Crónica, Spain
| | - Guiomar Bautista
- Department of Hematology, Hospital Puerta de Hierro, Madrid, Spain; Grupo Español de Leucemia Mieloide Crónica, Spain
| | - Francisca Ferrer-Marín
- Department of Hematology, Hospital Morales Meseguer, CIBERER.UCAM, Murcia, Spain; Grupo Español de Leucemia Mieloide Crónica, Spain
| | - Rolando Vallansot
- Department of Hematology, Hospital Joan XXIII, Tarragona, Spain; Grupo Español de Leucemia Mieloide Crónica, Spain
| | - Blanca Xicoy
- Department of Hematology, Institut Català d'Oncologia-Hospital Germans Trias i Pujol, Badalona, Josep carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Spain; Grupo Español de Leucemia Mieloide Crónica, Spain
| | - Àngela Sánchez
- Department of Hematology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Isabel Simon
- Department of Hematology, Hospital Virgen de Valme, Sevilla, Spain; Grupo Español de Leucemia Mieloide Crónica, Spain
| | - Ana Triguero
- Department of Hematology, Hospital Clinic, Barcelona, Spain
| | - Magdalena Sierra
- Department of Hematology, Hospital Universitario de Salamanca, Salamanca, Spain; Grupo Español de Leucemia Mieloide Crónica, Spain
| | - Luis Felipe Casado
- Department of Hematology, Hospital Virgen de Toledo, Toledo, Spain; Grupo Español de Leucemia Mieloide Crónica, Spain
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Jabbour E, Kantarjian H. Chronic Myeloid Leukemia: 2022 Update on Diagnosis, Therapy and Monitoring. Am J Hematol 2022; 97:1236-1256. [PMID: 35751859 DOI: 10.1002/ajh.26642] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 06/18/2022] [Indexed: 11/08/2022]
Abstract
DISEASE OVERVIEW Chronic Myeloid Leukemia (CML) is a myeloproliferative neoplasm with an incidence of 1-2 cases per 100,000 adults. It accounts for approximately 15% of newly diagnosed cases of leukemia in adults DIAGNOSIS: CML is characterized by a balanced genetic translocation, t (9;22) (q34;q11.2), involving a fusion of the Abelson gene (ABL1) from chromosome 9q34 with the breakpoint cluster region (BCR) gene on chromosome 22q11.2. This rearrangement is known as the Philadelphia chromosome. The molecular consequence of this translocation is the generation of a BCR::ABL1 fusion oncogene, which in turn translates into a BCR::ABL1 oncoprotein. FRONTLINE THERAPY Four tyrosine kinase inhibitors (TKIs), imatinib, dasatinib, bosutinib, and nilotinib are approved by the United States Food and Drug Administration for first-line treatment of newly diagnosed CML in chronic phase (CML-CP). Clinical trials with second generation TKIs reported significantly deeper and faster responses but had no impact on survival prolongation, likely because of the availability of effective TKIs salvage therapies for patients who have a cytogenetic relapse with frontline TKI therapy. SALVAGE THERAPY For CML post failure on frontline therapy, second-line options include second and third generation TKIs. Although potent and selective, these TKIs exhibit unique pharmacological profiles and response patterns relative to different patient and disease characteristics, such as patients' comorbidities, disease stage, and BCR::ABL1 mutational status. Patients who develop the T315I "gatekeeper" mutation display resistance to all currently available TKIs except ponatinib, asciminib, and olverembatinib. Allogeneic stem cell transplantation remains an important therapeutic option for patients with CML-CP and failure (due to resistance) of at least 2 TKIs, and for all patients in advanced phase disease. Older patients who have a cytogenetic relapse post failure on all TKIs can maintain long-term survival if they continue a daily most effective/least toxic TKI, with or without the addition of non-TKI anti-CML agents (hydroxyurea, omacetaxine, azacitidine, decitabine, cytarabine, busulfan, others). This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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Shimazu Y, Murata M, Kondo T, Minami Y, Tachibana T, Doki N, Uchida N, Ozawa Y, Yano S, Fukuda T, Kato J, Ara T, Eto T, Ishikawa J, Nakamae H, Tanaka J, Ichinohe T, Atsuta Y, Nagamura-Inoue T, Therapy C. The new generation tyrosine kinase inhibitor improves the survival of chronic myeloid leukemia patients after allogeneic stem cell transplantation. Hematol Oncol 2022; 40:442-456. [PMID: 35394658 DOI: 10.1002/hon.3000] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/08/2022] [Accepted: 03/31/2022] [Indexed: 11/08/2022]
Abstract
The introduction of tyrosine kinase inhibitors (TKIs) in chronic myeloid leukemia (CML) treatment has dramatically improved the prognosis of CML patients and reduced the number of patients receiving allogeneic stem cell transplantation (allo-SCT). However, the impact of the newest-generation TKIs on the overall survival (OS) after allo-SCT has not been well described. To investigate the beneficial effects of TKIs on the prognosis after allo-SCT, we conducted a retrospective observational study using the Transplant Registry Unified Management Program database in Japan. We analyzed 1,188 patients (male/female: 738/450; median age: 44 years; range: 16-75) who underwent their first allo-SCT between January 2001 and December 2018. We divided the patients into two groups according to the TKI treatment used before allo-SCT: group 1 was treated with the 1st generation TKI imatinib; group 2 was treated with the 2nd generation TKIs nilotinib, dasatinib, or bosutinib and/or the 3rd generation TKI ponatinib. We compared the post allo-SCT OS between the two groups. The 3-year OS rates (95%CI) of groups 1 and 2 were 59.3% (54.8-63.5%) and 65.8% (61.6-69.6%), respectively (p=0.017). Multivariate analysis confirmed that group 2 had superior OS after allo-SCT compared to group 1 (p=0.002). Other factors associated with superior prognosis were age ≤65, performance status (PS) 0/1, a 6/6 HLA-matched donor and chronic-phase (CP) disease status at allo-SCT. A subgroup analysis showed poor prognoses for patients who could not obtain a molecular response before allo-SCT and patients with positive T315I mutation in the BCR/ABL gene. In group 2, early allo-SCT was correlated with superior OS in patients with a blast-crisis disease status at allo-SCT (p=0.001). The cumulative incidence of non-relapse mortality rate significantly decreased in group 2 (p=0.0005). The post allo-SCT OS was improved both by pre- and post-management of allo-SCT and by the introduction of newer TKIs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yutaka Shimazu
- Department of Hematology, Kyoto University Hospital, Kyoto, Japan
| | - Makoto Murata
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takeshi Kondo
- Department of Hematology, Aiiku Hospital, Sapporo, Hokkaido, Japan
| | - Yosuke Minami
- Department of Hematology, National Cancer Center Hospital East, Chiba, Japan
| | | | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations TORANOMON, Tokyo, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Aichi, Japan
| | - Shingo Yano
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, the Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Jun Kato
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takahide Ara
- Department of Hematology, Hokkaido University Hospital, Hokkaido, Japan
| | - Testuya Eto
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Jun Ishikawa
- Department of Hematology, Osaka International Cancer Institute, Osaka, Japan
| | - Hirohisa Nakamae
- Department of Hematology, Osaka City University Hospital, Osaka, Japan
| | - Junji Tanaka
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Aichi, Japan.,Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Nagoya, Aichi, Japan
| | - Tokiko Nagamura-Inoue
- Department of Cell Processing and Transfusion, Department of Hematology/Oncology, Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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10
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How J, Venkataraman V, Hobbs GS. Blast and accelerated phase CML: room for improvement. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:122-128. [PMID: 34889372 PMCID: PMC8791122 DOI: 10.1182/hematology.2021000240] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Tyrosine kinase inhibitors (TKIs) revolutionized the treatment of chronic myeloid leukemia (CML). With TKI therapy, the percentage of patients who progress to accelerated phase (AP) or blast phase (BP) CML has decreased from more than 20% to 1% to 1.5% per year. Although AP- and BP-CML occur in a minority of patients, outcomes in these patients are significantly worse compared with chronic phase CML, with decreased response rates and duration of response to TKI. Despite this, TKIs have improved outcomes in advanced phase CML, particularly in de novo AP patients, but are often inadequate for lasting remissions. The goal of initial therapy in advanced CML is a return to a chronic phase followed by consideration for bone marrow transplantation. The addition of induction chemotherapy with TKI is often necessary for achievement of a second chronic phase. Given the small population of patients with advanced CML, development of novel treatment strategies and investigational agents is challenging, although clinical trial participation is encouraged in AP and BP patients, whenever possible. We review the overall management approach to advanced CML, including TKI selection, combination therapy, consideration of transplant, and novel agents.
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Affiliation(s)
- Joan How
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Vinayak Venkataraman
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Gabriela Soriano Hobbs
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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11
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Cortes J, Pavlovsky C, Saußele S. Chronic myeloid leukaemia. Lancet 2021; 398:1914-1926. [PMID: 34425075 DOI: 10.1016/s0140-6736(21)01204-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 01/04/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023]
Abstract
Tyrosine-kinase inhibitors have changed the natural history of chronic myeloid leukaemia in such a way that patients with adequate access to these agents, who are properly managed, and who respond well to this treatment can expect a near-normal life expectancy. Achieving this goal requires an adequate understanding of the patient's treatment goals, careful monitoring for the achievement of optimal response hallmarks, implementation of proper interventions according to the attainment of such endpoints, adequate recognition and management of adverse events, and acknowledgment of the relevance of comorbidities. Treatment with tyrosine-kinase inhibitors, once considered lifelong, has become terminable for at least some patients, and promising new agents are emerging for those whose disease does not respond to any of the multiple therapeutic options currently available. If these advances reach all patients with chronic myeloid leukaemia, cure might eventually become a reality in most instances.
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Affiliation(s)
- Jorge Cortes
- Georgia Cancer Center, Augusta University, Augusta, GA, USA.
| | | | - Susanne Saußele
- University Hospital Mannheim, Heidelberg University, Mannheim, Germany
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Sampaio MM, Santos MLC, Marques HS, Gonçalves VLDS, Araújo GRL, Lopes LW, Apolonio JS, Silva CS, Santos LKDS, Cuzzuol BR, Guimarães QES, Santos MN, de Brito BB, da Silva FAF, Oliveira MV, Souza CL, de Melo FF. Chronic myeloid leukemia-from the Philadelphia chromosome to specific target drugs: A literature review. World J Clin Oncol 2021; 12:69-94. [PMID: 33680875 PMCID: PMC7918527 DOI: 10.5306/wjco.v12.i2.69] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/22/2020] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm and was the first neoplastic disease associated with a well-defined genotypic anomaly - the presence of the Philadelphia chromosome. The advances in cytogenetic and molecular assays are of great importance to the diagnosis, prognosis, treatment, and monitoring of CML. The discovery of the breakpoint cluster region (BCR)-Abelson murine leukemia (ABL) 1 fusion oncogene has revolutionized the treatment of CML patients by allowing the development of targeted drugs that inhibit the tyrosine kinase activity of the BCR-ABL oncoprotein. Tyrosine kinase inhibitors (known as TKIs) are the standard therapy for CML and greatly increase the survival rates, despite adverse effects and the odds of residual disease after discontinuation of treatment. As therapeutic alternatives, the subsequent TKIs lead to faster and deeper molecular remissions; however, with the emergence of resistance to these drugs, immunotherapy appears as an alternative, which may have a cure potential in these patients. Against this background, this article aims at providing an overview on CML clinical management and a summary on the main targeted drugs available in that context.
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Affiliation(s)
- Mariana Miranda Sampaio
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Maria Luísa Cordeiro Santos
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Hanna Santos Marques
- Campus Vitória da Conquista, Universidade Estadual do Sudoeste da Bahia, Vitória da Conquista 45083-900, Bahia, Brazil
| | | | - Glauber Rocha Lima Araújo
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Luana Weber Lopes
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Jonathan Santos Apolonio
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Camilo Santana Silva
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Luana Kauany de Sá Santos
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Beatriz Rocha Cuzzuol
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | | | - Mariana Novaes Santos
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Breno Bittencourt de Brito
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | | | - Márcio Vasconcelos Oliveira
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Cláudio Lima Souza
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Fabrício Freire de Melo
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
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Smith G, Apperley J, Milojkovic D, Cross NCP, Foroni L, Byrne J, Goringe A, Rao A, Khorashad J, de Lavallade H, Mead AJ, Osborne W, Plummer C, Jones G, Copland M. A British Society for Haematology Guideline on the diagnosis and management of chronic myeloid leukaemia. Br J Haematol 2020; 191:171-193. [PMID: 32734668 DOI: 10.1111/bjh.16971] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/22/2020] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Adam J Mead
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Wendy Osborne
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Chris Plummer
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Gail Jones
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- BSH Haemato-Oncology Task Force representative
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Ohanian M, Kantarjian HM, Shoukier M, Dellasala S, Musaelyan A, Nogueras Gonzalez GM, Jabbour E, Abruzzo L, Verstovsek S, Borthakur G, Ravandi F, Garcia-Manero G, Tamamyan G, Champlin R, Pierce S, Ferrajoli A, Kadia T, Cortes JE. The clinical impact of time to response in de novo accelerated-phase chronic myeloid leukemia. Am J Hematol 2020; 95:1127-1134. [PMID: 32557828 DOI: 10.1002/ajh.25907] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 11/10/2022]
Abstract
We aimed to describe the impact of time to response on the outcomes of 75 patients with accelerated-phase chronic myeloid leukemia (CML-AP) at diagnosis. Patients had at least 1 feature of AP: blasts ≥15% (n = 2), basophils ≥20% (n = 19), platelets <100 × 109 /L (n = 7), cytogenetic clonal evolution (n = 34), or more than one factor (n = 13). Thirty-three patients received imatinib; 42 received a second-generation tyrosine kinase inhibitor (2GTKI) (19 dasatinib and 23 nilotinib). We used chi-square and Kaplan-Meier analyses to determine the impact of various degrees of molecular and cytogenetic response at early time points (3 and 6 months) on rates of overall cytogenetic and molecular response, overall survival (OS), event-free survival (EFS), transformation-free survival (TFS), and failure-free survival (FFS). After a median follow-up of 96 months (range: 18-224 months), the overall rate of complete cytogenetic response was 79%, of major molecular response, 71%, and of molecular reponse (MR)4.5, 59%. Patients who achieved a major cytogenetic response (MCyR) (n = 49) at 3 months had significantly better 3-year OS (94% vs 75%; P = .002), TFS (98% vs 73%; P < .001), EFS (93% vs 42%; P < .001), and FFS (83% vs 25%; P < .001) rates than patients who did not have MCyR at 3 months. Most (67%) who eventually achieved sustained MR4.5 had achieved MCyR at 3 months. In de novo CML-AP, early response at 3 and 6 months is a strong determinant of long-term outcome.
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Affiliation(s)
- Maro Ohanian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mahran Shoukier
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sara Dellasala
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Arine Musaelyan
- Department of Internal Medicine, RWJBH Healthcare System, Jersey City, New Jersey, USA
| | | | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lynne Abruzzo
- Department of Pathology, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gevorg Tamamyan
- Pediatric Cancer and Blood Disorders Center of Armenia, Yerevan State Medical University, Yerevan, Armenia
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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15
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Jabbour E, Kantarjian H. Chronic myeloid leukemia: 2020 update on diagnosis, therapy and monitoring. Am J Hematol 2020; 95:691-709. [PMID: 32239758 DOI: 10.1002/ajh.25792] [Citation(s) in RCA: 193] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/18/2020] [Indexed: 12/18/2022]
Abstract
DISEASE OVERVIEW Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm with an incidence of 1-2 cases per 100 000 adults. It accounts for approximately 15% of newly diagnosed cases of leukemia in adults. DIAGNOSIS CML is characterized by a balanced genetic translocation, t(9;22)(q34;q11.2), involving a fusion of the Abelson gene (ABL1) from chromosome 9q34 with the breakpoint cluster region (BCR) gene on chromosome 22q11.2. This rearrangement is known as the Philadelphia chromosome. The molecular consequence of this translocation is the generation of a BCR-ABL1 fusion oncogene, which in turn translates into a BCR-ABL oncoprotein. FRONTLINE THERAPY Four tyrosine kinase inhibitors (TKIs), imatinib, nilotinib, dasatinib, and bosutinib are approved by the United States Food and Drug Administration for first-line treatment of newly diagnosed CML in chronic phase (CML-CP). Clinical trials with second generation TKIs reported significantly deeper and faster responses, but they had no impact on survival prolongation, likely because of the existence of highly effective salvage therapies for patients who have a cytogenetic relapse with frontline TKI. SALVAGE THERAPY For CML post failure on frontline therapy, second-line options include second and third generation TKIs. Although potent and selective, these exhibit unique pharmacological profiles and response patterns relative to different patient and disease characteristics, such as patients' comorbidities, disease stage, and BCR-ABL1 mutational status. Patients who develop the T315I "gatekeeper" mutation display resistance to all currently available TKIs except ponatinib. Allogeneic stem cell transplantation remains an important therapeutic option for patients with CML-CP who have failed at least 2 TKIs, and for all patients in advanced phase disease. Even among older patients who have a cytogenetic relapse post failure on all TKIs, they can maintain long-term survival if they continue on a daily most effective/less toxic TKI, with or without the addition of non-TKI anti-CML agents (hydroxyurea, omacetaxine, azacitidine, decitabine, cytarabine, busulfan, others).
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Affiliation(s)
- Elias Jabbour
- Department of LeukemiaThe University of Texas M. D. Anderson Cancer Center Houston Texas USA
| | - Hagop Kantarjian
- Department of LeukemiaThe University of Texas M. D. Anderson Cancer Center Houston Texas USA
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[The guidelines for diagnosis and treatment of chronic myelogenous leukemia in China (2020 edition)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:353-364. [PMID: 32536131 PMCID: PMC7342066 DOI: 10.3760/cma.j.issn.0253-2727.2020.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Indexed: 01/29/2023]
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Abstract
PURPOSE OF REVIEW The marked improvement in clinical outcomes for patients with chronic myeloid leukaemia (CML) can be solely attributed to the introduction of targeted therapies against the fusion oncoprotein, BCR-ABL1. However, patient responses, although generally positive, remain heterogenous. Careful drug selection, ensuring the optimal TKI, is chosen for each patient and involves a complex decision process which incorporates consideration of numerous factors. RECENT FINDINGS For some patients, with disease characteristics that indicate adverse intrinsic disease biology, more potent BCR-ABL1 inhibition is often appropriate, whereas other patients with major co-morbidities will benefit from a less aggressive approach to avoid life-shortening toxicities. For the vast majority of patients, the long-term goal of therapy will be the achievement of a deep molecular response and subsequent treatment-free remission and this consideration will play a large part in the drug selection process. We explore early management of CML, from the first presentation through to frontline therapy selection.
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18
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Lauseker M, Bachl K, Turkina A, Faber E, Prejzner W, Olsson‐Strömberg U, Baccarani M, Lomaia E, Zackova D, Ossenkoppele G, Griskevicius L, Schubert‐Fritschle G, Sacha T, Heibl S, Koskenvesa P, Bogdanovic A, Clark RE, Guilhot J, Hoffmann VS, Hasford J, Hochhaus A, Pfirrmann M. Prognosis of patients with chronic myeloid leukemia presenting in advanced phase is defined mainly by blast count, but also by age, chromosomal aberrations and hemoglobin. Am J Hematol 2019; 94:1236-1243. [PMID: 31456269 DOI: 10.1002/ajh.25628] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/19/2019] [Accepted: 08/22/2019] [Indexed: 12/28/2022]
Abstract
Chronic myeloid leukemia (CML) is usually diagnosed in chronic phase, yet there is a small percentage of patients that is diagnosed in accelerated phase or blast crisis. Due to this rarity, little is known about the prognosis of these patients. Our aim was to identify prognostic factors for this cohort. We identified 283 patients in the EUTOS population-based and out-study registries that were diagnosed in advanced phase. Nearly all patients were treated with tyrosine kinase inhibitors. Median survival in this heterogeneous cohort was 8.2 years. When comparing patients with more than 30% blasts to those with 20-29% blasts, the hazard ratio (HR) was 1.32 (95%-confidence interval (CI): [0.7-2.6]). Patients with 20-29% blasts had a significantly higher risk than patients with less than 20% blasts (HR: 2.24, 95%-CI: [1.2-4.0], P = .008). We found that the blast count was the most important prognostic factor; however, age, hemoglobin, basophils and other chromosomal aberrations should be considered as well. The ELTS score was able to define two groups (high risk vs non-high risk) with an HR of 3.01 (95%-CI: [1.81-5.00], P < .001). Regarding the contrasting definitions of blast crisis, our data clearly supported the 20% cut-off over the 30% cut-off in this cohort. Based on our results, we conclude that a one-phase rather than a two-phase categorization of de novo advanced phase CML patients is appropriate.
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Affiliation(s)
- Michael Lauseker
- Institute for Medical Information Processing, Biometry, and EpidemiologyLudwig‐Maximilians‐Universität München Munich Germany
| | - Katharina Bachl
- Institute for Medical Information Processing, Biometry, and EpidemiologyLudwig‐Maximilians‐Universität München Munich Germany
| | - Anna Turkina
- National Research Center for Hematology Moscow Russia
| | - Edgar Faber
- Department of Hematology‐OncologyUniversity Hospital, Palacky University Olomouc Czech Republic
| | - Witold Prejzner
- Department of HematologyMedical University of Gdansk Gdansk Poland
| | - Ulla Olsson‐Strömberg
- Department of Internal Medicine, Department of Medical Science and Division of HematologyUniversity Hospital Uppsala Sweden
| | - Michele Baccarani
- Department of Hematology and Oncology L. and AUniversity of Bologna Bologna Italy
| | - Elza Lomaia
- Clinical oncology ‐ Research department of oncology and hematologyAlmazov Medical Research Center St Petersburg Russian Federation
| | - Daniela Zackova
- Department of Internal Medicine, Hematology and OncologyUniversity Hospital Brno and Masaryk University Brno Czech Republic
| | - Gert Ossenkoppele
- Department of HematologyAmsterdam University Medical Center, location VUmc Amsterdam The Netherlands
| | - Laimonas Griskevicius
- Vilnius University Hospital Santaros Klinikos and Institute of Clinical MedicineVilnius University Vilnius Lithuania
| | | | - Tomasz Sacha
- Chair and Department of HematologyJagiellonian University Hospital Kraków Poland
| | - Sonja Heibl
- Department for Internal Medicine IVKlinikum Wels‐Grieskirchen Wels Austria
| | - Perttu Koskenvesa
- Helsinki University Hospital Cancer Center and Hematology Research UnitHelsinki University Helsinki Finland
| | - Andrija Bogdanovic
- Clinic of Hematology CCS and Faculty of MedicineUniversity of Belgrade Belgrade Serbia
| | - Richard E. Clark
- Institute of Translational MedicineUniversity of Liverpool Liverpool UK
| | - Joelle Guilhot
- Clinical Investigation Center, INSERM CIC 1402, CHU Poitiers Poitiers France
| | - Verena S. Hoffmann
- Institute for Medical Information Processing, Biometry, and EpidemiologyLudwig‐Maximilians‐Universität München Munich Germany
| | - Joerg Hasford
- Institute for Medical Information Processing, Biometry, and EpidemiologyLudwig‐Maximilians‐Universität München Munich Germany
| | - Andreas Hochhaus
- Abteilung Hämatologie/Onkologie, Klinik für Innere Medizin IIUniversitätsklinikum Jena Jena Germany
| | - Markus Pfirrmann
- Institute for Medical Information Processing, Biometry, and EpidemiologyLudwig‐Maximilians‐Universität München Munich Germany
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Bonifacio M, Stagno F, Scaffidi L, Krampera M, Di Raimondo F. Management of Chronic Myeloid Leukemia in Advanced Phase. Front Oncol 2019; 9:1132. [PMID: 31709190 PMCID: PMC6823861 DOI: 10.3389/fonc.2019.01132] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/10/2019] [Indexed: 12/14/2022] Open
Abstract
Management of chronic myeloid leukemia (CML) in advanced phases remains a challenge also in the era of tyrosine kinase inhibitors (TKIs) treatment. Cytogenetic clonal evolution and development of resistant mutations represent crucial events that limit the benefit of subsequent therapies in these patients. CML is diagnosed in accelerated (AP) or blast phase (BP) in <5% of patients, and the availability of effective treatments for chronic phase (CP) has dramatically reduced progressions on therapy. Due to smaller number of patients, few randomized studies are available in this setting and evidences are limited. Nevertheless, three main scenarios may be drawn: (a) patients diagnosed in AP are at higher risk of failure as compared to CP patients, but if they achieve optimal responses with frontline TKI treatment their outcome may be similarly favorable; (b) patients diagnosed in BP may be treated with TKI alone or with TKI together with conventional chemotherapy regimens, and subsequent transplant decisions should rely on kinetics of response and individual transplant risk; (c) patients in CP progressing under TKI treatment represent the most challenging population and they should be treated with alternative TKI according to the mutational profile, optional chemotherapy in BP patients, and transplant should be considered in suitable cases after return to second CP. Due to lack of validated and reliable markers to predict blast crisis and the still unsatisfactory results of treatments in this setting, prevention of progression by careful selection of frontline treatment in CP and early treatment intensification in non-optimal responders remains the main goal. Personalized evaluation of response kinetics could help in identifying patients at risk for progression.
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Affiliation(s)
| | - Fabio Stagno
- Division of Hematology With BMT, AOU Policlinico “Vittorio Emanuele”, University of Catania, Catania, Italy
| | - Luigi Scaffidi
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Mauro Krampera
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Francesco Di Raimondo
- Division of Hematology With BMT, AOU Policlinico “Vittorio Emanuele”, University of Catania, Catania, Italy
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Myeloablative vs reduced-intensity conditioning allogeneic hematopoietic cell transplantation for chronic myeloid leukemia. Blood Adv 2019; 2:2922-2936. [PMID: 30396912 DOI: 10.1182/bloodadvances.2018024844] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/04/2018] [Indexed: 12/12/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is a potentially curative treatment of chronic myeloid leukemia (CML). Optimal conditioning intensity for allo-HCT for CML in the era of tyrosine kinase inhibitors (TKIs) is unknown. Using the Center for International Blood and Marrow Transplant Research database, we sought to determine whether reduced-intensity/nonmyeloablative conditioning (RIC) allo-HCT and myeloablative conditioning (MAC) result in similar outcomes in CML patients. We evaluated 1395 CML allo-HCT recipients between the ages of 18 and 60 years. The disease status at transplant was divided into the following categories: chronic phase 1, chronic phase 2 or greater, and accelerated phase. Patients in blast phase at transplant and alternative donor transplants were excluded. The primary outcome was overall survival (OS) after allo-HCT. MAC (n = 1204) and RIC allo-HCT recipients (n = 191) from 2007 to 2014 were included. Patient, disease, and transplantation characteristics were similar, with a few exceptions. Multivariable analysis showed no significant difference in OS between MAC and RIC groups. In addition, leukemia-free survival and nonrelapse mortality did not differ significantly between the 2 groups. Compared with MAC, the RIC group had a higher risk of early relapse after allo-HCT (hazard ratio [HR], 1.85; P = .001). The cumulative incidence of chronic graft-versus-host disease (cGVHD) was lower with RIC than with MAC (HR, 0.77; P = .02). RIC provides similar survival and lower cGVHD compared with MAC and therefore may be a reasonable alternative to MAC for CML patients in the TKI era.
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21
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Pushpam D, Bakhshi S. Paediatric chronic myeloid leukaemia: Is it really a different disease? Indian J Med Res 2019; 149:600-609. [PMID: 31417027 PMCID: PMC6702689 DOI: 10.4103/ijmr.ijmr_331_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Paediatric chronic myeloid leukaemia (CML) has biological and clinical differences from adult CML. Management of paediatric CML presents unique challenges in growing children, and there are no specific guidelines for paediatric CML. This review focusses on the clinical characteristics, diagnostic issues and management of paediatric CML. Major studies that provide the basis of managing paediatric CML are summerized here. Studies conducted on adult CML patients were used to guide the management of places where studies were lacking in paediatric CML. Recently, dasatinib and nilotinib have been approved for treatment of paediatric CML, and their role has been discussed in the current management perspective. Allogeneic transplant, fertility and vaccination in paediatric CML, have also been discussed.
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Affiliation(s)
- Deepam Pushpam
- Department of Medical Oncology, Dr. B.R. Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. B.R. Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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22
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Millot F, Maledon N, Guilhot J, Güneş AM, Kalwak K, Suttorp M. Favourable outcome of de novo advanced phases of childhood chronic myeloid leukaemia. Eur J Cancer 2019; 115:17-23. [PMID: 31082688 DOI: 10.1016/j.ejca.2019.03.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/25/2019] [Accepted: 03/22/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic myeloid leukaemia (CML) is very rare in children. The aim of the study is to report the experience within the I-CML-Ped study in children and adolescents presenting at diagnosis with advanced phase disease and to describe their characteristics and outcomes. METHODS Of 479 children and adolescents enrolled in the international registry for childhood chronic myeloid leukaemia (I-CML-Ped Study; www.clinicaltrials.govNCT01281735), 36 children (7.5%) presented at initial diagnosis with CML in advanced phase according to the European LeukemiaNet criteria. RESULTS Nineteen (4%) patients were diagnosed in accelerated phase (CML-AP), and among the 17 patients (3.5%) diagnosed in blastic phase (CML-BP), 70% presented with lymphoid immunophenotype. Initial treatment of CML-AP/CML-BP consisted of tyrosine kinase inhibitors (TKIs) with or without chemotherapy, leading to complete haematologic response in 33 of 36 (92%) patients. Seventeen patients proceeded to haematopoietic stem cell transplantation. At the last follow-up, 18 of 19 patients with de novo CML-AP are alive in at least major molecular response (MMR) (n = 16), in progression (n = 1) or in molecular relapse (n = 1) and 13 of 17 patients with de novo CML-BP are alive in at least MMR. Five-year overall survival rates are 94% (95% confidence interval [CI]: 66%-99%) and 74% (95% CI: 44%-89%) for patients diagnosed in CML-AP and CML-BP, respectively. CONCLUSION Children with advanced phase at diagnosis of CML seem to have a better survival rate than that reported for advanced phases evolving under TKI treatment.
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MESH Headings
- Adolescent
- Age of Onset
- Cancer Survivors
- Child
- Child, Preschool
- Databases, Factual
- Disease Progression
- Female
- Hematopoietic Stem Cell Transplantation/adverse effects
- Hematopoietic Stem Cell Transplantation/mortality
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Male
- Molecular Targeted Therapy
- Neoplasm Staging
- Protein Kinase Inhibitors/adverse effects
- Protein Kinase Inhibitors/therapeutic use
- Registries
- Time Factors
- Treatment Outcome
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Affiliation(s)
| | | | | | - Adalet Meral Güneş
- Department of Pediatric Hematology, Uludağ University Hospital, Görükle Bursa, Turkey
| | - Krzysztof Kalwak
- Department of Pediatric Hematology Oncology and Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Meinolf Suttorp
- Medical Faculty, Department of Pediatric Hematology and Oncology, Technical University, Dresden, Germany
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Nee A, Lipton JH. Update on the management of chronic myeloid leukemia: current best practice and future directions. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1609939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Aisling Nee
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey H. Lipton
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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24
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Allogeneic stem cell transplantation for chronic myeloid leukemia in the TKI era: population-based data from the Swedish CML registry. Bone Marrow Transplant 2019; 54:1764-1774. [DOI: 10.1038/s41409-019-0513-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/23/2019] [Accepted: 03/05/2019] [Indexed: 01/11/2023]
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25
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Long-term efficacy and safety of dasatinib in patients with chronic myeloid leukemia in accelerated phase who are resistant to or intolerant of imatinib. Blood Cancer J 2018; 8:88. [PMID: 30190469 PMCID: PMC6127283 DOI: 10.1038/s41408-018-0122-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/12/2018] [Indexed: 11/15/2022] Open
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26
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Wambolt SR, Garza J. Another Emergent Cause of Headache. Cureus 2018; 10:e2623. [PMID: 30027015 PMCID: PMC6044492 DOI: 10.7759/cureus.2623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We present a case of a subacute headache related to leukostasis secondary to accelerated chronic myeloid leukemia (CML), which required white blood cell (WBC) reduction in the emergency department. A 28-year-old male presented to the emergency department with a chronic headache found to be secondary to leukostasis from accelerated CML with a white blood cell count of 801,000 and 9% blasts. He had bilateral retinal hemorrhage and a headache associated with elevated intracranial pressure. Hydroxyurea and allopurinol were initiated in the emergency department and the patient was eventually transitioned to a tyrosine kinase inhibitor as outpatient therapy. Headaches are a frequent cause of emergency department visits, and this case illustrates another possible etiology of headache requiring emergent intervention.
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Affiliation(s)
| | - Juan Garza
- Emergency Medicine, UT Health Science Center San Antonio
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27
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Jabbour E, Kantarjian H. Chronic myeloid leukemia: 2018 update on diagnosis, therapy and monitoring. Am J Hematol 2018; 93:442-459. [PMID: 29411417 DOI: 10.1002/ajh.25011] [Citation(s) in RCA: 234] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 12/17/2017] [Indexed: 12/11/2022]
Abstract
DISEASE OVERVIEW Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm with an incidence of 1-2 cases per 100 000 adults. It accounts for approximately 15% of newly diagnosed cases of leukemia in adults. DIAGNOSIS CML is characterized by a balanced genetic translocation, t(9;22)(q34;q11.2), involving a fusion of the Abelson gene (ABL1) from chromosome 9q34 with the breakpoint cluster region (BCR) gene on chromosome 22q11.2. This rearrangement is known as the Philadelphia chromosome. The molecular consequence of this translocation is the generation of a BCR-ABL1 fusion oncogene, which in turn translates into a BCR-ABL1 oncoprotein. Frontline therapy: Four tyrosine kinase inhibitors (TKIs), imatinib, nilotinib, dasatinib, and bosutinib are approved by the United States Food and Drug Administration for first-line treatment of patients with newly diagnosed CML in chronic phase (CML-CP). Clinical trials with second generation TKIs reported significantly deeper and faster responses; this has not translated into improved long-term survival, because of the availability of effective salvage therapies. Salvage therapy: For patients who fail frontline therapy, second-line options include second and third generation TKIs. Second and third generation TKIs, although potent and selective, exhibit unique pharmacological profiles and response patterns relative to different patient and disease characteristics, such as patients' comorbidities, disease stage, and BCR-ABL1 mutational status. Patients who develop the T315I "gatekeeper" mutation display resistance to all currently available TKIs except ponatinib. Allogeneic stem cell transplantation remains an important therapeutic option for patients with CML-CP who have failed at least 2 TKIs, and for all patients in CML advanced phases.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia; The University of Texas M. D. Anderson Cancer Center; Houston Texas
| | - Hagop Kantarjian
- Department of Leukemia; The University of Texas M. D. Anderson Cancer Center; Houston Texas
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Alhuraiji A, Kantarjian H, Boddu P, Ravandi F, Borthakur G, DiNardo C, Daver N, Kadia T, Pemmaraju N, Pierce S, Garcia-Manero G, Wierda W, Verstovsek S, Jabbour E, Cortes J. Prognostic significance of additional chromosomal abnormalities at the time of diagnosis in patients with chronic myeloid leukemia treated with frontline tyrosine kinase inhibitors. Am J Hematol 2018; 93:84-90. [PMID: 29027261 DOI: 10.1002/ajh.24943] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 10/06/2017] [Accepted: 10/10/2017] [Indexed: 02/03/2023]
Abstract
Additional cytogenetic abnormalities (ACA) are considered a high risk feature in chronic myeloid leukemia (CML). However, its prognostic significance at the time of diagnosis in the setting of new tyrosine kinase inhibitors (TKIs) is less well understood. Patients with CML in CP with or without ACA at diagnosis treated with frontline TKIs in prospective clinical trials were analyzed for outcomes. Among 603 patients treated, 29 (5%) had ACA. Patients with ACA included 2 of 72 (2.8%) treated with imatinib 400 mg, 9 of 207 (4.3%) with imatinib 800 mg, 10 of 148 (6.7%) with dasatinib, 6 of 126 (4.7%) with nilotinib, and 2 of 50 (4%) with ponatinib. There was a significantly higher rate of complete cytogenetic response (CCyR) at 6 months in patients without ACA (P = .02). However cumulative CCyR and major molecular response (MMR) rates were not different. Similarly, MR4.0 and MR4.5 rates were similar for both groups; two CML-ACA patients maintained MR 4.5 for at least 2 years. At 5 years, ACA at diagnosis did not significantly impact transformation-free, failure-free, event-free, or overall survival expectations. Acknowledging small sample size estimates, response rates and survival outcomes were comparable in CP with ACA irrespective of whether chromosomal abnormalities were "major route" or other. The presence of ACA at diagnosis does not confer worse prognosis for patients with CML treated with TKI. Thus, the presence of ACA at diagnosis should not alter treatment strategies in these patients.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Female
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/immunology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Male
- Middle Aged
- Prognosis
- Protein Kinase Inhibitors/therapeutic use
- Treatment Outcome
- Young Adult
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Affiliation(s)
- Ahmad Alhuraiji
- Department of Hematology, Kuwait Cancer Control Center, Shuwaikh city, Kuwait
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajwal Boddu
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Courtney DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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29
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Soyer N, Uysal A, Tombuloglu M, Sahin F, Saydam G, Vural F. Allogeneic stem cell transplantation in chronic myeloid leukemia patients: Single center experience. World J Hematol 2017; 6:1-10. [DOI: 10.5315/wjh.v6.i1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/21/2016] [Accepted: 01/03/2017] [Indexed: 02/05/2023] Open
Abstract
Chronic myeloid leukemia (CML) is a myeloproliferative disease which leads the unregulated growth of myeloid cells in the bone marrow. It is characterized by the presence of Philadelphia chromosome. Reciprocal translocation of the ABL gene from chromosome 9 to 22 t (9; 22) (q34; q11.2) generate a fusion gene (BCR-ABL). BCR-ABL protein had constitutive tyrosine kinase activity that is a primary cause of chronic phase of CML. Tyrosine kinase inhibitors (TKIs) are now considered standard therapy for patients with CML. Even though, successful treatment with the TKIs, allogeneic stem cell transplantation (ASCT) is still an important option for the treatment of CML, especially for patients who are resistant or intolerant to at least one second generation TKI or for patients with blastic phase. Today, we know that there is no evidence for increased transplant-related toxicity and negative impact of survival with pre-transplant TKIs. However, there are some controversies about timing of ASCT, the optimal conditioning regimens and donor source. Another important issue is that BCR-ABL signaling is not necessary for survival of CML stem cell and TKIs were not effective on these cells. So, ASCT may play a role to eliminate CML stem cells. In this article, we review the diagnosis, management and treatment of CML. Later, we present our center’s outcomes of ASCT for patients with CML and then, we discuss the place of ASCT in CML treatment in the TKIs era.
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Söderlund S, Dahlén T, Sandin F, Olsson-Strömberg U, Creignou M, Dreimane A, Lübking A, Markevärn B, Själander A, Wadenvik H, Stenke L, Richter J, Höglund M. Advanced phase chronic myeloid leukaemia (CML) in the tyrosine kinase inhibitor era - a report from the Swedish CML register. Eur J Haematol 2016; 98:57-66. [PMID: 27428357 DOI: 10.1111/ejh.12785] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2016] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The primary goal in management of chronic phase (CP) chronic myeloid leukaemia (CML) is to prevent disease progression to accelerated phase (AP) or blast crisis (BC). We have evaluated progression rates in a decentralised healthcare setting and characterised patients progressing to AP/BC on TKI treatment. METHODS Using data from the Swedish CML register, we identified CP-CML patients diagnosed 2007-2011 who progressed to AP/BC within 2 yrs from diagnosis (n = 18) as well as patients diagnosed in advanced phase during 2007-2012 (n = 36) from a total of 544 newly diagnosed CML cases. We evaluated baseline characteristics, progression rates, outcome and adherence to guidelines for monitoring and treatment. RESULTS The cumulative progression rate at 2 yrs was 4.3%. All 18 progression cases had been treated with imatinib, and six progressed within 6 months. High-risk EUTOS score was associated to a higher risk of progression. Insufficient cytogenetic and/or molecular monitoring was found in 33%. Median survival after transformation during TKI treatment was 1.4 yrs. In those presenting with BC and AP, median survival was 1.6 yrs and not reached, respectively. CONCLUSION In this population-based setting, progression rates appear comparable to that reported from clinical trials, with similar dismal patient outcome. Improved adherence to CML guidelines may minimise the risk of disease progression.
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Affiliation(s)
- Stina Söderlund
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Section of Haematology, Uppsala University Hospital, Uppsala, Sweden
| | - Torsten Dahlén
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Ulla Olsson-Strömberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Section of Haematology, Uppsala University Hospital, Uppsala, Sweden
| | - Maria Creignou
- Department of Haematology, Linköping University Hospital, Linköping, Sweden
| | - Arta Dreimane
- Department of Haematology, Linköping University Hospital, Linköping, Sweden
| | - Anna Lübking
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Berit Markevärn
- Department of Haematology, Umeå University Hospital, Umeå, Sweden
| | - Anders Själander
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Hans Wadenvik
- Section of Haematology and Coagulation, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Leif Stenke
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Richter
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Martin Höglund
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Section of Haematology, Uppsala University Hospital, Uppsala, Sweden
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31
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[The guidelines for diagnosis and treatment of chronic myelogenous leukemia in China (2016 edition)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:633-9. [PMID: 27587241 PMCID: PMC7348542 DOI: 10.3760/cma.j.issn.0253-2727.2016.08.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Indexed: 01/30/2023]
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32
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DeFilipp Z, Langston AA, Chen Z, Zhang C, Arellano ML, El Rassi F, Flowers CR, Kota VK, Al-Kadhimi Z, Veldman R, Jillella AP, Lonial S, Waller EK, Khoury HJ. Does Post-Transplant Maintenance Therapy With Tyrosine Kinase Inhibitors Improve Outcomes of Patients With High-Risk Philadelphia Chromosome-Positive Leukemia? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:466-471.e1. [DOI: 10.1016/j.clml.2016.04.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/19/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
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Management of Elderly Patients with Newly Diagnosed Chronic Myeloid Leukemia in the Accelerated or Blastic Phase. Drugs Aging 2016; 33:335-45. [PMID: 26961697 DOI: 10.1007/s40266-016-0351-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In the elderly population, the accelerated and blastic phases of chronic myeloid leukemia (CML) are difficult to treat, not just because of the higher chance of acquired mutations than in younger individuals, but because of additional associated co-morbidities. Tyrosine kinase inhibitors are well-established in the treatment of the chronic phase of CML, and their use in advanced phases is ever-increasing. Elderly patients who are still eligible candidates for transplant can undergo reduced-intensity transplants from related or unrelated donors after reverting to chronic phase. Post-transplantation, these patients require adequate monitoring and therapy to prevent relapses. Newer modalities of treatment or interventions are urgently required in this complex group of patients.
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34
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Tanizawa A. Optimal management for pediatric chronic myeloid leukemia. Pediatr Int 2016; 58:171-9. [PMID: 26646444 DOI: 10.1111/ped.12876] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 11/19/2015] [Accepted: 12/01/2015] [Indexed: 12/11/2022]
Abstract
Chronic myeloid leukemia (CML) is rare among childhood leukemias. Its incidence increases with age, from 0.09/100 000 at ≤15 years old to 7.88/100 000 at ≥75 years old. There are several biological and clinical differences between pediatric and adult CML. Markedly increased leukocyte count and a higher incidence of splenomegaly are characteristic features at diagnosis in pediatric patients. The therapeutic approach to CML has changed since the introduction of the tyrosine kinase inhibitor (TKI) imatinib, followed by dasatinib and nilotinib. Given the efficacy of TKI in adult CML, TKI are regarded as the established first-line treatment in adult patients. In 2011, a prospective phase IV study in pediatric patients showed the excellent efficacy and safety of imatinib. Imatinib is also accepted as a first-line option for childhood chronic phase CML. Although the efficacy of dasatinib and nilotinib reported in adult studies seems very attractive for pediatric patients, neither drug has been prospectively investigated in a large pediatric cohort. TKI are designed to inhibit BCR-ABL1 kinase, but they have unfavorable effects, so-called "off-target" complications, such as growth impairment. Long-term morbidity due to TKI is unknown. Furthermore, the adverse effects on growing children have not been clearly elucidated, even though the exposure period to imatinib is relatively short. To establish the standard therapeutic management for pediatric CML, it is important to prospectively confirm the attractive outcomes obtained in adult studies via pediatric clinical trials with a careful monitoring system for TKI-induced adverse effects, especially in growing children.
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Affiliation(s)
- Akihiko Tanizawa
- Department of Human Resource Development for Cancer, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
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35
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Mukherjee S, Kalaycio M. Accelerated Phase CML: Outcomes in Newly Diagnosed vs. Progression From Chronic Phase. Curr Hematol Malig Rep 2016; 11:86-93. [DOI: 10.1007/s11899-016-0304-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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36
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DeFilipp Z, Khoury HJ. Management of advanced-phase chronic myeloid leukemia. Curr Hematol Malig Rep 2016; 10:173-81. [PMID: 25929768 DOI: 10.1007/s11899-015-0249-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The management of chronic myeloid leukemia (CML) in accelerated or blast phase (advanced phase) remains a significant challenge despite the introduction of very effective tyrosine kinase inhibitors (TKIs). The biology of advanced-phase CML is complex and engages several pathways that are not optimally targeted by TKIs. Allogeneic stem cell transplantation remains the only potentially curative therapy, but the effectiveness of this conventional approach is limited. New strategies are required to improve the outlook for these patients.
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Affiliation(s)
- Zachariah DeFilipp
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, 1365 Clifton Road NE C5010, Atlanta, GA, 30322, USA,
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37
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Jabbour E, Kantarjian H. Chronic myeloid leukemia: 2016 update on diagnosis, therapy, and monitoring. Am J Hematol 2016; 91:252-65. [PMID: 26799612 DOI: 10.1002/ajh.24275] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 12/09/2015] [Indexed: 12/16/2022]
Abstract
DISEASE OVERVIEW Chronic Myeloid Leukemia (CML) is a myeloproliferative neoplasm with an incidence of 1-2 cases per 100,000 adults. It accounts for approximately 15% of newly diagnosed cases of leukemia in adults. DIAGNOSIS CML is characterized by a balanced genetic translocation, t(9;22)(q34;q11.2), involving a fusion of the Abelson gene (ABL1) from chromosome 9q34 with the breakpoint cluster region (BCR) gene on chromosome 22q11.2. This rearrangement is known as the Philadelphia chromosome. The molecular consequence of this translocation is the generation of a BCR-ABL1 fusion oncogene, which in turn translates into a BCR-ABL oncoprotein. Frontline therapy: Three tyrosine kinase inhibitors (TKIs), imatinib, nilotinib, and dasatinib are approved by the United States Food and Drug Administration for first-line treatment of patients with newly diagnosed CML in chronic phase (CML-CP). Clinical trials with 2nd generation TKIs reported significantly deeper and faster responses; their impact on long-term survival remains to be determined. Salvage therapy: For patients who fail frontline therapy, second-line options include second and third generation TKIs. Although second and third generation TKIs are potent and selective TKIs, they exhibit unique pharmacological profiles and response patterns relative to different patient and disease characteristics, such as patients' comorbidities, disease stage, and BCR-ABL1 mutational status. Patients who develop the T315I "gatekeeper" mutation display resistance to all currently available TKIs except ponatinib. Allogeneic stem cell transplantation remains an important therapeutic option for patients with CML-CP who have failed at least two TKIs, and for all patients in advanced phase disease.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia; the University of Texas M. D. Anderson Cancer Center; Houston Texas
| | - Hagop Kantarjian
- Department of Leukemia; the University of Texas M. D. Anderson Cancer Center; Houston Texas
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38
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Amare PSK, Jain H, Kabre S, Walke D, Menon H, Sengar M, Khatri N, Bagal B, Dangi U, Jain H, Subramanian PG, Gujral S. Characterization of Genomic Events Other than Ph and Evaluation of Prognostic Influence on Imatinib in Chronic Myeloid Leukemia (CML): A Study on 1449 Patients from India. ACTA ACUST UNITED AC 2016. [DOI: 10.4236/jct.2016.74030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
The management of chronic myeloid leukaemia (CML) has changed extensively over the past 15 years. Prior to the development of targeted therapies and in the absence of allogeneic haematopoetic stem-cell transplantation (HSCT), the median survival was 5-7 years. HSCT was quickly established as the standard of care for eligible patients through the 1980s and 1990s, when considerable advances were made in the optimization of conditioning regimens and supportive care. Exploiting a deeper understanding of the molecular basis of CML, the development of tyrosine kinase inhibitors (TKIs) in the late 1990s revolutionized the management of the disease. TKIs offer the prospect of long-term disease control with a simple oral therapy, and are the first-line treatment in the 21(st) century. The majority of patients treated with TKIs achieve excellent responses with sustained treatment, and some even continue to have undetectable or exceptionally low level disease upon TKI withdrawal; however, for an almost equal number of patients, an adequate response cannot be achieved with any of the currently available TKIs. For those patients who fail to respond adequately to TKIs, HSCT offers the best prospect of long-term survival.
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40
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Thompson PA, Kantarjian HM, Cortes JE. Diagnosis and Treatment of Chronic Myeloid Leukemia in 2015. Mayo Clin Proc 2015; 90:1440-54. [PMID: 26434969 PMCID: PMC5656269 DOI: 10.1016/j.mayocp.2015.08.010] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 08/23/2015] [Accepted: 08/24/2015] [Indexed: 01/13/2023]
Abstract
Few neoplastic diseases have undergone a transformation in a relatively short period like chronic myeloid leukemia (CML) has in the last few years. In 1960, CML was the first cancer in which a unique chromosomal abnormality was identified and a pathophysiologic correlation suggested. Landmark work followed, recognizing the underlying translocation between chromosomes 9 and 22 that gave rise to this abnormality and, shortly afterward, the specific genes involved and the pathophysiologic implications of this novel rearrangement. Fast forward a few years and this knowledge has given us the most remarkable example of a specific therapy that targets the dysregulated kinase activity represented by this molecular change. The broad use of tyrosine kinase inhibitors has resulted in an improvement in the overall survival to the point where the life expectancy of patients today is nearly equal to that of the general population. Still, there are challenges and unanswered questions that define the reasons why the progress still escapes many patients, and the details that separate patients from ultimate cure. In this article, we review our current understanding of CML in 2015, present recommendations for optimal management, and discuss the unanswered questions and what could be done to answer them in the near future.
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MESH Headings
- Clinical Protocols
- Diagnosis, Differential
- Disease Progression
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/physiopathology
- Patient Outcome Assessment
- Philadelphia Chromosome
- Prognosis
- Protein Kinase Inhibitors/classification
- Protein Kinase Inhibitors/pharmacology
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Affiliation(s)
- Philip A Thompson
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston.
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41
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Innes AJ, Apperley JF. Chronic myeloid leukemia-transplantation in the tyrosine kinase era. Hematol Oncol Clin North Am 2014; 28:1037-53. [PMID: 25459178 DOI: 10.1016/j.hoc.2014.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) revolutionized the outlook for many patients with chronic myeloid leukemia (CML) in the 1980s. The introduction of the tyrosine kinase inhibitors (TKIs) nearly 15 years ago displaced HSCT as the first-line treatment for most CML patients. However, in the twenty-first century HSCT remains a viable treatment option for many patients with CML. This review focuses on the role of HSCT for CML in the TKI era, paying particular attention to patient selection and transplant outcome.
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Affiliation(s)
- Andrew J Innes
- Centre for Haematology, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Jane F Apperley
- Centre for Haematology, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK; Department of Clinical Haematology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK.
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Mathisen MS, Kantarjian HM, Cortes J, Jabbour EJ. Practical issues surrounding the explosion of tyrosine kinase inhibitors for the management of chronic myeloid leukemia. Blood Rev 2014; 28:179-87. [PMID: 24984571 DOI: 10.1016/j.blre.2014.06.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 06/05/2014] [Indexed: 02/03/2023]
Abstract
The advent of tyrosine kinase inhibitors (TKIs) has drastically changed the treatment outcome of chronic myeloid leukemia (CML). Imatinib was the first TKI approved, and has been considered the standard of care for more than a decade. Second generation compounds, namely dasatinib and nilotinib, are highly effective in newly diagnosed patients as well as those who fail imatinib. Bosutinib and ponatinib have also become available as second line options. With five agents from which to choose, selecting a TKI has become a challenge. Multiple tests are now available to determine a patient's disease status, making the ideal monitoring strategy unclear. The gold standard for response to TKI therapy remains the achievement of complete cytogenetic response. This review will discuss the practical aspects of selecting a TKI and monitoring a patient once on therapy, including when to consider a treatment change. Other relevant issues, including cost, compliance, role of allogeneic hematopoietic cell transplantation, and discontinuation of TKIs will also be covered.
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Affiliation(s)
- Michael S Mathisen
- M.D. Anderson Cancer Center, Department of Pharmacy, 1515 Holcombe BLVD, Unit 377, Houston, TX 77030, USA; M.D. Anderson Cancer Center, Department of Leukemia, 1515 Holcombe BLVD, Unit 428, Houston, TX 77030, USA.
| | - Hagop M Kantarjian
- M.D. Anderson Cancer Center, Department of Leukemia, 1515 Holcombe BLVD, Unit 428, Houston, TX 77030, USA.
| | - Jorge Cortes
- M.D. Anderson Cancer Center, Department of Leukemia, 1515 Holcombe BLVD, Unit 428, Houston, TX 77030, USA.
| | - Elias J Jabbour
- M.D. Anderson Cancer Center, Department of Leukemia, 1515 Holcombe BLVD, Unit 428, Houston, TX 77030, USA.
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