0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
338 Chronic Myelogenous Leukemia■Patient Education – Natural history of disease progression (chronic,
to accelerated, to blast phase) must be discussed, along with treat-
ment options (see below)
■HLA type patient and siblings
■Determine if patient is candidate for allogeneic hematopoietic cell
transplant; transplant only documented curative modality, but only
20% of patients are allotransplant candidates.specific therapy
■Virtually all chronic-phase patients are now treated initially with abl
kinase inhibitor, imatinib mesylate (Gleevec). >80% of patients will
achieve a complete cytogenetic remission on standard dose of 400
mg/day. Most patients remain PCR+for bcr/abl. Higher imatinib
doses may prove beneficial, but this remains unproven. Approx. 50–
70% of patients report nausea, fluid retention, GI upset, including
nausea, vomiting, and diarrhea. Hepatotoxicity reported in 1–3%,
neutropenia and thrombocytopenia in up to approx 1/3 of patients.
More potent second-generation abl kinase inhibitors are actively
being investigated in the clinic now.
■Allogeneic hematopoietic cell transplant- Only treatment known to
cure disease. Timing of transplant, especially for young patients with
matched related donors, remains controversial. Most experts suggest
initial trial of imatinib, but move to transplant for patients with sub-
optimal response to imatinib (failure to achieve a complete hema-
tologic response after 3 months, or failure to achieve any significant
cytogenetic response after 6 months, or failure to achieve a major
cytogenetic response after 1 year), or development of imatinib resis-
tance.
■Other useful drugs
■Hydroxyurea – For patients with inadequate response to imatinib.
0.5–2.0 gm/d as tolerated. WBC and platelet counts need to be mon-
itored frequently.
■Interferon-alpha – up to 9 million units/day as tolerated; may take
>3 months to control disease; 20% of patients will become entirely
Ph(−) for variable and in some cases prolonged periods of time.
Cytarabine – used in conjunction with interferon; benefit suggested
but not proven; 2O mg/m2/d×10 days each month.
■Cytosine arabinoside – dose depends on disease activity. 20 mg/m2
daily×2 weeks to full dose for blast transformation.
Busulfan – 2–6 mg P0 qd until WBC <30–40,000; then half dose until
count <20,000, when drug stopped. Observe until counts stabilize.