Internal Medicine

0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

Chronic Myelogenous Leukemia 339

1–2 mg P0 qd as maintenance until count l0,000, then stop. Can com-

promise the ability of a patient to be transplanted and therefore not

used for primary therapy.

Side Effects & Contraindications

■Interferon-alpha: flu-like symptoms (fatigue, myalgia, fever, bone

pain), rash, depression

■Contraindication – known hypersensitivity to interferon or vehicle

■Cytarabine: myelosuppression, mucositis, diarrhea, alopecia; Con-

traindication – known hypersensitivity to cytarabine or vehicle

■Hydroxyurea: myelosuppression, mucositis, diarrhea, rash, nausea

■Contraindication – known hypersensitivity to cytarabine or vehicle

■Busulfan: myelosuppression, marrow aplasia, mucositis, diarrhea,

hyperpigmentation

follow-up

■For responding patients on imatinib, especially potential trans-

plant candidates, frequent surveillance (∼q 3 months) of symptoms,

blood counts, and Q-PCR for changes in bcr/abl level are recom-

mended. Evidence for imatinib resistance or disease acceleration

should prompt rapid intervention with increased dose of imatinib,

second-generation abl kinase inhibitor, or transplantation for those

who are candidates.

complications and prognosis

■Patients who respond to imatinib with complete cytogenetic

response and 3- to 5-fold reduction of bcr/abl transcripts have excel-

lent prognosis. It is unknown if such patients are “clinically cured,”

as follow-up times are still relatively short.

➣∼4% of patients on imatinib will develop resistance per year. Such

patients may be salvaged with higher doses of imatinib, second-

generation abl kinase inhibitors, use of the above-mentioned

cytostatic or cytotoxic agents alone or in combination, or prefer-

ably stem cell transplant if the patient is still in chronic phase of

disease.

➣Prognosis is poor for patients who cannot be transplanted and

who develop abl kinase inhibitor resistance. GVHD remains the

major complication of allogeneic stem cell transplantation.

➣Patients who relapse after allogeneic stem cell transplantation

can be salvaged by donor lymphocyte infusions. Vaccines and

other forms of immunotherapy are under investigation and may

prove useful.