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Drugs & Diseases > Cancer Guides

Chronic Myelogenous Leukemia (CML)

Guidelines
Updated: Dec 23, 2016
Author: Karen Seiter, MD; Chief Editor: Emmanuel C Besa, MD more...

Management of Chronic Myelogenous Leukemia (CML)

Guidelines for the management of chronic myelogenous leukemia (CML) have been
issued by the following organizations:
National Comprehensive Cancer Network (NCCN) [1]
European Society of Medical Oncology (ESMO) [2]
European LeukemiaNet (ELN) [3]
For chronic-phase CML, all the guidelines recommend the following:
Any of three tyrosine kinase inhibitors (TKIs) (imatinib, nilotinib, or dasatinib)
are the first-line treatment for CML
In case of intolerance, patients can be switched to another TKI or bosutinib
All three TKIs can be used as second-line treatment; doses may differ in the
second- line setting, depending on the agent chosen
Hematopoietic stem cell transplantation (HSCT) should be considered in the case
of failure of two TKIs
For accelerated-phase CML, all the guidelines recommend the following:
TKI (imatinib, nilotinib, dasatinib or bosutinib).
Choice of TKI is based on prior therapy and/or BCR-ABL kinase domain
mutation status
Recommended doses of imatinib, nilotinib, and dasatinib are higher for
accelerated phase than for chronic phase
If resistance and/or intolerance to two or more TKIs occurs, consider
omacetaxine
Consider HSCT, based on treatment response and patient age
For blast-phase CML, all the guidelines recommend the following:
HSCT, preferably after response to induction therapy
 Patients in lymphoid blast phase can be treated with acute lymphoblastic
leukemia (ALL) induction chemotherapy regimens in combination with a TKI
Patients in myeloid blast crisis can be treated with acute myeloid leukemia
(AML) induction chemotherapy regimens in combination with a TKI
Monitoring
National Comprehensive Cancer Network (NCCN), European LeukemiaNet (ELN),
and European Society of Medical Oncology (ESMO) guidelines recommend the
following tests for monitoring response to tyrosine kinase inhibitor (TKI) therapy:
Bone marrow cytogenetics
Quantitative reverse transcription polymerase chain reaction (QPCR)
The three guidelines vary in their recommendations regarding response to first-line
treatment, as outlined below.
NCCN Recommendations
The desired responses to first-line treatment are as follows:
3 months: BCR-ABL1 transcripts 10% by QPCR or partial cytogenetic
response (PCyR) on bone marrow cytogenetics
6 months: BCR-ABL1 transcripts 10% by QPCR or PCyR on bone marrow
cytogenetics
12 months: Complete cytogenetic response (CCyR) on bone marrow
cytogenetics (if neither CCyR nor major molecular response [MMR] has been
previously achieved)
18 months: CCyR on bone marrow cytogenetics (if not in MMR and lack of
CCyR at 12 months)
Any time: Stable or improving MMR

European LeukemiaNet
The optimal responses to first-line treatment are as follows:
3 months: Ph+35%, and/or BCR-ABL110%
6 months: : PH+ 0%, and/or BCR-ABL1 < 1%
12 months: BCR-ABL10.1%

European Society of Medical Oncology (ESMO)

The optimal responses to first-line treatment are as follows:
3 months: Philadelphia chromosome positive (Ph+) 95%, or BCR-ABL< 10%
6 months: Ph+ 35%, or BCR-ABL < 10%
12 months: PH+ 0, or BCR-ABL 1%

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