Decision making at diagnosis in chronic myeloid leukemia

The diagnostic workup of Philadelphia positive (Ph+) chronic myeloid leukemia requires physical examination, blood counts and differential, marrow aspirate for cytology and cytogenetics, and the detection of BCR-ABL transcripts in marrow or blood. For patients in early chronic phase, first line treatment is Imatinib (IM) 400 mg daily. Response is monitored hematologically, cytogenetically (at least every 6 months) and molecularly by RQ-PCR (every 3 months). The response is optimal when a complete hematologic response is achieved in 3 months, a partial cytogenetic response in 6 months, a complete cytogenetic response in 12 months, a major molecular response in 18 months, and when the responses are stable over time. In case of suboptimal response or failure, a patient may still have a survival benefit by continuing IM treatment at 400 mg daily, but could or should be considered for IM dose increase to 600 and 800 mg, for second generation tyrosine kinase inhibitors (Nilotinib and Dasatinib), and for allogeneic stem cell transplantation.