Leukemia

Chronic Myelogenous Leukemia

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Chronic Myelogenous Leukemia, Chronic Myeloid Leukemia, CML

  • Epidemiology
  1. Common in Atomic bomb survivors
  2. Peak Incidence at ages 30 to 50 years old
  • Pathophysiology
  1. Chronic phase (Mild, indolent course)
    1. Excessive Granulocyte (Neutrophils) proliferation
  2. Blastic phase (Malignant, leukemic course)
    1. Increased blasts and Promyelocytes
  • Symptoms
  1. Asymptomatic in 20% of patients
  2. Weakness
  3. Hypermetabolism
    1. Weight loss
    2. Fever
  4. Arthralgias
  5. Bone pain
  6. Excessive bleeding (spontaneous or with surgery)
  • Signs
  1. Splenomegaly (90%)
  2. Hepatomegaly
  3. Lymphadenopathy
  • Labs
  1. Philadelphia Chromosome (95%)
    1. Reciprocal Chromosome translocation
      1. Long arm of Chromosome 22 (c-sis oncogene)
      2. Long arm of Chromosome 9 (c-abl oncogene)
    2. Translocation of C-abl at bcr breakpoint
      1. Forms bcr/abl
  2. Complete Blood Count
    1. Chronic Phase
      1. White Blood Cell Count > 200,000/uL
      2. Granulocytes (especially Neutrophils) predominate
    2. Transitional Phase (50% of patients)
      1. Leukocytosis
      2. Thrombocytosis or Thrombocytopenia
    3. Blast Phase
      1. Increased Leukocytosis
      2. Thrombocytosis
  3. Bone Marrow Biopsy and Peripheral Smear
    1. Chronic Phase
      1. Myeloblasts represent <5% of cells
    2. Blast Phase
      1. Large proportion of immature cells
    3. Images
      1. HemeoncCmlBlood.jpg
      2. HemeoncCmlMarrow.jpg
      3. HemeoncCmlBlastCrisis.jpg
  4. Vitamin B12 markedly elevated
  5. Leukocyte Alkaline Phosphatase reduced
  6. Uric Acid increased
  • Management
  • CML Treatment
  1. Treatment for cure
    1. Allogeneic Stem Cell Transplant (SCT)
  2. Chronic Phase suppression
    1. First Line
      1. Tyrosine Kinase inhibitor: Imatinib (Gleevac)
        1. Gleevac is generic in U.S. as of February 2016
      2. Interferon-alfa with Cytarabine or
        1. May be poorly tolerated
        2. Studies to date show unclear efficacy
          1. Baccarani (2002) Blood 99:1527 [PubMed]
          2. Guilhot (1997) N Engl J Med 337:223 [PubMed]
    2. Alternative (prior first line agents)
      1. Hydroxyurea (used to stabilize chronic phase)
      2. Busulfan
        1. Risk of myelosuppression
        2. Hydroxyurea is preferred
    3. Other Alkylating Agents (not in marrow transplant)
      1. Cytarabine
      2. Cyclophosphamide
      3. Melphalan
    4. Splenectomy rarely indicated
      1. Hypersplenism
      2. Repeated painful splenic infarctions
    5. Consider Bone Marrow Transplantation in first year
      1. Results in 70% long-term disease free survival
  3. Blast Crisis
    1. Often refractory to treatment
      1. Hydroxyurea
    2. Try protocols for Acute Lymphocytic Leukemia
      1. Vincristine
      2. Prednisone
  • Management
  • Surveillance of CML Survivors
  1. Complete Blood Count (CBC) every 3 months
    1. Hematology Consultation for Neutropenia (ANC <1000/mm3) or Thrombocytopenia (Platelet Count <50k/mm3)
  2. Symptom surveillance
    1. Diarrhea
    2. Fluid retention
    3. Nausea or Vomiting
    4. Headache
    5. Myalgias
    6. Rash
  3. Patients treated with Hematopoietic Stem Cell Transplantation
    1. See Hematopoietic Stem Cell Transplant for protocol
  • Course
  1. Initially indolent
  2. Later progresses to leukemic phase (Blast Crisis)
    1. Blast phase onset after 6-12 months post diagnosis
    2. Annual progression to blast phase: 25% of patients
  • Prognosis
  1. Five year survival
    1. Age under 50 years old: 84% five year survival
    2. Age over 50 years old: 48% five year survival
  • References
  1. (2001) Med Lett Drugs Ther 43(1106):49-50
  2. Druker in Abeloff (2004) Clinical Oncology p. 2899-915
  3. Enright in Hoffman (2000) Hematology 40:1155-67
  4. Davis (2014) Am Fam Physician 89(9): 731-8 [PubMed]