Managing the patient with chronic myeloid leukemia through and after allogeneic stem cell transplantation

Although the only curative therapy for chronic myeloid leukemia remains allogeneic stem cell transplantation (allo-SCT), early to mid-term results of imatinib in newly diagnosed patients are sufficiently impressive to have displaced allo-SCT to second- or third-line treatment. Patients now arrive at a decision for transplantation in a variety of disease situations: failing to achieve certain hematological, cytogenetic and molecular milestones by some pre-determined timepoint, having lost a previous best response or by progression to advanced phase. The decision, therefore, is not simply whether to transplant or not, but also how to transplant. Evolving transplant technology requires that the individual circumstances of each patient should be considered when recommending the procedure. Attempts to improve the safety of transplant are generally associated with a reduction in long-term disease control and patient monitoring, and management is life-long. The treatment of recurrent disease is no longer straightforward, with the choices being donor lymphocytes or tyrosine kinase inhibitors alone or in combination. This section will review the evidence supporting some of these decisions and highlight current controversies.