How I approach hematopoietic stem cell transplantation for CML in a TKI world

After the introduction of tyrosine kinase inhibitors (TKIs), the number of patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) for chronic phase chronic myeloid leukemia (CP-CML) has dramatically decreased. Imatinib was the first TKI introduced into the clinical arena, predominantly used in the first-line setting. In cases of insufficient response, resistance, or intolerance, patients with CML can subsequently be treated with a second-, third-, or fourth-generation TKI. However, despite the approval of first-, second-, third-, and fourth-generation TKIs, allo-HSCT still remains indicated for a minority of patients with CML. Here, we discuss the indications in the era of TKIs through different cases representing the clinical situations for which allo-HSCT remains the best option. We also propose our transplant strategy to decrease transplant-related morbidity, particularly graft-versus-host disease, and mortality in the particular context of CML, a disease that is one of the most sensitive to immune cellular therapy, allowing the use of a combination of donor lymphocyte infusion and TKIs for posttransplant molecular progression.