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Chronic Myelogenous Leukemia

NORD is very grateful to Olivia Lanes, NORD Intern and Thomas P. Loughran, Jr, MD, Professor of Medicine Director, Penn State Hershey Cancer Institute, for assistance in the preparation of this report.

Synonyms of Chronic Myelogenous Leukemia

  • CGL
  • chronic granulocytic leukemia
  • chronic myelocytic leukemia
  • chronic myeloid leukemia
  • GML

Disorder Subdivisions

  • No subdivisions found.

General Discussion

Summary
Chronic myelogenous leukemia (CML) accounts of about 20% of all leukemias affecting adults. It typically affects middle-aged individuals and rarely adolescents or children. CML is a slowly progressing blood and bone marrow disorder, characterized by the excessive development of white blood cells in the spongy tissue found inside large bones of the body (bone marrow), spleen, liver and blood. As the disease progresses, the leukemic (blast) cells invade other areas of the body including the intestinal tract, kidneys, lungs, gonads and lymph nodes. These diseased cells do not grow old and eventually die like normal cells. They build up in huge numbers, overwhelm healthy blood cells and damage the bone marrow.

Since CML progresses slowly, many people are first diagnosed during routine blood exams before they even show symptoms. There is no cure for CML because it is not possible to eliminate all of the diseased cells in the body, however, there are many approved treatments that can achieve a long-term remission. Patients respond best to treatment when CML is in its earliest stage, so it is important to diagnose the disease as early as possible. Possible symptoms that may indicate CML are fever, night sweats, fatigue, pain below the ribs on the left side, and inexplicable weight loss. If an individual is experiencing any of the above symptoms or other signs, it is important they make an appointment with their doctor to be tested for CML.

Introduction
There are three phases of chronic myelogenous leukemia. The first phase, or the chronic phase, is characterized by a slow, progressive overproduction of white blood cells. In chronic CML, fewer than 10% of the cells in the blood and bone marrow are blast (leukemic) cells. Patients in this phase have the best response to treatment. The next phase is transitional, and is called the accelerated phase, which occurs when 10%-19% of the cells are blast cells. The most advanced phase is the blastic phase. At this point, over 20% of the blood cells are blast cells). In the blastic phase, the leukemia is very aggressive and does not respond well to therapy. Approximately 85% of all individuals with chronic myelogenous leukemia enter this phase.

Symptoms

Many individuals with CML show nonspecific symptoms at the time of diagnosis. The most common symptoms are fatigue, weakness, itchiness, night sweats, abdominal discomfort, and weight loss. An abnormally enlarged spleen (splenomegaly) is usually discovered upon physical examination. CML is commonly diagnosed when an affected individual is undergoing blood tests for a different reason. Sometimes, no symptoms are present at all.

When the accelerated or blastic phase of CML occurs, an affected individual may experience severe weight loss, high fever, bone pain, enlargement of the liver and spleen, pain in the joints (arthralgia), , and hemorrhages appearing as patches of purplish discoloration on the skin and mucous membranes.

Causes

The exact cause of CML is not known. Blood samples of patients with CML show the presence of abnormal cells that reproduce more rapidly than normal cells. Ninety percent of these neoplastic cells show a consistent rearrangement of chromosomes. This rearrangement is the result of a transfer of genetic material from chromosome 22 to chromosome 9 and vice versa. As a result of this transference, chromosome 22 ends up shorter than normal. This shortened chromosome is known as the Philadelphia chromosome, and is present in the blood cells of 90% of people with CML. Formation of the Philadelphia chromosome results in a fused gene, called BCR-ABL. This gene contains instructions that make the disease blood cells produce far too much of a protein called tyrosine kinase. This protein causes the cancer by allowing the diseased blood cells to grow out of control.

Family history is not a risk factor for CML. The chromosome rearrangement resulting in the Philadelphia chromosome is believed to be acquired, meaning it develops after birth.
It is believed that in some cases, excessive exposure to radiation increases an individual's chances of developing the disease.

Affected Populations

CML is slightly more prevalent in males than in females. It may occur at any age, but predominately affects people in their 40s and 50s. There are more than 4,000 new cases of the 30,000 new cases of leukemia, diagnosed each year. There is an increased incidence rate of CML among people who have been exposed to radiation, such as the survivors of the atomic bombs dropped in Nagasaki and Hiroshima.

Although very rare in young patients, ages 20-29, CML may present itself in a more aggressive form, such as the accelerated phase or the blastic phase.

Related Disorders

Symptoms of the following disorders can be similar to those of chronic myelogenous leukemia. Comparisons may be useful for a differential diagnosis:

Polycythemia vera is a rare chronic myeloproliferative disorder characterized by overproduction of red blood cells and elements of the bone marrow involved in the formation of red blood cells (hematopoietic elements). In most cases, affected individuals may experience headaches, weakness, dizziness (vertigo), and/or a ringing noise in the ear (tinnitus). In some cases, individuals with polycythemia vera experience itching (pruritis), especially after a hot bath. Affected individuals often have an abnormally enlarged spleen (splenomegaly) and/or liver (hepatomegaly). In some cases, affected individuals may have associated conditions including high blood pressure (hypertension), the formation of blood clots (thrombosis), and/or rupturing of and loss of blood (hemorrhaging) from certain blood vessels. The exact cause of polycythemia vera is not known. (For more information on this disorder, choose "polcythemia vera" as your search term in the Rare Disease Database.)

Primary myelofibrosis is a rare disorder in which the cause is not known (idiopathic). Myelofibrosis is a condition characterized by formation of scar or fibrous tissue (fibrosis) within the bone marrow. In idiopathic myelofibrosis, the ability of the bone marrow to produce red blood cells may be impaired. Symptoms of idiopathic myelofibrosis may include abnormally low levels of circulating red blood cells (anemia), an abnormally large spleen (splenomegaly), an abnormally large liver (hepatomegaly), weight loss, weakness and fatigue due to replacement of normal bone marrow cells, and/or episodes of severe pain in the abdomen, bones, and joints. In many cases, myelofibrosis occurs in association with increased bone density and the formation of small sharp pieces of bone (spicules) within the marrow cavity and increased bone density (osteosclerosis). (For more information on this disorder, choose "primary myelofibrosis" as your search term in the Rare Disease Database.)

Many other types of leukemia may mimic CML. Leukemia is a general term that denotes cancer of the bone marrow. In leukemia, white bloods cells divide and grow uncontrollably causing problems in the bone marrow and affecting the production of other bone marrow cells (i.e., red blood cells, platelets, other white blood cells). A similar form of leukemia is chronic lymphocytic leukemia (CLL). In CLL, the abnormal cells arise from lymphocytes (immune system cells), instead of from myeloid cells such as the parent cells of granulocytes (bacteria-destroying cells),), like in CML. Symptoms of CLL are very similar to CML, and may include fever, pain from an enlarged spleen, night sweats, fatigue, weight loss, bacterial infections. Blood tests can determine CML from CLL. (For more information on this disorder, choose "Chronic Lymphocytic Leukemia" as your search term in the Rare Disease Database.)

Standard Therapies

Diagnosis
A diagnosis of CML is made based upon a thorough clinical evaluation, a detailed patient history and a variety of tests including blood tests, bone marrow examination, and chromosome analysis.

Routine blood tests may reveal abnormally high levels of white blood cells along with high numbers of immature white blood cells. If this is the case, a complete blood count (CBC) will be conducted. This test can provide a more detailed account of the abnormalities in the blood cells.

A sample of tissue taken from the bone marrow is needed to confirm a diagnosis. In individuals with advanced stage CML, the bone marrow has very little fat and numerous leukemic cells.

A fluorescence in situ hybridization (FISH) analysis and a polymerase chain reaction (PCR) test can identify the Philadelphia chromosome or the fused BCR-ABL gene that results from the chromosome translocation.

Clinical Testing and Work-Up
When treating CML, it is crucial to know what stage of the disease the individual is in. To determine staging, the following tests and procedures may be used:

Cytogenetic analysis: A test in which cells in a sample of blood or bone marrow are viewed under a microscope to look for certain changes in the chromosomes, such as the Philadelphia chromosome.

Bone marrow aspiration and biopsy: The removal of bone marrow, blood, and a small piece of bone by inserting a needing into the hipbone or breastbone. They are then screened by a pathologist for abnormal cells under a microscope.

The European LeukemiaNet guidelines for 2010 specify the recommended monitoring and management of CML:

http://www.leukemia-net.org/content/leukemias/cml/recommendations/e8078/infoboxContent8096/PocketCard_2010_final.pdf

Treatment
Tyrosine kinase inhibitors (TKIs) are the frontline therapy for CML.

In 2002, the FDA announced the approval of imatinib mesylate (Gleevec), as a therapeutic agent for CML.

Gleevec uses a technique known as molecular targeting to block the action of the protein tyrosine kinase, thought to be responsible for most cases of CML. Because it targets the specific cause of the disease, the treatment does not alter healthy tissues, and is thought to be easier on patients than other forms of treatment, such as interferon injections, chemotherapy, and bone marrow transplant.

For more information on Gleevec, please contact:

Novartis Pharmaceuticals Corporation
One Health Plaza
East Hanover, NJ 07936-1080
Phone: 1-888-669-6682

Other drugs that have recently been approved by the FDA are dasatinib (Sprycel) and nilotinib (Tasigna). They work in ways similar to Gleevec, by blocking tyrosine kinase.

In June of 2010, Tasigna was approved by the FDA to treat CML upon initial diagnosis. For more information about Tasigna, please contact:

Novartis Pharmaceuticals Corporation
One Health Plaza
East Hanover, NJ 07936-1080
Phone: 1-888-669-6682

Sprycel was approved in October of 2010 by the FDA to treat CML when other drugs, such as Gleevec, have been ineffective. For more information about Sprycel, please contact:

Bristol Myers Squibb
Corporate Headquarters
345 Park Avenue
New York, New York, 10154
Phone: 800-332-2056

Bosulif (bosutinib) by Pfizer was approved by the FDA in 2012 as a treatment for patients with chronic, accelerated or blast phase Philadelphia chromosome positive CML who are resistant to or who cannot tolerate other therapies. Bosulif works by blocking the signal of the tyrosine kinase that promotes the development of abnormal and unhealthy granulocytes. For more information, please go to www.BOSULIF.com or call 877-744-5675.

Synribo (omacetaxine mepesuccinate) by Teva Pharmaceuticals was approved by the FDA in 2012 under its accelerated approval program to treat adults with CML. This is a new treatment option for patients who are resistant to or cannot tolerate other FDA-approved drugs for chronic or accelerated phases of CML. Synribo blocks certain proteins that promote the development of cancerous cells. For more information, please go to http://www.tevagenerics.com or call 888-838-2872.

The following therapies have been used previously to treat CML:

The orphan drug Idarubicin HCI for injection (Idamycin) was approved by the Food and Drug Administration (FDA) in 1990 for the treatment of CML.

Interferon alfa-2a (Roferon A), administered by injection, received FDA approval for the treatment of CML in 1995.

Drugs that inhibit bone marrow activity (myelosuppressive drugs) may slow the progression of the disease. Hydroxyurea, a medication used to treat CML patients, may lower the white cell count and therefore reduce symptoms.

Radiation therapy of the spleen is another treatment option employed in only relatively few uncontrolled cases, either alone or in combination with chemotherapy, to slow the progression of the disease.

Bone marrow transplant, when performed during the early phase of the disease, can lead to remission and cure of this disease. However, this mode of treatment is not appropriate for all patients and does present some risks. The likelihood of success appears greatest among younger patients who are treated in the early stages of the disease.

Investigational Therapies

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government website.

For information about clinical trials being conducted at the National Institutes of Health (NIH) Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: prpl@cc.nih.gov

For information about clinical trials sponsored by private sources, contact:
www.centerwatch.com

The National CML Society provides current information about emerging drug therapies for CML: http://www.nationalcmlsociety.org/latest-developments/emerging-drug-therapies

Organizations related to Chronic Myelogenous Leukemia

References

TEXTBOOKS
Beers MH, Berkow R., eds. The Merck Manual, 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999:951-53.

Berkow R., ed. The Merck Manual-Home Edition. Whitehouse Station, NJ: Merck Research Laboratories; 1997:767-68.

Bennett JC, Plum F., eds. Cecil Textbook of Medicine. 20th ed. Philadelphia, PA: W.B. Saunders Co; 1996:925-29.

Thoene JG., ed. Physicians' Guide to Rare Diseases. Montvale, NJ: Dowden Publishing Company Inc; 1995:481-82.

JOURNAL ARTICLES
Kantarjian HM, Cortes J. New strategies in chronic myeloid leukemia. Int J Hematol. 2006;83:289-93.

Murgo AJ. Clinical trials of arsenic trioxide in hematologic and solid tumors: overview of the national cancer institute cooperative research and development studies. Oncologist. 2001; 6:22-28.

Druker BJ, et al., Lessons learned from the development of an abl tyrosine kinase inhibitor for chronic myelogenous leukemia. J Clin Invest. 2000;105:3-7.

Kantarjian HM, et al., Significance of FHIT expression in chronic myelogenous leukemia. Clin Cancer Res. 1999;5:4059-64.

Moracova J, et al., Polymerase chain reaction analyses should be used as a basis for clinical decision making in patients with chronic myelogenous leukemia. Blood. 1999;94:3609-11.

Sacci S, et al., Unexpected high incidence of severe toxicities associated with alpha-interferon, low dose cytosine arabinoside and all-trans retinoic acid in patients with chronic myelogenous leukemia. Leuk Lymphoma. 1999;35:483-89.

Reiter E, et al., Long-term follow-up of patients after related- and unrelated-donor bone marrow transplantation for chronic myelogenous leukemia. Ann Hematol. 1999;78:507-13.

Sacci S, et al., Chronic myelogenous leukemia in nonlymphoid blastic phase: analysis of the results of first salvage therapy with three different treatment approaches for 162 patients. Cancer. 1999;86:2632-41.

Hehlmann R., A chance of a cure for every patient with chronic myeloid leukemia. N Engl J Med. 1998;338:980

INTERNET
Mayo Clinic Staff. MayoClinic.com. Chronic myelogenous leukemia. http://www.mayoclinic.com/health/chronic-myelogenous-leukemia/DS00564. Updated October 30, 2010. Accessed March 5, 2012.

Emmanuel C Besa. Medscape. Chronic myelogenous leukemia. http://emedicine.medscape.com/article/199425-overview. Updated December 14, 2011. Accessed March 5, 2012.

National Cancer Institute. Chronic Myelogenous Leukemia Treatment. http://www.cancer.gov/cancertopics/pdq/treatment/CML/Patient/allPages. Updated February 17, 2012.. Accessed March 5, 2012.

The information in NORD’s Rare Disease Database is for educational purposes only. It should never be used for diagnostic or treatment purposes. If you have questions regarding a medical condition, always seek the advice of your physician or other qualified health professional. NORD’s reports provide a brief overview of rare diseases. For more specific information, we encourage you to contact your personal physician or the agencies listed as “Resources” on this report.

Report last updated: 2012/11/05 00:00:00 GMT+0

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