1. I’ve just been diagnosed with CML. Could you answer my questions?
Sameer Tulpule
Royal Hallamshire Hospital
Sheffield

3. What now?
Leukemia
Can be cured

4. Fast Facts
Rare disease 1 to 1.5 new cases per 100,000 population per year
Rare in young adults under 19 years
Not inherited – cannot pass down to kids

5. How did I get it?
In almost all cases there are no identifiable predisposing
causes
Radiation is the only clearly established external factor
predisposing to development of CML
Benzene is implicated only on an anecdotal basis

6. What is CML Wang et al. Genes Chromosomes Cancer. 2001;32:97

7. Diagnostic Considerations in Chronic Myeloid Leukemia
Demonstrating the presence of the t(9;22) or its gene product is
absolutely essential in diagnosing a patient with CML
Karyotyping in CML
1) Allows for the diagnosis of CML
2) Requires a bone marrow aspirate for
optimal metaphases

8. Yellow → fusion of Bcr and Abl
FISH in CML
Bcr- Ch 22
Ch 9
Ch 22
Abl – Ch 9
Bcr-Abl Fusion
Red → Bcr probe
Green → Abl Probe
Yellow → fusion of Bcr and Abl

9. Diagnostic Considerations in Chronic Myeloid Leukemia
Bcr-Abl
Bcr
Abl
cDNA
Quantitative RT-PCR
for Bcr-Abl in CML
1) Allows for the diagnosis of CML
2) Does not require a bone marrow aspirate for
optimal results
3) Can quantify the amount of disease

10. Disease Diagnosis and Monitoring in CML
Test
Target
Tissue
Sensitivity (%)*
Use
Cytogenetics
Ph chromosome BM
1-10
▪ Confirm diagnosis of CML
▪ Evaluate karyotypic
abnormalities other than Ph
chromosome (ie, clonal
evolution)
FISH
Juxtaposition of bcr and abl
PB/BM
0.5-5
▪ Routine monitoring of
cytogenetic response in
clinically stable patients
▪ Routine measurement of
MRD
RT-PCR
bcr-abl mRNA
▪ Determine the breakpoints of
the fusion genes
*Number of leukemic cells detectable per 100 cells.
BM = bone marrow; FISH = fluorescence in situ hybridization; PB = peripheral blood; MRD = minimal residual disease; RT-PCR = reverse transcriptase polymerase chain reaction.
Wang et al. Genes Chromosomes Cancer. 2001;32:97

11. Normal Bcr-Abl Signaling*
The kinase domain activates a substrate protein, eg, PI3 kinase, by phosphorylation
This activated substrate initiates a signaling cascade culminating in cell proliferation and survival
Substrate
Bcr-Abl
Effector P P
ADP
Bcr-Abl is a disregulated tyrosine kinase protein capable of both auto- and substrate phosphorylation.
Highly plastic structure with both open (active) and closed (autoinhibited) stages.
State is regulated both intramolecularly and by other proteins.
Bcr-Abl signaling begins when adenosine triphosphate (ATP) binds to the kinase domain. This allows the binding of the substrate to be phosphorylated. Following phosphate transfer, the phosphosubstrate is competent to bind to and activate downstream effector molecules. P
ATP P P P
SIGNALING
ADP = adenosine diphosphate; ATP = adenosine triphosphate; P = phosphate.
Savage and Antman. N Engl J Med. 2002;346:683
Scheijen and Griffin. Oncogene. 2002;21:3314.
Hantschel O, Superti-Furga G. Regulation of the c-Abl and Bcr-Abl tyrosine kinases. Nat Rev Mol Cell Biol. 2004;5:33-44.
Savage DG, Antman KH. Imatinib mesylate–a new oral targeted therapy. N Engl J Med. 2002;346:
Scheijen B, Griffin JD. Tyrosine kinase oncogenes in normal hematopoiesis and hematological disease. Oncogene. 2002;21:

12. Imatinib Mesylate: Mechanism of Action*
Imatinib mesylate occupies the ATP binding pocket of the Abl kinase domain
This prevents substrate phosphorylation and signaling
A lack of signaling inhibits proliferation and survival
Bcr-Abl P
ATP
At the molecular level, imatinib mesylate targets a specific part of the tyrosine kinase region of Bcr-Abl.
Imatinib mesylate is an ATP-mimetic agent that binds Bcr-Abl with greater affinity than ATP at its ATP-binding site.
The tyrosine kinase activity of Bcr-Abl is dependent on its ATPase activity.
Bcr-Abl–bound imatinib mesylate prevents ATP binding and hydrolysis and hence the tyrosine kinase action of Bcr-Abl.
This blocks the downstream substrate of Bcr-Abl, which is dependent on phosphorylation for activation.
This in turn blocks downstream signal transduction pathways activated by Bcr-Abl.
Imatinib mesylate
SIGNALING
Savage and Antman. N Engl J Med. 2002;346:683.
Savage DG, Antman KH. Imatinib mesylate–a new oral targeted therapy. N Engl J Med. 2002;346:
Scheijen B, Griffin JD. Tyrosine kinase oncogenes in normal hematopoiesis and hematological disease. Oncogene. 2002;21:

13. IRIS 8-Year Update Overall Survival (Intent-to-Treat) – Imatinib Arm
Estimated overall survival at 8 years was 85%
(93%, considering only CML related deaths) 1 2 3 4 5 6 7 8 9 A l i v e , % M o n t h s S c R a d m z u r : w C L O
% Alive 13

14. IRIS Study: Most Frequently Reported AEs
Imatinib is a Safe Drug....
IRIS Study: Most Frequently Reported AEs
Most Common Adverse Events (by 5 Years)
All Grade AEs Patients, %
Grade 3/4 AE’s Patients %
Superficial Edema 60 2
Nausea 50 1
Muscle cramps 49
Musculoskeletal pain 47 5
Diarrhea 45 3
Rash/skin problems 40
Fatigue 39
Headache 37
<1
Abdominal pain 4
Joint pain 31
Only Serious Adverse Events (SAEs) were collected after 2005
Grade 3/4 adverse events decreased in incidence after years 1-2
IRIS 8 year update

15. How often do I need tests

16. Definitions of Treatment Response
Level of Response
Definition
Complete hematological response
Normal CBC and differential, no extramedullary disease
Major cytogenetic response
0-35% Ph-positive metaphases*
- Partial cytogenetic response
1%-35% Ph-positive metaphases*
- Complete cytogenetic response
0% Ph-positive metaphases*
Major molecular response
≥ 3-log reduction of BCR-ABL mRNA from baseline
Complete molecular remission
Negativity by RT-PCR
* Cytogenetic response is based on analysis of at least 20 metaphases
Deininger, 2005; National Comprehensive Cancer Network, 2007.

17. Do I need repeated Bone marrows?No
Usually only at diagnosis
Part of trial
If there is loss of response

18. CML – Phases of Disease Phase Characteristics Chronic
Indolent course, often asymptomatic and found incidentally on routine physical exam
Predominance of mature white blood cells
Approximately 90% of patients are diagnosed at this stage
Median survival is 4–7 years (pre-tyrosine kinase inhibitor [TKI] therapy)
Accelerated
Transition generally occurs over a period of 1 year or more. Duration is 6 months to 1 year
Associated with progressive leukocytosis, thrombocytosis or thrombocytopenia, basophilia, increased blasts, splenomegaly, fever, bone pain
Clonal evolution may be present
Blast
Lasts only a few months – survival is poor if untreated
Associated with increasing blasts (>20%), progressive splenomegaly despite treatment, and clonal evolution
National Comprehensive Cancer Network, 2007;
National Cancer Institute, 2007; Calabretta & Perrotti, 2004; Cortes et al., 2006.

19. Summary Rare disease Potentially curable disease
Good long term survival
Imatinib has a good safety profile