I would lvery mcu appreciate the collegues opinions about a patient of 54 yo with no great comorbidities which consulted in July 2013 with lost of weight, 240.000 WBC with myelemia without blast excess, but 10% basophil 9.4 gt Hb normocytic and 1.500.000 platelet no coagulation disorders asociated. Spleen 10cm from the costal border. A CML was diagnosed with no cytogenetics alterations besides CR PHI
He began to be tretaed with Hydrea and Imatinib. 400 mg daily Platelets mounted to 2.400.000 and three apheresis were made without great sucess. We augmented the Imatinib to 600 mg/day and the the Hydrea to 5gr. The totoal aumont of platetelets mounted again to 4.000.0000 with no coagulation disorders associated. He received again three apheresis without abandoning oral treatment. He entered in an aplasia period were he need antibiotics, grow factors and even platelet transfusions.
He recupered his blood counts but always with 20.000-30.000 WBC, myelemia, anemia 9g(he neede some blood transfusions) and 1.700.000 platelets. as well as persistence of 10% basophilies
He is JAK 2 negative. The spleen has dismininshed but still palpable. He is in outpatients basis and doing well
He has one sister and one brother which are under HLA study. Currently we asked for mutations studies.

In our country we disposed Dasatinib and Nilotinib besides Imatininb . Imatinig is s offered principally as a copy and we have to mount the dose up to 800mg before changing of TKI and to demostrate the is not mutations associated

I would appreciate your opinion : shall I considered him as a primary failure as he has not entered in hematological remission? Will the other ITK which I disposed in my country of any benefit? If he has a related donor I entered him in a tranplant program? If he has not related donors should I look for an unrelated donor?

Thank you very much for your support

If you are sure that he has been compliant and I presume that he has now been on imatinib 800mg per day for at least 3 months, then this individual is a primary imatinib failure. Tlthough I am dubious that he will respond to another TKI, it is worth an attempt to try him on either nilotinib 400mg po bid or dasatinib 100mg od. If there is not hematologic remission within the month or so, I would push on aggressively to find him a donor related or unrelated as his prognosis on ongoing therapy is poor. If he appears to get a CHR, look for cytogenetic response or molecular response at the 3 month mark. Anything less than a 10% IS response would push me to consider an earlier allograft if one is available.