MANAGEMENT OF TKI RESISTANCE

A problem that may increase due to the widespread use of all of the commercially available TKIs
for CML is increased drug resistance. One of the most common mechanisms of resistance involves point
mutations in the kinase domain of BCR-ABL, which impairs the activity of the available TKIs. Second
generation TKIs are able to overcome most of the mutations that confer resistance to imatinib, though
novel mutations rendering the leukemia resistant to dasatinib and/or nilotinib have emerged. One
important mutation, the T315I, is known as the gatekeeper mutation, as it displays resistance to all
currently available TKIs except ponatinib.
Before defining a patient as having TKI-resistance and modifying therapy, treatment compliance
and drug-drug interactions should be ruled out. Rates of imatinib adherence have been estimated to range
from 75 to 90%, and lower adherence rates correlated to worse outcome [5052]. In one study of 87
patients with CML-CP treated with imatinib 400 mg daily, adherence rate of 90% or less resulted in
MMR in only 28.4% as compared with 94.5% in patients with >90% adherence rates (P<0.001) [50].
CMR rates were 0 vs. 43.8%, respectively, (P50.002), and no molecular responses were observed when
adherence rates were 80% or lower. Lower adherence rates have been described in younger patients, those
with adverse effects of therapy, and those who have required dose escalations [50].
Second and third generation TKIs
Before their approval to treat first-line CML-CP, both nilotinib and dasatinib were approved for
use in second-line CML-CP following prior therapy including imatinib [53,54]. Clinical studies of
second-line and third line TKIs are summarized in Table III. Based on these clinical studies, several
noteworthy ideas have emerged. First, second-line treatment with nilotinib or dasatinib can yield high
rates of response in patients who have inadequate response to imatinib, including high rates of MMR.
Second, dose escalation of imatinib can improve response rates in patients with inadequate response to
standard-dose imatinib, but switching to second-line nilotinib or dasatinib can be more effective [55].
Several studies that evaluated second-line nilotinib [56,57] or dasatinib [56,58] and high-dose imatinib
(400 mg BID) have demonstrated significantly higher rates of CHR, CCyR, and MMR with the newer
TKIs than with high-dose imatinib. Moreover, PFS in these studies was better with the newer TKIs than
with high-dose imatinib. In addition, earlier switch to second-line TKI may be more effective than later
switch. In the TIDEL-II study, patients who had suboptimal response to imatinib and were switched right
away to nilotinib had a higher rate of CMR at 12 months than patients who had dose escalation of
imatinib prior to being switched to nilotinib [59]. In a retrospective pooled analysis of three clinical
studies of second-line dasatinib for patients resistant to or intolerant of imatinib, patients who were
switched to dasatinib after the loss of MCyR (early intervention group) had higher rates of CHR, CCyR,
and MMR, as well as 24-month EFS, TFS, and OS, than patients who were switched after the loss of both
MCyR and CHR (late intervention group) [60]. Although this analysis included studies with distinct study
designs and various dosing schedules of dasatinib, the core finding that earlier switch to dasatinib was
associated with better outcomes than later switch was reasonably consistent.
Bosutinib was initially studied in patients that were resistant to or intolerant of imatinib [61].
After a dose escalation period, 500 mg once daily was selected to go forward as the phase II dose, with
the potential for dose escalation to 600 mg once daily for patients not meeting prespecified benchmarks.
There were 288 patients enrolled in the pivotal phase II trial, with more than two thirds of the patients
documented as having imatinib-resistant disease. The primary endpoint was MCyR at 6 months, and this
was achieved in 31% of the patients treated. At any point during follow up, 41% achieved a CCyR.

Bosutinib appeared to retain activity across most known mutations that confer imatinib resistance, except
for the T315I. Responses were independent of whether patients were resistant to or intolerant of imatinib.
The most common toxicities noted were diarrhea, nausea, vomiting, and rash. Diarrhea occurred in 84%
of the patients overall, with 9% experiencing an event classified as grade 3 (there were no grade 4 events
documented). Other notable adverse events included myelosuppression and liver function test
abnormalities.
Ponatinib is considered a third generation TKI, as it is the first compound in the class considered
to exhibit activity against CML in the presence of a T315I mutation [62]. It is considered greater than 500
times as potent than imatinib at inhibiting BCR-ABL [63]. Evidence to support the approval of ponatinib
was presented in the phase II PACE trial, where 449 patients with heavily pretreated CML or Philadelphia
chromosome-positive acute lymphoblastic leukemia were enrolled [64]. Patients were considered for this
trial if they were resistant to or intolerant of dasatinib or nilotinib. Alternatively, any patient with a T315I
mutation could be included. The dose of ponatinib was 45 mg once daily, and patients were stratified by
phase of disease and whether or not there was a T315I mutation. Focusing on the 267 patients who
received ponatinib in the CP, 56% achieved a MCyR by 12 months, which included 70% of CP patients
with a T315I mutation (n545). Patients responded more favorably if they had received fewer TKIs. The
most common adverse events were rash, dry skin, and abdominal pain. Other notable toxicities in the
PACE study included hypertension and pancreatitis. Serious events possibly related to the drug included
arterial thrombotic events, and the rate was reported to increase with longer durations of exposure to
ponatinib. This led to a temporary suspension of the sale of ponatinib in the United States, as well as the
modification or closure of several clinical trials. Revised labeling and a restricted access program were
put in place allowing the manufacturer to resume its marketing.
How to select a second or third line option
At the time of treatment failure, patients should undergo bone marrow biopsy to allow proper
determination of disease phase and documentation of any clonal evolution. All patients should have their
CML cells tested for BCR-ABL kinase domain mutations, as this will help guide the decision on which
TKI to select. Dasatinib and nilotinib retain activity against most of the known mutations that confer
resistance to imatinib [65,66]. When selecting between dasatinib and
nilotinib, in vitro and in vivo data have identified distinct mutations that exhibit decreased sensitivity to
each of the agents [67,68]. The clinician may tend to favor dasatinib if the patient has the following
mutations at the time of disease progression: Y253H, E255K/V, or F359C/V. Alternatively, nilotinib may
be a better selection in the presence of the V299L and F317L mutations. For patients lacking these
mutations, the choice once again calls into consideration toxicity profile and cost.
The available data also indicate that bosutinib can be used for patients with most known
mutations that lead to imatinib failure [61]. Like dasatinib and nilotinib, bosutinib lacks activity against
T315I. Bosutinib may be a reasonable choice for patients who fail imatinib who are not good candidates
for dasatinib or nilotinib. Bosutinib has a relatively distinct toxicity profile from the other TKIs, with the
predominant problem being diarrhea and other gastrointestinal complaints. Recently, an analysis was
conducted to closely characterize the toxicity of bosutinib and the management strategy [69].
Diarrhea was documented in 82% of the overall cohort (n5570), the majority of which was grades 1/2 in
severity. Myelosuppression and liver function test abnormalities were also common. The authors found
that with appropriate supportive care and monitoring, most patients are able to continue on therapy with
periodic dose interruptions or adjustment.

Ponatinib should be considered the agent of choice for any patient that develops a T315I mutation
and in instances where other TKIs are not indicated. There are currently no other commercially available
TKIs that have activity against this mutation. The risk for thrombotic events with ponatinib is serious, but
the benefits outweigh the risks for most patients with a T315I mutation, as there are very few viable
options for disease control.
Second and third generation TKIs have not been compared headto-head, so we currently select
one or the other based on the side effect profile, mutations profile, drug interactions, compliance issues,
and the patients preexisting medical conditions. We do a mutational analysis in patients who are failing
imatinib or second generation TKIs, or those who progress to AP/BP. We do not test baseline mutational
analysis on patients with newly diagnosed CML in CP, as it has not proven to predict treatment outcome
either.
Allogeneic stem cell transplantation
The number of patients undergoing alloSCT for CML-CP has dropped significantly since TKIs
were introduced, and has more of an important role when patients evolve into AP/BC (see below).
However, alloSCT remains an important therapeutic option for CMLCP in the following situations:
patients who fail at least 2 TKIs and potentially patients harboring the T315I mutation after a trial of
ponatinib therapy [70].
TREATMENT DURATION AND DISCONTINUATION
The Stop Imatinib (STIM) trial sought to investigate the risk of relapse in patients on imatinib
with ongoing CMR for >2 years who stopped treatment [71,72]. At the time of the most recent update,
100 patients had a median follow up of 50 months and were monitored closely for evidence of molecular
relapse. Overall, 61% experienced a molecular relapse, with 95% of the events occurring within 7 months
of stopping imatinib. Almost all patients were able to re-achieve their CMR once imatinib therapy was
restarted. One patient did have possible loss of cytogenetic response, necessitating a change in therapy to
dasatinib. Having a low-risk Sokal score and duration of imatinib therapy >60 months predicted for
continued CMR after therapy cessation.
The results of the STIM trial have been confirmed by other large groups of CML researchers. The
TWISTER study followed 40 patients who stopped imatinib after being without detectable minimal
residual disease for >2 years [73]. Patients were followed for a minimum of 15 months (median 43
months) from the time they stopped imatinib. Over the course of the study, 22 of 40 patients became
molecularly positive. Nearly 70% of the molecular relapses occurred within the first 6 months of
treatment cessation. Similar, patients who resumed TKIs were able to recapture deep molecular responses.
Interestingly, highly sensitive patient specific PCR was able to detect the original CML clone in several of
the patients who remained off imatinib for several years. This indicates that it may not be necessary to
completely eradicate the disease to allow patients to enjoy a functional cure.
The previous studies contained heterogeneous groups of patients, particularly ones exposed to
interferon prior to the imatinib era. There have been conflicting results as to whether prior exposure to
interferon plays a major role in sustaining deep molecular responses after TKI withdrawal. Therefore, the
French group conducted a follow-up study to STIM enrolling patients who have only been exposed to
imatinib as CML therapy (STIM2) [74]. The inclusion criteria were similar to those used in STIM1. There
were 124 patients identified who stopped imatinib therapy. With a median follow up of 12 months, 48
patients had molecularly relapsed, 94% of which occurred within 6 months of TKI withdrawal. All

patients remained sensitive to imatinib or a second generation TKI upon rechallenge. It has also been
noted in this study and others that patients with low level positivity for BCR-ABL transcripts may be able
to remain off therapy with only close monitoring. This was recently addressed systematically by French
investigators, where it appeared safe and effective to only resume patients on TKI therapy if their
transcript level became >0.1% (i.e., loss of MMR) [75].
This data indicates that stopping TKI therapy is feasible, and some patients may actually be cured
of the disease. Nevertheless, at present, stopping TKI therapy should only be done in the context of a
clinical trial.
ADVANCED STAGE CML
Patients with accelerated or blastic phase CML may receive initial therapy with TKIs (newer
generation TKIs like dasatinib or ponatinib preferred over imatinib) to reduce the CML burden, and be
considered for early alloSCT [7680]. Response rates with combinations of TKIs and chemotherapy are
40% in nonlymphoid BP CML and 7080% in lymphoid BP CML [8183]. Median survival times are 6
12 months, and 1224 months, respectively. The addition of TKIs to chemotherapy has improved the
response rates and prolonged the median survival time in BP CML.
At present, alloSCT is the only curative therapy for accelerated and BP CML: overall cure rates
are in the range of 1540% and 520%, respectively [37,70]. Patients with cytogenetic clonal evolution as
the only AP criterion have a long-term event-free survival rate of about 60% [84]. Otherwise, TKIs
provide hematologic responses in 80% of patients and an estimated 4-year survival rates of 4055% in AP
CML, but only a 40% response rate and a median survival of 912 months in BP CML. Patients in the
accelerated or BP should be encouraged to participate in investigational strategies to improve their
prognosis. Patients with de novo CML AP have a better outcome with front-line TKI therapy than patients
who evolve from chronic to AP. The estimated 68 year survival rates with TKI therapy in de novo AP
CML are 6080% [84]. Such patients may continue on TKI therapy as their long-term treatment if they
achieve a CCyR on TKI therapy.
AlloHSCT should be considered early on for patients in AP disease based on response to TKI
therapy. The only curative option for patients in BP disease is AlloSCT. TKIs monotherapy or in
combination with chemotherapy may serve as a good option for those who are not candidates for
transplant, or as a bridge to alloHSCT. The role of TKIs before and after transplant is being currently
evaluated. Accumulating data show that TKIs do not seem to increase transplant related complications
and when used after low intensity conditioning regimens, may delay relapse rates and need for donor
lymphocyte infusions.
CONCLUSIONS AND FUTURE DIRECTIONS
In 2013, CML experts and patients with CML have multiple treatment options in the CML
therapeutic armamentarium, including five TKIs (imatinib, nilotinib, dasatinib, bosutinib, and ponatinib),
omacetaxine (protein synthesis inhibition), and several older agents (hydroxurea, interferon alpha,
busulfan, 6-mercaptopurine, cytarabine, decitabine, etc.). Most patients with CML would be expected to
live their normal functional life, and be potentially functionally, though not molecularly, cured, as long as
they continue therapy with TKI based regimens, are compliant with the treatment, and are monitored
closely for signs of resistance, to change therapy in a timely manner and/or consider alloHSCT before
CML progression. Future directions will focus on the potential molecular cure of CML (i.e., achievement
of a durable CMR and its persistence after discontinuation of TKI therapy). This is not a trivial issue

since, with effective TKI therapy, and full treatment penetration worldwide (to 100% of all diagnosed
patients and continuation of TKI therapy without interruptions) the prevalence of CML would increase
annually and plateau at around 2030 to 2040 at a rate 35 times the incidence. This figure is estimated to
be close to 160,000 patients with CML in the US and about 3 million patients worldwide. This may
represent a considerable burden on patients and the healthcare systems in relation to drug availability,
compliance, potential development of long-term side effects, and costs. Therefore, it is critical to continue
research into therapies that increase the rates of durable CMRs. This may be achievable with the current
more potent new generation TKIs alone, or in combination with other available (peg-interferon alpha-2,
omacetaxine, and decitabine) or investigational therapies (JAK2 inhibitors, hedgehog inhibitors, stem cell
poisons, and vaccines). Such strategies may improve the eradication of minimal residual disease,
potentially obviating the need for indefinite therapy with TKIs. Further understanding of the
pathophysiologic events downstream of BCR-ABL may help in the development of new strategies to
target them.