IntroductionChronic myeloid leukemia (CML) is a clonal myeloproliferative disorder originating in a hematopoietic stem cell. It is characterized by the Philadelphia (Ph) chromosome, 1 arising from a reciprocal translocation between the long arms of chromosomes 9 and 22, resulting in fusion of the BCR gene on chromosome 22 with the ABL oncogene on chromosome 9, with expression of its fusion gene product, BCR-ABL, a constitutively active tyrosine kinase. 2 The deregulated BCR-ABL tyrosine kinase activity is essential for its transforming ability, 3 resulting in phosphorylation of cellular substrates and activation of signal transduction pathways, including the RAS-ERK cascade, JAK-STAT, PI3-kinase, c-Myc, c-CBL, and CrKL, affecting cell growth, stromal interaction, and apoptosis. [4][5][6] Imatinib mesylate (IM; Novartis Pharma, Basel, Switzerland) is a tyrosine kinase inhibitor (TKI) active against ABL, c-KIT, and PDGFR, acting by competitive inhibition of adenosine triphosphate binding to the tyrosine kinase. 7 Despite an impressive rate of durable complete cytogenetic response in chronic phase CML patients treated with IM, 8 only a minority of patients achieve complete molecular remission. 9 At least 2 mechanisms of resistance appear to account for residual disease in these patients: the innate insensitivity of primitive quiescent CML stem/progenitor cells, which greatly overexpress BCR-ABL, to IM 10,11 and BCR-ABL kinase mutations, 12 which are present before IM therapy in a subgroup of patients and result in IM resistance. 13,14 However, there is currently no direct evidence that these resistance mechanisms, observed in vitro, are responsible for residual disease in IM-treated patients.Two main strategies to overcome IM resistance have emerged. These are the development of second generation TKIs 15,16 and the use of IM in drug combinations. 17 Dasatinib (Sprycel, formerly BMS-354825; Bristol-Myers Squibb, Stamford, CT) is an oral, multitargeted inhibitor of BCR-ABL and SRC kinases, with greatly improved potency against wild-type (WT) BCR-ABL, capable of binding all known BCR-ABL kinase mutants resistant to IM except T315I. 15 In our previous work, although dasatinib induced durable inhibition of BCR-ABL in primitive progenitor cells from CML patients compared with either IM or nilotinib, which were ineffective, 11,18 none of these TKIs targeted the most primitive, quiescent CML stem/progenitor cells. Of a wide range of rational drug combinations, 17 the only agent to synergize with IM against these cells was the cytostatic farnesyltransferase inhibitor (FTI) lonafarnib (Schering-Plough). 17 FTIs inhibit oncogenic RAS and have entered clinical trials in solid tumors and acute leukemias. [19][20][21] However, the observed antitumor effects of FTIs are not solely the result of RAS inhibition 22,23 ; they may also act by inhibiting farnesylation of other proteins. 24,25 BMS-214662 is a cytotoxic FTI 26 that produces potent tumor regression and curative responses in human tumor xenografts and transgenic tumor mode...