IntroductionChronic myelogenous leukemia (CML) is a consequence of reciprocal translocation between chromosomes 9 and 22 resulting in the so-called Philadelphia chromosome, 1,2 in which the first exon of the c-Abl gene is replaced with sequences of the breakpoint cluster region (bcr) gene 3,4 to create the Bcr/Abl oncogene. The constitutively active kinase activity of Bcr/Abl in the cytosol contributes to its transforming function 5 and drug resistance through activation of several key survival pathways, including the mitogen-activated protein kinase/extracellular signal-regulating kinase cascade, nuclear factor B, and the signal transducer and activator of transcription (Stat) family. [6][7][8] Previous studies showed that reducing intracellular levels of Bcr/Abl mRNA or protein led to inhibition of proliferation and clonogenic survival of Bcr/Abl-expressing leukemia cells. 9,10 The introduction of imatinib mesylate (Gleevec; STI-571; CGP57148B; Novartis, East Hanover, NJ) revolutionized the treatment of CML, because it selectively inhibits the kinase activity of Bcr/Abl 11 without adversely affecting normal cells. Imatinib mesylate is currently used as frontline therapy for CML and is effective in most cases. However, although imatinib mesylate produces treatment responses at both the hematologic and cytogenetic levels, a growing number of patients in blast crisis eventually experience relapse despite continued treatment with imatinib mesylate. [12][13][14] Mutations within the kinase domain of Abl that interfere with the binding of the drug constitute a primary cause of resistance, [15][16][17][18][19][20][21][22] although other mechanisms have been proposed. Many different approaches to overcome clinical resistance to imatinib mesylate have been described. Farnesyltransferase inhibitors such as SCH66336 and the proteasome inhibitor bortezomib (Velcade) were shown to have growth inhibitory effects on certain imatinib mesylate-resistant leukemias. 23 The pyrido-pyrimidine-type kinase inhibitors PD166326 and SKI-606 24 are active against common kinase-domain mutants of Bcr/Abl that cause resistance to imatinib mesylate. However, these agents do not affect the kinase activity of the T315I mutant, which sterically reduces drug/kinase affinity and prevents direct contact of these agents with the Bcr/Abl protein. Other kinase inhibitors such as PD180970 and CGP76030 show similar restrictions in affinity for the T315I mutant. 25 Recently, second-generation compounds such as nilotinib (AMN107), with higher affinity for abl, or dasatinib (BMS-354825), with high affinity for both abl and src kinases, have been tested in phase 1 and 2 trials. Despite their effectiveness against many Bcr/Abl mutants in imatinib mesylate-resistant disease, these agents cannot suppress the kinase activity of T315 mutants, suggesting that the emergence of the T315 mutation in patients with CML will severely reduce the benefit of these kinase inhibitors. 26,27 The novel compound ONO12380 was recently reported to inhibit Bcr/Abl kinase activi...