IntroductionChronic myelogenous leukemia (CML) is a hematopoietic stem cell malignant disease 1 that arises from a reciprocal translocation between chromosomes 9 and 22. 2 It is characterized by a massive expansion of myeloid progenitors as well as more differentiated cells originating from the malignant clone. The disease progresses from an initial chronic phase through an accelerated phase followed by an inevitable acute leukemia or blast crisis as the malignant cells lose their ability to differentiate. The translocation (9;22)(q34;q11) fuses a truncated BCR gene (chromosome 9) to sequences upstream of the second exon of ABL (chromosome 22). The resulting fusion gene encodes a protein tyrosine kinase, Bcr-Abl, with more elevated and disregulated activity compared with c-abl. Expression of Bcr-Abl in mice was found to induce a CML-like myeloproliferative disorder, [3][4][5][6][7] indicating that Bcr-Abl plays a key role in leukemic transformation. Additional studies have shown that the tyrosine kinase activity is critical to the transforming ability of 7,8 making it an attractive target for drug development.Imatinib mesylate (STI571; formerly CGP571418B; Gleevec; Novartis Pharmaceuticals, East Hanover, NJ) is a 2-phenylaminopyrimidine derivative developed as a potent inhibitor of the Abl protein tyrosine kinases (v-Abl, Bcr-Abl, and c-Abl). 9,10 It also has activity against the platelet-derived growth-factor receptor (PDGF-R), 10 c-Kit, 11 ARG, 12 and their fusion proteins, Tel-Abl and Tel-PDGF-R, 13 but does not affect other kinases.Phase I and phase II clinical trials of imatinib mesylate in the treatment of chronic-phase CML showed that it is well tolerated, with few adverse effects. 14 Complete hematologic responses and cytogenetic responses, including complete cytogenetic responses, were reported in a significant proportion of patients. Activity against more advanced accelerated and blast-crisis phases of CML was also observed. 15 Imatinib mesylate is currently approved for the treatment of patients with chronic-phase CML in whom interferon therapy has failed and for accelerated-phase and blast-crisis disease. However, the durability of responses to imatinib mesylate, the agent's impact on long-term survival and normal hematopoiesis, and its role in the treatment of CML compared with other modalities remain unclear.In vitro studies have shown that imatinib mesylate inhibits growth of cell lines expressing Bcr-Abl. 10,13,16,17 Additionally, the numbers of colony-forming cells (CFCs) in peripheral blood or bone marrow from patients with CML have been found to be The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked ''advertisement'' in accordance with 18 U.S.C. section 1734. For personal use only. on May 9, 2018. by guest www.bloodjournal.org From reduced, with minimal inhibition of normal cells. 10,17 One study showed that imatinib mesylate inhibited the enhanced replating ability of granulocyte-macroph...