This is a rather unusual case of a patient with CML who does not tolerate, hematologically, four TKI. Severe leukopenia and thrombocytopenia prevent from giving “full dose” of any drug, and are probably due to a significant reduction of the normal hemopoietic stem cell pool, that can be considered as a marker of advanced disease. Therefore, on one hand I agree with the indication for allogeneic SCT. The problem is not so much the donor – a good, matched, unrelated donor, possibly also sex-matched, male in this case – can be as good as a matched sib. The problem is GVHD, particularly the chronic one. For a patient who is 57 years old, the probability of developing an extensive GVHD is likely close to 50%, and it is not much different if one does a myeloablative or a RIC transplant. The choice between a myeloablative and a RIC transplant should be based on the clinical conditions of the patient (comorbidities, smoking habit, and so on). The results are not different in terms of overall survival, but are probably slightly better for leukemia-free survival, in case of a myeloablative procedure.
Curiously, this patient was never given imatinib. I would strongly recommend to try imatinib before SCT, beginning 200 mg daily for 10 days, then moving to 300 mg daily for another 10 days, then, if blood counts are fine, to 400 mg daily, and assessing at 3 months the molecular response on peripheral blood, and the cytogenetic response on marrow, with conventional chromosome banding analysis. A patient like this is worthy of a bone marrow aspirate, of a bone marrow biopsy, and also of a mutational analysis.
Good luck, and best regards, Michele Baccarani