Interesting case. I think that at the moment the problem of this patient is MDS turning to secondary AML and not CML (BCR/ABL negative). In my opinion it is correct to move this patient to allotransplant, MUD or Haploidentical if a MUD is not readily available. It cannot be defined an MDS secondary to CML as MDS was already present in 2013 according to the morphological changes observed in BM (although cytogenetic markers like the trisomy 8 detected more recently were not reported). It is one of the cases in which two independent malignant clones are present. If the allotransplant is planned at the end of March, I would not perform any additional consolidation treatment as this would risk to delay the BMT procedure and would give additional toxicity. I would not resume the TKI treatment after transplant in absence of a return to positivity of BCR-ABL.
Yours, Beppe

Male, 47 years old. Healthy. Soccer player.
Chronic phase CML in 2013. Started with imatinib. Suboptimal doses because of hematologic intolerance. He switched to dasatinib. He mainteined cytopenias. Bone marrow with myelodisplastic elements. Thinking of toxicity related to ITK he was off ITK for 8 months. In november 2016, 100% Ph+, he started nilotinib with good response, achieving complete molecular response. Always with some grade of cytopenias.
In december 2019 in a routine control he appeared with pancytopenia: Hg 6.3 WBC 2000 Gran 600 and platelets 30000. Flow cytometry showed 10, 5 % of myeloblasts and myelodisplastic changes. Bone marrow biopsy with excess of blasts. Cytogenetics with trisomy 8. Acute myeloid leukemia molecular estudies negative. BCR ABL negative. Molecular complete response. T315I negative.
He went to an induction protocol(cytarabine daunorrubicine) achiveing negative minimal residual desease. Bad tolerance to standard dose cytarabine (fever and diarrea) Now he has normal counts with excelent performance status. Under nilotinib. We are planning an alogenic transplant (haplo identical) for the last week of march or first week april. Should we give him a consolidation treatment before transplant? Which protocol? High dose or intermediate dose cytarabine?