Many people with CML do not havesymptoms when it is diagnosed. The leukemia is often found when their doctor orders blood tests for an unrelated health problem or during a routine checkup. Even when symptoms are present, they are often vague and non-specific.

Signs and symptoms of chronic myeloid leukemia

Symptoms of CML can include the following:

• weakness
• fatigue
• night sweats
• weight loss
• fever
• bone pain
• an enlarged spleen (felt as a mass under the left side of the ribcage)
• pain or a sense of "fullness" in the belly
• feeling full after eating even a small amount of food

But these aren't just symptoms of CML. They can occur with other cancers, as well as many non-cancerous conditions.

Some patients have bone pain or joint pain caused by leukemia cells spreading from the marrow cavity to the surface of the bone or into the joint.

Problems caused by a shortage of blood cells

Many of the signs and symptoms of CML occur because the leukemia cells replace the bone marrow's normal blood-making cells. As a result, people with CML do not make enough red blood cells, properly functioning white blood cells, and blood platelets.

• Anemia is a shortage of red blood cells. It can cause weakness, tiredness, and shortness of breath.

• Leukopenia is a shortage of normal white blood cells. This shortage increases the risk of infections. Although patients with leukemia may have very high white blood cell counts, the leukemia cells do not protect against infection the way normal white blood cells do.

• Neutropenia means that the level of normal neutrophils is low. Neutrophils, a type of white blood cell, are very important in fighting infection from bacteria. People who are neutropenic have a high risk of getting very serious bacterial infections.

• Thrombocytopenia is a shortage of blood platelets. It can lead to excess bruising or bleeding, with frequent or severe nosebleeds and bleeding gums. Some patients with CML actually have too many platelets (thrombocytosis). But since those platelets often do not function properly, these people often have problems with bleeding and bruising as well.

Types of samples used to test for chronic myeloid leukemia

If signs and symptoms suggest you may have leukemia, the doctor will need to check samples (specimens) of blood and bone marrow to be certain of this diagnosis. Other tissue and cell samples may also be taken in order to treat CML.

Blood samples

Blood samples for tests for CML are generally taken from a vein in the arm.

Bone marrow samples

Bone marrow samples are taken from a bone marrow aspiration and biopsy. These 2 tests are usually done at the same time. The samples are taken from the back of the pelvic (hip) bone, although in some cases they may be taken from the breastbone (sternum) or other bones.

For a bone marrow aspiration, you lie on a table (either on your side or on your belly). After the area is cleaned, the skin over the hip and the surface of the bone is numbed with local anesthetic, which may cause a brief stinging or burning sensation. A thin, hollow needle is then inserted into the bone and a syringe is used to suck out a small amount of liquid bone marrow (about 1 teaspoon). Even with the anesthetic, most patients still feel some brief pain when the marrow is removed.

A bone marrow biopsy is usually done just after the aspiration. A small piece of bone and marrow (about 1/16 inch in diameter and 1/2 inch long) is removed with a slightly larger needle that is twisted as it is pushed down into the bone. The biopsy may also cause some brief pain. Once the biopsy is done, pressure will be applied to the site to help prevent bleeding.

These samples are sent to a lab, where they are looked at under a microscope for leukemia. These tests may also be done after treatment to see if the leukemia is responding to treatment.

Lab tests

One or more of the following lab tests may be used, either to diagnose CML or to help determine how advanced the disease is.

Blood cell counts and blood cell exam

The complete blood count (CBC) is a test that measures the levels of different cells, like red blood cells, white blood cells, and platelets, in the blood. The CBC often includes a differential (diff), which is a count of the different types of white blood cells in the blood sample. In a blood smear, some of the blood is put on a slide to see how the cells look under the microscope. Most patients with CML have too many white blood cells with many early (immature) cells. Sometimes CML patients have low numbers of red blood cells or blood platelets. Even though these findings may suggest leukemia, this diagnosis usually needs to be confirmed with a bone marrow test.

Blood chemistry tests

These tests measure the amount of certain chemicals in the blood, but they are not used to diagnose leukemia. They can help find liver or kidney problems caused by the spread of leukemia cells or by the side effects of certain chemotherapy drugs. These tests also help determine if treatment is needed to correct low or high blood levels of certain minerals.

Routine exam under a microscope

The samples of blood and bone marrow are looked at under a microscope by a pathologist (a doctor who specializes in diagnosing diseases with lab tests) and may be looked at by a hematologist/oncologist (a doctor specializing in treating blood diseases and cancer) as well.

The doctors will look at the size and shape of the cells in the samples and whether they contain granules (small spots seen in some types of white blood cells).

An important factor is whether the cells look mature (like normal circulating blood cells) or immature (lacking features of normal circulating blood cells). The most immature cells are called myeloblasts (often called blasts).

An important feature of a bone marrow sample is how much of it is blood-forming cells - this is known as cellularity. Normal bone marrow contains both blood-forming cells and fat cells. When the bone marrow has more blood-forming cells than expected, it is said to be hypercellular. If too few of these cells are found, the marrow is called hypocellular. In people with CML, the bone marrow is often hypercellular because it is full of leukemia cells.

Leucocyte alkaline phosphatase (LAP) score

This test was once used to see if the cause of a high white blood cell count might be CML. It is rarely used now, since there are better ways to check the blood for suspected CML. The leucocyte alkaline phosphatase (LAP) score is a cytochemistry test -- cells from the sample are placed on microscope slides, and chemical stains (dyes) that react only with certain types of cells are added. The stains cause color changes which can be seen only under a microscope. Normally the LAP score goes up as the white blood cell (WBC) count goes up. But people with CML tend to have high WBC counts with low LAP scores.

Genetic tests

Some sort of gene testing will be done to look for the Philadelphia chromosome and/or the bcr-abl gene.

Conventional cytogenetics: This test looks at chromosomes (pieces of DNA) under a microscope to find any changes. It is also called karyotyping. Chromosomes in a cell can best be seen when the cell is dividing. That is why to do this test, a sample of blood or bone marrow has to be grown (in the lab) so that the cells start to grow and divide. This takes time, and is not always successful. Normal human cells contain 23 pairs of chromosomes, each of which is a certain size. The leukemia cells in many CML patients contain an abnormal chromosome known as the Philadelphia chromosome, which looks like a short chromosome 22. It is caused by swapping pieces (translocation) between chromosomes 9 and 22 (see the section "Do we know what causes chronic myeloid leukemia?"). Finding a Philadelphia chromosome is helpful in diagnosing CML. Even when the Philadelphia chromosome can't be seen, other tests can often find the bcr-abl gene.

Fluorescent in situ hybridization: Fluorescent in situ hybridization (FISH) is another way to look at chromosomes. This test uses special fluorescent dyes that only attach to specific parts of chromosomes. FISH can be used to look for specific pieces of the bcr-abl gene on chromosomes. It can be used on regular blood or bone marrow samples without culturing the cells first. FISH is very accurate, and is used in many medical centers.

Molecular testing

Polymerase chain reaction (PCR): This is a super-sensitive test for looking for the bcr-abl oncogene in leukemia cells. It can be done on blood or bone marrow samples and can detect very small amounts of bcr-abl, even when doctors can't find the Philadelphia chromosome in bone marrow cells with cytogenetic testing. PCR can be used to help diagnose CML and is also useful after treatment to see if copies of the bcr-abl gene (and hence leukemia cells) are still there. If copies of this gene are still present it means that the leukemia is still present, even when the cells aren't visible under the microscope.

Imaging tests

Imaging tests produce pictures of the inside of the body. There are several imaging tests that might be done in people with leukemia. They are not needed to diagnose the leukemia, but they may be done to help find out the extent of the disease.

Computed tomography scan

The computed tomography (CT) scan is a type of x-ray test that produces detailed, cross-sectional images of your body. Unlike a regular x-ray, CT scans can show the detail in soft tissues (such as internal organs). This test can help tell if any organs in your body are enlarged. It isn't usually needed to diagnose CML, but it may be done if your doctor suspects leukemia is growing in an organ, like your spleen.

Instead of taking one picture like a regular x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into detailed images of the part of your body that is being studied.

Often before any pictures are taken, you may be asked to drink1 to 2 pints of a liquid called "oral contrast." This helps outline the intestine more clearly. You may also receive an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline blood vessels and internal organs.

The IV injection of contrast dye can cause some flushing (redness and a feeling of warmth in the face or elsewhere). Some people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.

CT scans take longer than regular x-rays. You need to lie still on a table while they are being done. During the test, the table moves in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined lying in the ring while the pictures are being taken.

Magnetic resonance imaging scan

Magnetic resonance imaging (MRI) scans are very helpful in looking at the brain and spinal cord. These scans can also be used to look at other areas of the body. MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed by the body and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. Not only does this create images of cross-sectional slices of the body like a CT scanner, it can also produce images of slices that are parallel with the length of your body. A contrast material might be injected, just as with CT scans, but this is done less often.

MRI scans take longer than CT scans, often up to an hour. You may have to lie inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces. Newer, "open" MRI machines may help with this problem. The MRI machine makes loud buzzing noises that you may find disturbing. Some places provide headphones to block this noise out.

Ultrasound

Ultrasound uses sound waves and their echoes to make a picture of internal organs or masses. For this test a small, microphone-like instrument called a transducer is placed on the skin (which is first lubricated with oil). It gives off sound waves and picks up the echoes as they bounce off the organs. The echoes are converted by a computer into an image that is shown on a computer screen.

Abdominal ultrasound may be used to look for enlarged organs in your abdomen, like the liver and spleen.

This is an easy test to have done, and it uses no radiation. You simply lie on a table, and a technician moves the transducer over the part of your body being looked at.

Chest x-ray

A plain x-ray of your chest can be done in most outpatient settings. In patients with CML, it isn't needed for a diagnosis, but an x-ray may be used to see if you have normal lungs or if you have an infection.

Last Medical Review: 11/05/2009
Last Revised: 11/05/2009