When can Chronic Myeloid Leukemia (CML) patients undergo surgery?

Timing of Surgery in CML Patients

CML patients can undergo elective surgery when their disease is well-controlled on tyrosine kinase inhibitor (TKI) therapy with stable blood counts, particularly when white blood cell counts are maintained below 10,000/μL and platelet counts are adequate for hemostasis.

Disease Control Assessment Before Surgery

The primary consideration for surgical timing in CML patients is achieving adequate disease control:

• White blood cell count management: Target WBC <10,000/μL before elective procedures, as hyperleukocytosis increases perioperative thrombotic and bleeding risks 1, 2
• Platelet count adequacy: Ensure platelet counts are sufficient for hemostasis (generally >50,000/μL for minor procedures, >80,000-100,000/μL for major surgery) 2
• Disease phase matters critically: Patients in chronic phase (CP) on stable TKI therapy have significantly better surgical outcomes than those in accelerated or blast phase 1, 3

TKI Management Perioperatively

Continue TKI therapy through the perioperative period whenever possible, as interruption risks disease progression:

• Most TKIs (imatinib, dasatinib, nilotinib, bosutinib, asciminib) can be safely continued perioperatively with minimal impact on wound healing or bleeding risk 3, 2
• Brief interruption (24-48 hours) may be considered for major surgery with high bleeding risk, but resume as soon as oral intake is tolerated 2
• Coordinate with hematology regarding TKI management, particularly for patients on dasatinib (which has antiplatelet effects) or ponatinib (which increases thrombotic risk) 2

Urgent/Emergency Surgery Considerations

For urgent or emergency procedures, surgery should not be delayed for disease optimization:

• Proceed with surgery regardless of blood counts when life-threatening conditions exist (acute abdomen, trauma, critical infections) 1
• Cytoreduction with hydroxyurea can rapidly reduce WBC if hyperleukocytosis is present, but should not delay necessary urgent intervention 1, 2
• Platelet transfusion support should be available for thrombocytopenic patients 2

Specific Clinical Scenarios

Elective Surgery in Well-Controlled CML

• Patients achieving complete hematologic response (CHR) or better on TKI therapy can undergo elective surgery with standard perioperative protocols 3, 2
• No specific delay required beyond standard surgical preparation 3

Surgery in Poorly Controlled Disease

• For patients with rising WBC counts (increases >10,000/μL within 3 months) or disease progression, defer elective surgery until disease control is re-established 4
• Consider urgent hematology consultation and potential treatment intensification before elective procedures 2

Splenectomy Considerations

• Massive splenomegaly (>20 cm below costal margin) may require splenectomy, splenic irradiation, or JAK inhibitor therapy before other major surgical procedures 4
• Coordinate timing with transplant center if patient is transplant candidate 4

Common Pitfalls to Avoid

• Do not unnecessarily discontinue TKIs perioperatively: This is the most common error, as disease progression can occur rapidly with TKI interruption 3, 2
• Do not delay urgent surgery for hematologic optimization: Life-threatening conditions take precedence over blood count management 1
• Do not assume all TKIs have identical perioperative profiles: Dasatinib has antiplatelet effects and ponatinib increases thrombotic risk, requiring individualized management 2
• Do not proceed with elective surgery during blast crisis or accelerated phase: These patients require disease-directed therapy first, as surgical mortality is prohibitively high 1, 2

Monitoring Requirements

• Check complete blood count within 1 week before elective surgery 2
• Verify adequate platelet function if on dasatinib (consider platelet function testing for major surgery) 2
• Resume TKI therapy within 24-48 hours postoperatively once oral intake tolerated 3, 2
• Monitor for disease progression if TKI interruption exceeds 48-72 hours 2