shared:heme:aml
Table of Contents
Acute Myeloblastic Leukemia
Epidemiology
- Most common acute leukemia in adults
- Median age at diagnosis 65
- M > F
Etiology
- Can arise from an underlying hematologic disorder (MDS, ET/PV)
- Consequency of prior therapy
- Topoisomerase agents
- Radiation
- Chemical: smoking, dry cleaning, paint
- Family/hereditary: Trisomy 21, Fanconi, ataxia telangectasia
Manifestations
- Marrow failure: fatigue, dyspnea, easy bleeding/bruising, infection
- Extramedullary spread
- Lekemia cutis
- Gingival involvement (M5 or ?myeloblastic)
- Myeloid sarcoma
- WBC variable
- DIC in APL
Diagnosis
- Blasts 20% in bone marrow or peripheral blood
- Cytogenic t(8, 21), inv 10, t(15,17) often with less than 20%
- Also sometimes less than 20% with myeloid sarcoma
- Auer rods not always present, but nearly pathognomonic
Classification
- FAB: M1 through M5
- AML with MDS
- AML NOS
Genomics
- FLIP3
- TP53
- IDH1/IDH2
Risk Stratification
| Risk category | Management | |
|---|---|---|
| Poor | Treatment → transplant | complex karyotype, TP53 |
| Intermediate | Treatment → transplant | |
| Favorable | Treatment, no transplant | t(15,17) or APL |
* Usually allogeneic transplant
Evaluation
- H&P
- ECOG
- CBC with diff, CMP, uric acid, LDH
- Coags
- BM with cytogenetics and molecular studies
- +/- CNS imaging if neuro symptoms
- +/- LP (FLIP3, TP53, M5, etc.)
- TTE/MUGA (anthrocyclines)
- MUGA
- Antimicrobials
Treatment
- Induction: age, ECOG, cytogenics
- Usually 7+3
- Hypomethylating agent + venetoclax
- older
- unable to tolerate
- complex cytogentics (TP53)
- recheck BM in 28 days
- Remission: less than 5% blasts
- Consider reinduction if more than 5% blasts
- 5+3
- higher intensity (cytarabine, FLAG-IDA, CLAG-M)
- Consolidation
- HIDAC 3-4 cycles
- Liposomal cytarabine/daunorubicin 1-2 cycles
- Hypomethylating agent + venetoclax
- Other FDA approved drugs
- Glasdegib
- Ivosidenib
- Enasidenib
- ?
Supportive care
- Transfusions
- Leukodepleted
- irradiated
- PPx
- Prompt treatment of neutropenic fever
- G-CSF/GM-CSF for septic shock: usually not given due to theoretical risk of inducing more blasts
Acute Promyeoblastic Leukemia
- Highly curable
- Frequently associated with DIC with previous regimen of cytarabine and daunorubicine
- Tretinoin/Antimicrobials
- side effect: differentiation syndrdome, treat with steroids
- Arsenic Trioxide: monitor QT
- Idarubicin? Mylotarg? For high-risk (WBC > 10)
shared/heme/aml.txt · Last modified: 2020/02/18 12:15 by 127.0.0.1