AML Flashcards
AML signs and symptoms
anemia (fatigue, SOB)
thrombocytopenia (bleeding risk)
neutropenia (ANC <500mcL or ≤1000mcL with anticipated decrease to <500mcL within 48 hours)
TLS
CNS involvement (somnolence, HA, confusion- rare)
What oncologic emergency (besides TLS) can occur in AML?
Hyperleukocytosis
Features of hyperleukocytosis
WBC ≥100K/mcL
Poor prognosis
Increases risk of CNS involvement and TLS
Signs/symptoms of hyperleukocytosis
Blood sludging, stupor, SOB, vision changes, stroke, respiratory failure, cardiac ischemia, renal failure, retinal hemorrhage possible
Hyperleukocytosis management
Hydroxyurea to kill the circulating cells to prep for induction treatment
Hydroxyurea AEs
N/V/D, watch for TLS
AML risk factors
increasing age, prior chemo, prior pelvic radiation, smoking, radiation exposure, benzene exposure, pesticide exposure, petrochemical exposure
AML treatment algorithm: step 1
Determine if the patient is a candidate for aggressive induction chemo
Induction chemotherapy criteria
Most patients <60 years
Patients ≥60 without significant comorbidities or end-organ dysfunction, good performance status
Patients with aggressive disease course (have hyperleukocytosis or TLS at presentation)
Patients who are candidates for allogeneic stem cell transplant
If the patient qualifies for aggressive induction chemo, what do you give them?
7+3 regimen (preferred), liposomal daunorubicin/cytarabine, or clinical trial
7+3 regimen components
7-day infusion of cytarabine continuous IV infusion
3 days of anthracycline bolus dose
Days 1-7 of chemo administration
N/V, GI effects, fatigue. WBC counts drop like crazy
Days 8-24 of chemo administration
AEs: fatigue, fever/infection, high RBC and platelet transfusion requirement. Infection risk begins here
Days 25+ of chemo administration
discharge from hospital once ANC >500 and no longer platelet transfusion dependent
Additional induction regimens: FLT3-ITD or FLT3-TKD positive
Midostaurin
Additional induction regimens: favorable/intermediate cytogenetics
GO
Additional induction regimens: secondary AML treatment
Liposomal daunorubicin and cytarabine
Step 2a: what to do when the patient qualifies for aggressive induction disease after treatment
do a bmbx 14 days later and assess if they’re leukemia free or not
Step 3a: patient is leukemia free
await count recovery +/- G-CSF, repeat bone marrow biopsy to document complete remission, then consolidation and consideration for bone marrow transplant if complete remission
Step 3b: patient is NOT leukemia free
re-induction or salvage therapy → if it continues, supportive care/comfort measures or consolidation and consideration for bone marrow transplant
If the patient doesn’t qualify for aggressive induction chemo, what are your treatment options?
clinical trial, “low intensity chemo,” gemtuzumab ozogamicin (GO), targeted therapy (if actionable mutation) until disease progression
Step 2b: what to do when the disease progresses
Supportive care/comfort measures
Response criteria in AML
“Leukemia-free state”- day 14 bone marrow biopsy
Goal: <5-10% blasts, hypocellular (<10-20% cells)
Criteria for complete remission
<5% blasts and ANC >1000mcL AND platelets >100K/mcL
