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Acute myeloid leukemia

What's new

Added 2020 ISTH, 2020 ASH, 2020 ESMO, 2018 ASCO, 2017 ACP/ASH and 2015 BCSH guidelines for the diagnosis and management of acute myeloid leukemia.

Background

Overview

Definition
AML is a hematopoietic stem cell malignancy associated with abnormal differentiation and proliferation of myeloid clone cells.
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Pathophysiology
AML is caused by malignant transformation of hematopoietic progenitor cells secondary to genetic mutations that can be inherited or occur sporadically.
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Epidemiology
The age-adjusted incidence of AML in the US is 4.3 per 100,000 person-years.
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Disease course
The oncogenic transformation of hematopoietic progenitor stem cells leads to the production of malignant clones causing increased myeloid blasts (myeloblasts, monoblasts, megakaryoblasts) in the bone marrow and peripheral blood, multiorgan infiltration by blast cells, bone marrow failure, and death.
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Prognosis and risk of recurrence
The median overall survival of AML is 8.5 months, with 2-year and 5-year overall survival being 32.0% and 24.0%, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute myeloid leukemia are prepared by our editorial team based on guidelines from the American Society of Hematology (ASH 2020), the European Society of Medical Oncology (ESMO 2020), the International Society on Thrombosis and Haemostasis (ISTH 2020), the Congress of Neurological Surgeons (CNS 2018), the Infectious Diseases Society of America...
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Classification and risk stratification

Classification: as per ASH/CAP 2017 guidelines, Use the current WHO terminology for the final diagnosis and classification of acute leukemia.
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Diagnostic procedures

Tissue biopsy: as per ASH/CAP 2017 guidelines, Perform fresh bone marrow aspiration in all patients with suspected acute leukemia, and use a portion of aspirate to prepare smears for morphologic evaluation. Evaluate adequate bone marrow trephine core biopsy, bone marrow trephine touch preparations, and/or marrow clots in conjunction with the bone marrow aspirates, if performed.
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  • Ancillary testing

Medical management

Induction chemotherapy, patients eligible for standard treatment: as per ASH 2020 guidelines, Initiate antileukemic therapy over best supportive care in older adult patients with newly diagnosed AML being candidates for antileukemic therapy.
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  • Induction chemotherapy (patients ineligible for standard treatment)

  • Consolidation therapy

  • Management of relapsed/refractory disease

  • Management of thrombocytopenia

  • Management of DIC

Therapeutic procedures

Leukapheresis
As per ESMO 2020 guidelines:
Do not perform leukapheresis in patients with non-APL AML.
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Avoid performing leukapheresis for hyperleukocytosis in patients with APL because it may exacerbate coagulopathy.
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  • Blood transfusion

Specific circumstances

Pregnant patients, diagnosis: as per BCSH 2015 guidelines, Use the WHO classification for diagnosing AML in pregnant patients as for nonpregnant patients.
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  • Pregnant patients (general principles of management)

  • Pregnant patients (chemotherapy)

  • Pregnant patients (supportive therapy)

  • Pregnant patients (delivery)

  • Patients with APL (induction and consolidation therapy)

  • Patients with clonal eosinophilia

  • Patients with CNS involvement

Preventative measures

Antibiotic prophylaxis: as per ASCO/IDSA 2018 guidelines, Administer antibiotic prophylaxis with a fluoroquinolone in most patients with AML/myelodysplastic syndromes being at high risk for febrile neutropenia or profound, protracted neutropenia.
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  • Antifungal prophylaxis