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Acute myeloid leukemia

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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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 Infectious Diseases Society of America (IDSA/ASCO 2018), the Congress of Neurological Surgeons (CNS 2018), the College of American Pathologists (CAP/ASH 2017), the British Society for Haematology (BSH 2017), the British Committee for Standards In Haematology (BCSH 2015), and the Infectious Diseases Society of America (IDSA 2011).
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Guidelines

1.Classification and risk stratification

Classification: use the current WHO terminology for the final diagnosis and classification of acute leukemia.
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2.Diagnostic procedures

Tissue biopsy: 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

3.Medical management

Induction chemotherapy, patients eligible for standard treatment, ASH: 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

4.Therapeutic procedures

Leukapheresis
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

5.Specific circumstances

Pregnant patients, diagnosis: 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

6.Preventative measures

Antibiotic prophylaxis: 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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