Acute myeloid leukemia (AML) remains the most common form of acute leukemia among adults and accounts for the largest number of annual deaths due to leukemias in the United States. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for AML provide recommendations on the diagnostic evaluation and workup for AML, risk assessment based on cytogenetic and molecular features, treatment options for induction and consolidation therapies for younger and older (age ≥ 65 years) adult patients, and key supportive care considerations.

Abstract

Acute myeloid leukemia (AML) remains the most common form of acute leukemia among adults and accounts for the largest number of annual deaths due to leukemias in the United States. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for AML provide recommendations on the diagnostic evaluation and workup for AML, risk assessment based on cytogenetic and molecular features, treatment options for induction and consolidation therapies for younger and older (age ≥ 65 years) adult patients, and key supportive care considerations.

NCCN Categories of Evidence and Consensus

Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.

Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.

All recommendations are category 2A unless otherwise noted.

Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

Overview

Acute myeloid leukemia (AML) is a heterogeneous hematologic malignancy characterized by the clonal expansion of myeloid blasts in the peripheral blood, bone marrow, and/or other tissues. It is the most common form of acute leukemia among adults and accounts for the largest number of annual deaths from leukemias in the United States. An estimated 13,780 people will be diagnosed with AML in 2012, and 10,200 patients will die of the disease.1 The median age of diagnosis is 67 years, with 54% of patients diagnosed at 65 years or older (and approximately a third of these diagnosed at ≥ 75 years of age).2 Thus, as the population ages, the incidence of AML, along with myelodysplasia, seems to be rising. Environmental factors that have long been established to increase the risks of myelodysplastic syndromes (MDS) and AML include prolonged exposure to petrochemicals; solvents such as benzene; pesticides; and ionizing radiation.3 Equally disturbing is the increasing incidence of treatment-related myelodysplasia and acute leukemia in survivors of tumors of childhood and young adulthood. Therapy-related myeloid leukemia (secondary MDS/AML) is a well-recognized consequence of cancer treatment in a proportion of patients receiving cytotoxic therapy for solid tumors or hematologic malignancies.

Although the exact incidence of therapy-related MDS/AML is unknown, and varies depending on the types of treatment modalities used for a given primary tumor, recent reports suggest that therapy-related MDS/AML may account for 5% to 20% of patients with MDS/AML.46 The rate of therapy-related MDS/AML is higher among patients with certain primary tumors, including breast cancer, gynecologic cancers, and lymphomas (both non-Hodgkin's lymphoma and Hodgkin lymphoma), largely owing to the more leukemogenic cytotoxic agents that are commonly used in the treatment of these tumors.69 The 2 well-documented categories of cytotoxic agents associated with the development of therapy-related MDS/AML are alkylating agents (eg, cyclophosphamide, melphalan) and topoisomerase inhibitors/agents that interact with topoisomerase (eg, etoposide, doxorubicin, mitoxantrone).4,7,8 Treatment with antimetabolites, such as the purine analog fludarabine, has also been associated with therapy-related MDS/AML in patients with lymphoproliferative disorders, particularly when administered in combination with alkylating agents.10,11 Radiotherapy, especially in the context of myeloablative therapy (eg, total-body irradiation or radioimmunotherapy) given before autologous stem cell transplantation, may also increase the risk of therapy-related MDS/AML.12,13

F1NCCN Clinical Practice Guidelines in Oncology: Acute Myeloid Leukemia, Version 2.2012

Version 2.2012, 05–25-12 ©2012 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 10, 8; 10.6004/jnccn.2012.0103

F2NCCN Clinical Practice Guidelines in Oncology: Acute Myeloid Leukemia, Version 2.2012

Version 2.2012, 05–25-12 ©2012 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 10, 8; 10.6004/jnccn.2012.0103

F3NCCN Clinical Practice Guidelines in Oncology: Acute Myeloid Leukemia, Version 2.2012

Version 2.2012, 05–25-12 ©2012 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 10, 8; 10.6004/jnccn.2012.0103

F4NCCN Clinical Practice Guidelines in Oncology: Acute Myeloid Leukemia, Version 2.2012

Version 2.2012, 05–25-12 ©2012 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 10, 8; 10.6004/jnccn.2012.0103

F5NCCN Clinical Practice Guidelines in Oncology: Acute Myeloid Leukemia, Version 2.2012

Version 2.2012, 05–25-12 ©2012 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 10, 8; 10.6004/jnccn.2012.0103

F6NCCN Clinical Practice Guidelines in Oncology: Acute Myeloid Leukemia, Version 2.2012

Version 2.2012, 05–25-12 ©2012 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 10, 8; 10.6004/jnccn.2012.0103

F7

Acute Myeloid Leukemia, Version 2.2012

Clinical trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. All recommendations are category 2A unless otherwise indicated.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 10, 8; 10.6004/jnccn.2012.0103

The disease course of therapy-related MDS/AML is generally progressive and may be more resistant to conventional cytotoxic therapies than de novo cases of MDS/AML.8 Importantly, clinical outcomes in patients with therapy-related AML have been shown to be significantly inferior (both in terms of relapse-free and overall survivals) compared with patients with de novo cases,7,14 except those with the therapy-related acute promyelocytic leukemia (APL) subtype6,15 or the favorable-risk core binding factor (CBF) translocations. The proportion of patients with unfavorable cytogenetics tends to be higher in the population with therapy-related AML. Even among the subgroup with favorable karyotypes, those with therapy-related AML tend to do less well.

The NCCN AML Panel convenes annually to update recommendations for the diagnosis and treatment of AML in adults. These recommendations are based on a review of recently published clinical trials that have led to significant improvements in treatment or have yielded new information regarding biologic factors that may have prognostic importance. Most improvements in recent years have been in the treatment of patients with APL, which serves as a paradigm for understanding how the biology of the disease can inform treatment.

Initial Evaluation

The initial evaluation of AML has 2 objectives. The first is to characterize the disease process based on factors such as 1) prior toxic exposure, 2) antecedent myelodysplasia, and 3) karyotypic or molecular abnormalities, which may provide prognostic information that could impact responsiveness to chemotherapy and risk of relapse. The second objective focuses on patient-specific factors, including assessment of comorbid conditions, which may affect an individual's ability to tolerate chemotherapy. Both disease-specific and individual patient factors are taken into consideration when deciding treatment.

Diagnosis

Over the past 3 decades, the classification system for AML has evolved from the French American British (FAB) system, which relied on cytochemical stains and morphology to separate AML from acute lymphoblastic leukemia (ALL) and to categorize the disease based on degree of myeloid and monocytic differentiation, to the system developed by the WHO.

In 1999, the WHO developed a newer classification system, which incorporates information from cytogenetics and evidence of dysplasia to refine prognostic subgroups that may define treatment strategies.16 During this transition from the FAB system to the WHO classification, the percent blasts threshold for defining high-grade MDS and AML was lowered. The FAB classification (1976) had set the threshold between high-grade MDS and AML at 30% blasts, whereas the WHO classification lowered the threshold for diagnosing AML to 20% or more blasts; this was based on the finding that the biologic behavior (and survival outcomes) of the FAB MDS subgroup of “refractory anemia with excess blasts in transformation (RAEB-T)” with 20% to 30% blasts was equally grim compared with that of patients with greater than 30% blasts. In addition, the WHO classification system allows AML to be diagnosed regardless of the percentage of marrow blasts in patients with abnormal hematopoiesis and characteristic clonal structural cytogenetic abnormalities with t(15;17), t(8;21), and inv(16) or t(16;16).

In 2003, the International Working Group for the Diagnosis and Standardization of Response Criteria accepted the cytochemical and immunophenotypic criteria of WHO as the standard for diagnosing AML, including the reporting of dysplasia according to morphology.17 However, no evidence shows that dysplasia represents an independent risk factor, because it is frequently linked to poor-risk cytogenetics.

In 2008, the WHO revised the diagnostic and response criteria for AML to include additional recurrent genetic abnormalities created by reciprocal translocations/inversions, and a new provisional category for some of the molecular markers that have been found to have prognostic impact.18 In the 2008 WHO classification, the category of AML with recurrent genetic abnormalities was expanded to include the following: t(9;11)(p22;q23), t(6;9) (p23;q34) (provisional entity), inv(3)(q21;q26.2) or inv(3;3)(q21;q26.2) (provisional entity), and t(1;22)(p13;q13) (provisional entity), in addition to the previously recognized t(8;21)(q22;q22); inv(16) (p13;1q22) or t(16;16)(p13.1;q22); and t(15;17) (q22;q12) [APL subtype]. In addition, AML with molecular lesions such as mutated NPM1 or CEBPA genes are considered provisional entities (further information on these genetic lesions is provided later).18

The accurate classification of AML requires multidisciplinary diagnostic studies (using immunohistochemistry, cytochemistry, or both, in addition to molecular genetics analysis) in accordance with the 2008 WHO classification. The NCCN AML Panel suggests that complementary diagnostic techniques can be used at the discretion of the pathology departments of the individual institutions. Some cases may still show evidence of both myeloid and lymphoid antigen expression on the leukemic cells. When presented with rare cases such as acute leukemias of ambiguous lineage (including mixed phenotype acute leukemias, as defined by the 2008 WHO classification), consultation with an experienced hematopathologist should be sought. Aberrant expression of differentiation antigens present at diagnosis may allow tracking of residual blasts through flow cytometry in follow-up samples that may appear normal according to conventional morphology. The use of immunophenotyping and molecular markers to monitor minimal residual disease (MRD) in adult AML has not yet been incorporated into postremission monitoring strategies, except in patients with APL.

Cytogenetics and Risk Stratification: Although cytogenetic information is often unknown when treatment is initiated in patients with de novo AML, karyotype represents the single most important prognostic factor for predicting remission rate, relapse risks, and overall survival (OS) outcomes. The cytogenetic risk categories adopted by these guidelines are primarily based on analyses of large datasets from major cooperative group trials (see “Risk Status Based on Cytogenetics and Molecular Abnormalities,” page 995).1921 In an analysis of data from pediatric and adult patients with AML (N = 1612) enrolled on the United Kingdom Medical Research Council (UK MRC) AML 10 trial, the 5-year survival rates for those with favorable, intermediaterisk, and poor-risk cytogenetics were 65%, 41%, and 14%, respectively.20 In a review of data from adult patients treated on a phase III SWOG/ECOG intergroup study (N = 609), the 5-year survival rates for those with favorable, intermediate-risk, and unfavorable cytogenetics were 55%, 38%, and 11%, respectively.21 Similarly, in a retrospective review of adult patients with AML treated on CALGB protocols (N = 1213), the 5-year survival rates for those with favorable, intermediate-risk, and poor-risk cytogenetics were 55%, 24%, and 5%, respectively.19

Therefore, the importance of obtaining adequate samples of marrow or peripheral blood at diagnosis for full karyotyping and fluorescence in situ hybridization (FISH) cytogenetic analysis for the most common abnormalities cannot be overemphasized. Although FISH studies for common cytogenetic abnormalities may provide a rapid screening to identify either favorable or unfavorable risk groups, they do not provide a full picture of the genetic factors, which contribute to risk.

In the past 5 years, the presence of autosomal chromosome monosomies in AML has emerged as an important prognostic factor associated with extremely poor prognosis.2224 Data from 3 large studies have identified monosomal karyotypes (defined as having ≥ 2 autosomal monosomies, or a single monosomy with additional structural abnormalities) as a subset of unfavorable cytogenetic prognosticators. Although complex karyotype (having ≥ 3 clonal cytogenetic abnormalities) and -5 or -7 monosomies are categorized in the high-risk/unfavorable cytogenetics group, the presence of a monosomal karyotype was found to confer further negative prognostic influence within the high-risk group. The first study to identify this high-risk subgroup was HOVON. In a joint study conducted by the Dutch-Belgian and Swiss cooperative groups (HOVON/SAKK) evaluating the correlation between cytogenetics and OS outcomes in patients aged 60 years or younger with AML (N = 1975), the 4-year OS rate in patients with monosomal karyotype was 4% compared with 26% in those with complex karyotype (but without monosomal karyotype).22

These findings were confirmed in subsequent analyses from other large cooperative group studies. In an analysis of data from patients treated on SWOG protocols (N = 1344; age 16–88 years), 13% of patients were found to have monosomal karyotype; nearly all of these cases (98%) occurred within the unfavorable cytogenetics category.23 The incidence of monosomal karyotype increased with age, from 4% in patients aged 30 years or younger to 20% in those older than 60 years. Among patients with unfavorable cytogenetics, the 4-year OS rate in the subgroup of patients with monosomal karyotype was 3% compared with 13% in the subgroup without monosomal karyotype. In patients with monosomy 7, monosomal karyotype did not appear to influence outcomes (4-year OS, 0%-3%); the 4-year OS rates for patients with inv(3)/t(3;3) and t(6;9) and those without monosomal karyotype, were 0% and 9%, respectively.23 In a recent retrospective study that evaluated the prognostic impact of monosomal karyotype in older patients (age > 60 years; N = 186) with unfavorable cytogenetics treated on a GOELAMS trial, the 2-year OS rate was significantly decreased among patients with monosomal karyotype compared with those without this abnormality (7% vs. 22%; P < .0001); similar outcomes were observed within the subgroup of patients with complex karyotype.24

These studies show that monosomal karyotype, independent of other unfavorable cytogenetic factors, confers very poor prognosis in both young and older patients with AML.

Molecular Markers and Risk Stratification: The intermediate-risk cytogenetic category is the most heterogeneous group in AML, because it encompasses both normal karyotype without gross structural abnormalities and those with structural changes that are considered neither poor-risk or favorable. Based on retrospective analysis of data from large cooperative group studies, 40% to 50% of patients with de novo AML have normal karyotype, which is associated with an intermediate risk in terms of survival outcomes.19,20 However, clinical outcome, even in patients with normal karyotype AML (NK-AML), is heterogeneous.

Molecular profiling is increasing the ability to identify mutations at the molecular level, which carry prognostic impact. Thus, in addition to basic cytogenetic analysis, new molecular markers help to refine prognostics groups, particularly in patients with a normal karyotype. These markers include FMS-like tyrosine kinase 3 (FLT3), c-KIT, nucleophosmin (NPM1), and CEBPA gene mutations.2536 Tests for these molecular markers are becoming more common in commercial reference laboratories and in referral centers. Therefore, it is important for physicians to submit sufficient samples to reserve aliquots of cryopreserved marrow from the time of diagnosis to allow for molecular diagnostic tests in patients with normal karyotype.

The 2 most frequent molecular lesions with prognostic impact in patients with AML are mutations of the FLT3 gene (37%-46% of patients) encoding a receptor tyrosine kinase involved in hematopoiesis,29,37,38 and mutations of the NPM1 gene (28%-35%)35,37,39 encoding a shuttling protein within the nucleolus. The NPM1 mutation has been shown to be associated NK-AML with a reported frequency of 48% to 53%.27,33,38 A single NPM1 mutation, which localizes to the cytoplasm, confers a higher complete response (CR) rate and improved event-free survival (EFS) and OS compared with patients with NK-AML with wild-type NPM1, resulting in outcomes similar to patients with favorable cytogenetics (eg, CBF AML).27,28,33,35,36 Two major classes of activating FLT3 mutations have been identified in patients with AML, which include the internal tandem duplications (ITD) and tyrosine kinase domain (TKD) point mutations.4045 FLT3-ITD occurs in approximately 30% of cases and is more common than FLT3-TKD mutations, which occur in approximately 10% of patients.25,29,38,4448 Numerous studies have shown the negative prognostic influence of FLT3-ITD in patients with AML, resulting in shorter remission durations (eg, decreased disease-free survival [DFS] in patients with a CR) and poorer survival outcomes compared with patients with wild-type FLT3.25,29,41,42,44,46,47,49 Among patients with FLT3-ITD and NK-AML, median OS from the time of diagnosis ranged from 6 to 12 months.25,29,44,47

Interestingly, a study in patients with NK-AML showed that prognosis was worse among patients with FLT3-ITD without a wild-type FLT3, compared with those with FLT3-ITD but having a wild-type FLT3 in the second allele. The median OS among patients with FLT3-ITD in the absence of a wild-type FLT3 was only 7 months compared with 46 months among both the patient subgroups with wild-type FLT3 with or without FLT3-ITD.44 The FLT3-TKD mutations predominantly occur independently of FLT3-ITD, and most frequently involve mutations in the D835 residue of a tyrosine kinase domain. Although the presence of FLT3-TKD mutations has been shown to be associated with shorter remission durations (eg, decreased DFS) and decreased OS outcomes in some studies,29,41,45,48 other studies have reported no impact of FLT3-TKD on prognosis38,49,50 or even a favorable outcome on OS with FLT3-TKD mutations.51 In the latter study from the UK MRC, the 5-year OS rate among patients with and without FLT3-TKD mutations was 53% versus 37%, respectively. Patients with a higher level of FLT3-TKD mutations (> 25%) had a significantly higher 5-year OS rate compared with those with lower levels of mutations, which showed an OS rate similar to that of patients without FLT3-TKD mutations (71% vs. 37%; adjusted P = .004).51

The discrepant findings from these studies may be a result of important differences between the studies in factors such as patient baseline characteristics, presence of concurrent genetic lesions (eg, NPM1, CEBPA mutations), or inclusion of the APL subtypes. Studies have shown that FLT3-TKD mutations can occur in a subgroup of patients with the prognostically favorable NPM1 or CEBPA mutations.38,50 Moreover, FLT3-TKD mutation as the sole genetic aberration or occurring concurrently with t(15;17)/PML-RARA (underlying lesion in the APL subtype) or with FLT3-ITD (FLT3 double mutation) has been associated with poorer outcomes.38,50

The CEBPA gene encodes for CCAAT/enhancer binding protein alpha (C/EBPα), a transcription factor that plays a key role in the differentiation of granulocytes.31 Mutations in CEBPA have been reported in 7% to 11% of patients with AML (or 13%-15% of those with NK-AML) and has been associated with a favorable outcome (similar to patients with CBF translocations) with regard to increased remission duration and OS outcomes compared with wild-type CEBPA.30,37,38,5254 However, as a caveat, a recent study indicated that the OS benefit with CEBPA was observed for patients with double mutations of CEBPA but not for those with a single mutation of the gene; the 8-year OS rates reported in this study for patients with double-mutated CEBPA, single mutation of CEBPA, and wild-type gene were 54%, 31%, and 34%, respectively.53

Recently, other common molecular lesions with prognostic impact have been identified in patients with AML. The most common of these include mutations in IDH1 and IDH2 genes, which encode for isocitrate dehydrogenase 1 and 2, respectively, and mutations in DNMT3A, which encode for DNA methyltransferase 3A. Mutations in IDH1 have been reported in 6% to 9% of AML cases, with a higher frequency reported among patients with NK-AML (8%-16%).37,5560 IDH1 mutation was found to occur concurrently with NK-AML and NPM1 mutations.5558,60 This mutation has also been found to be associated with wild-type CEBPA and the absence of FLT3 abnormalities (eg, FLT3-ITD or FLT3-TKD mutations).58

Findings from published reports on the prognostic effects of IDH1 mutations have been inconsistent. Although some studies showed no prognostic effect of IDH1 mutations on OS when considering all IDH mutations (IDH1 and IDH2 combined) or in the overall patient population,55–58 IDH1 mutations seemed to be associated with significantly worse outcomes in the subgroup of patients with NK-AML with favorable- or intermediate-risk disease.55,58,60 In the subgroup of patients younger than 60 years with favorable-risk AML (NPM1 mutation without FLT3-ITD) in a study of patients with NK-AML, IDH1 mutation was associated with a significantly decreased 5-year DFS rate (42% vs. 59%; P = .046) and trend for decreased OS rate (50% vs. 63%) compared with patients who had wild-type IDH.58 In another study, IDH mutations (IDH1 and IDH2 combined) were associated with significantly inferior 5-year relapse-free survival rates (37% vs. 67%; P = .02) and OS rates (41% vs. 65%; P = .03) in the subgroup of patients with favorable-risk AML (normal karyotype with NPM1 mutation without FLT3-ITD).60 This prognostic significance was observed when IDH1 and IDH2 mutations were separately analyzed, although patient numbers were small for each subgroup and statistical significance was reached only for the relapse-free survival analysis.60 IDH1 mutation was also associated with worse EFS and OS outcomes among the subgroup of patients with intermediate-risk NK-AML (wild-type NPM1 without FLT3-ITD).55 Mutations in IDH2 have been reported in 8% to 12% of patients with AML,37,55,56,60,61 with a frequency of 19% reported among those with normal karyotype.58 The presence of IDH2 mutations was mutually exclusive with IDH1 mutation in nearly all cases.55,56,58 Mutations have been identified in R172 and R140 of the IDH2 gene, with R140 mutation occurring more frequently.58,60,61 Interestingly, the IDH2-R172 mutation seemed to be mutually exclusive with NPM1 mutations and FLT3-ITD.58,60,61

Similar to findings with IDH1 mutations, reports on the prognostic effect of IDH2 mutations have also been inconsistent. Some studies have reported the lack of prognostic value of IDH2 mutations55,56,60 whereas others have reported favorable outcomes with IDH2 mutations.37,61 In one study, an association was found between IDH2 mutations and poorer prognosis in the subgroup of patients with NK-AML with otherwise favorable risk (NPM1 mutation without FLT3-ITD).60 However, in another recent study, IDH2 mutation (restricted to IDH2-R140) was associated with improved survival among the overall study population, and among the subgroup of patients with favorable risk (intermediate-risk AML with NPM1 mutation without FLT3-ITD).37 In this latter subgroup, presence of IDH1 or mutations was associated with significantly increased 3-year OS rate compared with patients with NPM1 mutation without FLT3-ITD and without IDH1 or IDH2 mutations (89% vs. 31%; P < .0001). These results seem to suggest that in patients with NK-AML without FLT3-ITD, NPM1 mutations confer a survival benefit only in the presence of concurrent IDH mutations.37 The conflicting findings from the above studies require further investigation.

The DNMT3A mutations have been reported in 18% to 22% of patients with AML,37,62,63 with a frequency of 29% to 34% in those with NK-AML.6466 R882 is the most commonly mutated residue. This mutation has also been observed in conjunction with NPM1 mutations and FLT3 mutations.63,65,66 Data concerning the prognostic significance of DNMT3A mutations have thus far been conflicting. Some studies in the overall AML population and in patients with intermediate risk reported no significant effect of DNMT3A mutations on survival outcomes,37,65 whereas other studies have shown a negative prognostic effect in the overall population or specific subgroups.6264,66 Studies have shown significantly decreased OS outcomes among patients with DNMT3A mutations compared with those with the wild-type gene (median OS, 12–21 vs. 40–41 months).62,63 Significantly decreased OS with DNMT3A mutations has also been reported in the subgroup of patients with NK-AML with wild-type NPM1 with or without FLT3-ITD or NPM1 mutation in the presence of FLT3-ITD, but not in the favorable subgroup with NPM1 mutation without FLT3-ITD.63 A recent study reported that in younger patients (age < 60 years) with NK-AML, presence of DNMT3A mutations was associated with significantly decreased OS compared with the wild-type gene (5-year OS rate, 23% vs. 45%; P = .02).66 Another recent study also showed that in younger patients (age < 60 years) with NK-AML, DNMT3A mutation was associated with significantly decreased DFS (3-year rate, 20% vs. 49%; P = .007) and a trend toward decreased OS.64 Interestingly, in this latter study, non-R882 DN-MT3A mutations were significantly associated with poorer outcomes in patients younger than 60 years (but not R882 mutations); in contrast, in patients aged 60 years and older, DNMT3A-R882 mutations (but not non-R882 mutations) were associated with significantly decreased DFS (3-year rate, 3% vs. 21%; P = .006) and OS (3-year rate, 4% vs. 24%; P = .01).64 The authors concluded that the prognostic relevance of DNMT3A mutations may depend on age and mutation type. Currently, the interactions of both IDH1 or IDH2 and DNMT3 mutations with other molecular changes require further investigation to determine the prognostic value in patients with NK-AML. Neither of these genetic mutations is available for testing outside of the research setting. Other candidate genes currently being evaluated for prognostic importance include TET2 and RUNX1.

As seen from the earlier discussions, patients with NK-AML may present with multiple molecular lesions. NPM1 mutations can occur concurrently with FLT3-ITD, and patients who have both genetic lesions have an outcome more similar to those with isolated FLT3-ITD mutations.27,33 Thus, NPM1 mutation confers favorable prognosis only in the absence of FLT3-ITD.38 Similarly, the benefit in OS outcomes seen with CEBPA mutations seems to be lost in the presence of concurrent FLT3-ITD.53 As previously mentioned, FLT3-TKD in the presence of FLT3-ITD or occurring with t(15;17)/PML-RARA seems to be associated with poorer prognosis. In contrast, FLT3-TKD may be associated with an additional favorable prognosis in the presence of NPM1 or CEBPA mutations.50

Both the NCCN and the European LeukemiaNet (ELN) classify patients with NK-AML and mutated NPM1 or CEBPA (without FLT3-ITD) as having favorable risk.67 In the ELN guidelines, patients with NK-AML with both mutated NPM1 and FLT3, and those with wild-type NPM1 and mutated FLT3 or wild-type NPM1 and FLT3 are categorized as having intermediate-risk AML (“Intermediate I” group).67 ELN classifies patients with t(9;11)(p22;q23), MLLT3-MLL and other cytogenetic abnormalities that fall into neither the favorable or adverse category into the “Intermediate II” group. A recent analysis that evaluated the prognostic value of the ELN risk classification (based on data from the German AML96 study) showed that for patients aged 60 years and younger, median relapse-free survival was shorter for the Intermediate I than for the Intermediate II group (7.9 vs. 39.1 months, respectively). In patients older than 60 years, no major difference was observed (9.6 vs. 11.6 months, respectively).68 In this analysis, median OS between the Intermediate I and Intermediate II groups were not as widely separated among patients aged 60 years and younger (13.6 vs. 18.7 months, respectively); in patients older than 60 years, median OS was similar between the 2 intermediate groups (9.5 vs. 9.2 months, respectively).68 However, based on the substantial difference in relapse-free survival data between the Intermediate I and Intermediate II groups defined by ELN, the NCCN has continued to place NK-AML with FLT3-ITD mutations in the unfavorable risk group rather than the intermediate risk group (see “Risk Status Based on Cytogenetics and Molecular Abnormalities,” on page 995). Although data are emerging on the prognostic relevance of mutations in the IDH and DNMT3A genes (see earlier discussions), the role of these molecular lesions on the risk stratification of patients with AML remains to be defined. Therefore, these molecular markers have not been incorporated into the risk categorization schema in the current guidelines.

In patients with the favorable-risk CBF AML [eg, t(8;21) or inv(16)], the presence of a mutation in c-KIT significantly increased the risk of relapse.26,32,34 c-KIT mutations have been reported in approximately 20% of patients with CBF AML.32,69 Studies have shown that c-KIT mutations are associated with decreased remission duration (eg, EFS and relapse-free survival) and decreased OS in both groups of patients with t(8;21) or inv(16).26,32,34,69 Patients with t(8;21) or inv(16)/t(16;16) with c-KIT mutation are categorized as having intermediate risk AML (see “Risk Status Based on Cytogenetics and Molecular Abnormalities,” on page 995).

Although none of the genetic abnormalities discussed earlier affect the initial course of AML treatment, they provide prognostic information that may influence subsequent treatment decisions. Research into basic leukemia biology using banked samples from clinical trials may provide keys to altered cellular pathways, which may lead to new treatment options. The new risk stratification incorporating molecular data along with cytogenetics is summarized in the guidelines (see “Risk Status Based on Cytogenetics and Molecular Abnormalities,” on page 995).

Workup

Extramedullary presentation, including central nervous system (CNS) disease, is uncommon in patients with AML. Patients with significant CNS signs or symptoms at presentation should be evaluated using appropriate imaging techniques, such as radiography, CT, or MRI for detection of intracranial bleeding, leptomeningeal disease, or mass lesions in either the brain or spinal cord. However, if symptoms persist, and bleeding and mass/lesions are excluded, the patient should have a lumbar puncture (LP) for diagnostic and possible therapeutic purposes once coagulopathy has been corrected and adequate platelet support is available. Routine screening LPs are not warranted at the time of diagnosis in patients with AML. However, for patients at high risk for CNS disease, such as those with monocytic differentiation (M4 or M5 morphology) or high WBC count (> 100,000/mcL) at presentation, a diagnostic LP should be considered as part of the documentation of remission status. For patients who present with solitary extramedullary disease (often referred to as myeloid sarcoma, granulocytic sarcoma, or chloroma) without overt marrow disease, the initial treatment should still be based on systemic induction chemotherapy. Radiation or surgical resection may be incorporated with systemic chemotherapy in emergent situations; however, these modalities, if needed at all, should be optimally deferred until count recovery to avoid excess toxicity.

Coagulopathy is fairly common at presentation in many leukemias; it is therefore standard clinical practice to screen for coagulopathy by evaluating prothrombin time, partial thromboplastin time, and fibrinogen as part of the initial workup and before performing any invasive procedure. The need for a cardiac evaluation should be determined by individual risk factors, such as patient and family history or previous malignancy treated with cardiotoxic drugs or thoracic radiation. HLA typing should be performed in all patients with newly diagnosed AML for whom allogeneic hematopoietic stem cell transplantation (HSCT) would be considered. HLA typing of family members is recommended for patients younger than 60 years who do not have favorable-risk cytogenetics. Tissue typing should be broadened to include unrelated donor searches in patients younger than 60 years with karyotypes or molecular abnormalities deemed highrisk. In the high-risk group, a donor search should begin while the patient is recovering from induction chemotherapy rather than waiting for remission to be achieved. Many institutions also use HLA typing to select platelet donors for allogeneic HSCT.

Principles of AML Treatment

Treatment of acute leukemia has been divided into induction chemotherapy and postremission (or consolidation) therapy. Although obtaining a remission is the first step in controlling the disease, it is also important for patients to emerge from the induction phase in a condition to tolerate subsequent, more intensive treatments during consolidation to achieve durable disease control. Patients who do not receive postremission therapy will experience relapse, usually within 6 to 9 months. The induction strategy is influenced by individual patient characteristics such as age, presence of comorbid conditions affecting performance status, and preexisting myelodysplasia. This is particularly true of elderly patients with AML. Patients whose performance status would make them poor candidates for the standard antineoplastic regimens may still be able to participate in clinical trials using epigenetic agents designed to target this underserved patient population. If a clinical trial is not an option, then low-intensity therapy or supportive care may be the appropriate choice. In younger patients, strategies for consolidation are based on the potential risk of relapse, with higher-risk patients receiving more aggressive therapy.

Cytogenetic and molecular lesions are the most significant prognostic indicators, with failure to achieve remission after 1 cycle of induction therapy and tumor burden (WBC ≥ 100,000/mcL) included as poor-risk factors for long-term remission. At several points during the course of treatment, response is assessed based on bone marrow morphology and cytogenetic and molecular responses (see pages 997 and 998 for definitions of complete and partial response and disease relapse).

Finally, all patients require attentive supportive care related both to the underlying leukemia (ie, tumor lysis syndrome) and the adverse effects of chemotherapy (see on page 996).

Management of AML

Most initial treatment decisions for AML are based on age, history of prior myelodysplasia or cytotoxic therapy, and performance status. Although karyotype and molecular markers are powerful predictors of DFS outcomes, induction chemotherapy will be initiated before this information is available in most instances. The intent of traditional induction chemotherapy is to produce a major reduction in the leukemic burden and to restore normal hematopoiesis.

Recommendations for induction chemotherapy in patients with AML consider age 60 years as a therapeutic divergence point. This is based on the higher prevalence of unfavorable cytogenetics and antecedent myelodysplasia, along with a higher incidence of multidrug resistance in patients older than 60 years, and an increased frequency of comorbid medical conditions that affect the patient's ability to tolerate intensive treatment.70 Because complete remission rates rarely exceed 70% in younger patients and 50% in older patients, substantial opportunity exists for innovative clinical trials involving both patient populations. The guidelines consider recommendations for patients older or younger than 60 years of age separately.

Management of AML in Patients Younger Than 60 Years

Induction Therapy: Standard induction regimens are appropriate for patients younger than age 60 years. These regimens are based on a backbone of cytarabine and an anthracycline, and have changed little in the past 25 years. Historically, in most large cooperative group trials, daunorubicin has been the most commonly used anthracycline at doses of 45 to 60 mg/m2 × 3 days. Idarubicin, which has a longer intracellular retention time, used at doses of 12 mg/m2 × 3 days, has had comparable remission rates with fewer patients requiring additional therapy at day 15 to achieve remission. CR rates for patients who are 50 years or younger have consistently been in the 60% to 70% range in most large cooperative group trials of infusional cytarabine and anthracycline. A large randomized phase III ECOG study reported a significant increase in CR rate (71% vs. 57%; P < .001) and median OS (24 vs. 16 months; P = .003) using daunorubicin 90 mg/m2 × 3 days (n = 327) versus 45 mg/m2 × 3 days (n = 330) in patients with previously untreated AML younger than 60 years.71 Based on subgroup analyses, however, the survival benefit with high-dose daunorubicin was shown to be restricted to patients with favorable- and intermediate-risk cytogenetic profiles (median OS, 34 vs. 21 months; P = .004) and those younger than 50 years (median OS, 34 vs. 19 months; P = .004). The survival outcome for patients with unfavorable cytogenetics was poor, with a median OS of only 10 months in both treatment arms.71 In a European trial that compared idarubicin 12 mg/m2 × 3 or 4 days versus daunorubicin 80 mg/m2 × 3 days in patients between ages 50 and 70 years, CR rates were 83% and 70%, respectively (P = .024).72 No difference was seen in relapse rate, EFS, or OS outcomes between the treatment arms. According to the NCCN AML Panel, infusional cytarabine × 7 days combined with either idarubicin or escalated daunorubicin is a category 1 recommendation.

For patients with impaired cardiac function, other regimens that combine nonanthracycline agents (eg, fludarabine73 or topotecan74) with cytarabine have been published.

High-dose cytarabine therapy during induction was explored previously in 2 large cooperative group trials. In an Australian Leukemia Study Group trial,75,76 patients younger than 60 years were randomized (N = 301) to receive either high-dose cytarabine (3 g/m2 every 12 hours on days 1, 3, 5, and 7 for a total of 24 g/m2) or standard cytarabine therapy (100 mg/m2/d ×× 7 days via continuous infusion); pa-7 days via continuous infusion); pa-7 days via continuous infusion); patients in both arms received daunorubicin (50 mg/m2 on days 1–3) and etoposide (75 mg/m2/d × 7 days). The CR rates were equivalent in both arms (71% and 74%, respectively), with significantly higher 5-year relapse-free survival rates with high-dose cytarabine (48% vs. 25%; P = .007).76 Patients in both treatment arms received only 2 cycles of standarddose cytarabine, daunorubicin, and etoposide for consolidation therapy. Median remission duration was 45 months for the high-dose arm, compared with 12 months for the standard treatment arm.75 However, treatment-related morbidity and mortality were higher in the high-dose cytarabine arm; the 5-year OS rates were 33% in the high-dose arm compared with 25% with the standard dose.76

In a large SWOG study,77 patients younger than 65 years (N = 665) were randomized to receive high-dose cytarabine (2 g/m2 every 12 hours × 6 days for a total of 24 g/m2; patients aged < 50 years were initially randomized to receive 3 g/m2 at the above schedule before the high-dose arm was redefined to 2 g/m2 because of toxicity concerns) or standard-dose cytarabine (200 mg/m2/d × 7 days); patients in both treatment arms also received daunorubicin (45 mg/m2/d × 3 days). Patients treated in the high-dose cytarabine arm received a second high-dose cycle for consolidation, whereas patients in the standard-dose arm were randomized to receive consolidation therapy with either 2 cycles of standard-dose cytarabine or 1 cycle of high-dose cytarabine plus daunorubicin. The CR rates were similar, with 55% for the high-dose arm compared with 58% for the standard-dose arm for patients younger than 50 years, and 45% for high-dose cytarabine versus 53% for standard-dose therapy for patients 50 to 65 years of age. DFS rate (for patients with a CR) and OS rate (for all patients) at 4 years was not significantly different between treatment arms. Induction therapy with high-dose cytarabine was associated with significantly higher rates of treatment-related mortality (14% vs. 5% for patients age < 50 years; 20% vs. 12% for patients age 50–64 years; P = .003) and grade 3 or higher neurologic toxicity (8% vs. 2% for patients < 50 years; 5% vs. 0.5% for patients age 50–64 years; P < .0001).77

For patients younger than 50 years, consolidation with high-dose cytarabine was associated with similar rates of treatment-related mortality (2% vs. 0%) and grade 3 or higher neurologic toxicity (2% vs. 0%) compared with standard dose. For patients younger than 50 years who received high-dose cytarabine at the 3-g/m2 dose schedule for induction, the rates of treatment-related deaths (10% vs. 5%) and grade 3 or greater neurologic toxicity (16% vs. 2%) were higher than for those who received the standard dose. Similarly, for patients younger than 50 years who received high-dose cytarabine at the 3-g/m2 dose schedule for consolidation, the rates of treatment-related deaths (4% vs. 0%) and grade 3 or greater neurologic toxicity (16% vs. 0%) were higher than for those who received the standard dose.77

Younger patients (age < 50 years) who received high-dose cytarabine induction and consolidation in the SWOG trial had the best OS and DFS rates at 4 years(52% and 34%, respectively) compared with those who received standard-dose induction and consolidation (34% and 24%, respectively) or standard induction with high-dose consolidation (23% and 14%, respectively).77 However, the percentage of patients achieving a CR who did not proceed to consolidation was twice as high in the high-dose cytarabine induction arm.77 The risks for neurotoxicity and renal insufficiency are increased with high-dose cytarabine; therefore, both renal and neurologic function should be closely monitored in patients receiving this treatment. In a CALGB trial,78 the subgroup of patients aged 60 years or younger (n = 156) who received standard-dose cytarabine-daunorubicin induction therapy and 4 courses of high-dose cytarabine consolidation (3 g/m2 every 12 hours on days 1, 3, and 5, per course) experienced a 4-year DFS rate of 44%. Among all patients who received consolidation with high-dose cytarabine, the rates of treatment-related deaths and serious neurotoxicity were 5% and 12%, respectively.78

Because the OS outcomes for the high-dose arm in the SWOG trial (high-dose cytarabine induction and 2 cycles of high-dose cytarabine consolidation; 4-year OS rate of 52% for patients age < 50 years) is comparable to those of the CALGB trial with standard-dose infusional cytarabine induction and 4 cycles of high-dose cytarabine consolidation (4-year OS rate of 52% for patients age ≤ 60 years), the use of high-dose cytarabine in the induction phase outside of a clinical trial remains controversial. The decision to use high- versus standard-dose cytarabine for induction might be influenced by consolidation strategies; fewer high-dose consolidation cycles may be needed for patients induced with high-dose cytarabine or for those who will undergo early autologous HSCT. Although the remission rates are similar for high- and standard-dose cytarabine, 2 studies have shown more rapid marrow blast clearance after 1 cycle of high-dose therapy and a DFS advantage for patients aged 50 years or younger who received the high-dose therapy.79 No data are available using more than 60 mg/m2 of daunorubicin or 12 mg/m2 of idarubicin with high-dose cytarabine. High-dose cytarabine plus an anthracycline as induction therapy is considered a category 2B recommendation for patients younger than 60 years.

With either high- or standard-dose cytarabine-based induction for younger patients, between 20% and 45% of these patients will not enter remission. In a recent report of 122 patients treated with high-dose cytarabine and daunorubicin, the remission rates were strongly influenced by cytogenetics, with CR rates of 87%, 79%, and 62% for favorable-, intermediate-, and poor-risk groups, respectively.80

Patients with antecedent hematologic disease or treatment-related secondary leukemia are considered poor-risk, unless they have favorable cytogenetics, such as t(8;21), inv(16), t(16;16), or t(15;17). In addition, patients with unfavorable karyotypes, such as -7, -5, 11q23 abnormalities or complex cytogenetic abnormalities, are also considered poor-risk. Although all patients with AML are best managed within the context of an appropriate clinical trial, this poor-risk group of patients, in particular, should be entered into a clinical trial (incorporating either chemotherapy or low-intensity therapy), if available, because only 40% to 50% of these patients experience a CR with standard induction therapy. In addition, HLA testing should be performed promptly in those who may be candidates for either fully ablative or reduced-intensity allogeneic HSCT from a matched sibling or an unrelated donor, which constitutes the best option for long-term disease control.

Because of the decreased probability of achieving remission through induction chemotherapy, transplantation without induction chemotherapy may be considered for patients with antecedent myelodysplasia or treatment-related leukemia who have an available sibling donor and who have a relatively low percentage of marrow involvement. In a European Group for Blood and Marrow Transplantation (EBMT) trial,81 patients with high-risk myelodysplasia or AML evolving from myelodysplasia who received allogeneic HSCT without prior cytarabine-based chemotherapy had a 3-year DFS rate of 34%. Patients who received initial chemotherapy and experienced a CR had a 45% DFS rate, compared with 10% for patients who did not experience response to chemotherapy before transplantation.81 An alternative strategy for patients with antecedent myelodysplasia who have not received a hypomethylating agent would be a trial of either decitabine or azacytidine while a rapid donor search is initiated.

Postinduction Therapy: To judge the efficacy of the induction therapy, a bone marrow aspirate and biopsy should be performed 7 to 10 days after completion of induction therapy. In patients who have received standard-dose cytarabine induction and have residual blasts without hypoplasia, additional therapy with standard-dose cytarabine and anthracycline should be considered. For those with significant residual blasts or clear-cut induction failure, escalation to high-dose cytarabine with or without an anthracycline is the most common salvage strategy. Other options include an allogeneic HSCT if a matched sibling or alternative donor has been identified, or participation in a clinical trial. For patients whose clinical condition has deteriorated such that active treatment is no longer appropriate, best supportive care should be continued. If the marrow is hypoplastic (defined as cellularity < 10%-20% and residual blasts < 5%-10%), additional treatment selection may be deferred until marrow recovery, when the remission status can be assessed.

Patients initially treated with high-dose cytarabine and who have significant residual blasts 7 to 10 days after completion of induction chemotherapy are considered to have experienced induction failure. These patients should be considered for a clinical trial, allogeneic HSCT with matched sibling or matched unrelated donor, or best supportive care. Additional high-dose cytarabine at this time is unlikely to induce remission in these cases. If an HLA-matched sibling or matched unrelated donor has been identified, an allogeneic HSCT may salvage 25% to 30% of patients with induction failure. If no donor is immediately available, patients should be considered for a clinical trial. Again, if the patient's clinical condition has deteriorated to a point at which active therapy would be detrimental, best supportive care may be the most appropriate option.

Occasionally, patients with both myeloid and lymphoid markers at diagnosis (biphenotypic leukemia) may experience response to ALL therapy if an AML induction regimen failed.3 Treatment decisions for patients with significant reduction without hypoplasia or those with hypoplasia are deferred until the blood counts recover and a repeat marrow is performed to document remission status. Response is then categorized as complete response or induction failure.

Postremission or Consolidation Therapy: Although successful induction therapy clears the visible signs of leukemia in the marrow and restores normal hematopoiesis in patients with de novo AML, additional postremission therapy (ie, consolidation) is needed to reduce the residual abnormal cells to a level that can be contained by immune surveillance.

Since 1994, multiple (3–4) cycles of high-dose cytarabine therapy have been the standard consolidation regimen for patients younger than 60 years with either good- or intermediate-risk cytogenetics. This consolidation therapy is based on a CALGB trial comparing 100 mg/m2, 400 mg/m2, and 3 g/m2 doses of cytarabine.78 The 4-year DFS rate for patients receiving consolidation with 3 g/m2 of high-dose cytarabine was 44%, with a 5% treatment-related mortality rate and a 12% incidence of severe neurologic toxicity. Although the initial report did not break down remission duration by cytogenetic groups, subsequent analysis showed a 5-year relapse-free survival (continuous CR measured from time of randomization) rate of 50% for CBF AML, 32% for patients with normal karyotype, and 15% for patients in other cytogenetic categories, overall (P < .001). Among the patients who received high-dose cytarabine consolidation, the 5-year relapse-free survival rate was 78% for CBF AML, 40% for normal karyotype, and 21% for other cytogenetic categories.80 Notably, however, in patients with CBF AML who were treated with postremission therapy with high-dose cytarabine, the presence of c-KIT mutations resulted in poorer outcomes.32 In an analysis of patients with CBF AML treated on CALGB trials (n = 110), c-KIT mutations among patients with inv(16) were associated with a higher cumulative incidence of relapse at 5 years (56% vs. 29%; P = .05) and decreased 5-year OS rate (48% vs. 68%) compared with wild-type c-KIT; in multivariate analysis, the presence of c-KIT mutations remained a significant predictor of decreased OS in the subgroup with inv(16). In patients with t(8;21), c-KIT mutations were also associated with a higher incidence of relapse at 5 years (70% vs. 36%: P = .017), but no differences were observed in 5-year OS (42% vs. 48%).32 The CALGB trial also included maintenance chemotherapy following the consolidation phase; however, not all patients in remission received maintenance (55% of patients in CR) following high-dose cytarabine consolidation.78 Subsequent clinical trials have not included maintenance as postremission therapy.

The recent shortages of several chemotherapy agents have raised the question of how best to use cytarabine. The HOVON/SAKK study compared a double-induction concept using intermediate- or high-dose cytarabine as part of an induction/consolidation regimen in a phase III randomized study in patients (age 18–60 years) with newly diagnosed AML (N = 860).82 Patients were randomized to treatment with an “intermediate-dose” cytarabine regimen (cycle 1: cytarabine, 200 mg/m2 × 7 days + idarubicin, 12 mg/m2 × 3 days; cycle 2: cytarabine, 1 g/m2 every 12 hours × 6 days + amsacrine, 120 mg/m2 × 3 days) [12 g/m2 cytarabine] or a “high-dose” cytarabine regimen (cycle 1: cytarabine, 1 g/m2 every 12 hours × 5 days + idarubicin, 12 mg/m2 × 3 days; cycle 2: cytarabine, 2 g/m2 every 12 hours × 4 days + amsacrine, 120 mg/m2 × 3 days) [26 g/m2 cytarabine]. Patients who experienced a CR after both treatment cycles were eligible to receive consolidation with a third cycle of chemotherapy or autologous or allogeneic HSCT.82 A similar proportion of patients in each treatment arm received consolidation with a third chemotherapy cycle (26%-27%), autologous HSCT (10%-11%), and allogeneic HSCT (27%-29%). No significant differences were observed between the intermediate- and high-dose arms in rates of CR (80% vs. 82%), 5-year EFS (34% vs. 35%), or 5-year OS (40% vs. 42%),82 results that seem comparable to those from the CALGB study with high-dose cytarabine.78 More than 50% of patients in each arm had already experienced a CR when they received cycle 2. The 5-year cumulative rate of relapse risk was also similar between treatment arms (39% vs. 27%, respectively).82 Outcomes were poor for patients with monosomal karyotype at baseline (n = 83), although the high-dose regimen was associated with significantly improved rates of 5-year EFS (13% vs. 0%; P = .02) and OS (16% vs. 0%; P = .02) compared with those of the intermediate-dose in this subgroup. The incidence of grade 3 or 4 toxicities after cycle 1 was higher in the high-dose arm than in the intermediate-dose arm (61% vs. 51%: P = .005), but the incidence of 30-day mortality was the same in both arms (10%).82 This study suggests that 2 cycles of intermediate-dose cytarabine (1 g/m2 every 12 hours × 6 days; total dose 12 g/m2 per cycle) for each consolidation cycle may be a feasible alternative to the current NCCN recommendations of 3 cycles of high-dose cytarabine (3 g/m2 for 6 doses; total dose of 18 g/m2 per cycle). However, what importance amsacrine may have served in the outcomes of the HOVON/SAKK study is currently not known.

Other options for consolidation strategies include one or more cycles of high-dose cytarabine followed by autologous HSCT or allogeneic HSCT from matched sibling or unrelated donors. When choosing among these options, decisions are influenced by: 1) the expected relapse rate with high-dose cytarabine consolidation chemotherapy (which in turn is strongly influenced by cytogenetic and molecular abnormalities); 2) the additional morbidity and mortality associated with the transplant procedure, which in turn are strongly influenced by patient-specific comorbidity; and 3) salvage therapy options. Factors such as patient age, comorbid conditions, and features of the disease at diagnosis, including elevated leukocyte counts (≥ 50,000/mcL) or number of cycles of induction to achieve remission, should play a role in choosing a consolidation strategy, as should issues regarding fertility and salvage options. Patients who require 2 cycles of chemotherapy to achieve a remission are likely to have more resistant disease and should be considered for a more intensive approach as initial consolidation whenever possible.

Previous version of these guidelines have used cytogenetics as the major defining criteria for risk of relapse. In the latest versions of these guidelines, the panel has endeavored to incorporate emerging data on the influence of mutations in specific genes such as c-KIT, FLT3, CEBPA, and NPM1 on subsets of patients within a cytogenetic category (see “Risk Status Based on Cytogenetics and Molecular Abnormalities,” on page 995).

In the EORTC/GIMEMA trial comparing outcomes between patients aged 45 or younger in no-donor (patients in CR planned for autologous HSCT) versus donor groups (patients in CR with matched sibling donor planned for allogeneic HSCT) on an intent-to-treat basis, the 4-year DFS rate for the subgroup with good-risk cytogenetics [eg, t(8;21) or inv(16)] was 66% for the no-donor group (n = 73; 63% underwent HSCT) and 62% for the donor group (n = 50; 72% underwent HSCT).83 Treatment-related mortality rates were 6% and 17%, respectively.

Outcomes from the earlier phase III SWOG/ECOG study in younger patients (age ≤ 55 years) also suggested similar outcomes in those with favorable cytogenetics undergoing HSCT; based on intent-to-treat analysis, the 5-year survival rate (from time of CR) was 71% for the autologous HSCT group (n = 26; 65% underwent HSCT) and 63% for the allogeneic HSCT group (n = 19; 84% underwent HSCT).21 The UK MRC study (AML 10) also reported no DFS or OS advantage with allogeneic HSCT among patients (age < 55 years) with favorable-risk cytogenetics.84 These data suggest that in the favorablerisk subgroup of patients with AML, the potential advantage with allogeneic HSCT in preventing relapse may be offset by high rates of transplant-related deaths. Outcomes from multiple cycles of high-dose cytarabine consolidation are comparable to results with autologous HSCT. Thus, for this subgroup of patients, high-dose cytarabine followed by autologous HSCT should be the preferred HSCT option, and allogeneic HSCT may be better reserved as salvage therapy or for those with c-KIT mutations.

The panel has provided the following options for consolidation therapy for patients with better risk cytogenetics (those with CBF leukemia, without c-KIT mutations): 1) 3 to 4 cycles of high-dose cytarabine (category 1); or 2) 1 to 2 cycles of high-dose cytarabine followed by autologous HSCT (category 2B). However, outcomes in favorable-risk patients who have c-KIT mutations are more similar to those of patients with intermediate-risk karyotype, and these patients should be considered for either clinical trials targeted toward the molecular abnormality or consolidation strategies similar to those used in the intermediate-risk group. A well-thought-out plan for salvage therapy with either a matched sibling or unrelated donor HSCT should be an important part of the treatment decision for these patients.

The panel members agreed that transplant-based options (either matched sibling or alternate donor allogeneic HSCT, or 1–2 cycles of dose-intensive cytarabine followed by autologous HSCT) afforded a lower risk of relapse and a somewhat higher DFS as consolidation for most patients with intermediaterisk cytogenetics. In the previously discussed SWOG/ECOG trial, the 5-year survival rates (from time of CR) for patients with intermediate-risk cytogenetics were 36% for the autologous HSCT group (n = 37; 59% underwent HSCT) and 52% for the allogeneic HSCT group (n = 47; 66% underwent HSCT).21 In the UK MRC AML 10 trial, significant benefit with allogeneic HSCT was observed for the subgroup of patients with intermediate-risk cytogenetics (but not for those with favorable or high-risk cytogenetics); in this subgroup, the DFS (50% vs. 39%; P = .004) and OS rates (55% vs. 44%; P = .02) were significantly higher among the donor groups than the no-donor groups.84 In the aforementioned EORTC/GIMEMA trial, the 4-year DFS rate among patients with intermediate-risk AML was 48.5% for the no-donor group (n = 104; 62.5% underwent HSCT) and 45% for the donor group (n = 61; 75% underwent HSCT).83 The incidence of relapse was 47% and 35%, respectively, and the incidence of deaths in CRs was 5% and 20%, respectively. The 4-year OS rate among intermediate-risk patients was 54% for the no-donor group and 53% for the donor group.83 Other options for this group include clinical trials or multiple courses (3–4) of high-dose cytarabine consolidation.85 Alternative regimens incorporating intermediate doses of cytarabine (1.5–2 g/m2) may also be reasonable in this group. Comparable 5-year DFS rates were reported in patients younger than 60 years with normal karyotype after either 4 cycles of intermediate- or high-dose cytarabine (41%) or autologous HSCT (45%).85

During the past 3 to 5 years, “normal” cytogenetics have been shown to encompass several molecular lesions with divergent risk behaviors. A large German trial has revealed additional molecular prognostic markers for patients with NK-AML.27 The presence of an isolated NPM1 or CEBPA mutation improves prognosis only slightly less than for patients with CBF translocations (see “Initial Evaluation” on page 999). For this subset of patients, therapy with multiple cycles of high-dose cytarabine is a category 1 option, and allogeneic HSCT should be reserved until relapse. Another option for this group is 1 to 2 cycles of high-dose cytarabine-based consolidation followed by autologous HSCT (category 2B). In contrast, patients with an isolated FLT3-ITD mutation and normal karyotype have an outlook similar to those with poor-risk cytogenetics34 and should be considered for a clinical trial or early allogeneic HSCT. In a recent report that evaluated the ELN risk classification in a large cohort of patients, those in the “Intermediate I” risk group (which includes all patients with NK-AML with FLT3 abnormalities and those lacking both FLT3 and NPM1 mutations), relapse-free survival was more favorable with allogeneic HSCT (94 vs. 7.9 months without allogeneic HSCT).68 Preliminary trials incorporating FLT3 inhibitors either as part of induction or postremission therapy (including post-HSCT) continue; however, the agents currently under investigation have shown only minimal impact. The panel strongly recommends clinical trials as standard therapy for patients with poor prognostic features, which include FLT3 abnormalities in the setting of otherwise normal karyotype, high WBC (> 50,000/mcL) at diagnosis, or 2 cycles of induction therapy needed to achieve CR.

In the aforementioned EORTC/GIMEMA trial, a 43% 4-year DFS rate was reported in the donor group of patients with poor-risk cytogenetics (n = 64; 73% underwent HSCT); this was significantly higher than the 4-year DFS rate (18%; P = .008) among the no-donor group (n = 94; 46% underwent HSCT), although only approximately half of the patients were able to proceed with the planned HSCT in the no-donor group.83 The SWOG/ECOG trial reported a 5-year survival rate (from time of CR) of 44% with allogeneic HSCT (n = 18; 61% underwent HSCT) and 13% with autologous HSCT (n = 20; 50% underwent HSCT) among the subgroup of patients with unfavorable cytogenetics; moreover, the 5-year survival rate was similar between those allocated to autologous HSCT and those intended for chemotherapy consolidation alone (13% and 15%, respectively).21

The panel uniformly endorsed allogeneic HSCT with matched sibling or matched unrelated donor (including cord blood) or clinical trial as consolidation therapy for patients with poor-risk cytogenetics or molecular abnormalities. Another option for this group is 1 to 2 cycles of high-dose cytarabine-based consolidation followed by autologous HSCT, if allogeneic transplant is not an available option.

Management of AML in Patients Older Than 60 Years

Induction Therapy: The creation of separate guidelines for patients older than 60 years recognizes the poor outcomes in this group treated with standard cytarabine and an anthracycline. In patients older than 60 years, the proportion of those with favorable CBF translocations decreases, as does the number with isolated NPM1 mutations, whereas the number of those with unfavorable karyotypes and mutations increases. Secondary AML, either related to prior myelodysplasia or prior chemotherapy, also increases, along with a higher rate of multidrug resistance protein expression. Although studies in the Swedish Leukemia Registry documented improvement in outcomes for patients younger than 60 years over the past 3 decades, no similar improvement was observed for the older population.70,74 Treatment-related mortality frequently exceeds any expected transient response in this group, particularly in patients older than 75 years or in those who have significant comorbid conditions or ECOG performance status greater than 2.

For older patients (age > 60 years) with AML, the panel recommends using patient performance status, in addition to adverse features (eg, unfavorable cytogenetics and therapy-related AML or prior MDS) and comorbid conditions, to select treatment options rather than relying on a patient's chronologic age alone. A treatment decision-making algorithm for previously untreated, medically fit, elderly patients (age ≥ 60 years) with AML was recently developed by the German AML cooperative group. Based on data from a large study in elderly patients (N = 1406), patient and disease factors significantly associated with CR and/or early death were identified and risk scores were developed based on multivariate regression analysis.86 The predictive model was subsequently validated in an independent cohort of elderly patients (N = 801) treated with 2 courses of induction therapy with cytarabine and daunorubicin. The algorithm, with or without knowledge of cytogenetic or molecular risk factors, predicts the probability of achieving a CR and the risk for an early death for elderly patients with untreated AML, who are medically fit and therefore considered eligible for intensive treatments.86 The factors included in the algorithm are the following: body temperature (≤ 38°C, > 38°C), hemoglobin levels (≤ 10.3, > 10.3 g/dL), platelet counts (≤ 28K, > 28K-≤ 53K, > 53K-≤ 10K, > 10K counts/mcL), fibrinogen levels (≤ 150, > 150 mg/dL), age at diagnosis (60–64, > 64–67, > 67–72, > 72 years), and type of leukemia (de novo, secondary). The algorithm can be accessed online at http://www.aml-score.org/.

Older adults with intact functional status (ie, ECOG score 0–2), minimal comorbidity, and favorable cytogenetic or molecular mutations, may benefit from standard therapies regardless of chronologic age. A reasonable treatment regimen for these patients includes standard-dose cytarabine (100–200 mg/m2 by continuous infusion per day × 7 days) along with 3 days of anthracycline. Although patients older than 75 years with significant comorbidities generally do not benefit from conventional chemotherapy treatment, the rare patient with favorable or normal karyotype and no significant comorbidities might be the exception to this dogma. For patients with NK-AML, the remission rates are 40% to 50% with cytarabine combined with idarubicin, daunorubicin or mitoxantrone. The randomized French ALFA-9801 study (N = 468) showed that idarubicin induction (the standard 12 mg/m2 × 3 days or intensified with 12 mg/m2 × 4 days) compared with high-dose daunorubicin (up to 80 mg/m2) yielded a significantly higher CR rate in patients aged 50 to 70 years (80% vs. 70%, respectively; P = .03).72 The median OS for all patients was 17 months. The estimated 2-year EFS and OS rates were 23.5% and 38%, respectively, and estimated 4-year EFS and OS rates were 18% and 26.5%, respectively; no differences were observed between treatment arms with regard to EFS, OS, and cumulative relapse rates.72 In the HOVON trial, which randomized patients aged 60 years and older to induction therapy with standard-dose cytarabine combined with either standard-dose daunorubicin (45 mg/m2 × 3 days; n = 411) or dose-escalated daunorubicin (90 mg/m2 × 3 days; n = 402), the CR rate was 54% and 64%, respectively (P = .002).87 No significant differences were observed in EFS, DFS, or OS outcomes between treatment arms. Among the subgroup of patients aged 60 to 65 years (n = 299), an advantage with dose-escalated compared with standard-dose daunorubicin was observed with regard to rates of CR (73% vs. 51%), 2-year EFS (29% vs. 14%), and 2-year OS (38% vs. 23%). These outcomes with dose-escalated daunorubicin seemed similar to those with idarubicin (12 mg/m2 × 3 days) from the ALFA-9801 study, in which the 3-year EFS and OS rates were 30% and 40%, respectively.88 In the HOVON trial, the benefit in OS outcomes for the dose-escalated daunorubicin group was observed only in patients aged 65 years and younger or in those with CBF translocations.87

Another option for patients who are medically fit is the purine nucleoside analogue clofarabine (currently FDA-approved only for the treatment of relapsed or refractory pediatric ALL). In a large phase II study from the MD Anderson Cancer Center, 112 patients (age > 60 years; median age, 71 years), most of whom had additional risk factors, received clofarabine, 30 mg/m2 intravenously for 5 days.89 CR/complete response with incomplete platelet recovery (CRp) was achieved in 46% of patients, with a 30-day mortality rate of 10%. Patients who experienced a remission continued to receive therapy every 4 to 6 weeks to maintain remission for up to 6 additional treatment cycles. For the entire patient cohort, the median DFS and OS were 37 and 41 weeks, respectively; patients experiencing a CR had a median OS of 72 weeks.89 An ECOG-led phase III trial is currently in progress, which will compare induction therapy with single-agent clofarabine versus cytarabine/daunorubicin in patients older than 60 years. Consolidation therapy in this trial would be either continuation of clofarabine or intermediate-dose cytarabine.

For patients who are deemed unfit for standard induction or intermediate-intensity therapy such as clofarabine, recent options have focused on epigenetic agents, including hypomethylating drugs such as 5-azacytadine and decitabine, alone or in combination with histone deacetylase inhibitors.

An international randomized phase III study by Fenaux et al.90 compared the hypomethylating agent 5-azacytidine with conventional care (best supportive care, low-dose cytarabine, or intensive chemotherapy) in patients with MDS (N = 358). Although this study was designed for evaluation of treatment in patients with high-risk MDS (based on FAB criteria), 113 study patients (32%) fulfilled criteria for AML using the 2008 WHO classification, with marrow-blast percentage between 20% and 30%.90,91 In the subgroup of these patients with AML, a significant survival benefit was found with 5-azacytidine compared with conventional care regimens, with a median OS of 24.5 versus 16 months (hazard ratio [HR], 0.47; 95% CI, 0.28–0.79; P = .005).91 The 2-year OS rate was 50% and 16%, respectively (P = .001).

Another hypomethylating agent, decitabine, has also been evaluated as remission induction therapy for older patients with AML.92 In a phase II study in patients aged 60 years and older (N = 55; median age, 74 years), the CR rate with this agent (20 mg/m2/d for 5 days) was 24% (including 6/24 patients [24%] with poor-risk cytogenetics), and the median EFS and OS were 6 and 8 months, respectively.92 In an open-label randomized phase III study, decitabine was compared with physician's choice (either low-dose cytarabine or supportive care) in older patients (age ≥ 65 years) with newly diagnosed AML.93 Based on the protocol-specified final analysis of the primary end point (OS), decitabine was associated with a statistically nonsignificant trend for increased median OS compared with physician's choice (7.7 vs. 5 months; HR, 0.85; 95% CI, 0.69–1.04; P = .10). A subsequent post hoc analysis of OS with additional follow-up time showed the same median OS with a statistically significant advantage associated with decitabine (HR, 0.82; 95% CI, 0.68–0.99; P = .03). The CR (including CRp) rate was significantly higher with decitabine (18% vs. 8%; P = .001).93 Both azacytidine and decitabine are approved by the FDA as treatment for patients with MDS.

The United Kingdom National Cancer Research Institute AML 14 trial randomized 217 older patients (primarily age > 60 years; de novo AML, n = 129; secondary AML, n = 58; high-risk MDS, n = 30) unfit for chemotherapy to receive either low-dose cytarabine subcutaneously (20 mg twice daily for 10 consecutive days, every 4–6 weeks) or hydroxyurea (given to maintain target WBC counts < 10,000/mcL).94 Patients were also randomized to receive all-trans retinoic acid (ATRA) or no ATRA. Low-dose cytarabine resulted in a CR rate of 18% (vs. 1% with hydroxyurea) and a survival benefit compared with hydroxyurea in patients with favorable or normal karyotype. No advantage was observed with the addition of ATRA. The median DFS in patients who achieved a CR with low-dose cytarabine was 8 months.94 Even with this “low-intensity” treatment approach, induction death occurred in 26% of patients, and overall prognosis remained poor for older patients who cannot tolerate intensive chemotherapy regimens.

The panel has included subcutaneous cytarabine, 5-azacytidine, and decitabine as low-intensity treatment options, and clofarabine as an intermediate-intensity treatment option for patients with AML who are 60 years or older. Best supportive care includes red cell and platelet transfusions to alleviate symptoms of anemia and thrombocytopenia; prophylactic antibiotic and antifungal drugs to reduce the risk of infection; and hydroxyurea for management of leukocytosis.

Older adults with newly diagnosed AML with ECOG performance status score of 0 to 2, with or without adverse features (such as therapy-related AML/prior MDS or unfavorable cytogenic or molecular markers) may be managed with one of the following options: clinical trial, standard infusional cytarabine and anthracycline; low-intensity therapy (eg, subcutaneous cytarabine, azacitidine, or decitabine); or intermediate-intensity therapy with clofarabine (category 2B).

Patients with an ECOG performance status score of greater than 2 or those with significant comorbidities (regardless of performance status score) are more likely to experience toxicity and less likely to benefit from standard-induction chemotherapy. For these patients, the panel feels it is reasonable to offer low-intensity therapy or best supportive care. Participation in a clinical trial investigating novel agents may also be appropriate for patients with a performance status score of greater than 2 without significant comorbid conditions.

Postinduction Therapy: Similar to younger patients, older patients who receive standard cytarabine/anthracycline induction are evaluated with a bone marrow evaluation 7 to 10 days after completion of chemotherapy and categorized according to the presence of blasts or hypoplasia. Patients with residual blasts without hypoplasia may receive additional standard-dose cytarabine with an anthracycline or mitoxantrone. A repeat bone marrow evaluation is performed in these patients and in those with hypoplasia after induction to document remission status. Because many older patients have some evidence of antecedent myelodysplasia, full normalization of peripheral blood counts often does not occur even if therapy clears the marrow blasts. Thus, many phase I/II trials for AML in the older patient include categories such as CR incomplete (CRi) for patients who have fewer than 5% marrow blasts but mild residual cytopenia.

Many of the newer treatment strategies are designed to work more gradually using agents that may allow expression of tumor suppressor genes (eg, a methyltransferase inhibitor such as decitabine or 5-azacytidine) or increase apoptosis (eg, histone deacetylase inhibitors). Thus, success in these trials may be assessed using indirect measures, such as hematologic improvement or decreased transfusion requirements and survival, without actually achieving CR. Frequently, in these trials, marrow examination is not performed until completion of 1 to 2 cycles of therapy.

Postremission Therapy: Patients who achieve a CR (including CRi) with standard induction chemotherapy may receive further consolidation with these agents. The French ALFA 98 trial randomized patients aged 65 years and older who achieved remission (n = 164 randomized for postremission therapy), to consolidation with either 1 additional course of standard-dose cytarabine (200 mg/m2 × 7 days) plus the anthracycline to which they had been randomized for induction (idarubicin, 9 mg/m2 × 4 days or daunorubicin, 45 mg/m2 × 4 days) or 6 monthly courses of anthracycline (1 day only) at the above doses and 60 mg/m2 of cytarabine every 12 hours as a subcutaneous infusion at home for 5 days each month.95 Based on intent-to-treat analysis, patients randomized to the ambulatory arm had a significantly higher 2-year DFS rate (28% vs. 17%; P = .04) and OS rate (from time of CR; 56% vs. 37%; P = .04) compared with the single course of intense chemotherapy consolidation. In addition, the 2-year death rate in CR was significantly lower in the ambulatory arm (0% vs. 5%; P = .04) and no differences were observed in the cumulative relapse rate between arms.95 Although the CALGB trial did not show an overall benefit for higher doses of cytarabine consolidation in older patients, a subset of patients with a good performance status, normal renal function, and a normal or low risk karyotype might be considered for a single cycle of cytarabine (1.0–1.5 g/m2/d × 4–6 doses) without an anthracycline.

The role of myeloablative allogeneic HSCT is limited in older patients because of significant comorbidities; however, ongoing interest has been shown in reduced-intensity conditioning (RIC) allogeneic HSCT as consolidation therapy.96,97 Case series and analysis of registry data have reported encouraging results, with 40% to 60% 2-year OS rates and 20% nonrelapse mortality for patients who underwent transplant in remission.96,97 In a retrospective analysis comparing outcomes with RIC allogeneic HSCT and autologous HSCT in patients aged 50 years and older based on large registry data, allogeneic HSCT was associated with lower risk for relapse and superior DFS and OS relative to autologous HSCT.96 The authors also noted that a survival benefit was not observed in the subgroup of patients undergoing allogeneic HSCT in first CR because of an increased incidence of nonrelapse mortality.

Estey et al.98 prospectively evaluated a protocol in which patients aged 50 years and older with unfavorable cytogenetics would be evaluated for a RIC allogeneic HSCT. Of the 259 initial patients, 99 experienced a CR and were therefore eligible for HSCT evaluation; of these patients, only 14 ultimately underwent transplantation because of illness, lack of donor, refusal, or unspecified reasons. The authors compared the results of RIC allogeneic HSCT with those from matched subjects receiving conventional-dose chemotherapy. This analysis suggested that RIC allogeneic HSCT was associated with improved relapse-free survival, and the authors concluded that this approach remains of interest.98 In an analysis of outcomes between 2 different strategies for matched sibling allogeneic HSCT, outcomes in younger patients (age ≤ 50 years; n = 35) receiving conventional myeloablative allogeneic HSCT were compared with those in older patients (age > 50 years; n = 39) receiving RIC allogeneic HSCT.99 This study showed similar rates of 4-year nonrelapse mortality (19% and 20%, respectively), and no difference was seen in relapse and OS rates.99

A recent retrospective study based on data in older patients (age 50–70 years) with AML compared outcomes in patients who underwent allogeneic HSCT (either myeloablative conditioning or RIC; n = 152) and those who did not receive HSCT in first CR (chemotherapy only; n = 884).100 Allogeneic HSCT in first CR was associated with a significantly lower 3-year cumulative relapse rate (22% vs. 62%; P < .001) and higher 3-year relapse-free survival rate (56% vs. 29%; P < .001) compared with the non-HSCT group. Although HSCT was associated with a significantly higher rate of nonrelapse mortality (21% vs. 3%; P < .001), the 3-year OS rate showed a survival benefit with HSCT (62% vs. 51%; P = .012).100

Among the patients who underwent allogeneic HSCT, myeloablative conditioning was used in 37% of patients, whereas RIC was used in 61%. Survival outcomes between these groups were similar, with a 3-year OS rates of 63% and 61%, respectively.100 Another recent study evaluating treatment in older patients (age 60–70 years) compared outcomes between RIC allogeneic HSCT (reported to the Center for International Blood and Marrow Transplant Research; n = 94) and standard chemotherapy induction and postremission therapy from the CALGB studies (n = 96).101 Allogeneic HSCT in first CR was associated with significantly lower 3-year relapse (32% vs. 81%; P < .001) and higher 3-year leukemia-free survival rates (32% vs. 15%; P < .001) compared with the chemotherapy-only group. As would be expected, allogeneic HSCT was associated with a significantly higher rate of nonrelapse mortality (36% vs. 4%; P < .001) at 3 years; the 3-year OS rate was not significantly different between the groups (37% vs. 25%; P = .08), although a trend was seen favoring allogeneic HSCT.101

Collectively, these studies suggest that RIC allogeneic HSCT is a feasible treatment option for patients aged 60 years and older, particularly those in first CR with minimal comorbidities and who have an available donor. For this strategy to be better used, potential transplant options should be considered during induction therapy, and unrelated donor options/searches explored earlier in the disease management.

The guidelines note that RIC allogeneic HSCT is considered an additional option for patients aged 60 years and older for the following situations: 1) as postremission therapy in those experiencing a CR to induction therapy, or 2) as treatment of induction failure (in the context of a clinical trial) only in patients with low-volume disease.

Postremission Surveillance and Salvage Therapy for AML

The guidelines recommend monitoring complete blood counts, including platelets, every 1 to 3 months for the first 2 years after patients have completed consolidation therapy, then every 3 to 6 months thereafter for a total of 5 years. Bone marrow evaluation is recommended only if the hemogram becomes abnormal, rather than as routine surveillance at fixed intervals, unless this is being performed as part of a clinical research protocol.

A matched unrelated donor search (including cord blood) should be initiated for high-risk patients who would be candidates for HSCT in first CR, or considered at first relapse in appropriate patients concomitant with initiation of reinduction therapy.

Treatment strategies for relapse are categorized according to patient age. For patients younger than 60 years who have experienced a relapse, enrollment in clinical trials is considered an appropriate strategy and is a strongly preferred option by the panel. If the relapse occurs after a relatively “long” (> 12 months) period of remission, retreatment with the previously successful induction regimen is an option. If the relapse is detected when the tumor burden is low and the patient has a previously identified sibling or unrelated donor, salvage chemotherapy followed by allogeneic HSCT can be considered. Transplant should be considered only if the patient has entered remission or in the context of a clinical trial.

Similarly, patients 60 years or older who are physically fit and wish to pursue treatment after relapse may be offered the following options: 1) therapy on clinical trial (strongly preferred option by the panel); or 2) salvage chemotherapy followed by matched sibling or alternate donor HSCT (again, transplant should be considered only if the patient has entered remission or in the context of a clinical trial); or 3) retreatment with the initial successful induction for a patients with a long initial remission duration (ie, relapse > 12 months). Best supportive care is always an option for patients who cannot tolerate or do not wish to pursue further intensive treatment.

The guidelines provide a list of several commonly used salvage regimens (see page 998). The regimens represent purine analog (eg, fludarabine, cladribine, clofarabine)-containing regimens, which have shown remission rates of 30% to 45% in several clinical trials, and those that have been used as the comparator arms in U.S. cooperative group trials in the past decade. The representative regimens included are: 1) cladribine, cytarabine, and granulocyte colony-stimulating factor (G-CSF), with or without mitoxantrone or idarubicin102,103; 2) fludarabine, cytarabine, and G-CSF (FLAG regimen) with or without idarubicin104,105; 3) etoposide and cytarabine, with or without mitoxantrone106; or 4) clofarabine, cytarabine and G-CSF.107 In addition, high-dose cytarabine, if not previously used as treatment for persistent disease at day 15, with or without anthracycline may also be considered in the salvage setting. Notably, these salvage treatment options are aggressive regimens intended for appropriate patients who can tolerate such therapies; for other patents, less aggressive treatment options may include low-dose cytarabine94,108 or hypomethylating agents.9193,109111

Supportive Care for AML

Although variations exist between institutional standards and practices, several supportive care issues are important to consider in the management of patients with AML. In general, supportive care measures may include the use of blood products or transfusion support, tumor lysis prophylaxis, neurologic assessments, antiinfective prophylaxis, and use of growth factors. These supportive care measures are tailored to address the specific needs and infection susceptibility of each individual patient.

When transfusion support is required, leukocytedepleted blood products should be used for transfusion. Radiation of all blood products is advised in all patients receiving immunosuppressive therapy, particularly for patients receiving fludarabine-based regimens and those undergoing HSCT. Cytomegalovirus (CMV) screening for potential HSCT candidates is left to institutional policies regarding provision of CMV-negative blood products to patients who are CMV-negative at time of diagnosis.

Standard tumor lysis prophylaxis includes hydration with diuresis, alkalinization of the urine, and allopurinol administration or rasburicase treatment. Rasburicase is a genetically engineered recombinant form of urate oxidase enzyme. Rasburicase should be considered as initial treatment in patients with rapidly increasing blast counts, high uric acid, or evidence of impaired renal function.

Patients who receive high-dose cytarabine should be closely monitored for changes in renal function, because renal dysfunction is highly correlated with increased risk of cerebellar toxicity. Patients should be monitored and assessed for nystagmus, dysmetria, slurred speech, and ataxia before each dose of high-dose cytarabine; patients exhibiting any neurologic signs should discontinue high-dose cytarabine, and all subsequent cytarabine therapy must be administered as standard dose. Patients who develop cerebellar toxicity should not be rechallenged with high-dose cytarabine in future treatment cycles.112 High-dose cytarabine should also be discontinued in patients with rapidly rising creatinine caused by tumor lysis.

Decisions regarding the use and choice of antibiotics to prevent and treat infections should be made by the individual institutions based on the prevailing organisms and their drug resistance patterns. A randomized phase III study has shown that in patients with neutropenia undergoing induction chemotherapy for AML or MDS, posaconazole was significantly more effective in preventing invasive fungal infections than fluconazole or itraconazole, and was associated with improved OS outcomes.113 However, azoles should not be given during anthracycline chemotherapy because they impair drug metabolism and can increase toxicity.

Growth factors have no clear role in initial induction therapy; however, they may be considered as part of supportive care for postremission therapy. Use of growth factors may be a confounding factor in the interpretation of pathology results from bone marrow evaluations. Therefore, G-CSFs or granulocyte-macrophage colony-stimulating factors should be discontinued for a minimum of 7 days before bone marrow samples are assessed when documenting remission status.

Evaluation and Treatment of CNS Leukemia

Leptomeningeal involvement is much less frequent (< 3%) in patients with AML than in those with ALL; therefore, the panel does not recommend LP as part of the routine diagnostic workup. However, if neurologic symptoms (eg, headache, confusion, altered sensory input) are present at diagnosis, an initial CT/MRI should be performed to rule out the possibility of intracranial hemorrhage or presence of mass/lesion. If no mass effect is seen, cerebrospinal fluid (CSF) cytology should be sampled by LP. If the LP is negative, the patient can be followed with a repeat LP if symptoms persist. If the LP is positive, intrathecal chemotherapy with cytarabine or methotrexate is recommended, given concurrently with systemic induction therapy. Initially, the intrathecal therapy should be given twice weekly until the cytology shows no blasts, and then weekly for 4 to 6 weeks. High-dose cytarabine, when used as part of induction therapy, may substitute for intrathecal chemotherapy because it crosses the blood-brain barrier; the CSF must then be reassessed after completion of induction therapy, and further therapy should be given as appropriate. The use of liposomal cytarabine, which has a longer half-life, for intrathecal use offers the benefit of less frequent (once weekly) administration.

Individual Disclosures for the NCCN Acute Myeloid Leukemia Panel Members

T1

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