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Acute leukemia Resident Survival Guide
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];

Synonyms and keywords: Acute lymphocytic leukemia, Acute myeloid leukemia, ALL, AML

Overview

Acute Leukemia is a malignancy of bone marrow myeloid and lymphoblastic precursor cells, in which these poorly differentiated hematopoietic cells proliferate rapidly. Hence, their accumulation would disrupt the performance of bone marrow to produce normal blood cells

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Causes

AML and ALL are life-threatening diseases, which would result in death if left untreated. In the majority of cases, etiology is not apparent.

Common Causes of AML

• Gene mutations:FLT3, IDHI, IDH2, KRAS, DNMT3A, NPM1
• Chromosomal translocations, deletions, and inversions
• Benzene or radiation exposure chronically

Common Causes of ALL

• Radiation exposure:
• Genetic disorders; e.g., Down syndrome, ataxia-telangiectasia, Fanconi anemia
• Certain infections: e.g., HTLV-1

FIRE

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

• Focused Initial Rapid Evaluation (FIRE) in AML :

Obtain patient's medical history and focus on these signs and symptoms: ❑ Fatigue ❑ Weight loss ❑ Anorexia ❑ Bone pain ❑ Bleeding ❑ Early satiety ❑ History of specific and chronic exposures such as alkylating agents, benzene, radiation, or previous chemotherapy ❑ Headache ❑ History of recurrent fever

Examine the patient: ❑ Fever ❑ Ecchymosis ❑ Lymphadenopathy ❑ Splenomegaly ❑ Hepatomegaly ❑ Mediastinal mass ❑ Abnormalities in cranial nerve examination ❑ Skin Petechiae ❑ Testicular enlargement <

Hematologic evaluation: ❑ CBD including platelets and WBCs) ❑ Uric acid, BUN, Cr, Liver function tests, bilirubin,Ca, P, Sodium, potassium, ❑ amylase, and lipase ❑ Lactate dehydrogenase ❑ PT, PTT ❑ D-dimer, fibrinogen ❑ Viral antibodies, (varicella-zoster, CMV), HSV-1 ❑ Peripheral blood smear

Radiologic assessment: ❑ CXR (PA and lateral) ❑ PET or CT scan (if extramedullary disease is doubted based on symptoms and physical exam) ❑ CT, or MRI, and other imaging methods to diagnose ICH, brain or spinal cord tumors, and leptomeningeal disease (if patient presenting notable CNS signs and symptoms

❑ Bone marrow aspiration and biopsy

• Focused Initial Rapid Evaluation (FIRE) in ALL:

Take a precise medical history and focus on these signs and symptoms: ❑ Fatigue ❑ Anorexia ❑ Bone and joint pain ❑ Bleeding ❑ Weakness and lethargy ❑ History of prior exposures with alkylating agents, radiation, or previous chemotherapy (less prevalent than AML) ❑ Headache ❑ History of bleeding or unexplained bruising ❑ History of congenital syndroms ❑ Night sweats, weight loss and fever(B symptoms) ❑ Abdominal distention

Examine the patient: ❑ Fever ❑ Tachycardia ❑ Mediastinal mass ❑ Lymphadenopathy ❑ Splenomegaly ❑ Hepatomegaly ❑ Abnormalities in cranial nerve examination ❑ Skin Petechiae ❑Testicular enlargement (rare)

Hematologic evaluation: ❑ CBD including platelets and WBCs) ❑ Uric acid, BUN, Cr, Liver function tests, bilirubin ❑ Lactate dehydrogenase , potassium, phosphates, and calcium ❑ d-dimer, fibrinogen, PT, and PTT ❑ Peripheral blood smear

Radiologic assessment: ❑ CXR (PA and lateral) to rule out mediastinal masses ❑ Brain CT scan and MRI with contrast if neurologic signs and symptoms have existed ❑ Scrotal ultrasound for assessing testicular involvement ❑ Echocardiogram or cardiac scan A whole body PET or CT scan when lymphoblastic lymphoma is doubted

❑ Bone marrow aspiration and biopsy

❑ Lumbar puncture

Diagnosis

Diagnostic criteria of acute myeloid leukemia and acute lymphoblastic leukemia are similar to one another.

• According to the 2016 WHO criteria observing ≥20% blasts in the bone marrow biopsy or peripheral blood smear is diagnostic for AML. These genetic abnormalities in AML are diagnostic even with less than 20% marrow blasts: inv(16), t(16;16), t(8;21), and t(15;17).

• Presenting ≥20% of leukemic lymphoblasts in bone marrow aspirate and biopsy would prove ALL.

Treatment

Treatment of a patient with definitive AML

Treating for the first time(new case)

Cases with relapsed/refractory AML

Favorable-Risk Cytogenetics

Intermediate-Risk Cytogenetics

Poor-Risk Cytogenetics

Salvage therapy

Select one of these therapies: ❑ 1. Induction treatment: Cytarabine-based regimen + Daunorubicin. If a complete remission is achieved, postremission consolidation therapy as maintenance should be started: intermediate dose of Cytarabine) ❑ 2.Investigational drugs(clinical trial): for cases aged younger than 60 years, a standard chemotherapy regimen including a backbone of Cytarabine + Anthracycline has been recommended. After complete remission, postremission therapy have to be regarded.

Select one of these treatments: ❑ 1. Investigational therapy: for patients older than 65 or have more comorbidities and high-risk illnesses or cases who cannot tolerate Cytarabine-based regimen + Daunorubicin, changing their regiments to an investigational therapy could be regarded. (administrate one chemotherapy drug or combine their treatment with non-intensive medications fitting with the patient such as decitabine, azacitidine). After complete remission, postremission therapy have to be regarded. ❑ 2. Induction treatment: Cytarabine-based regimen + Daunorubicin (could be suitable for young and elderly patients). If complete remission(CR) is achieved, postremission consolidation therapy as maintenance should be started to prevent relapse, including: Allogenic hematopoietic cell transplantation, which is the preferred treatment, or If the patient is younger than 60 years autologous hematopoietic cell transplantation is recommended, or Intermediate dose of Cytarabine

Select one of these therapies: 1. Induction treatment: Cytarabine-based regimen + Daunorubicin (could be suitable for both young and elderly patients). After complete remission(CR) achieved, postremission consolidation therapy should be started to prevent relapse, including Allogenic hematopoietic cell transplantation, which is the preferred treatment. When there is not any accessible HLA-matched donor, using an alternate donor has been recommended. 2. Investigational therapy: for patients older than 65 or have more comorbidities and high-risk illnesses or cases who cannot tolerate Cytarabine-based regimen + Daunorubicin, changing their regiments to an investigational therapy could be regarded. (administrate one chemotherapy drug or combine their treatment with non-intensive medications fitting with the patient such as decitabine, azacitidine). After complete remission, postremission therapy has to be regarded.

Patients with relapsed and refractory AML who has an HLA-matched donor accessible for allogenic HCT or cases who attained second complete remission after salvage therapy while there is an available appropriate donor should undergo allogenic hematopoietic cell transplantation. Those who do not have these conditions have to be treated based on clinical trials (investigational therapy).

Treatment of acute lymphoblastic leukemia includes three phases:

• Induction therapy, i.e., prednisolone, vincristine, cytarabine
  
• Administrating Central Nervous System prophylaxis, i.e., methotrexate
• Chemotherapy as a maintenance treatment for two years
• Stem cell transplantation in adults who are eligible while there is a suitable donor

Do's

• Before starting the therapy, taking a precise history and physical examination have to be done to diagnose any kind of comorbidities ,i.e. heart failure or renal diseases that affect the prognosis and treatment choices.

• HLA-typing evaluation have to be done for all of the AML cases In the pretreatment assessment.
• Seven days after the induction phase of chemotherapy ended, bone marrow biopsy must be done in order to assess the remission situation.
• In the induction chemotherapy process of AML for most of the cases, cytarabine IV infusion should be administrated for seven days consecutively + anthracycline on days one to three.(known as "7+3" regimens)

Don'ts

• If the patient with AML has a coagulopathy disorder and is susceptible to bleeding, do not have to undergo lumbar puncture in the workup process before correcting that.
• Without the assessment of cardiac symptoms and echocardiogram, chemotherapy medications which are cardiotoxic should not be administrated.

References