Acute Myelogenous Leukemia

Aka: Acute Myelogenous Leukemia, Acute Myeloid Leukemia, AML, Acute Myelocytic Leukemia, Acute Erythroblastic Leukemia

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II. Epidemiology

  1. Most common Acute Leukemia of adults (80% of cases)

III. Pathophysiology

  1. Myelodysplastic disorder or preleukemia in 25%
    1. Anemia or Cytopenia precedes Leukemia by years

IV. Risk Factors: Prior Chemotherapy

  1. Agents
    1. Alkylating Agents
      1. Chlorambucil
      2. Cyclophosphamide
    2. Nitrosourea
    3. Procarbazine
  2. Conditions
    1. Hodgkin's Disease
    2. Multiple Myeloma
    3. Ovarian Cancer

V. Symptoms

  1. See Acute Leukemia
  2. Constitutional symptoms
    1. Fever
    2. Fatigue
    3. Weight loss
  3. Anemia-related symptoms
    1. Shortness of Breath
    2. Exertional Chest Pain
  4. Thrombocytopenia related symptoms
    1. Excessive bleeding or Bruising

VI. Signs

  1. Hepatosplenomegaly and Lymphadenopathy are rare (contrast with Acute Lymphocytic Leukemia)

VII. Labs

  1. See Acute Leukemia
  2. Peripheral Smear findings specific for Acute Myelogenous Leukemia
    1. Immature Myeloblasts (blast cells) on Peripheral Smear
    2. Auer rods may be found (inconsistent)

VIII. Diagnosis

  1. Sources
    1. Peripheral Blood Smear
    2. Bone Marrow Biopsy
  2. Studies to distinguish between AML and ALL
    1. Flow cytometry with immunophenotyping
      1. Sorts and counts cells by cell surface markers
    2. Cytogenetic testing
      1. Chromosome evaluation (karyotype or fluorescence in situ hybridization analysis)

IX. Management

  1. Induction of Severe Myelosuppression (60-80% remission)
    1. Cytarabine
    2. Daunorubicin or Mitoxantrone or amsacrine
    3. 6-Thioguanine
  2. Repeat cycles of consolidation Chemotherapy
  3. Bone Marrow Transplantation improves survival

X. Management: Surveillance of survivors treated with Chemotherapy and radiation

  1. Complete Blood Count with differential
    1. Every 1-2 months for 3 years THEN
    2. Every 3-6 months for up to 5 years
  2. Cardiac testing
    1. Echocardiogram every 2 years
    2. Electrocardiogram every 2 years
    3. MUGA Scan (Multi Gated Acquisition Scan, radionuclide angiography) every 5 years
    4. Holter Monitor every 5 years

XI. Management: Surveillance of survivors miscellaneous

  1. Treated with Hematopoietic Stem Cell Transplantation
    1. See Hematopoietic Stem Cell Transplant for protocol

XII. Complications

  1. CNS Leukemia (10-20%)

XIII. Prognosis

  1. Remission 9 months to 2 years after Chemotherapy
  2. Five year survival
    1. Age <50 years: 55%
    2. Age >50 years: 14%
  3. Relapse is common
    1. Much less amenable to treatment
    2. Median survival after relapse: 3-6 months
  4. Factors suggestive of better prognosis
    1. Chromosomal abnormalities: t(8;21), t(15;17), inv 16
  5. Factors suggestive of poor prognosis
    1. Age over 60 years
    2. Chromosomal abnormalities: -5, -7, t(9;22)
    3. Acute Promyelocytic Leukemia
    4. Monocytic or myelomonocytic Leukemia
    5. Preleukemia history
    6. Cytotoxic Chemotherapy for prior malignancy

XIV. References

  1. Cornell (2012) Dis Mon 84(4):219-38 [PubMed]
  2. Davis (2014) Am Fam Physician 89(9): 731-8 [PubMed]
  3. Vardiman (2009) Blood 114(5): 937-51 [PubMed]

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