Acute Myelogenous Leukemia

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

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II. Epidemiology

  1. AML is the most common Acute Leukemia in adults (80% of cases)
    1. Remaining 20% are Acute Lymphoblastic Leukemia cases in adults >50 years
  2. Median Age at AML diagnosis: 68 years old

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. Unintentional Weight Loss
  3. Anemia-related symptoms
    1. Shortness of Breath
    2. Exertional Chest Pain
    3. Pallor
  4. Thrombocytopenia related symptoms
    1. Excessive bleeding or Bruising
    2. Petechiae
    3. Conjunctival Hemorrhage

VI. Signs

  1. Hepatosplenomegaly and Lymphadenopathy are uncommon (contrast with Acute Lymphocytic Leukemia)
  2. Gum infiltration may occur

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. Blast cell predominance (both AML and ALL)
    1. However, blast cell absence on Peripheral Smear does not exclude Acute Leukemia
  3. Studies to distinguish between AML and ALL
    1. Myeloblasts represent >20% of cells in Bone Marrow or peripheral blood sample in AML
    2. Flow cytometry with immunophenotyping
      1. Sorts and counts cells by cell surface markers
    3. Cytogenetic testing
      1. Chromosome evaluation (karyotype or fluorescence in situ hybridization analysis)

IX. Management: Acute

  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 or Hematopoietic Stem Cell Transplantation improves survival
  4. Small Molecule Inhibitors (e.g. Venetoclax)

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

  1. Annual physical exam (or more often in first few years)
  2. Complete Blood Count with differential
    1. Every 1-2 months for 2 years THEN
    2. Every 3-6 months for up to 5 years
  3. Cardiac testing
    1. Indications
      1. Treatment with Anthracycline-based agents, e.g. Daunorubicin, Doxorubicin)
      2. Consult hematology and cardiology regarding local protocols and indications based on patient history
    2. Echocardiogram every 2 years
    3. Electrocardiogram baseline and every 2 years
    4. MUGA Scan (Multi Gated Acquisition Scan, radionuclide angiography) every 5 years
    5. 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 (U.S., 2000 to 2018)
    1. Age <50 years: 55%
    2. Age 50 to 64 years: 30%
    3. Age >65 years: 7%
  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. Gbenjo (2023) Am Fam Physician 107(4): 397-405 [PubMed]
  4. Vardiman (2009) Blood 114(5): 937-51 [PubMed]

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