Treatment of Acute Myeloid Leukemia (AML)

Introduction to AML Treatment

The American College of Cardiology and other guideline societies recommend initiating induction chemotherapy with an anthracycline (daunorubicin 60-90 mg/m² or idarubicin 12 mg/m² for 3 days) combined with cytarabine 100-200 mg/m² continuous infusion for 7 days (the "7+3" regimen) for newly diagnosed AML patients eligible for intensive therapy, followed by risk-stratified consolidation therapy with high-dose cytarabine for favorable-risk patients or allogeneic stem cell transplantation for intermediate/high-risk patients in first complete remission 1, 2

Before initiating therapy, a comprehensive diagnostic evaluation including peripheral blood and bone marrow samples for morphology, cytochemistry, immunophenotyping, cytogenetic analysis, and molecular testing (FLT3, NPM1, CEBPA mutations) should be obtained 1, 2
HLA typing of the patient and family members should be done immediately to identify potential transplant donors 2
Echocardiography should be performed for patients with cardiac risk factors or history of heart disease before anthracycline administration 1, 2
Coagulation screening should be done prior to central venous line insertion 1
Risk stratification determines treatment intensity, with favorable risk including t(8;21), inv(16)/t(16;16), mutated NPM1 without FLT3-ITD, biallelic CEBPA mutations 1

The "7+3" regimen consisting of cytarabine 100-200 mg/m² continuous IV infusion days 1-7 and daunorubicin 60-90 mg/m² IV days 1-3 (for patients <65 years) or idarubicin 12 mg/m² IV days 1-3 should be administered 2, 3, 1, 2
Emergency leukapheresis is required before chemotherapy for patients with white blood cell count >100,000/mcL to prevent leukostasis complications 3, 1

Evaluate bone marrow morphology at count recovery (typically days 28-35) after induction, not earlier, as premature assessment can be misleading 4, 5
Complete remission criteria include normal bone marrow cellularity with <5% blasts, morphologically normal hematopoiesis, peripheral blood count recovery (neutrophils >1,000/μL, platelets >100,000/μL), and no extramedullary disease 5, 3, 6, 2

For favorable-risk AML, high-dose cytarabine consolidation without transplantation should be administered, with cytarabine 1-3 g/m² IV every 12 hours on days 1, 3, 5, repeated for 2-4 cycles 2, 3, 1, 2
For intermediate and high-risk AML, allogeneic stem cell transplantation in first complete remission should be considered for patients with HLA-identical sibling donor or matched unrelated donor 3, 1, 2

Primary induction failure or relapsed disease requires re-induction chemotherapy followed by allogeneic stem cell transplantation for patients achieving second remission 3, 5, 2
Matched unrelated donor transplantation should be considered for patients in second or subsequent remission 3, 2
Clinical trial enrollment should be considered whenever possible 1, 5

For patients with poor performance status, significant comorbidities, or age >65 years not eligible for intensive therapy, hypomethylating agents (azacitidine, decitabine), venetoclax combinations with hypomethylating agents, low-dose cytarabine, or best supportive care should be considered 1, 3, 1

AML treatment must be conducted in specialized centers with full hematology and medical oncology services, bone marrow transplant unit collaboration, infectious disease expertise, adequate transfusion services, and psycho-oncology support 3, 1, 2

Monitor for relapse with bone marrow morphology every 3 months for 24 months, differential blood counts every 3 months for 5 years, and molecular MRD assessment every 3 months from bone marrow (or every 4-6 weeks from peripheral blood) for 24 months in patients with molecular markers 5

Do not delay ATRA initiation in suspected APL while awaiting genetic confirmation—early bleeding is the most lethal complication 4
Do not perform bone marrow assessment too early (day 10-14) after induction in APL, as differentiation requires more time and premature assessment is misleading 4
Do not mix induction regimens from one protocol with consolidation from another—use complete treatment algorithms consistently to achieve expected outcomes 4
Do not overlook supportive care, which is essential and includes prophylaxis for tumor lysis syndrome, infection (antimicrobial prophylaxis), bleeding, and thrombosis 5