Management of Acute Myeloid Leukemia (AML)

Diagnosis and Risk Assessment

The European Society for Medical Oncology recommends AML diagnosis requires examination of peripheral blood and bone marrow samples with morphological examination, cytochemistry, immunophenotyping, cytogenetic and molecular analysis 3, 4
Risk stratification should consider patient factors, such as age, performance status, and comorbidities, as well as disease factors, including initial leukocyte count, AML subtype, karyotype, and molecular markers, according to the European Society for Medical Oncology 5, 6
Favorable risk features include t(8;21), t(16;16), mutations in C/EBPa and nucleophosmin genes, as stated by the European Society for Medical Oncology 5
Adverse risk features include complex karyotype, antecedent myelodysplastic syndrome, and FLT3 mutations, as noted by the European Society for Medical Oncology 5
Pre-treatment evaluation should include cardiac assessment with echocardiography for patients with cardiac risk factors, as recommended by the European Society for Medical Oncology 4
Coagulation screening prior to central venous line insertion is also recommended by the European Society for Medical Oncology 6
HLA typing for potential transplant candidates and their family members is suggested by the European Society for Medical Oncology 3

The National Comprehensive Cancer Network recommends first-line therapy for all newly diagnosed patients eligible for intensive treatment should include one cycle of induction with standard-dose cytarabine and an anthracycline 7, 4
Patients with acute promyelocytic leukemia (APL) should receive all-trans retinoic acid (ATRA) in addition to chemotherapy, as recommended by the European Society for Medical Oncology 6
Emergency leukapheresis may be required for patients presenting with hyperleukocytosis, according to the European Society for Medical Oncology 4
Response evaluation should be performed through clinical examination, serial peripheral blood counts, and bone marrow aspirates, as stated by the European Society for Medical Oncology 4
Complete remission (CR) is defined as normal bone marrow cellularity with <5% blasts and recovery of normal hematopoiesis, as defined by the European Society for Medical Oncology 3

The National Comprehensive Cancer Network recommends that after achieving CR, patients should receive consolidation therapy based on risk stratification 7, 6
Patients with favorable risk features should receive chemotherapy consolidation, preferably with high-dose cytarabine, as recommended by the European Society for Medical Oncology 6, 8
Patients aged <60 years with intermediate or high-risk features should be considered for allogeneic stem cell transplantation, according to the National Comprehensive Cancer Network 7

Myeloablative allogeneic stem cell transplantation from an HLA-compatible sibling should be performed in first CR for children with intermediate-high risk cytogenetics or who achieved CR after second course of therapy, as recommended by the European Society for Medical Oncology 7, 8
Stem cell transplantation from an unrelated donor is recommended in first CR for adults ≤30 years, as suggested by the National Comprehensive Cancer Network 7
Reduced-intensity conditioning allogeneic HCT should be considered for patients ≥60 years in first CR with minimal comorbidities, according to the National Comprehensive Cancer Network 2

Patients aged <60 years who are not candidates for allogeneic stem cell transplantation or lack a donor should be considered for autologous stem cell transplantation, as recommended by the European Society for Medical Oncology 7
The role of autologous transplantation remains controversial in AML, as noted by the European Society for Medical Oncology 6

Options for relapsed/refractory disease include clinical trials, low-intensity therapy, and best supportive care, as recommended by the National Comprehensive Cancer Network 2, 1
Patients in second or subsequent remission may qualify for allogeneic transplantation with an unrelated donor, according to the European Society for Medical Oncology 6, 8

For older patients or those unfit for intensive chemotherapy, lower-intensity options include hypomethylating agents, venetoclax combinations, and targeted therapies, as recommended by the National Comprehensive Cancer Network 2, 1
Best supportive care is also an option for older adults or those with significant comorbidities, as suggested by the National Comprehensive Cancer Network 1

Treatment should be conducted in centers with multidisciplinary expertise and adequate infrastructure, as recommended by the European Society for Medical Oncology 4
Clinical trials should be considered whenever possible, according to the National Comprehensive Cancer Network 2
Supportive care is crucial and includes transfusion support, antimicrobial prophylaxis, and management of treatment-related complications, as stated by the European Society for Medical Oncology 3
Molecular testing is increasingly important for targeted therapy selection and MRD monitoring, as noted by the European Society for Medical Oncology 5