Institute of Medical Oncology, Inselspital and University of Berne, Berne, Switzerland
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Incidence |
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Diagnosis |
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Risk assessment |
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If fungal infection is suspected a thoracic CT scan and an abdominal ultrasound or a CT scan may be performed to assess liver, spleen, lymph nodes and kidneys for possible pathological alterations. Cardiac examination including echocardio-graphy is recommended for patients with risk factors or a history of heart disease [A].
In addition to haematological and chemistry tests a coagulation screening is to be performed prior to the insertion of central venous lines. Human leucocyte antigen (HLA) typing should be performed on patients who are candidates for an allogeneic bone marrow or stem cell transplant, and should include their family members [A].
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Treatment plan |
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Whenever possible AML treatment should be in clinical trials and in centres offering a multidisciplinary approach. Such centres should provide an adequate infrastructure including a full haematology and medical oncology service, close collaboration with a bone marrow transplant unit as well as an infectious disease unit and an adequate transfusion service.
Induction chemotherapy
Chemotherapy should be postponed until satisfactory material for all diagnostic tests has been harvested. Patients with excessive leucocytosis at presentation may require emergency leucapheresis prior to induction chemotherapy.
Induction chemotherapy should include an anthracycline and cytosine arabinoside [II, A]. Patients failing to respond to one to two cycles of such treatment are considered refractory. In addition, APL induction chemotherapy should include all-trans retinoic acid (ATRA) [II, A].
Consolidation therapy
Patients entering clinical and haematological remission should receive one to several cycles of post-remission therapy [II, A]. There is no consensus on a single preferred post-remission treatment strategy. Patients with good risk features as defined above should receive chemotherapy only, preferably including high-dose cytarabine. Other patients with an HLA-identical sibling are candidates for allogeneic stem cell transplantation in first remission [III, A]. Patients with particular poor risk features and no donor in their family may qualify for allogeneic transplant with an unrelated matched donor [III, A]. The role of high-dose consolidation chemotherapy with autologous peripheral stem cell support in AML is controversial. Maintenance chemotherapy and ATRA are beneficial in APL [III, A].
Therapy of relapsed or refractory patients
Patients in second or subsequent remission may qualify for allogeneic transplantation with an unrelated donor. In relapsed APL arsenic trioxide can induce remission even if patients have become refractory to ATRA [III, B].
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Response evaluation |
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Follow-up |
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Note |
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Literature |
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Coordinating author for the ESMO Guidelines Task Force: M. F. Fey, Institute of Medical Oncology, Inselspital and University of Berne, Berne, Switzerland.
Approved by the ESMO Guidelines Task Force: August 2002.
Correspondence to:
ESMO Guidelines Task Force
ESMO Head Office
Via La Santa 7
CH-6962 Viganello-Lugano
Switzerland
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References |
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2. Grimwade D, Walker H, Oliver F et al. The importance of diagnostic cytogenetics on outcome in AML: analysis of 1612 patients entered into the MRC AML 10 trial. Blood 1998; 92: 23222333.
3. Appelbaum FR, Baer MR, Carabasi MH et al. National Comprehensive Cancer Network. NCCN practice guidelines for acute myelogenous leukemia. Oncology 2000; 14: 5361.[Medline]
4. Zittoun RA, Mandelli F, Willemze R et al. Autologous or allogeneic bone marrow transplantation compared with intensive chemotherapy in acute myelogenous leukemia. N Engl J Med 1995; 332: 217223.