ACUTE MYELOID LEUKEMIA : SOME NOTES FROM DR FREDERICK APPELBAUM COMMENTS

* classification under the FAB was abandoned because it did not give prognosis information

* 4 groups based on Cytogenetics
1. No significant Cytogenetic abnormality : considered the INTERMEDIATE GROUP
2. Unfavorable group with 5q - 7(Monosomy)
3. Favorable group Inv 16, (15,17), (8,21)
4. Unclassified

The favorable have 55% 5 Year survival
Intermediate have 38% 5 year survival
Unfavorable had 11% 5 year survival

ADD NPM1 as good prognosis
ADD CEBPA as good
BUT  FLT-3 as bad despite favorable basic category
C-KIT positive is also bad in Adult only

other cytogenetic of interest N-RAS, NPM and IDH1 Mutation

15 other Mutations for our BUFF in genetic

KIT          MLL             CBL       PTEN      JAK2         DNMT3A      EZHZ      TET2      WT-1
IDH-1      N-RAS        P53         RUNX-1     ASXL-1    PHF-6
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IF YOU FINISH LOOKING AT THE 15
WELL LOOK ALSO   ERG   MN1    EVI-1   BAALC   CD34
---------------------------------------PLUS MICRO--RNA, METHYLATION

ADD TO DNA SEQUENCING , TRANSPTOSOME SEQUENCING TO SEE FURTHER


ELN 2012
CATEGORIES OF AML

1. favorable include Inv 16,( 8,21), NPM1, CEBPA and wild type FLT-3

2. Int-1   NPM1 Mutated and FLT3 Mutation
3.  int-2   t(9,11) and NOS
4. Unfavorable   inv 3  (3,3)   t(6,9)   -5  -7  17p  and complex abnormalities

remember good or favorable is not good or favorable anymore if noted after chemotherapy for another primary.

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In all patients, obtain  (I will send you an angry letter if H&P not completed in EMR!) OK!

1.  CBC DIFF and Comprehensivve Metabolic panel
2. Uric acid level ---not high, start Allopurinol
                           ---high start Rasburicase
3.PT and PTT if DIC start ATRA
4. Bone marrow Biopsy
5.Immunophenotyping
to detect the 1% of Mixed phenotype which is of poorer prognosis
and to be able to detect persistence of disease with PCR better accomplished through this method
6.Cytogenetic   which should include CEBPA, FLT-3, and NPM-1, C-Kit

7.HLA typing NOW  NOW   NOW!
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Please note  age (65) and comorbidities as you ponder if patient can sustain high dose treatment
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Treatment

-start Hydration and Alkalinization
-Allopurinol Vs Rasburicase based on Uric Acid level
-DIC start ATRA no matter what
-start Antibiotic, antiViral and antifunga Coverages NOW
-Consider Fertility Issue now
-speak to family
and start Induction
and consider consolidation based on circumstances per standard of care


In elderly >65,   or >60 with significant comorbidity
Death occurs during induction
so please consider
1.LOW DOSE ARAC-C
2. 5-AZACYTIDINE
3. DECITABINE
4. CLOFARABINE
5. FOR 5q- TRY REVLIMID!
-----------------------these are my notes------------