Health Professionals  /  Acute myeloid leukemia

Acute myeloid leukemia

Prognostic factors

Good risk:

• t(8 ;21) with WBC < 25 and unmutated c-kit
• inv(16), t(16 ;16) and unmutated c-kit
• t(15 ;17)
• normal cytogenetics with positive NPM and negative FLT3-ITD

NB: in patients with CBF leukemia, it is not considered a poor prognostic feature if 2 inductions are required to obtain a CR.

Intermediate risk:

• normal cytogenetics with negative NPM or positive FLT3-ITD
• + 8 as sole abnormality
• t(8 ;21) with WBC > 25 or mutated c-kit
• inv 16 with mutated c-kit
• secondary leukemia with good risk cytogenetics
• other cytogenetic abnormalities

Poor risk:

• complex cytogenetics: ≥ 3 abnormalities
• inv(3) or t(3 ;3)
• t(6 ;9)
• chromosome 5 or 7 abnormalities
• + 8 with another cytogenetic abnormality (other than t(8;21), inv(16))
• 11q23 *
• t(9 ;22)
• secondary leukemia (without evidence of good risk cytogenetics)
• hyperleucocytosis at diagnosis: WBC > 50 -100 x 109/L*
• intermediate cytogenetics and patient required 2 inductions to achieve CR*

* 11q23, WBC 50-100, or 2 inductions to achieve CR: if no related donor is available, the decision to proceed with an unrelated donor transplant needs to take into consideration the other prognostic factors of the leukemia, the comorbidities of the patient as well as the compatibility of the donor (it would be quite reasonable to postpone the transplant until relapse in patients with comorbidities or if the donor is less than a 8/8 match)

Cytogenetics not available at diagnosis

Try to obtain unstained bone marrow slides in order to perform FISH studies for the good risk cytogenetic abnormalities.

If the FISH is negative or if it is not possible to perform, consider the risk as intermediate.

1st complete remission

Good risk

No transplant

Intermediate Risk

1. Related HLA identical donor:
   • Allo transplant as soon as 1st CR is documented
   • Consolidation is not required but should be given if anticipated delay > 1 month between documentation of CR and transplant admission
2. No related HLA identical donor:
   • Perform high resolution HLA typing at Héma-Québec but transplant only at relapse

Poor risk

1. HLA identical related donor:
   • Allo transplant as soon as 1st CR is documented
   • Consolidation is not required but should be given if anticipated delay > 1 month between documentation of CR and transplant admission
2. No HLA identical donor:
   • Unrelated donor transplant as soon as a donor is identified
3. If unrelated donor is not found after 3 months of searching:
   • Cord blood transplant or
   • Haploidentical transplant (research protocol)

1st early relapse

1. Definition
   • Without preexisting MDS: ≤ 10% blasts in bone marrow
   • With preexisting MDS: ≤ 20% blasts in bone marrow
2. Related or unrelated donor transplant
   • Proceed to transplant if able to perform immediately

Acute myeloid leukemia in 2nd or 3rd CR

1. Related or unrelated donor transplant
2. Unrelated donor not identified after 3 months of searching
   • Cord blood or
   • Haploidentical transplant (research protocol)

Refractory leukemia

We do not perform transplant for refractory leukemia.

Pre transplant lumbar puncture

Lumbar puncture must be negative prior to initiating conditioning regimen.

We recommend giving a dose of intrathecal Methotrexate before transplant (ideally with the pretransplant LP).

Age requirements for transplant

1. Myeloablative related allogeneic transplant
   ≤ 60 years old
2. Unrelated donor transplant
   ≤ 60 years old
   If the patient is between the ages of 50 and 60 the unrelated donor has to be HLA identical (10/10) or a 9/10 match with a single DQ mismatch.
3. Related nonmyeloablative transplant
   On protocol (CBMTG): 70 years old
   Off protocol: ≤ 65 years old