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Home Cancer Leukemia Acute Myeloid Leukemia (AML)

Acute Myeloid Leukemia (AML)

Acute Myeloid Leukemia (AML), is a cancer of the blood–forming tissue, primarily the bone marrow and lymph nodes.
AML is also called Acute Non–lymphocytic Leukemia or Acute Myelogenous Leukemia, and is divided into several subtypes. It is less common than Acute Lymphocytic Leukemia (also called Acute Aymphoblastic Leukemia or ALL), another form of leukemia that occurs in children. Children with Down’s Syndrome have an increased risk of AML during the first three years of life.

In rare cases, AML tumor cells appear as a solid tumor called isolated Granulocytic Sarcoma or Chloroma. Leukemia can be acute (progressing quickly with many immature blasts) or chronic (progressing slowly with more mature–looking cancer cells). Acute myeloid leukemia can occur in both children and adults. Different treatments are used for adults and for children.

Like all types of leukemia, the cause in most cases is unknown. Leukemia is not infectious and is not passed on from parent to child. People exposed to high levels of radiation, such as survivors of the atomic bombs in Japan and patients who have received radiotherapy, have a slightly greater chance than other people of developing leukemia in later years.

Exposure to benzene, a chemical that is added to petrol can cause acute leukemia but this is only true when the level of benzene is very high. There is no evidence of a risk to people using lead–free petrol. Cigarette smoking has been reported to be a very important risk factor for AML. Some reports have estimated that as many as a quarter of all cases of AML may be caused by smoking. Patients treated with drugs for cancer may, in later years, develop a so–called secondary leukemia due to the action of these drugs on the blood cells in the bone marrow. This is known as secondary AML. Unfortunately, secondary AML is often very resistant to treatment. There is no convincing evidence that any other chemicals cause AML. Although viruses can cause leukemia in various animals, there is no evidence that viruses or indeed any other infectious agent, causes AML in humans.

Treatment of Acute Myeloid Leukemia
The standard treatment for AML is the use of drugs to kill the abnormal cells. It is usual to commence treatment quickly after diagnosis as Acute Leukemias’ progress rapidly if not treated. About 80% of younger patients achieve complete remission whereas in patients over 65 years achieve remission between 50 and 60%.

This is usually achieved by using two drugs in combination, usually Daunorubicin and Cytarabine. The one form of AML which receives very different treatment is M3 or Acute Promyelocytic Leukemia, (type M3 AML). This is the only form of AML which responds to the drug Retinoic acid used alongside conventional drug treatment. Almost all drugs used in the treatment of leukemia may cause nausea, vomiting and inflamed mucous membranes (lining of the mouth and gut). They also cause bone marrow depression. This will be carefully monitored by blood counts and bone marrow biopsies.

Any patient who experiences bleeding or signs of infection should contact their doctor or the hospital care team immediately. Slight bleeding when cleaning your teeth may be expected. Any patient who has symptoms which are causing concern should not hesitate to contact their doctor or the hospital. A patient with a low Neutrophil count may not have obvious symptoms if they have an infection. For this reason any patient with low Neutrophils should take their temperature regularly and contact the doctor if they develop a raised temperature.

Drugs and Treatment In Remission
Daunorubicin
This is a very effective drug in destroying leukemia cells in the body and in securing complete remission. It is usually given by intravenous injection on one to three occasions during each course of treatment. It can cause nausea and vomiting at the time of administration. It often causes hair loss starting ten to twenty days after administration, but the hair always re–grows when the drug is stopped. Patients who have had many courses of Daunorubicin will be carefully monitored to avoid any damage to the heart. Similar drugs to Daunorubicin are Doxorubicin (Adriamycin), Idarubicin and Epirubicin.

Cytosine Arabinoside
Cytosine Arabinoside, which is also known as Cytarabine, or as Ara–C is used to get patients into remission. It can then be given as part of consolidation treatment. It is given by injection. Patients who are on Cytarabine may need to drink more fluid to keep their kidneys working well. Nausea and vomiting are the most common side–effects. In very high doses this may cause nervous system toxicity. When taking Cytarabine it is very important to attend for regular check–ups and to report any symptoms to the hospital immediately.

Retinoic Acid
This is a special form of treatment which works not by killing all dividing cells but by persuading cells to grow old and die naturally. It is only effective against AML type M3, Promyelocytic leukemia. If only Retinoic acid is given almost all patients will relapse. It is normal to give Retinoic acid along with the same drugs as for other types of AML.

Treatment in remission
This consists of further courses of intensive chemotherapy. One of the most common forms of treatment in remission is with high doses of Cytarabine. If the disease is classified as good risk based on chromosome tests it is likely to respond very well to standard drugs. There is a good chance that long–term remission, i.e. a “Cure” will be achieved with this treatment alone. If the disease is standard risk there are neither good nor bad risk factors and it is therefore harder to predict the outcome of standard chemotherapy. There is still a real possibility of cure from drugs alone but this cannot be so confidently predicted.

It is probably in the standard risk group that clinical trials are most important and valuable in improving the treatment choices available. Patients with standard risk disease may be recommended to consider a bone marrow transplant if a well matched donor is available. Alternatively, patients may be considered for an autologous transplant (which uses the patients own stem cells). If the disease is classified as poor risk it is less likely that it will respond well to standard chemotherapy. It is very important to remember that some patients with poor risk disease will do well on chemotherapy alone but it is in this group that a bone marrow transplant is most likely to be recommended if a donor is available.

Secondary AML
Secondary AML refers to cases which occur in patients who have been treated for other malignant disease or for cases which arise in patients who already have a condition such as Myelofibrosis.

Secondary AML tends not to respond to standard treatment. Because of the effects on the bone marrow of the initial disease most patients with secondary AML are not able to have an autologous stem cell transplant. If they are otherwise suitable they may be candidates for a donor bone marrow. If you are a patient with secondary AML your doctor will discuss treatment options with you.

Prognosis of Acute Myeloid Leukemia
In all types of leukemia, it is important to understand that the only person who can tell a patient what is the appropriate treatment for them and advise on the likely outcome (prognosis), is the patient’s own specialist. In very general terms the chances of getting an initial remission are between 50–80% depending on the age of the patient. The chances of long–term survival are very dependent on whether the condition is good risk, standard risk or poor risk.

For patients with good risk, there is about a 60% or better chance of being alive and well at five years. For patients with standard risk it is very much harder to predict the likely outcome of treatment with conventional drug therapy. In the case of patients with poor risk, the chance of long–term survival without a successful bone marrow or stem cell transplant is extremely low. The chance of survival post–transplant is difficult to predict as it depends on a number of factors including the patient’s age and general health and how closely the donor is matched.

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