Table 4.
General approach to patients with AML at MD Anderson in 2020.
| Disease | Therapy and comments | % 5-year survival |
|---|---|---|
| APL |
-ATRA plus arsenic trioxide- -GO added for high-risk APL or persistent molecular disease ≥ 2–3 months into CR |
80–90 |
| CBF AML |
-FLAG-GO induction + 4 + 6 consolidations -age ≥ 60 years: adjusted dose FLAG-GO -Intolerance to FLAG-GO: decitabine or azacitidine × 12 (according to molecular MRD) ± targeted therapies (i.e., GO as tolerated); -Monitor response with real-time qPCR testing (goal: >3-log reduction) |
80 |
| AML in younger patients |
-FLAG-IDA, CLIA induction + 6 consolidations -FLT3 ITD: add FLT3-inhibitor (gilteritinib on study) -Clinical trials: venetoclax added to CLIA or FIA; -Future: activity of FLT3 inhibitors regardless of FLT3 status; IDH inhibitors + chemotherapy in patients with IDH1/2 mutations |
40–50 |
| AML in older patients/unfit for intensive chemotherapy (age > 60–70 years; 8-week mortality ≥ 20–30%) |
-Cladribine plus low-dose cytarabine alternating with HMA -Clinical trial: cladribine-low-dose cytarabine- azacitidine + venetoclax -Clinical trial: decitabine 10 days + venetoclax -“Triplet” combinations on clinical trials (mutation specific): Decitabine/azacitidine + venetoclax + quizartinib/gilteritinib (FLT3-mutated) Azacitidine + venetoclax + IDH inhibitor (IDH mutated) Azacitidine + venetoclax + APR246 (TP53 mutated) Azacitidine + venetoclax + magrolimab -Other investigational agents |
20–30 |
| Allogeneic SCT |
-In CR1 if poor cytogenetics, or FLT3 ITD high allelic ratio, or adverse mutations, or MRD positive in CR, and low treatment related mortality of SCT procedure -CR2 and beyond: all potential patients |
|
| Salvage therapy |
-CRD1 ≥ 12 months: high-dose cytarabine-based regimens -FLAG-IDA + Venetoclax on clinical trial -CRD1 < 12 months: phase 1–2 trials -Always recheck for mutations (next-generation sequencing), particularly for FLT3 and IDH1/2 mutations; if mutations then target-based therapy |
|
| Supportive measures |
-Antibiotic/antifungal prophylaxis -Protected environment/reverse isolation if age ≥ 50 years + intensive chemotherapy, or if age ≥ 60 years + low-intensity therapy |
APL acute promyelocytic leukemia, ATRA all-transretinoic acid, GO gemtuzumab ozogamicin, FLAG-Ida, FAI fludarabine, high-dose cytarabine, idarubicin, CLIA cladribine, high-dose cytarabine, idarubicin, HMA hypomethylating agent.