Describe the general treatment approach.
The treatment of acute leukemia is decided by a hematologist-oncologist specialist depending on the specific subtype and results of molecular testing.
Pretreatment: All patients should have prechemotherapy screening as part of preparation for cancer treatment.
Systemic chemotherapy: The regimen of choice is based on individual patient and disease factors.
Intrathecal chemotherapy (commonly used): Consider adding for patients with or at high risk of CNS infiltration (e.g., all patients with ALL).
Targeted chemotherapy: Consider adding for leukemias with specific immunophenotype and genetic profiles, e.g., Philadelphia translocation.
Adjunctive treatment, e.g., radiation therapy, immunotherapy, or stem cell transplantation (SCT): Consider based on individual evaluation.
Supportive care: Provide holistic care to reduce symptoms and support patients and carers (see “Principles of cancer care”).
Management of complications: initiate monitoring, prevention, and early aggressive treatment as needed for infection, bleeding, pancytopenia, and oncologic emergencies
Which treatment improves prognosis?
Early and aggressive chemotherapy improves the prognosis, e.g., 80–90% of patients with ALL achieve complete remission with chemotherapy.
Describe principles of systemic chemotherapy.
Regimens vary depending on the subtype of leukemia, the age of the patient, and immunophenotype and genetic study results.
Average duration for an adult with ALL is 4–8 weeks
Reinduction therapy may be required in case of relapse or failure of primary induction
Consolidation chemotherapy: average duration for an adult with ALL is 4–8 months
Maintenance chemotherapy: average duration for an adult with ALL is 2–3 years
Describe the management of CNS infiltration.
Intrathecal chemotherapy: administration of chemotherapeutic agents (e.g., triple therapy with methotrexate, cytarabine, and hydrocortisone) directly into the subarachnoid space via lumbar puncture or using an intraventricular catheter with a reservoir placed under the scalp
Indications in ALL: Prevention of leukemic meningitis in all patients at the time of diagnosis
Indications in AML
Treatment of patients with confirmed CNS infiltration
Prevention in patients with high-risk APL
CNS radiotherapy: Consider directed radiation therapy alongside intrathecal chemotherapy in select patients.
Describe advanced therapies such as targeted therapy or stem cell transplantation.
Targeted therapy: Nonstandard chemotherapy or immunotherapy is indicated if certain mutations or markers are detected.
Tyrosine kinase inhibitors (TKIs)
Philadelphia chromosome-positive ALL: BCR-ABLTKIs, e.g., imatinib, ponatinib)
FLT3-ITD AML: Consider midostaurin
Autologous or allogeneic stem cell transplantation: Indications include patients with poor prognostic factors (e.g., unfavorable cytogenetics) and those who do not achieve remission with chemotherapy
Describe the management of complications.
Tumor lysis syndrome (TLS)
Management: typically includes fluid therapy (oral or IV) and rasburicase
Prophylaxis: Consider hydration, and urate-lowering therapy (i.e., allopurinol or rasburicase).
Leukostasis (e.g., due to hyperleukocytosis): Consider IV fluid resuscitation and/or cytoreductive therapy.
See “Oncologic emergencies” for details.
Anticancer therapy-induced myelosuppression: anemia , thrombocytopenia, and neutropenia
Can lead to acute gout, uric acid stones, and urate nephropathy
Consider hydration, fluid administration, and urate-lowering therapy (e.g., allopurinol and rasburicase) as prophylaxis prior to chemotherapy.