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Treatment of Acute Myeloid Leukemia

Treatment Plan

Experience shows that certain patient groups will not benefit from the most intensive chemotherapy schedules. In these cases, the treatment is "watchful waiting" or less potent chemotherapy. This applies to:

  • Patients over 70 years, or patients under 70 with reduced health condition not due to leukemia, or other serious illness in addition to leukemia.
  • Older patients with certain forms of acute leukemia which, from experience, are refractory to intensive chemotherapy combinations. These types are the terminal acute leukemia occurring during treatment for other diseases, for example, polycythemia vera, myelofibrosis, aplastic anemia, myelodysplastic syndrom (MDS), and after treatment of Hodgkin's or non-Hodgkin's lymphoma or multiple myeloma.

With these exceptions, combinations of chemotherapy are given to all patients with acute myeloid leukemia, but treatment is adapted for age, health status, and comorbidity.

Treatment program

Cytarabine (cytosine arabinoside) is included in all chemotherapy combinations administered to induce remission of acute myeloid leukemia.


Treatment plan for acute myeloid leukemia < 60 years
Medication Administration method

Treatment 1A

Daunorubicin 50 mg/m2 day 1, 2, 3 intravenous infusion
Cytosine arabinoside 200 mg/m2 day 1–7 intravenous infusion over 24 hours
Treatment 1B is administered if there is no marrow aplasia and < 5% blasts in marrow smear 14 days after start

Treatment 1B

Daunorubicin 50 mg/m2 dag 1, 2 intravenous infusion
Cytosine arabinoside 200 mg/m2 day 1–5 intravenous infusion over 24 hours
Consolidation treatment: Treatment 2–5 assumed CHR after treatment 1A, possibly 1A + 1B

Treatment 2-5

Cytosine arabinoside 3 g/m2 x 2 days 1,3, 5 intravenous infusion over 3 hours

For FAB subgroup M3, a modified regimen is given in addition to the vitamin A derivative, tretinoin (ATRA).

Cytarabine combined with idarubicin is about as effective as daunorubicin in an equipotent dose, in terms of bringing the patient into remission.

Complete hematological remission

Remission criteria:

  • B-neutrophile > 1 x 109/l
  • Thrombocytes > 100 x 109/l
  • no need for blood transfusion
  • < 5% blasts in normal cellular bone marrow smear
  • absence of extramedullary leukemia

All patients under 60 years and their siblings, parents, and sometimes children, should have their tissue typed after remission is reached. All patients who have reached complete hematological remission (CHR), must have additional treatment (consolidation treatment (treatment 2-5)), otherwise there will be recurrence of the disease, almost without exception. This treatment regimen causes complete hematological remission (CHR) in about 80% of patients, and 4 year survival of 40-45%. Four year recurrence-free survival in patients with t(8;21) and Inv(16) is 70–80 %. Patients with cytogenetic anomalies and a high risk for recurrence have about 20% chance of recurrence-free survival.

Patients with a family donor are offered allogeneic stem cell transplant treatment in the first CHR except for patients with favorable prognostic signs. Critical weight is put on  the cytogenetic deviations of the leukemia cells at the time of diagnosis. In some patients with high risk criteria, who do not have a family donor, it is possible to search for an unrelated donor.

In patients who are in complete or partly hematological remission, blood values and bone marrow must always be checked before starting a new course. It is important to be aware that patients undergoing combination treatment rarely have normal blood and bone marrow function even if they are in complete hemotological remission. These blood and bone marrow changes are therefore not a sign of leukemia, but rather a result of the treatment.

Patients over 60 years

High-dose consolidation treatment or allogeneic stem cell transplantion treatment with myloablative pre-treatment are not appropriate for patients over 60 years due to the high risk of toxicity and death related to treatment. All patients must be assessed individually. An alternative is to administer 2-4 courses with combinations of amsacrine, etoposide, mitoxantron, and cytarabine, which are adapted for patient response and possible observed toxic damage. Other regimens are also used. It has not been shown whether any specific regimen is clearly the best. 

Refractory disease and recurrence during treatment

These patients have a poor prognosis and should receive palliative treatment with transfusions, antibiotics for infections, and chemotherapy combinations to control the disease. Patients who have suitable family donors and are not transplanted in the first remission are candidates for an allogeneic stem cell transplantation at the start of remission, and should therefore be followed carefully. A transplantation at the start of recurrence, from a donor who is not a biological relative, is not feasible for practical reasons. 

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